Brachytherapy for penile cancer: efficacy and impact on sexual function

The impact of diagnosis and treatment of penile cancer on intimacy: a qualitative assessment

Penile cancer is a rare malignancy (0.5-0.93/100,000 in Western countries) with significant psychosocial and sexual repercussions. This qualitative study explored the impact of penile cancer diagnosis and treatment on intimacy. A convenience sample was identified of 20 potential candidates who were at least 5 months post penile cancer surgery at a hospital centralizing penile cancer care. Participants were recruited by telephone and admitted until data saturation was reached, resulting in a sample of nine men (44-74 years old), none withdrew from participation. All interviews were performed by the same female researcher with no prior relationship to the men. The one-time interviews (35-61 min) followed a semi-structured interview guide, were audio-recorded and transcribed verbatim. Three researchers analysed the data independently using descriptive phenomenological analysis, resulting in a gradually drawn up coding tree mapping out the patient's journey. The central themes that emerged were: (1) Intimate area led to diagnostic delays, intensified diagnosis and induced secrecy; (2) Impact on sexuality prior to surgery; (3) The voyage of sexual re-discovery; (4) A partnered voyage of sexual discovery; (5) Care needs related to intimate area. This study highlights the need for comprehensive and personalized care, including pre-surgical information provision and post-surgical psychosexual support. Addressing the current unmet needs of men with penile cancer requires guidelines for psychosexual interventions and proactive efforts to reduce stigma and to raise awareness.

Brachytherapy and external beam radiation in the management of primary penile cancer - Game changer for organ preservation?

OBJECTIVE

In squamous cell carcinoma of the penis (PeCa), treatment options for primary tumors vary by disease stage and may include surgery, radiation, topical chemotherapy, or laser excision. This review aims to highlight the current evidence on the value of radiotherapy as an organ-preserving strategy in primary PeCa.

MATERIAL AND METHODS

Manuscripts on primary PeCa treatment with external beam radiotherapy (EBRT) and brachytherapy were evaluated via Scopus, PubMed/MEDLINE, and Web of ScienceTM (2013-2023) to assess their efficacy and safety. Animal studies, studies with <5 patients, and case reports were excluded.

RESULTS

Radiotherapy offers the potential for organ preservation with tumor control rates comparable to radical surgery, while disease-specific survival rates up to 70 % were experienced with EBRT. Brachytherapy (BT) is the preferred method of irradiation for glans-limited tumors, whereas a higher relapse risk is expected for tumors >4 cm. BT shows 73 % amputation-free survival at 8-10 years and 81 % progression-free survival at 5-10 years. Compared with BT, total amputation significantly improves 5-year disease-free survival rate. BT offers a superior 5-year local control and penile preservation rates compared to EBRT. Common acute toxicities of brachytherapy include radiodermatitis, sterile urethritis, and urethral adhesions. The primary late adverse events of BT are soft tissue necrosis (0-31 %) and meatal stenosis (0-43 %).

CONCLUSION

BT is a favorable radiation modality, offering an efficient and conservative approach. HDR BT is favored for its enhanced dose distribution and radiation protection. Collaboration between radiation oncologists and urologists is essential in order to provide an optimal patient selection and manage toxicities thus optimizing patient outcomes.

Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review

Treatment of penile cancer (PC) focuses on organ preservation, employing various surgical and non-surgical approaches. These interventions may lead to disfigurement, impacting patients' functional outcomes and psychosocial well-being. We reviewed studies related to penile health and PC up to February 2024, limited to studies published in English. Studies employing health-related quality of life (HRQoL) assessments have identified a detrimental association between aggressive treatment and overall health status, physical functioning, and relationships. In contrast, organ-sparing demonstrates improved measures related to HRQoL and sexual function. Assessment through validated questionnaires reveals diverse voiding outcomes, and varying impacts on QoL and sexual activity, emphasizing the necessity for multidisciplinary personalized care. Studies highlight substantial variations in sexual function, with patients reporting adaptations, reduced satisfaction, and concerns about body image and sexual well-being. Furthermore, unmet needs include challenges in patient-clinician communication, obtaining information, and accessing psychosocial support. Patient experiences underscore the importance of timely diagnosis, treatment access, and addressing psychological consequences. Organ-sparing approaches have higher QoL preservation and sexual function. Individualized support, including sexual therapy, support groups, and family counseling, is essential for post-treatment rehabilitation. Timely diagnosis and comprehensive care are paramount in addressing the multifaceted impact of PC on patients and families.

