Treatment-Seeking, Aspects of Sexual Activity and Life Satisfaction in Men with Laser-Treated Penile Carcinoma

doi:10.1016/j.eururo.2007.10.028

European Urology

Volume 54, Issue 3, September 2008, Pages 631-639

https://doi.org/10.1016/j.eururo.2007.10.028 Get rights and content

Abstract

Objectives

The aims were to assess the initial symptoms of penile carcinoma and patients’ time frame in treatment seeking, and to describe the effect of laser treatment on sexual activity and life satisfaction.

Patients and methods

A retrospective face-to-face structured interview study of patients laser treated for localised penile carcinoma at the department of Urology in Örebro, Sweden, during 1986 to 2000. Sixty-seven was treated and 58 of them (mean age, 63 yr; range, 34–90) were alive at the time of this study. Forty-six (79%) agreed to participate.

Results

Ninety-six percent of the patients recalled their first symptom of penile carcinoma. Superficial ulceration and fissures were the most common symptoms (39%). Thirty-seven percent delayed seeking treatment for more than 6 mo.

The patients had a greater lifetime number of sexual partners and a greater lifetime prevalence of STIs than a Swedish representative comparator population.

Some aspects of sexual life, such as manual stimulation/caressing and fellatio, decreased markedly after laser treatment.

Patient satisfaction with life as a whole was approximately the same as that of the general population.

Conclusions

Patients delayed seeking treatment for a considerable period, despite awareness of the first local symptoms. Men with laser-treated localised penile carcinoma resume their sexual activities to a large extent after the treatment. Except for satisfaction with somatic health, similar—or even higher—proportions of patients than comparators are satisfied with life as a whole and with other domains of life including satisfaction with sexual life.

Introduction

The incidence of penile carcinoma in Sweden is 1.5–2 per 100,000 men per year. It mainly occurs in elderly men; mean age at diagnosis in Sweden is 67 yr [1].

The gold standard therapy has for decades been partial or total penectomy. This treatment is often followed by major side-effects that impact on sexual function and quality of life [2]. Since organ-sparing laser techniques were introduced in the 1980s, the results on localised disease have been promising, with excellent preservation of the penis as well as local disease control that are equivalent with conventional treatments [3], [4], [5], [6], [7], [8], [9].

The rarity of the disease makes it difficult to perform randomised trials, and we know little about the psychosexual factors involved in patients’ perception of the first symptoms and about the time frame in treatment seeking. Studies exploring patient's psychosexual distress and quality-of-life issues generally include small samples with different treatment modalities [2], [10], [11].

We have previously shown that 65% of those who had been sexually active before laser treatment resumed their sexual activities with small reductions in sexual function and satisfaction [12].

The primary objectives of this study were to assess the initial clinical symptoms of penile carcinoma, assess the time between initial symptoms and treatment seeking, and describe the effect of laser treatment of penile carcinoma on sexual activity and life satisfaction.

Section snippets

Methods

The study cohort has been previously described in detail [12] and consisted of a consecutive series of 67 patients referred to the Department of Urology, Örebro University Hospital, Örebro, Sweden, for laser-treatment of penile carcinoma from 1986 to 2000. Fifty-eight of these were alive when this retrospective study was initiated; 46 (79%) of them agreed to participate. Twelve declined to participate; they did not differ significantly from those who participated with regards to age, tumour

Results

Thirty-six (78%)of 46 patients had a steady partner relationship: 31 of these had the same partner as before treatment, whereas 5 had changed his partner after treatment. All reported being heterosexual.

Patient characteristics are presented in Table 1.

Discussion

Hence, men who received laser treatment for localised penile carcinoma coped well with nearly all aspects of life afterwards and resumed their sexual activity to a large extent. These men, as a group, achieved their goals in life concerning life as a whole and most domains of life at a level comparable to the general Swedish male population. One domain in which they failed to reach their goals to a significant extent was that of health.

The investigation suffers from some possible limitations.

Conclusions

To a considerable extent depending upon having or not having a partner, many Swedish men who observe the first symptoms of penile carcinoma often delay seeking treatment. Men who received laser treatment for localised penile carcinoma resumed their sexual activities to a great extent, and experienced levels of satisfaction with sexual life and with most other aspects of life that are equal to those of the general male population aged 34–74 yr. Laser treatment is thus an excellent treatment

Conflicts of interest

The authors have nothing to disclose.

Acknowledgement

This study was supported by grants from Maud and Birger Gustavssons Foundation.

