Current surgical management of penile cancer
Section snippets
Surgical management of the primary tumor
Surgical resection of the primary penile tumor should result in complete removal of the cancerous lesion with as much organ preservation as possible to preserve functional and cosmetic outcomes and avoid psychological distress. This is especially important in patients who develop penile cancer at a younger age (approximately 20% <40 years of age at presentation).1 It is essential, however, to remove all malignant tissue with negative surgical margins in order to optimize oncological outcomes
Surgical treatment of carcinoma in situ (Tis)
For penile carcinoma in situ (CIS) of the glans or shaft associated with small (1-2 cm), mucosal, and superficial lesions, topical treatment with 5% imiquimod or 5% 5-fluorouracil is an effective first-line treatment with complete response in 50%-60% of patients.3 It is applied on the penile lesion for 4 weeks on alternating days with minimal systemic absorption. If topical chemotherapy fails, it should not be repeated, and laser therapy with CO2 or neodymium-doped yttrium-aluminum garnet
Surgical treatment of Ta/T1 disease
Penis-preserving resection is typically recommended for small and locally invasive lesions (Ta/T1) of which 80% present on the glans penis and prepuce.7 Intraoperative assessment of surgical margins by frozen section is recommended as positive margins lead to local recurrence. For grade (G) 3 and 4 T1 penile tumors or those that demonstrate lymphovascular invasion (LVI) (T1b) with an increased chance of recurrence, more extensive surgical intervention with partial penectomy may be required for
Surgical treatment of T2-T4 disease
Total glansectomy is the best surgical approach for T2 lesions confined to the glans with reconstruction of the glans using an STSG and formation of a new urethral meatus at the tip of the shaft. The glans “cap” is dissected free off the corporal heads, taking care to prevent inadvertent injury to the spongiosum. Frozen sections from the corporal tips and distal urethra can be taken intraoperatively to ensure negative surgical margins and adequate oncological control. This approach allows for
Surgical management of regional lymph nodes
As the presence and extent of regional lymph node (LN) metastases is the single-most-important prognostic factor in determining the long-term survival of patients with invasive penile cancer, careful examination of the groin and pelvis through physical examination and cross-sectional imaging is imperative in determining the palpability, location, mobility or fixation, number, laterality, and size of inguinal, pelvic, or distant metastatic disease.21
Although 18F-fluorodeoxyglucose–positron
Dynamic sentinel node biopsy
Dynamic sentinel node biopsy (DSNB) is a minimally invasive technique developed in patients with nonpalpable groins to evaluate for regional metastatic disease. DSNB assesses individual ILNs based on the assumption that primary afferent lymphatic drainage from penile cancer goes initially to only a single zone.29 Technetium-99m-labeled nanocolloid as well as patent blue dye isosulfan blue is injected around the primary penile cancer site (within 1 cm) and a gamma-ray detection camera and a probe
Surgical treatment of nonpalpable ILNs
The management of ILNs in patients with normal groins on physical examination is dependent on the stage, grade, and the presence or absence of LVI in the primary penile tumor. Tumors with a low risk of inguinal metastatic spread (4%) include those that are G1 or G2 as well as pTis, pTa, and pT1 disease without LVI (pT1a).37 Surveillance of regional LNs with serial imaging and physical examination is most appropriate in this setting.38 For pT1 disease with LVI (pT1b), pT2-pT4, or G3 or G4 penile
Surgical treatment of palpable ILNs
In patients with unilateral or bilateral clinically palpable ILNs (cN1 or cN2), the likelihood of inguinal metastatic disease is very high, and only additional imaging with 18F-fluorodeoxyglucose–PET/CT, magnetic resonance imaging, or ultrasound will provide additional information about the status of the pelvic LNs.26 DSNB is also contraindicated in men with clinically palpable groins.32
Although in prior clinical practice, antibiotic therapy was given for 4-6 weeks to rule out LN enlargement
Surgical treatment of pelvic LNs
In men with 2 or more positive ILNs or any ILN with extracapsular extension (pN3), an ipsilateral PLND is indicated for appropriate surgical treatment and staging.58 The boundaries of PLND include the iliac bifurcation proximally, ilioinguinal nerve laterally, and the obturator nerve medially. PLND involves removal of the obturator, internal iliac, and external iliac LNs as well as any clinically positive LNs in the pelvis. Ipsilateral PLND may be performed in the same operative setting as that
Endoscopic surgical approach to LND
Video endoscopy ILND (VEIL) and robot-assisted laparoscopic ILND may be utilized in the future treatment of locally advanced penile cancer with the potential for fewer complications without compromising oncological outcomes.61 Inguinal endoscopic dissection was first described by Bishoff et al62 in 2 cadaveric models and in a patient with stage T3N1M0 penile carcinoma. The same surgical and oncological principles should be adhered to as with the open approach, and suitable candidates should
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Cited by (8)
Development of a Novel Prognostic Risk Score for Predicting Complications of Penectomy in the Surgical Management of Penile Cancer
2019, Clinical Genitourinary CancerCitation Excerpt :PC remains rare in Western countries; however, high-grade and invasive PC are recognized to cause significant morbidity and mortality. In patients who have high-risk T1 disease, the National Comprehensive Cancer Network and European Association of Urology guidelines endorse either total or partial penectomy as recommended surgical management to both reduce the risk of recurrence and improve cancer-specific survival.8 Overall, local disease can be cured in 80% of patients by excisional techniques.3
Penile Cancer: Contemporary Lymph Node Management
2017, Journal of UrologyCitation Excerpt :The procedure involves excision of the obturator, internal iliac and external iliac nodes as well as any clinically positive nodes in the region. Carefully occluding the lymphatic channels with surgical clips or ligation and the insertion of a suction drain are recommended to manage postoperative lymphocele.46 In addition to its potential for diagnostic staging, PLND can improve survival in patients with high risk disease but it is of limited benefit in those with low risk disease.
Advances in penile reconstructive techniques for primary penile tumors
2019, AME Medical JournalSurgical Reconstruction After Penile Cancer Surgery
2017, Current Sexual Health ReportsClinical considerations and surgical management of groin disease in penile and scrotal cancer
2017, Malignancies of the Groin: Surgical and Anatomic ConsiderationsCutaneous malignancies in HIV
2017, Current Opinion in HIV and AIDS