To present early outcome data from patients treated for invasive penile cancers with organ-sparing surgery, as the treatment of such malignancies has traditionally either been amputative surgery or radical radiotherapy, both associated with significant physical and psychosexual morbidity.
PATIENTS AND METHODS
A consecutive series of patients referred over a 3-year period for the treatment of penile malignancy were analysed prospectively. After clinical staging and grading, those patients requiring surgery were offered either a glans-preserving or a glans-removing procedure.
Of the 78 patients referred, 49 required surgery, with penile-preserving procedures in 39 of them; 32 were newly diagnosed tumours and seven were recurrences after radiotherapy. The tumour grade and stage were G1 in 11, G2 in 17 and G3 in 10 (one had melanoma and was not graded); and Ta in two, T1 in 19, T2 in 17 and T3 in one. The mean follow-up was 16 months, with nine patients followed for ≥ 2 years. Complications included two patients who required immediate revisional surgery for positive resection margins, and one with radio-necrosis. One patient who had a glans-preserving procedure developed a recurrence, whereas none of those who had the glans removed did so.
With careful patient selection and meticulous follow-up, most patients with invasive penile carcinoma can be offered penile-preserving surgery.
In industrialized countries penile cancer is an uncommon malignancy, with a reported annual incidence of 1 in 100 000 of the male population. Thus an average district general hospital in the UK will treat only one or two such patients per year. The management of invasive penile cancer has changed little over the years. Options have included amputative surgery or radical radiotherapy. Although the radical surgical approach has resulted in local control rates of > 90%, it is also associated with significant psychological and functional problems [1,2]. The local failure rate for radiotherapy is higher, at ≈ 45%, and the technique is limited to smaller tumours . This has led to the development of several surgical organ-preserving techniques, e.g. laser ablation or excision, and Mohs’ micrographic surgery [4–6]. These techniques aim to remove as little of the functional anatomy as possible, without compromising local oncological control. Thus far, these techniques have only been used successfully for treating pre-invasive and the most superficially invasive tumours. Furthermore, no controlled trials comparing the various organ-preserving techniques have been published. Recently, organ-preserving techniques for more advanced tumours have been described (personal communication, Bracka and Watkin). Over the last 3 years these techniques have been used in our department to treat invasive penile malignancies, in all patients in whom it was considered possible without compromising oncological control; herein we present our early outcome data.
PATIENTS AND METHODS
We prospectively analysed a consecutive series of patients treated using organ-preserving penile surgery; all patients had surgery by one surgeon at a tertiary referral (and the regional oncological) centre over a period of 3 years. Patients were referred from a supra-regional network and all were reviewed within the context of a multidisciplinary team meeting.
Tumours were clinically staged with US and/or CT and confirmed in all cases by a deep biopsy; they were assessed histologically by a dedicated uropathologist. Regional and metastatic disease was assessed clinically and with CT. Patients were staged in accordance with the revised 1997 American Joint Committee on Cancer TNM staging system. The patients were then offered one of several techniques, outlined below. Full details of the surgical procedures will be described elsewhere (Bracka et al., in preparation).
The principles of the surgery are broadly based on glans-preserving and glans-removing procedures. The latter are the mainstay of organ-sparing penile surgery and are described in more detail below. All patients are circumcised unless already circumcised as part of the diagnostic evaluation; > 80% of penile tumours occur on the glans, prepuce and coronal sulcus, and are therefore amenable to this approach (Fig. 1).
Glans-preserving procedures comprise: (i) Partial glansectomy with primary glans closure; this is suitable for small isolated lesions of the glans penis with normal residual glans epithelium. This is essentially an excision biopsy of small distal tumour; (ii) partial glansectomy with graft reconstruction of the glans; this is suitable for larger lesion where primary closure may not be possible or where it would give an unacceptable cosmetic result. The graft used is either a partial-thickness graft, harvested from the lateral aspect of the thigh, or full-thickness penile shaft skin graft.
