A Comparative study of two types of organ-sparing surgeries for early stage penile cancer: Wide local excision vs partial penectomy

Stigma and its associations with self-confidence and sexual relations in 4 types of premature ejaculation

BACKGROUND

Although men with premature ejaculation (PE) always show more negative emotions, including embarrassment, guilt and worry, this may be related to the stigma of PE. To investigated stigma and its associations with self-confidence and sexual relations in 4 PE syndromes, a survey was conducted in our hospital from December 2018 to December 2019 among 350 men with self-reported PE and 252 men without self-reported PE. The stigma, self-confidence and sexual relations were assessed by the Social Impact Scale (SIS) and Self-Esteem and Relationship questionnaire (SEAR), respectively. Ejaculation control, sexual life satisfaction and distress caused by PE were evaluated by the Index of PE.

RESULTS

Men with self-reported PE had higher internalized shame and social isolation scores and lower SEAR scores than control subjects. The highest score of internalized shame and social isolation and the lowest score of SEAR appeared in men with lifelong PE (LPE). After age adjustment, the positive relationships were stronger between distress about PE and internalized shame. Whereas, the stronger negative associations were found between social isolation and sexual satisfaction. The strongest association was observed between social isolation and sexual relationship. Therefore, the stigma associated with PE adversely affects the self-confidence, self-esteem, and sexual relationships of men with PE.

CONCLUSION

Men with PE, especially LPE, have a high level of stigma and disharmonious sexual relations, and often lack self-confidence and self-esteem, which have a certain negative impact on their physical and mental health and life. These will be the key issues to be considered when we formulate a personalized treatment plan for PE.

Penile carcinoma: A retrospective analysis of 93 patients at a tertiary care center in Jakarta, Indonesia

OBJECTIVES

Penile carcinoma (PC) is a rare disease with considerable physical and psychological impact. To date, there is no data regarding PC prevalence and characteristics in Indonesia. This study aimed to analyze the characteristics of patients with PC in Indonesia and determine cumulative survival rates and time to disease progression.

METHODS

This was a retrospective study of all patients diagnosed with PC at Cipto Mangunkusumo General Hospital from 1995 to 2014, with a minimum of 1 year follow-up. The outcomes of the study were cumulative survival rates and time-to-disease progression.

RESULTS

Ninety-three subjects were recruited, with a mean age of 49.44 ± 13.62. Inguinal lymph node dissection (ILND) was performed in 49 (53%) patients. The mean survival in the ILND group was better compared to the non-ILND group (80.7 months vs. 67.1 months; p = 0.032). Time-to-progression in the ILND group was significantly longer than in the non-ILND group (71.7 months vs. 54.3 months; p = 0.022). No significant difference in survival between the total and partial penectomy (PP) groups was observed (p = 0.701). Time-to-progression in total penectomy (TP) was significantly longer than in PP (68 months vs. 56.0 months; p = 0.023). In Cox-regression analysis, after adjustment of other variables, history of ILND, higher stage of cancer, and older age were found to affect the survival of patients.

CONCLUSION

ILND in PC led to better survival and reduced disease progression. The type of penectomy is only associated with progression but not survival. TP had a longer time to disease progression compared to PP.

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.

Sexual Outcomes after Conservative Management for Patients with Localized Penile Cancer

BACKGROUND

Men with localized invasive penile cancer (PC) can be treated with organ-sparing treatments with different functional and aesthetical outcomes. Thus, the aim of this study is to investigate sexual outcomes in patients with PC confined to the glans that underwent wide local excision (WLE) vs. glansectomy with urethral glanduloplasty.

METHODS

Complete data from 60 patients with PC were analyzed at our institution from 2017 to 2022. Patients were asked for personal habits and clinical features. PC was assessed with a clinical visit and imaging techniques. At the outpatient follow-up visit or phone call, all patients compiled the Changes in Sexual Function Questionnaire (CSFQ) and the International Index of Erectile Function in its short 5-item form (IIEF-5). Erectile function (EF) impairment was categorized using Cappelleri's criteria.

RESULTS

Overall, 34 patients with PC confined to the glans (c ≤ T2N0) were included. Of those, 12 underwent WLE and 22 underwent glansectomy with urethral glanduloplasty. Using multivariable logistic regression, glansectomy (OR: 3.49) and diabetes (OR: 2.33) were associated with erectile disfunction (IEEF < 22). Meanwhile, using multivariable linear regression analysis, younger patients (Coeff: -2.41) and those that underwent glansectomy (Coeff: -7.5) had a higher risk of sexual function impairment, according to the CSFQ.

