Anatomic considerations of the penis and its lymphatic drainage

A few clinical caveats relevant to penile neurovascular and lymphatic anatomy deserve special emphasis. First, it is clear from the work of Breza and others that the neurovascular anatomy of the penis differs from patient to patient, especially with regard to the arterial supply. It seems prudent to identify an accessory pudendal artery during pelvic lymphadenectomy and nerve-sparing prostatectomy in order to prevent a neurologically intact penis being left with an inadequate corporal blood supply. From an anatomic perspective, it appears that the sentinel lymph node biopsy might be useful in the management of superficial carcinoma of the prepuce or skin of the penis, as these areas drain to the superomedial zone of the superficial inguinal nodes, to which the sentinel node belongs. However, most tumors of the penis involve the glans. Thus, the sentinel node biopsy will not reliably predict nodal involvement for all clinical stage I lesions, as the lymphatics from the glans may bypass the superficial nodes to invade the pelvic nodes directly. Finally, it remains to be determined what impact, if any, the improved understanding of penile anatomy will have for the patient with carcinoma of the penis. The extent of dissection, both in partial penectomy and in nodal dissection, deserves careful consideration. Armed with a clearer understanding of the anatomy of the penis, the urologist can choose a plan of surgical treatment wisely.