The role of radiotherapy in the management of squamous cell cancer of the penis

PURPOSE

To review the evidence for radiotherapy in the management of primary penile cancer, either as brachytherapy or external beam radiation, and the role of external beam radiotherapy in node positive penile cancer.

METHODS

English language literature was reviewed for the past 3 decades. As penile cancer is uncommon in developed nations, high quality evidence to guide management is limited. Single institution reports often span decades during which time staging systems and treatments have evolved, reducing their relevance to current practice. Successful clinical trials require collaboration not only among disciplines but also among multiple institutions and nations.

RESULTS

Radiotherapy is a definitive organ-preserving option for T1-T2 penile cancers. Interstitial brachytherapy is associated with penile preservation in 85% of men at 5 years, maintained in 70% by 10 years. Results of external radiotherapy are not quite as promising but nonetheless 60% of men will have an intact penis at 5 years. Inguino-pelvic external radiotherapy has been reported to increase overall survival when delivered as adjuvant treatment for men with pN3 groin but pN0 pelvic nodes, and improve disease specific survival for those with involved pelvic nodes. InPACT (ECOG-ACRIN_8134) is investigating the role of inguino-pelvic chemo-radiotherapy for men with pN3 inguinal nodes but imaging negative pelvic nodes.

CONCLUSIONS

Radiotherapy has a well-defined role to play in treatment of squamous cell cancers of other sites, such as vulva, anal canal, uterine cervix and head and neck malignancies. Emerging data support the incorporation of radiotherapy into treatment paradigms for penile cancer.

Function Preservation With Brachytherapy: Reviving the Art. Improving Quality of Life With Brachytherapy for Urological Malignancies

Brachytherapy for localised prostate, muscle-invasive bladder and penile cancer is well established, providing high tumour dose delivery and minimising normal tissue doses compared with external beam techniques. In prostate cancer, the main impact on quality of life relates to diminished sexual function and irritative or obstructive urinary symptoms, which are seen up to 15 years after treatment. Significant changes in bowel function are rare. Compared with radical prostatectomy or external beam radiotherapy, irritative or obstructive urinary symptoms are more prominent, whereas incontinence is less than after radical prostatectomy and bowel changes are less than after external beam radiotherapy. For muscle-invasive bladder cancer, when compared with radical cystectomy, although no difference is seen for urinary symptoms or fatigue, role and social functioning scores are higher and there is better post-treatment sexual function in both men and women. Compared with surgical treatment for penile cancer, brachytherapy results in better erectile function scores than after glansectomy and partial penectomy and high quality of life scores, with good satisfaction ratings for cosmetic appearance.

Updates in the use of radiotherapy in the management of primary and locally-advanced penile cancer

Objective

Penile cancer is a rare malignancy in most developed countries, but may represent a significant oncologic challenge in certain African, Asian, and South American regions. Various treatment approaches have been described in penile cancer, including radiotherapy. This review aimed to provide a synopsis of radiotherapy use in penile cancer management and the associated toxicities. In addition, we aimed to discuss palliative radiation for metastases to the penis and provide a brief overview of how tumor biology may assist with treatment decision-making.

Methods

Peer-reviewed manuscripts related to the treatment of penile cancer with radiotherapy were evaluated by a PubMed search (1960–2021) in order to assess its role in the definitive and adjuvant settings. Selected manuscripts were also evaluated for descriptions of radiation-related toxicity.

Results

Though surgical resection of the primary is an excellent option for tumor control, select patients may be treated with organ-sparing radiotherapy by either external beam radiation or brachytherapy. Data from randomized controlled trials comparing radiotherapy and surgery are lacking, and thus management is frequently determined by institutional practice patterns and available expertise. Similarly, this lack of clinical trial data leads to divergence in opinion regarding lymph node management. This is further complicated in that many cited studies evaluating lymph node radiotherapy used non-modern radiotherapy delivery techniques. Groin toxicity from either surgery or radiotherapy remains a challenging problem and further risk assessment is needed to guide intensification with multi-modal therapy. Intrinsic differences in tumor biology, based on human papillomavirus infection, may help aid future prognostic and predictive models in patient risk stratification or treatment approach.

Conclusion

Penile cancer is a rare disease with limited clinical trial data driving the majority of treatment decisions. As a result, the goal of management is to effectively treat the disease while balancing the importance of quality of life through integrated multidisciplinary discussions. More international collaborations and interrogations of penile cancer biology are needed to better understand this disease and improve patient outcomes.

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

Context

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.