CONCLUSIONS

Patients with PC ≤ T2N0 that underwent WLE have better outcomes in terms of sexual functioning than the patients who underwent glansectomy and uretheral gladuloplasty. Further research is needed to clarify the outcomes of penile-sparing surgery, to inform patients in pre-surgical counseling more comprehensively, and to meet their post-operative expectations more effectively.

Functional outcomes and health-related quality of life following penile cancer surgery: a comprehensive review

INTRODUCTION

Organ-sparing surgery (OSS) in penile cancer management aspires to maintain organ form and function and preserve health-related quality of life (HRQoL), yet there is a lack of integrated evidence exploring these outcomes.

OBJECTIVES

The aim sought to review HRQoL, functional, aesthetic, and psychological outcomes following OSS or radical penectomy for penile cancer.

METHODS

A systematic review of MEDLINE and Cochrane databases included studies reporting on function (sexual, urinary or sensory), genital appearance or HRQoL/psychological well-being following surgical treatment of primary penile cancer. English-language reports (2000-2022), incorporating patient-reported or objective clinical outcome measures, were eligible. Studies of nonsurgical treatment strategies and those in the context of metastatic disease were excluded. Data were compiled and analyzed.

RESULTS

Twenty-six studies were included. Sexual function was the most studied outcome (754 pooled respondents; 19 studies), most frequently with the original 15-item and abridged 5-item International Index of Erectile Function. Preservation of erectile function following OSS is generally described, with some reduction in overall sexual satisfaction cited. Heterogeneous assessment of voiding function with little preoperative evaluation render interstudy comparison difficult. Most patients appear able to void from a standing position following OSS, with spraying the most common symptom. Maintenance of some sensory function is described with both split-thickness skin grafting and urethral glanduloplasty following radical glansectomy. Limited studies suggest reasonable patient satisfaction with genital cosmesis post-OSS. A negative impact on HRQoL is described in most studies following penile cancer surgery, variably correlated with aggressiveness of penile surgery and addition of lymphadenectomy. Anxiety, depression, and reduced self-esteem have been reported in penile cancer survivors. Relationship well-being varies, with some survivors reporting this to be unchanged.

CONCLUSION

OSS can preserve elements of sexual, urinary, and sensory function, supporting advantages over radical penectomy for eligible patients. However, a comprehensive understanding remains limited due to small, heterogeneous patient cohorts, challenges in obtaining premorbid data, and variability in outcome measures. Standardization of patient-reported outcomes following OSS is desirable.

European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update

CONTEXT

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.

OBJECTIVE

To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer.

EVIDENCE ACQUISITION

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.

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.

PATIENT SUMMARY

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.

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 and urinary function after organ sparing surgery for penile cancer: A questionnaire study of consecutive patients over a 3-year period in a single region

Objective:

The European Association of Urology recommends organ-sparing surgery (OSS) for localised penile cancer. We aimed to assess the impact of OSS including glans reconstruction on erectile, sexual and urinary function.

Method:

Local ethics approval was obtained. Patients coded for glans resurfacing, glansectomy and partial penectomy from 2015 to 2018 were identified across two trusts. Background characteristics, histology, staging and follow-up were recorded. Two questionnaires were used to assess function: a custom questionnaire on patient reported outcomes and the International Index of Erectile Function (IIEF) Questionnaire. Anonymised questionnaires were sent to each patient with prepaid return envelopes included.

Results:

A total of 28/64 (44%) questionnaires were returned complete. The mean age of participants was 71(35–93) and body mass index (BMI) 28(20–38). There was 1 glans resurfacing, 1 circumcision and wide local excision, 8 glansectomy and 18 partial-penectomy patients (of which 4 and 13 declined reconstruction, respectively). Sexual satisfaction (SS) and erectile function (EF) declined postoperatively while sexual desire was preserved. Subjective glans sensitivity reduced independent of technique. Glans reconstruction reduced the impact on IIEF in glansectomy (13.5 versus 25.3, p < 0.05) but not partial-penectomy (13.4 versus 13.8). SS was worse in partial-penectomy patients undergoing glans reconstruction on patient-reported outcome measures (PROM) (SS change: −4.0/10 with reconstruction versus −0.9/10 without, p < 0.05). Urinary symptoms appear limited to spraying and change of flow of urine, with some patients reporting the need to pass urine sitting down.

Conclusion:

Sexual and erectile function is impaired post-OSS in penile cancer while sexual desire is preserved. Simultaneous glans reconstruction appears to minimise this impact in glansectomy patients when assessed by IIEF. A validated PROM questionnaire could improve preoperative counselling, and guide postoperative sexual recovery.

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.

