Letter to the Editor Publication of patient series, particularly on rare tumors such as penile cancer, necessitates the contextualization of presented data with guideline recommendations Dear Editor, With great interest, we read the publication on a retrospective study involving 93 patients with predominantly surgically treated penile cancer (PeCa) from a 20-year period (1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) at a major Indonesian university hospital. 1 In Germany, we face the issue of lacking centralized PeCa management, which we assume to be the same for our Indonesian colleagues, given their low average numbers of less than five patients per year. Consecutively, from Germany, we often look enviously to the Netherlands, where centralization of PeCa patients has led to a significantly better adherence to guidelines and, presumably, as a result, to improved survival rates for these patients. 2,3 We commend the authors for their candid analysis of the data. However, we have several remarks. First, the surgical repertoire of a urological clinic should not be limited solely to amputative procedures (of the total 83 surgically treated patients, 58% and 42% received a total/total penectomy (TP) and partial/partial penectomy (PP), respectively). The local surgical standard should be an organ-preserving approach (OPA), which is not reconcilable with the resection of parts of the Corpora cavernosa (i.e., PP). For 44% of the study cohort, in which the PeCa was limited solely to the glans penis, an OPA should have been mandatory. Moreover, a general surgical resection safety margin of 2 cm cited by the authors clearly contradicts the feasibility of an OPA and also controverted the recommendations of international guidelines in place at the beginning of the study period. Second, the criteria for inguinal lymph node dissection (ILND) should not solely rely on the algorithm presented by the authors, which was exclusively based on the detection of enlarged lymph nodes in clinical palpation and/or ultrasound, but should also include indications for ILND in clinically node-negative patients (starting from tumor stage pT1bN0). In the study group, the authors reported 10 patients at tumor stage pT1aN0 (Union internationale contre le cancer (UICC) stage 1), three of whom presumably received an unwarranted ILND, and another 25 at UICC stage 3 (c/pN+), of whom 10 did not receive any ILND, thus questioning their assignment to this tumor stage. It would have been prudent to separately present the clinical and pathological N-stages to better categorize the association of tumor stages and administered therapies. Third, although we also believe in the prognostic significance of ILND, we estimate the authors' conclusions concerning an overall survival (OS) improvement as a result of performing an ILND to be unjustified based on the presented data and its analyses. According to the OS-curves, about 70% of patients survived, implying an estimated 28 endpoints fo...
