Penile cancer is a rare disease, with an incidence of 1/100 000 males in Europe. However, in some areas such as South America, Africa, and Asia, it represents 1–2% of malignant disease cases among males [1].

In patients with penile cancer, the most important prognostic factor for survival is the presence and extent of nodal metastases, with 5-yr cancer-specific survival rates of approximately 93%, 75%, 50%, and 17% for N0, N1, N2, and N3 disease, respectively [2].

To date, clinical lymph node TNM staging is mainly based on physical examination of both groins [3]. However, this has limitations in detecting suspect inguinal nodes (especially in obese patients) and the risk of micrometastasis can be up to 25% even when nodes are not suspicious on palpation [4]. Moreover, it has been shown that treating (micro)metastatic disease at an early stage leads to better oncological outcome in comparison to surgery when nodes become palpable [4].

Thus, as noninvasive staging options (nomograms, imaging) are not reliable enough to detect micrometastatic disease, invasive surgical staging remains indispensable [5]. However, as only 20–25% of all clinically node-negative cases harbour occult metastasis, surgical staging represents overtreatment in most cases. For selection of patients who are especially at risk of nodal metastases, risk categories based on tumour stage, grade of differentiation, and lymphovascular or perineural invasion of the primary tumour have been established [5]. The most widely used surgical staging options are dynamic sentinel node biopsy (DSNB) and (radical or modified) inguinal lymphadenectomy (ILND) [6], [7], [8]. In centres that perform DSNB, this procedure is often preceded by ultrasound (US) with fine-needle aspiration cytology (FNAC) for cases with suspicious nodes on US [9]. More recently, video-endoscopic inguinal lymphadenectomy (VEIL), including a robot-assisted approach (RA-VEIL), was introduced with the aim of reducing the morbidity of open ILND [10], [11]. Previous guidelines generally recommended surgical staging for intermediate- and high-risk tumours, with the method used for surgical staging left to the surgeon’s discretion as the diagnostic accuracy and complication rates of the techniques available are not well established [5].

The present systematic review was undertaken by the European Association of Urology (EAU) and American Society of Clinical Oncology (ASCO) Collaborative Penile Cancer Guidelines Panel to evaluate current evidence on the diagnostic accuracy and safety of minimally invasive nodal staging techniques.