Objective

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.

Evidence acquisition

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.

Evidence synthesis

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.

Conclusions

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.

Patient summary

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.

Sexual function in the penile cancer survivor: a narrative review

Squamous cell carcinoma of the penis is a rare malignancy among men in North America and Europe with an incidence of <1 per 100,00 men. Of all genitourinary cancers, penile carcinoma has the potential to jeopardize sexual function the most. The treatment modalities of penile carcinoma span the gamut from organ-sparing treatments such as topical therapy, laser therapy, radiotherapy, glansectomy, wide-local excision and partial or total penectomy. There is a relative paucity of data in the medical literature describing the impact of penile cancer treatment on sexual function. The majority of available studies use retrospective data from small samples utilizing heterogeneous study tools such as patient interviews and non-validated questionnaires. The most commonly used validated instrument to evaluate sexual outcomes is the International Index of Erectile Function Questionnaire (IIEF), but is limited in that it does not assess patients who perform self-stimulation or achieve sexual stimulation by any means other than penetrative intercourse. Though advances in clinical research continue; large, well-designed comparative studies using validated instruments are elusive. The sexual outcomes after penile cancer are reviewed from the available published data to better assist the patient and the treating physician with medical decision making. With a detailed assessment of sexual outcomes, the physician is better equipped in providing patient centered care to achieve outcomes meaningful for each patient.

Phallus Preservation in Penile Cancer Surgery: Patient-reported Aesthetic & Functional Outcomes

OBJECTIVE

To assess patient-reported outcomes of oncoplastic penile reconstruction using standardized questionnaires. Whilst organ-preserving penile cancer surgery has evolved, aiming to preserve genital function, reduce psychological morbidity of radical penectomy, and maximise patient quality of life, few studies have evaluated patients' final perceptions.

METHODS

Following ethical approval, patients post partial/radical glansectomy with reconstruction 2016-2019, under a single surgeon, were identified. Patients were posted a modified Index of Male Genital Image, the IIEF-5, a customised questionnaire exploring outcomes of urinary and sensory function and the EORTC QLQ-C30 to complete and return. Questionnaires were nonidentifiable, however study ID linked responses to the procedure performed.

RESULTS

A total of 130 questionnaires were received from 35 patients post penile reconstruction, giving a response rate of 71.4% (35/49). Mean time from surgery was 22 months (4-51), and mean age 61 years (31-79). The majority (82.4%, n = 28) were satisfied or felt neutral about the appearance of their genitalia. High satisfaction with postprocedure urinary function was reported; 85.3% (29/34) could void from a standing position and 79.4% (27/34) reported little or no spraying of urine. Nineteen patients (55.89%) were sexually active, with mean IIEF-5 scores of 14.9 (5-25) (partial glansectomy) and 15.8 (5-25) (radical glansectomy). Mean QoL over past week on 7-point EORTC QLQ-C30 scale was 5.88 (3-7).

CONCLUSION

We report good aesthetic and functional outcomes in a unique study exploring penile cancer surgery patient-reported outcome measures. These results strongly support phallus-preserving phallic-preserving strategies as the standard of care in eligible patients undergoing penile cancer surgery.

High-dose rate brachytherapy in localized penile cancer: 5-Year clinical outcome analysis

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Penile cancer is a rare tumor.

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The organ preservation perspective makes the treatment challenging.

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For early stage, conservative brachytherapy achieved excellent oncological outcome.

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Conservative brachytherapy reported encouraging functional results.

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HDR brachytherapy represents an attractive therapeutic option.

Purpose

To analyze the oncological outcome and toxicity profile after conservative treatment based on multicatheter interstitial high-dose rate brachytherapy (MHB) for patients presenting a localized penile cancer.

Materials and methods

Patients with histologically proven, non-metastatic (T1-T2 N0-N2 M0) localized penile cancer were treated with MHB. Needles were placed under general anesthesia into the target volume using a dedicated template. Treatment planning was performed using a post-implant CT-scan to deliver 35 Gy or 39 Gy (9f, 5d) for adjuvant or definitive treatment respectively. Five-year oncological outcome was evaluated with local relapse-free (LRFS), regional relapse-free (RRFS), and metastasis-free survival (MFS), specific (SS) and overall survival (OS). In pre-treatment and follow-up consultations, skin, urinary and sexual toxicities were investigated using CTCAEv4.0 classification, International Prostate Symptom Score (IPSS) and International Index of Erectile Function 5-items (IIEF-5). Dosimetry data were also analyzed.

