Penile Cancer: Surgical Therapy

The diagnosis of penile cancer must be confirmed by biopsy (tissue removal) via wedge excision (surgical removal (excision) of a wedge-shaped section of tissue). Histologic (fine tissue) confirmation of the diagnosis is required to guide management if:

  • There is doubt about the exact nature of the lesion (e.g., CIS, metastasis (daughter tumors), or melanoma)
  • Treatment with topical (local) agents, radiotherapy, or laser surgery is planned
  • Lymph node treatment is based on preoperative histologic information (risk-adapted strategy) .

The therapeutic goal is the safe and permanent removal of the tumor with good functional and cosmetic outcome. For small tumors, penis-preserving therapy is the goal. Therapy of primary tumor [1, 3; S3 Guideline]

Stage Therapy
Tis, Ta, and small tumor recurrences:
  • Local excision with safety distance with or without circumcision (foreskin circumcision); intraoperative frozen section examination of resection margins.
  • Laser ablation/laser therapy with CO2 laser or with neodymium: yttrium-aluminum-garnet (Nd:YAG) laser in combination with fluorescence diagnostics.
  • Photodynamic and topical (superficial) therapy with 5-fluorouracil (5-FU) or 5% imiquimod cream – only with attention to regular control biopsies. (local control rates of about 50%).
  • In case of extensive carcinoma-in-situ of the glans (glans) or extensive recurrence (recurrence of the disease) is a complete ablation of the glans epithelium.
T1a and T1b stages
  • Excision with safety distance if necessary with laser with or without circumcision; intraoperative frozen section examination of resection margins.
  • Extensive pT1b or multilocular tumors: glansectomy (complete removal of the glans penis (glans)).
Early T3 tumors
  • Early T3 tumors with incipient infiltration of the corpus cavernosum (erectile tissue): partial penile amputation
Advanced T3 tumors well
  • Extensive or complete penile amputation with the creation of a perineal urethrostomy (boutonniere/urethral perineal fistula); question of a minimal safety margin is thereby relativized.

More hints

  • Local recurrence rate for T2 tumors is well below 10% in centers; local recurrence alone does not significantly worsen prognosis.
  • EAU guidelines currently recommend a safety margin of ≥ 3 mm [see below].

Lymph node management [1; S3 line].

Management of the regional inguinal lymph nodes (inguinal lymph nodes) is critical for long-term survival! Approximately 20% of all patients with non-enlarged inguinal lymph nodes already have occult metastases (micrometastases: Cell cluster that has reached a size of 0.2 to 2 mm, which is a criterion for a malignant tumor due to the invasive growth behavior). Regional lymph node recurrences lead to a significant worsening of prognosis (5-year survival rate: 40%). Note: From stage pT1G2, invasive lymph node staging should be performed regardless of whether lymph nodes are already palpable or not. The procedure is performed depending on the palpability of the lymph nodes:

  • Nonpalpable lymph nodes: Removal of the sentinel lymph node (sentinel lymph node; first barrier for settled tumor cells); if this lymph node is affected, complete removal of the inguinal lymph nodes of the affected side is performed.
  • Palpable lymph nodes: Excisional biopsy with frozen section examination or fine needle biopsy if necessary;
    • Detection of lymph node metastases: radical inguinal lymphadenectomy with extended dissection field on the affected side one as a therapeutic measure.
    • Absence of evidence of lymph node metastases: bilateral modified inguinal lymphadenectomy (inguinal lymph node removal).

Notice: It is now common practice to always perform invasive lymph node staging using dynamic sentinel lymph node biopsy (DSNB) or modified lymphadenectomy (lymph node removal) to exclude micrometastases.Procedure for subsequent lymph node situations:

  • Fxed/exulcerated inguinal lymph nodes (inguinal lymph nodes with tumor-like change): in most cases, complete resection of the metastases (surgical removal of the daughter tumors) is primarily no longer possible; as a result, this clinical subgroup has a poor prognosis.Neoadjuvant chemotherapy (NACT), i.e., chemotherapy before surgery to reduce the tumor mass, may improve the prognosis.
  • Presence of ≥ 2 affected lymph nodes of the same groin or capsular overgrowth in the lymph node: ipsilateral pelvic lymphadenectomy (lymph node removal of the pelvic lymph nodes on the same side).