Glans-removing procedures comprise: (i) Glansectomy with partial-thickness skin graft reconstruction; this technique involves isolating and excising the glans from the corpora cavernosa (Fig. 2a–d). A circumferential incision is made in the distal shaft skin down to Buck's fascia. At this level, a plane is developed distally to separate the glans from corporal heads. The urethra is divided and frozen sections taken from the tunica albuginea and distal urethral margin. The urethra is then mobilized to allow formation of a urethrostomy at the tip of the penis. The shaft skin is sutured 2 cm from the tip leaving the corporal heads exposed. A split-thickness skin graft is quilted to the exposed corpora to create a neoglans. A urethral catheter is inserted and the patient remains on bed rest for 5 days. If the frozen sections are positive a more extensive resection is required; (ii) glansectomy, distal corporectomy with reconstruction of corporal heads and grafting; this is suitable for distal tumours invading the tunica albuginea and/or corpora cavernosa and can be combined with a penile-lengthening procedure. The aim is to preserve as much corporal length as possible. Once tumour clearance is confirmed by a frozen section, the corporal heads are reconstructed and grafted as described above.
Of 78 patients who were referred to the department for the management of penile cancer over the 3-year period, 49 required surgery for invasive tumours beyond a curative circumcision, with penile-preserving procedures used in 39 of them. Of these, 32 patients were referred with a new diagnosis, whilst another seven were referred for the management of recurrence after radiotherapy (Table 1). The procedures are also summarized in Table 1; 38 of the patients had squamous cell carcinoma (SCC) and one had a melanoma. An analysis of the clinical staging of the tumours treated is also shown in Table 1.
Table 1. The demographics of the patients
Mean (range) age, years
Distal urethral carcinoma
Penile preserving surgery
Median age, years
with primary repair
with graft reconstruction
Glansectomy + reconstruction
Glansectomy, distal corporectomy + reconstruction
Clinical staging and pathological grading
Early complications related to the procedure included two patients who required revisional surgery for positive margins; frozen sections had not been taken in either. In one of these the tumour was incorrectly thought to be very superficial and in the other the patient was anaesthetically unstable and the procedure had to be concluded promptly. In all cases where frozen sections were analysed they were accurate. One patient had partial graft loss requiring re-grafting; another had radio-necrosis of the glans which required debridement. Late procedure-related complications consisted of two patients who had graft overgrowth of the external urethral meatus. Both were managed by a temporary use of a spigot and required no surgical intervention. No patients had a meatal stenosis requiring surgical correction. There were no deaths during or soon after surgery.
The mean follow-up was 16 months; nine patients were followed for ≥ 2 years. Of those who had partial glansectomy, one had a tumour recurrence on the residual glans; none of those who had the glans removed had tumour recurrence.
Here we report the early results of organ-preserving surgery for treating invasive penile malignancies. Conventional treatment options for invasive penile cancers have been either amputative surgery or radical radiotherapy. Classical partial penectomy provides excellent local control rates but is associated with significant physical and psychosexual complications . Loss of corporal length not only makes urination in an upright position difficult (and sometimes impossible) but also interferes with sexual function. The poor cosmetic results are frequently made worse by skin tethering, and the not-infrequent meatal stenosis often requires surgical correction. Radiotherapy is a well-established organ-preserving technique but is also fraught with problems . There are local recurrences in up to 45% of cases and almost all patients have acute radiation reactions which, when severe, may necessitate termination of treatment [3,8,9]. Furthermore, up to 40% of patients have chronic radiation reactions, including deep radiation necrosis, which can lead to amputation of the penis [10,11]. The skin changes that are associated with radiotherapy make early diagnosis of a recurrence difficult.
Conventional amputative surgery is based on a surgical doctrine that states that resection margins of 2 cm are necessary to achieve local oncological control . A partial penectomy would be used if there was ‘adequate’ stump remaining, otherwise a radical penectomy would be considered. This value of 2 cm is not supported by scientific methods and several authors have recently challenged it. A series of 14 patients who had undergone ‘conventional surgery’ for penile SCC included seven in whom the margins were ≤ 10 mm . In the 33-month follow-up, none of the patients developed a recurrence. Another group reviewed 64 partial and total penectomy specimens, reporting that < 25% of tumours had microscopic spread beyond 5 mm of the gross tumour margin, and importantly found no evidence of discontinuous spread . They concluded that a 2-cm margin was unnecessary and this practice has resulted in the over-treatment of many tumours.