Results

From 03/2006 to 05/2020, with a median follow-up of 72.4 months [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], 29 pts, mainly T1 (75.9%) and N0 (89.7%), underwent MHB. Eleven (38%) and 18 pts (62%) received MHB as adjuvant or definitive treatment respectively. Five-year LRFS, RRFS, MFS, SS and OS were 82%, 82%, 89%, 88% and 73% respectively. Six patients (20.7%) experienced local relapse and underwent salvage penectomy leading to a penile preservation rate of 79.3%. Acute skin toxicity was reported 1 month after MHB, with 28% G1, 66% G2 and 6% G3. Late skin complications were telangiectasia for 5 pts (17%) and necrosis for 3 pts (10.3% requiring hyperbaric oxygen therapy). Comparing pre- and post-treatment status, no significant change was observed for skin appearance, IPSS and IIEF-5.

Conclusion

MHB represents an efficient first line conservative treatment option for early penile cancers. Oncological outcome and late toxicity profile appear encouraging. However, larger-scale cohorts with longer follow-up are needed to more accurately precise the features of the best candidate to MHB.

Penile Cancer: Managing Sexual Dysfunction and Improving Quality of Life After Therapy

PURPOSE OF REVIEW

To review the most current literature on how the treatment for penile cancer can affect quality of life and to discuss current treatment options to overcome sexual dysfunction and ultimately improve patient wellbeing.

RECENT FINDINGS

Multiple medical and surgical therapies exist to address the high incidence of sexual dysfunction following penile cancer treatment. Advancements and refinements in the neophalloplasty, penile prosthesis, and penile lengthening procedures have opened the door to improved long-term outcomes. Additionally, studies continue to highlight the severe psychological toll that penile cancer treatment can have on patients. We explore the potential options for addressing the inherent psychologic effects of these treatments and highlight the need for further research in this domain. Although rare, it is important for all urologists to be familiar with the treatments and post-treatment sequelae of penile cancer. Penile cancer is associated with dramatic decline in quality of life and sexual function. Multiple medical and surgical therapies exist that addresses these concerns. Additionally, urologists must also be mindful of the psychologic component regarding surgical disfigurement and the decline in sexual function.

Penile sparing therapy for penile cancer

Penile cancer is a rare malignancy with a reported incidence of 0.66–1.44 per 100,000 men, and a reported mortality of 0.15–0.37 per 10,000 men. Expert clinical examination and histological diagnosis from biopsy is required to determine the extent and invasion of disease, which is paramount in planning of appropriate treatment. Management of loco-regional penile cancer can be divided into management of primary tumour and management of regional lymph nodes. This review article will focus on the management of the primary penile tumour with particular focus on penile sparing therapies. The aim of primary penile tumour management is to completely remove the tumour whilst preserving as much organ function as possible. Preservation of the penis is important as it allows patients to maintain urinary and sexual function, as well as quality of life. With the majority of penile cancer confined to the glans and foreskin, most penile cancers can be managed with organ-preserving therapy. A wide variety of treatment options are available, and this review aims to describe each of the options including the reported oncological and functional outcome for the different therapies for penile cancer.

Oncological outcomes in the management of cT1-T2 cN0 penile squamous cell carcinoma

INTRODUCTION

Squamous cell carcinoma (SCC) of the penis is a rare disease comprising 1% of all male cancer. Options for the management of cT1-T2 cN0 penile SCC include partial penectomy (PP), considered the standard, and brachytherapy (BT), which offers acceptable local disease control and organ preservation. The purpose of our study was to assess and describe the oncological outcome for both treatments in a tertiary care center.

METHODS

We performed a contemporary retrospective study of patients with early-stage penile cancer treated surgically or by BT at a tertiary center between 2000 and 2016. Demographic, management, and followup data were obtained from an institutional database. Descriptive statistics and survival analysis using Kaplan-Meier plots were calculated. Local and regional recurrences were compared in both groups (BT vs. PP).

RESULTS

A total of 51 patients with cT1-T2N0 penile SCC treated with BT (35) and PP (16) were analyzed. Median followup was 37.1 (13.9-68) and 25.4 months (18-52.3) for the BT and PP groups, respectively. Recurrence developed in seven (20%) patients treated with BT. Median time to recurrence was 35.2 months (range 2.9-95.8). No recurrences were reported in patients treated with PP. Forty-four (86.2%) patients were alive with no evidence of disease at the last followup. Overall survival was 62.7%. Complications after primary tumor treatment were urethral stenosis (15.7%), penile necrosis (7.8%), and local infection (2%).