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2023, European Urology
Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines.
To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer.
Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.
Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preservation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (≥pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommendation are low in comparison to those for more common diseases.
This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ-preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced disease stages. Referral to centres of expertise is recommended.
Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, management of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisation of penile cancer services.
Diagnostic Accuracy of Dynamic Sentinel Lymph Node Biopsy for Penile Cancer: A Systematic Review and Meta-analysis
2023, European Urology Focus
A dynamic sentinel lymph node biopsy (DSNB) is used for inguinal lymph node staging in patients presenting with primary penile cancer with clinically impalpable inguinal lymph nodes (cN0). Further completion radical inguinal lymph node dissection (RLND) is offered to patients diagnosed with metastatic inguinal nodes following a DSNB.
To identify the diagnostic accuracy of a DSNB and RLND to detect lymph node metastasis.
A systematic literature search was performed on PubMed Medscape, EMBASE, Google Scholar, and Cochrane database for relevant studies between January 1, 2000 and April 30, 2022. Studies were included if a DSNB was offered to cN0 patients and if RLND was offered to patients with positive histology at the DSNB. Risk of bias and confounding assessments were performed. Diagnostic odds ratio, pooled sensitivity/specificity, and heterogeneity analyses were displayed.
Overall, 2893 patients in the 28 studies analysed underwent a DSNB. Twenty-one studies reported patients undergoing RLND for a positive DSNB. A DSNB showed pooled weighted sensitivity of 0.87 (95% confidence interval [CI]: 0.82–0.91) and pooled log diagnostic odds ratio of 6.17 (95% CI: 5.47–6.87). A DSNB showed pooled weighted sensitivity of 0.50 (95% CI: 0.24–0.59), specificity of 0.82 (95% CI: 0.78–0.87), and a log diagnostic odds ratio of 1.18 (95% CI: 0.29–2.97) for detecting further positive lymph nodes at RLND. High heterogeneity, mostly caused by study design, characteristics of the included patients, DSNB technique used, surgical experience/centre case volumes, and follow-up schedule, represents the main limitation of this meta-analysis. Several sensitivity analyses to address these issues support our findings.
A positive DSNB is poorly able to discriminate which patients will have further metastatic involvement at completion RLND. Better stratification of these patients would avoid unnecessary overtreatment and possible postoperative comorbidities.
This analysis of the data from the published literature provides evidence that the diagnostic accuracy of a dynamic sentinel lymph node biopsy (DSNB) requires further improvement. Moreover, a high proportion of patients with a positive DSNB undergo unnecessary radical lymph node dissection; better stratification of these patients might help determine avoidable overtreatment and postoperative comorbidities.
French AFU Cancer Committee Guidelines - Update 2022-2024: penile cancer
2022, Progres en Urologie
To update French oncology guidelines concerning penile cancer.
Comprehensive Medline search between 2020 and 2022 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.
Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organsparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.
Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.
L’objectif de cette publication est de proposer les recommandations du Comité de cancérologie de l’Association française d’urologie (CCAFU) établies par le sous-groupe des organes génitaux externes pour le diagnostic, le traitement et le suivi des tumeurs malignes du pénis.
Le groupe de travail multidisciplinaire a mis à jour les recommandations de 2020-2022 en s’appuyant sur une analyse exhaustive de la littérature selon les critères méthodologiques de la grille AGREE-II.
Le carcinome épidermoïde est la tumeur maligne du pénis la plus fréquente. L’examen clinique permet le plus souvent d’apprécier l’extension locale de la tumeur mais une imagerie par résonance magnétique (IRM) (en érection pharmaco-induite) peut préciser son infiltration en profondeur. Une évaluation clinique de l’extension régionale est indispensable par la palpation bilatérale des aires ganglionnaires inguinales. En l’absence d’adénopathie palpée, aucune imagerie ne peut écarter les micrométastases (25 % des cas) rendant l’exploration lymphonodale invasive systématique en dehors des tumeurs de faible risque. Une recherche de ganglion sentinelle est recommandée en première intention. Le curage bilatéral modifié, plus morbide, est la seule autre option. En cas d’adénopathie palpée, un bilan