Several penile-preserving surgical techniques have already been described. One of the best documented is laser treatment, either in the form of ablation or excision. Both techniques offer excellent cosmetic results, with low local recurrence rates (0–6%) for pre-invasive lesions [4,6]. However, treatment of invasive tumours has resulted in high local failure rates, with some series reporting complete local recurrence rates for T2 tumours [4,6]. Laser treatment is probably best reserved for treating superficial lesions.
Mohs’ micrographic surgery has also been used to treat penile carcinomas . The tumour is excised in horizontal slices, with the base of each slice being examined microscopically by systematic frozen sections; if positive, further slices of tissue are excised until the ‘mapping’ frozen-section biopsies of the excised tissue are negative. At that point another section of tissue is removed to ensure a clear resection margin. Despite a 6% local recurrence rate and good cosmetic results, it has failed to gain wide acceptance. Two likely reasons for this are that urologists are not exposed to this highly specialized technique, and that it is very time consuming. To date, only one series of Mohs’ micrographic surgery for penile cancers has been reported.
Glansectomy is a technique that thus far has not been well reported. Davis et al. reported three patients who had a glansectomy for verrucous carcinoma, angiosarcoma and a melanoma. None of these patients had a local recurrence and all resumed normal urinary and sexual function. Hatzichristou et al. reported seven glansectomies for verrucous carcinoma; with a follow-up of up to 65 months, they reported only one local recurrence that was surgically saved. Again all patients resumed normal urinary and sexual function shortly after surgery.
About 80% of penile carcinomas occur distally, involving the glans, coronal sulcus or prepuce, and are potentially amenable to organ-preserving surgery . In the present series, 39 of 49 patients who required surgical intervention beyond a circumcision were offered an organ-preserving treatment, not limited to Ta and T1 tumours. Indeed, 17 procedures were for T2 tumours and one for a distal T3 tumour. Recurrences after radiotherapy can also be salvaged using this approach. Seven of 10 patients referred for management of such recurrences were offered organ-sparing surgical treatment; of these, one had radionecrosis that required surgical debridement. Deep radionecrosis after a biopsy for suspected recurrence is a well-documented late complication of radiotherapy, occurring in up to 15% of cases . There were three conventional partial penectomies; one was for a sarcoma, one because the patient was anaesthetically unfit and one had known metastatic prostate cancer. Seven patients had a radical penectomy. Retrospectively reviewing these seven patients, two could have been offered an organ-sparing procedure.
Partial glansectomy removes the part of the glans involved by the tumour, leaving behind glans epithelium with malignant potential, but total glansectomy removes all the tissue that may give rise to de novo tumour. In the present series there was one recurrence (3%) with a tumour arising within unstable epithelium after a partial procedure. Careful follow-up of these patients is therefore mandatory.
Total glansectomy with reconstruction has become the standard procedure which we are able to offer patients with large distal tumours when referred to our department. Limitations of this procedure relate to the proximal location of the tumour, its stage and the patient's general health status. Reconstruction adds to the operative time and for some frail patients it may not be appropriate. In our practice, age alone was not considered a contraindication to organ-preserving surgery. Even at this early stage of follow-up, these results are encouraging, as most local recurrences should be diagnosed within 2 years of treatment . The late local recurrence rate for this technique is unknown. The benefits over partial penectomy include better preservation of functional length and the potential for normal sexual function. The importance of maintaining sexual function should not be underestimated. In some series a significant proportion of patients reported that they would choose treatment that increased their chance of remaining sexually potent over treatment that would give them a survival benefit. This is the subject of an ongoing study, but thus far patients treated with organ-sparing techniques and who were sexually active before treatment have continued to be so afterward.
In conclusion, with careful patient selection and meticulous follow-up, most patients with invasive penile carcinoma can be offered penile-preserving surgery. Cancer control rates are excellent in the short term. Long-term recurrence rates are unknown. Conventional partial penectomy should be reserved for very frail patients or where palliation only is required.
The surgical techniques described have been developed by Mr Aiver Bracka, and without his advice and guidance it would not have been possible to achieve these results.