CONCLUSIONS

PP provides acceptable local control with organ preservation in early-stage penile SCC. BT was able to offer organ preservation in 69% of men. Future prospective studies are needed to compare other organ-conserving treatment modalities with PP.

High-dose-rate brachytherapy for localized penile cancer: Evolution of a technique

PURPOSE

High-dose-rate (HDR) brachytherapy is a convenient treatment option for selected patients with T1-T2 penile squamous cell carcinoma (SCC), providing high rates of penile preservation and tumor control. We present the results of penile SCC treated with HDR brachytherapy either interstitially or via a surface mold.

METHODS AND MATERIALS

Between November 2009 and April 2019, seven patients (2 T1a and 5 T2) were treated with interstitial HDR and 8 (1 Tis, six T1a, and one T1b) with surface mold. Prescribed dose for interstitial patients ranged from 38.4 Gy in 6 days (3.2 Gy × 12) to 53 Gy in 9 days (3.12 × 17), BID. All patients treated with mold brachytherapy received 40 Gy in 10 fractions BID. Toxicity and oncological results were assessed for both groups, and their relation with dosimetry is described.

RESULTS

Median follow up was 90 months for interstitial and 27 months for those treated with surface mold. Fourteen of 15 patients are alive and disease-free; one surface mold patient died of non-small-cell lung cancer. There was one relapse in each group, each treated with salvage penectomy. The potency was preserved in 82%. For interstitial, G2 necrosis occurred in 43%, G2 meatal stenosis in 29% and G3 stenosis in 14%.

CONCLUSIONS

Both techniques have excellent rates of tumor control and organ preservation. Implant geometry and homogeneity constraints must be carefully designed to minimize toxicity in interstitial brachytherapy. Urethral contouring and reporting of dosimetric parameters should be defined.

Long-term evaluation of urinary, sexual, and quality of life outcomes after brachytherapy for penile carcinoma

PURPOSE

Brachytherapy (BT) is an effective organ-preserving treatment for selected localized penile carcinoma, providing high local control rates. Long-term functional results however, are still insufficiently evaluated.

METHODS AND MATERIALS

All consecutive patients treated with low-dose-rate or pulse-dose-rate BT in our institute for a localized penile cancer and who were in first complete remission and followed for at least 3 years were included. A self-reporting questionnaire was sent, to assess: 1/urinary function, 2/sexual function, 3/cosmetic aspect of the penis, and 4/quality of life.

RESULTS

Thirty-nine patients fulfilled inclusion criteria and were sent the questionnaire. Twenty-three patients (59%) answered. Median age was 63.4 years, (interquartile range [IR]: 49.7-67.0). Median followup was 5.9 years (IR: 5.2-6.7). The urinary scores showed moderate lower urinary tract symptoms. During the followup, a urethral dilation or self-catheterization had been necessary in 30% and 13%, respectively. Sixteen (70%) patients continued to maintain a sexual activity and the erectile dysfunction was mild. Finally, quality of life was good with a median score of 80/100 (IR = 65-90) and was only impacted by pain (p = 0.02). Overall, 57% and 39% declared having none or moderate pain/discomfort, respectively.

CONCLUSIONS

Although this questionnaire needs to be validated in an independent cohort, our results show the moderate impact of BT on functional outcomes, confirming that it is an adequate first-intent organ-sparing strategy in patients with localized penile carcinoma.

Comparison of efficacy between brachytherapy and penectomy in patients with penile cancer: a meta-analysis

We conducted a meta-analysis to compare the efficacy of brachytherapy and penectomy in patients with penile cancer. We searched the published articles in the PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases up to March 20, 2017. Twenty-two studies entered the final analyses. We used five-year overall survival rate, five-year local control rate, disease-free progression and lymph node positive rate to assess the efficacy. The meta-analysis found that patients who received penectomy had higher five-year local control rate (85% vs 80%, odds ratio = 0.72, 95% confidence interval: 0.58–0.90), five-year disease-free progression rate (77% vs 72%, odds ratio = 0.77, 95% confidence interval: 0.63–0.93) and lymph node positive rates (24% vs 20%, odds ratio = 0.79, 95% confidence interval: 0.64–0.98) than brachytherapy. No significant difference was observed for two group in five-year overall survival rate (76% vs 74%, odds ratios = 1.11 with the 95% confidence interval: 0.91–1.36). Both of penectomy and brachytherapy can improve the survival status. Penectomy provided better control efficacy, and not improved the survival status compared with brachytherapy solely. However, further research was required because of retrospective nature and potential bias of the data.