d’extension doit être réalisé, par une tomographie par émission de positons (TEP-TDM) au 18F-FDG et à défaut par une tomodensitométrie thoraco-abdomino-pelvienne. En cas d’adénopathie(s) mobile(s) (cN1/cN2), une cytoponction à l’aiguille fine est proposée puis suivie d’un curage inguinal. Le traitement de la tumeur est le plus souvent chirurgical. Il doit être le plus conservateur possible, avec un impératif de marges saines. Dans certains cas, une curiethérapie ou un traitement topique peut être proposé. La prise en charge thérapeutique des aires ganglionnaires doit être systématique, si possible lors du traitement de la tumeur initiale. Seule la lymphadénectomie inguinale a un rôle curatif chez les patients ayant une atteinte d’un ganglion unique (stade pN1). En cas d’extension ganglionnaire plus étendue, une prise en charge multimodale avec chimiothérapie est recommandée (GETUG 25). L’inclusion des patients dans des essais thérapeutiques est à privilégier dès que possible.
Le traitement des cancers du pénis est essentiellement chirurgical plus ou moins associé à une chimiothérapie en cas d’extension ganglionnaire. Le facteur pronostique principal est l’atteinte ganglionnaire justifiant une prise en charge diagnostique et thérapeutique précoce des aires inguinales.
What Is the Most Effective Management of the Primary Tumor in Men with Invasive Penile Cancer: A Systematic Review of the Available Treatment Options and Their Outcomes
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Citation Excerpt :
No change in sexual function after Moh’s micrographic surgery treatment was reported by 57.5% of men in one trial [94]. QoL was assessed in ten studies including 346 men [12,15,20,24,40,54,62,78,83,89]. The European Organisation for Research and Treatment of Cancer (EORTC) Core Quality of Life (EORTC QLQ-C30) questionnaire was used most frequently.
The primary lesion in penile cancer is managed by surgery or radiation. Surgical options include penile-sparing surgery, amputative surgery, laser excision, and Moh’s micrographic surgery. Radiation is applied as external beam radiotherapy (EBRT) and brachytherapy. The treatment aims to completely remove the primary lesion and preserve a sufficient functional penile stump.
To assess whether the 5-yr recurrence-free rate and other outcomes, such as sexual function, quality of life, urination, and penile preserving length, vary between various treatment options.
The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED), Google Scholar, and ClinicalTrials.gov were searched for publications from 1990 through May 2021. Randomized controlled trials, nonrandomized comparative studies (NRCSs), and case series (CSs) were included.
The systematic review included 88 studies, involving 9578 men from 16 NRCSs and 72 CSs. The cumulative mean 5-yr recurrence-free rates were 82.0% for penile-sparing surgery, 83.9% for amputative surgery, 78.6% for brachytherapy, 55.2% for EBRT, 69.4% for lasers, and 88.2% for Moh’s micrographic surgery, as reported from CSs, and 76.7% for penile-sparing surgery and 93.3% for amputative surgery, as reported from NRCSs. Penile surgery affects sexual function, but amputative surgery causes more appearance concerns. After brachytherapy, 25% of patients reported sexual dysfunction. Both penile-sparing surgery and amputative surgery affect all aspects of psychosocial well-being.
Despite the poor quality of evidence, data suggest that penile-sparing surgery is not inferior to amputative surgery in terms of recurrence rates in selected patients. Based on the available information, however, broadly applicable recommendations cannot be made; appropriate patient selection accounts for the relative success of all the available methods.
We reviewed the evidence of various techniques to treat penile tumor and assessed their effectiveness in oncologic control and their functional outcomes. Penile-sparing as well as amputative surgery is an effective treatment option, but amputative surgery has a negative impact on sexual function. Penile-sparing surgery and radiotherapy are associated with a higher risk of local recurrence, but preserve sexual function and quality of life better. Laser and Moh’s micrographic surgery could be used for smaller lesions.
French ccAFU guidelines – update 2020–2022: penile cancer
2020, Progres en Urologie
Objective. – To update French oncology guidelines concerning penile cancer.
Methods. – Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.
Results. – Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organ-sparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.
Conclusions. – Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.
Introduction. – L’objectif de cette publication est de proposer les recommandations du Comité de cancérologie de l’Association française d’urologie (CCAFU) établies par le sous-groupe des organes génitaux externes pour le diagnostic, le traitement et le suivi des tumeurs malignes du pénis.
