The management of cancer of the penis remains a challenging dilemma for today’s clinician. Because of a low incidence (2120 new cases projected in 2017)1 and a paucity of high-level evidence, physicians may often find themselves with limited opportunities to gain further experience in managing this disease. This limitation is amplified when considering the subset of patients with lymph node–positive (LN+) penile cancer. The advent of treatment guidelines provides more structure in terms of the best management, but it also poses questions regarding how closely these guidelines are being followed and if not, why not?