[Impact of organ sparing therapy in penile carcinoma on sexual and erectile function]

INTRODUCTION

Penile carcinoma is one of the less frequent tumors of the genitourinary system, however its effect on the patients' sex life and quality of life is of great impact. Studies about the influence on patients' sex life are scarce.

OBJECTIVES

To characterize sexual activity with penetration of patients with penile carcinoma who underwent different conservative therapeutic approaches and to evaluate pre and post treatment erectile function. Secondarily, to compare the results between the patients who underwent partial penectomy to those subjected to other conservative therapies.

MATERIAL AND METHODS

Review of patients' records diagnosed with penile carcinoma and observed at the Portuguese Institute of Oncology of Oporto between 2005 and 2015, to obtain demographic, clinical and histopathological data. Telephone interviews for the completion of the International Index of Erectile Function-5 (IIEF-5) questionnaire to patients undergoing treatment in that period.

RESULTS

16 out of the 107 patients met the inclusion criteria (n=16), with an average IIEF-5 score of 23.44 (10-25), lowering this value to 16.56 (5-25) after therapy, p<0,05. Fifteen out of the 16 patients kept sexual activity (93.8%) and one (6.25%) suspended due to erectile dysfunction. IIEF-5 score after treatment in the subgroup that underwent partial penectomy was lower when compared to the other subgroup of patients subjected to others conservative therapies, without statistical significance.

CONCLUSION

Although penile carcinoma treatment has an impact in erectile function with statistical significance, the majority of patients keeps an active sexual life with penetration after treatment. It's not possible to conclude that less invasive therapies are associated with better erectile function.

Sexual outcomes after partial penectomy for penile cancer: results from a multi-institutional study

Penile cancer is an uncommon malignancy. Surgical treatment is inevitably mutilating. Considering the strong impact on patients' sexual life we want to evaluate sexual function and satisfaction after partial penectomy. The patients in this study (n = 25) represented all those who attended our institutions and were diagnosed and treated for penile cancer from October 2011 to November 2013. All patients underwent partial penectomy and followed-up (mean: 14 months; range: 12-25). Sexual presurgical baseline was estimated using the International Index of Erectile Dysfunction 15 (IIEF-15). Sexual outcomes of each patient were estimated considering four standardized and validated questionnaires. We analyzed the means and ranges of IIEF-15 including erectile function (IIEF-1-5 and -15), orgasmic function (IIEF-9 and -10), sexual desire (IIEF-11 and -12), intercourse satisfaction (IIEF-6-8), and overall satisfaction (IIEF-13 and -14). Then, we also used Quality of Erection Questionnaire (QEQ), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) and Self-Esteem and Relationship (SEAR) to evaluate the sexual function and satisfaction of our patients. The final results showed that penile cancer leads to several sexual and psychosexual dysfunctions. Nevertheless, patients who undergo partial penectomy for penile cancer can maintain the sexual outcomes at levels slightly lower to those that existed in the period before surgery.

Sexuality in Surgically Treated Carcinoma Penis Patients and Their Partners

Most common treatment offered to carcinoma penis patients is surgery. This results in not only mutilation of the genitals but also affects their sexuality. The treating physician fails to address the issue due to the paucity of the data in this regard. Hence, we decided to evaluate sexuality in these patients after surgical treatment for penile cancer. Most of the times, their partners also face problems of sex and sexuality, regarding which there is no literature. Hence, we decided to include their partners also in the study. We retrieved records of the patients who underwent surgical treatment for carcinoma penis at our institute. After obtaining ethical committee approval, they were invited along with their partners for personal interview. After obtaining written informed consent from each of them, they were administered sexual functioning questionnaire (SFQ). Sexuality was evaluated based on the scores obtained. Performance anxiety was reported by majority of these patients. Their sexual interest, arousal and desire remained almost intact with reduction in satisfaction more so in total penectomised patients. Though the partners had accepted the global reduction in sexuality as their fate, their interpersonal relationship remained little disturbed. The study reveals that sexuality is more than the sexual intercourse alone. Proper pre-operative counselling of these patients and their partners by the treating urologist helps better post-treatment adjustment with regards to sexuality in these patients as well as their partners.

Sexuality After Cancer: A Model for Male Survivors

INTRODUCTION

For men with cancer, sexual dysfunction is a common issue and has a negative impact on quality of life, regardless of whether he has a partner. In general, sexuality encompasses much more than intercourse; it involves body image, identity, romantic and sexual attraction, and sexual thoughts and fantasies.