Erectile function after partial penectomy for penile cancer

PURPOSE

To evaluate the erectile function in patients who underwent partial penectomy and identify factors associated with penile functional status.

MATERIALS AND METHODS

We identified patients who underwent partial penectomy due to penile cancer between 2009 and 2014. Clinical and pathological characteristics included patient age at the time of diagnosis, obesity, hypertension, dyslipidemia, diabetes, smoking, metabolic syndrome, Eastern Cooperative Oncology Group (ECOG) status, penile shaft length, tumor size, primary tumor stage (pT), clinical nodal status, and local recurrence. Erectile function was assessed prospectively with the International Index of Erectile Function (IIEF-5) at least 3 months after partial penectomy.

RESULTS

A total of 81 patients met analysis criteria. At the diagnosis, the median age was 62 years (range from 30 to 88). Median follow-up was 17 months (IQR 7-36). Of total patients, 37 (45%) had T2 or higher disease. Clinically positive nodes were present in 16 (20%) patients and seven (8.6%) developed local recurrence. Fifty patients (62%) had erectile dysfunction (ED) after partial penectomy, 30% had moderate or severe erectile dysfunction scores. Patients with ED versus without ED were similar in baseline characteristics except for age, penile shaft length, and presence of inguinal adenopathy (p <0.05). Multivariate analysis using logistic regression confirmed that older patients, shorter penile shaft length, and clinically positive lymph node were significantly associated with ED.

CONCLUSION

Partial penectomy due to penile cancer provides adequate local control of the disease, however, proper counselling is important especially in relation to ED consequences. Preservation of penile length yields to more optimal erectile recovery.

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.

Mohs micrographic surgery for male genital tumors: Local recurrence rates and patient-reported outcomes

BACKGROUND

Local recurrence rates (LRRs) after Mohs micrographic surgery (MMS) for male genital cancers have been reported in only a few small case series, and patient-reported outcomes (PROs) have not been studied.

OBJECTIVE

To determine the LRR and PROs after MMS for male genital skin cancers.

METHODS

Retrospective review of all male genital skin cancers removed with MMS between 2008 and 2019 at an academic center. LRR was determined by chart review and phone calls. PROs were assessed by survey.

RESULTS

A total of 119 skin cancers in 108 patients were removed with MMS. Tumors were located on the penis (90/119) and scrotum (29/119). Diagnoses included squamous cell carcinoma in situ (n = 71), invasive squamous cell carcinoma (n = 32), extramammary Paget disease (n = 13), melanoma (n = 2), and basal cell carcinoma (n = 1). The LRR was 0.84% (1/119), with a mean follow-up time of 3.25 years (median, 2.36 years). The majority of survey respondents reported no changes in urinary (66%) or sexual functioning (57.5%) after surgery.

LIMITATIONS

Retrospective single-center experience; short follow-up time; low survey response rate; no baseline functional data.

CONCLUSION

MMS for male genital skin cancer has a low LRR and high patient-reported satisfaction with urinary and sexual function.

Organ-sparing surgery of penile cancer: higher rate of local recurrence yet no impact on overall survival

PURPOSE

To report on the oncological outcome of organ-sparing surgery (OSS) compared to (total or partial) penectomy regarding recurrence patterns and survival in squamous cell carcinoma (SCC) of the penis.

METHODS

This was a retrospective study of all patients with penile SCC and eligible follow-up data of at least 2 years at our institution. Patients with tumors staged ≥ pT1G2 underwent invasive lymph node (LN) staging by dynamic sentinel-node biopsy or modified inguinal lymphadenectomy. Radical inguinal lymphadenectomy was performed when LNs were palpable at diagnosis and in those with a positive LN status after invasive nodal staging. Follow-up visits were assessed, and local, regional and distant recurrences were defined and analyzed.

RESULTS

55 patients were identified with a mean follow-up of 63.7 months. Surgical management was OSS in 26 patients (47.2%) and partial or total penectomy in 29 cases (52.8%). Histopathological staging was: pTis (12.7%), pTa (16.3%), pT1a (18.2%), pT1b (5.5%), pT2 (29.1%) and pT3 (18.2%), respectively. Patients in the penectomy group were significantly older (mean 68 vs. 62 years; p = 0.026) with a higher rate of advanced tumor stage (≥ pT2: 44.8% vs. 11.5%; p = 0.002). The local recurrence rate was 42.3% (n = 11) following OSS compared to 10.3% (n = 3) after penectomy (p = 0.007). Kaplan-Meier curves showed no significant differences between the two groups regarding metastasis-free and overall survival.

CONCLUSIONS

OSS is associated with a higher local recurrence rate compared to penectomy, yet it has no negative impact on overall and metastasis-free survival.