Matériel et méthodes. – Le groupe de travail multidisciplinaire a mis à jour les recommandations de 2018-2020 en s’appuyant sur une analyse exhaustive de la littérature selon les critères méthodologiques de la grille AGREE-II.
Résultats. – Le carcinome épidermoïde est la tumeur maligne du pénis la plus fréquente. L’examen clinique permet le plus souvent d’apprécier l’extension locale de la tumeur mais une imagerie par résonance magnétique (IRM) (en érection pharmaco-induite) peut préciser son infiltration en profondeur. Une évaluation clinique de l’extension régionale est indispensable par la palpation bilatérale des aires ganglionnaires inguinales. En l’absence d’adénopathie palpée, aucune imagerie ne peut écarter les micrométastases (25 % des cas) rendant l’exploration lymphonodale invasive systématique en dehors des tumeurs de faible risque. Une recherche de ganglion sentinelle est recommandée en première intention. Le curage bilatéral modifié, plus morbide, est la seule autre option. En cas d’adénopathie palpée, un bilan d’extension doit être réalisé, par une tomographie par émission de positons (TEP-TDM) au 18F-FDG et à défaut par une tomodensitométrie thoraco-abdomino-pelvienne. En cas d’adénopathie(s) mobile(s) (cN1/cN2), une cytoponction à l’aiguille fine est proposée puis suivie d’un curage inguinal.
Le traitement de la tumeur est le plus souvent chirurgical. Il doit être le plus conservateur possible, avec un impératif de marges saines. Dans certains cas, une curiethérapie ou un traitement topique peut être proposé. La prise en charge thérapeutique des aires ganglionnaires doit être systématique, si possible lors du traitement de la tumeur initiale. Seule la lymphadénectomie inguinale a un rôle curatif chez les patients ayant une atteinte d’un ganglion unique (stade pN1). En cas d’extension ganglionnaire plus étendue, une prise en charge multimodale avec chimiothérapie est recommandée (GETUG 25). L’inclusion des patients dans des essais thérapeutiques est à privilégier dès que possible.
Conclusions. – Le traitement des cancers du pénis est essentiellement chirurgical plus ou moins associé à une chimiothérapie en cas d’extension ganglionnaire. Le facteur pronostique principal est l’atteinte ganglionnaire justifiant une prise en charge diagnostique et thérapeutique précoce des aires inguinales.
What are the unmet supportive care needs of men affected by penile cancer? A systematic review of the empirical evidence
2020, European Journal of Oncology Nursing
Citation Excerpt :
The devastating impact that a new diagnosis of penile cancer and related treatments was identified as a clinically significant theme across many of the studies related to unmet intimacy needs. Several studies identified that participants reported that their relationship with their partners was affected by sexual dissatisfaction (Bhat et al., 2018; Delaunay et al., 2014; Ficarra et al., 2000; Skeppner and Fugl-Meyer, 2015; Skeppner et al., 2008; Sosnowski et al., 2016; Wan et al., 2018). Moreover, in one study, 90% of the participants experienced anxiety in relation to their sexual performance (Bhat et al., 2018).
To systematically evaluate evidence regarding the unmet supportive care needs of men affected by penile cancer and their partners to create a holistic model of care and inform clinical practice guidelines.
We searched CINAHL, MEDLINE, PsychINFO, Embase, and the Cochrane Library (CCRT and CDSR) controlled trials databases and clinicaltrial.gov from 1990 to April 2020. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.
18 articles were included, reporting the results from 17 studies. Included reports used qualitative (seven studies) and survey (ten studies). Across these studies, men reported that the diagnosis and subsequent treatment of penile cancer affected physical, psychological and sexual well-being with each facet impacting and being intertwined with the other at varying degrees. There was varying complexity of unmet needs in men and partners pre-surgery, post-surgery and into survivorship.
Moderate evidence exists that men affected by penile cancer experience a range of unmet supportive care needs across the international literature. Further work to evaluate the impact of penile cancer on partners is required.

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Penile CancerTreatment-Seeking, Aspects of Sexual Activity and Life Satisfaction in Men with Laser-Treated Penile Carcinoma

Abstract

Objectives

Patients and methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflicts of interest

Acknowledgement

J Urol

Urology

J Urol

Urology

Urology

Urology

J Urol

Eur Urol

Urol Clin North Am

Lancet Oncol

J Sex Med

The National Penile Cancer Register in Sweden 2000–2003

Scand J Urol Nephrol

Sexuality in patients treated for penile cancer: patients’ experience and doctors’ judgement

Br J Urol

Comparison of the quality of life of patients treated by surgery or radiotherapy in epidermoid cancer of the penis

Prog Urol

Penile Cancer
Treatment-Seeking, Aspects of Sexual Activity and Life Satisfaction in Men with Laser-Treated Penile Carcinoma