AIM

Acknowledging that cancer affects multiple physical and psychosocial domains in patients, the authors propose that such changes also inform sexual function for the male survivor.

METHODS

An in-depth review of the literature describing alterations to sexual functioning in men with cancer was undertaken. Based on this and the clinical expertise of the authors, a new model was created and is presented.

RESULTS

This biopsychosocial model is intended to expand the understanding of male sexuality beyond a purely biomedical model that addresses dysfunction as distinct from the context of a man's life and sexual identity.

CONCLUSION

Most data on sexual dysfunction in men with cancer are derived from those with a history of prostate cancer, although other data suggest that men with other types of malignancies are similarly affected. Unfortunately, male sexuality is often reduced to aspects of erection and performance. Acknowledging that cancer affects multiple physical and psychosocial domains in patients, the authors propose that such changes also inform sexual function for the male survivor. This biopsychosocial model might form the basis for interventions for sexual problems after cancer that includes a man and his partner as a complex whole.

Low-dose brachytherapy for early stage penile cancer: a 20-year single-institution study (73 patients)

Purpose/objectives

The aim of this study is to analyze the results of exclusive interstitial brachytherapy (IBT) as a conservative approach in the treatment of penile cancer confined to the glans or the shaft with long-term follow-up in a single institution.

Materials/methods

Between July 1992 and November 2013, 73 consecutive patients with non-metastatic invasive penile cancer were treated by Low dose rate (LDR) IBT in our institution. The localization of the primary lesion was glands in 67 patients (91.8 %) and shaft in 6 patients (8.2 %). All 73 patients presented with squamous cell carcinoma with grades of differentiation as follows: 34 patients with grade 1 (44.7 %), 9 patients with grade 2 (11.8 %), 9 patients with grade 3 (11.8 %) and 21 patients unknown (28.8 %). Six patients (7.8 %) presented with in situ carcinoma, 55 patients (75,3 %) presented with T1, 11 patients (15 %) presented with T2, and one patient (1.3 %) presented with Tx. Inguinal nodal dissection was performed in 29 patients (38.2 %); 13 patients (17.8 %) presented with histologically confirmed positive ganglion. After circumcision, IBT was performed using a hypodermic needle. The median dose delivered was 60 Gy (range, 40 to 70 Gy). The median activity of the iridium-192 wire was 1.12 mCi/cm, and the median reference isodose rate was 0.4 Gy/h (range, 0.2–1.2). Patients with histological inguinal metastases received external beam radiotherapy to the selected inguinal affected area with a median dose of 45 Gy (30–55 Gy).

Results

The median follow-up time was 51.8 months (range 34.4 to 68.7). The 5-year overall survival was 82.0 %, with eight deaths from cancer and five non-cancer-related deaths. Disease-specific survival was 91.4 %, relapse-free survival was 64.4 %, and local relapse-free survival as 74 %. Total or partial penile preservation was 87.9 % at 5-years. Complications rates at 5 years were 6.6 % urethral stenosis (five patients), two patients (2.6 %) with pain related to sexual intercourse and four patients (5.3 %) with dysuria grade 2. Five patients (6.8 %) required penile amputation for necrosis.

Conclusions

IBT provides good local control with organ preservation, excellent tolerance and low complication rates in early-stage penile cancers.

Organ-sparing treatment of penile cancer with interstitial pulsed-dose-rate brachytherapy

AIM

To assess the efficacy and toxicity profile of protocol-based interstitial pulsed-dose-rate (PDR) brachytherapy for penile carcinoma.

PATIENTS AND METHODS

From August 2002 to February 2014, 13 men with penile cancer were treated by interstitial brachytherapy. The tumor stage was T1 for eight patients, T2 for four patients, and T3 for one patient. The tumor grade was well differentiated for five patients and moderately differentiated for seven patients, while it was unknown for one patient. Lymph node staging was positive for three of 13 patients. All patients were treated using interstitial PDR brachytherapy with dose specifications according to the Paris system. For data collection of erectile dysfunction, the International Index of Erectile Function questionnaire was used, supplemented by the follow-up data.

RESULTS

The median follow-up was 54.0 months (range, 13-155 months). Only one patient (1/13, 7.7 %) with local failure was documented. At 5 and 10 years, the local cumulative recurrence rate, disease-free survival, and the cancer-specific survival rates were 12.5 % (95 % CI, 80.4-119.6), 80.8 % (95 % CI, 75.2-124.8), and 77.9 % (95 % CI, 74.3-125.7), respectively. At the time of analysis, nine of 13 men were alive; two of 13 men died of distant metastases from the tumor and two for other reasons with no sign of cancer disease. Serious late side effects such as soft tissue necrosis occurred in four of 13 patients (30 %) and all were successfully treated with medication. Mutilating salvage surgery was not necessary in any of the cases. Urethral stenosis was documented for two of 13 (15.4 %) and dysuria occurred in four of 13 patients (30.8 %). Eight of 11 men (72.7 %) never or only sometimes had erectile dysfunction.

CONCLUSION

In selected patients, interstitial PDR brachytherapy of penile cancer is effective as an organ-sparing treatment. It yields satisfactory results for the conservation of sexual function.

Pharmacologic and surgical therapies for sexual dysfunction in male cancer survivors

The recent recognition that many men experience sexual dysfunction following their diagnosis and treatment of genitourinary cancers, has led to the development multiple varied strategies that attempt to restore or preserve that function. In this manuscript we review the understanding of why it happens, highlight novel management strategies and discuss the concept of penile rehabilitation (PR) following prostate cancer (PCa) treatment, glans preserving strategies among men diagnosed with penile cancer and address the controversial issue of testosterone therapy in men with PCa.

Evaluation of sexual functions and sexual behaviors after penile brachytherapy in men treated for penile carcinoma

Purpose

To assess sexual functions and behaviors of men treated by penile brachytherapy for a cancer of the penis.

Materials and methods

Thirty eight men (19 patients treated by penile brachytherapy for a cancer of the penis and 19 age paired-matched controls) participated in a survey about sexuality. The mean age of patients and controls were 73.2 +/- 11.7 and 70.0 +/- 10.5 years, respectively (NS). Controls were men without penile pathology, without history of cancer and no evidence of cognitive impairment. All agreed to participate in the survey about sexuality using 2 questionnaires : the IIEF questionnaire, which explores 4 domains of sexual functions, namely erection, satisfaction, orgasm and desire, and a questionnaire created using the BASIC IDEA grid, which addresses nine domains: behavior, affect, sensation, self-image, cognition, interpersonal, drugs, expectation and attitude.

Results

Patients had better scores than controls in 3 domains of the IIEF: erection, desire and satisfaction. These results contrasted with the frequency of intercourse and the quality of erection (evaluated through the BASIC IDEA questionnaire) that were not significantly different between the two populations. Patients also had significantly higher frequency of masturbation (p <0.001) lower worry about sexual performance and higher expected satisfaction for future life (p: 0.021) than controls.

Conclusion

Penile brachytherapy is a treatment of cancer of the penis that seems to have a moderated impact on sexual functions since most of sexual scores are not inferior in these patients than in age pair-matched controls.

High-dose-rate interstitial brachytherapy for T1-T2-stage penile carcinoma: short-term results

PURPOSE

Interstitial brachytherapy (IBT) is a preferred treatment option over partial penectomy in selected patients with T1-T2-stage penile carcinoma because of its organ preservation ability. Literature is mostly based on the use of low-dose-rate IBT, and experience with high-dose-rate (HDR) IBT is extremely limited. We studied the role of HDR-IBT alone in patients with T1-T2-stage penile carcinoma.

METHODS AND MATERIALS

Between April 2010 and July 2013, 14 patients with T1-T2-stage penile carcinoma were treated with HDR-IBT at our center. Size of the primary lesion ranged from 1.5 to 4.0cm. A two-to-four-plane free-hand implant was performed using plastic catheters. The prescribed dose of HDR-IBT was 42-51Gy in 14-17 fractions using twice-a-day fractionation schedule. Patients were followed up regularly for assessment of local control, survival, toxicity, and sexual function.

RESULTS

At a median followup of 22 months, 2 patients developed recurrent disease at locoregional site. The 3-year overall survival was 83% with penis preservation rate of 93%. All patients developed acute Grade III skin toxicity that healed during 6-8-weeks time. Urethral stenosis and soft tissue necrosis was not seen in any of the patients. A total of 4 patients experienced mild asymptomatic fibrosis in the implanted area. Around 10 patients had satisfactory sexual function status at the last followup visit.

CONCLUSIONS

Although it was a small sample size, our results have demonstrated excellent local control rate and acceptable toxicity with HDR-IBT in patients with T1-T2-stage penile carcinoma.