Glans Resurfacing for the Treatment of Carcinoma In Situ of the Penis: Surgical Technique and Outcomes

Bowen's disease revealing a penile invasive squamous cell carcinoma: Case report and review of literature

INTRODUCTION

Bowen's disease (BD) represents an in situ squamous cell carcinoma that can progress to an invasive one without treatment. Various options for Bowen's disease have been delineated, each with its set of advantages and disadvantages.

CASE PRESENTATION

We report the case of a 60-year-old patient with a history of chronic smoking and a background of multiple partners and recurrent urethritis. The patient presented with a maculopapular lesion on the lateral aspect of the penis, evolving for 5 years. A biopsy confirmed the diagnosis of Bowen's disease. The patient underwent an excision of the lesion which the histology showed an infiltrating basosquamous cell carcinoma.

DISCUSSION

The diagnosis of Bowen's disease requires a biopsy and is based on histological examination. Only surgical treatment allows for the identification, through histological analysis of the excised specimen, of any potential invasive area that may not have been identified in the biopsy. Nonsurgical therapies are also an option with high recurrence rates.

CONCLUSION

Bowen's disease management requires a personalized approach, considering factors like lesion characteristics, patient-related variables and treatment efficacy. An adapted follow-up is recommended due to the recurrence risk associated with various treatments.

Oncological Outcomes of Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) Laser Ablation for Penile Cancer

OBJECTIVE

To report oncological outcomes after thulium-yttrium-aluminum-garnet (Tm:YAG) laser ablation for penile cancer patients.

MATERIALS AND METHODS

We retrospectively analyzed 71 patients with ≤cT1 penile cancer (2013-2022). All patients underwent Tm:YAG ablation with a RevoLix 200W continuous-wave laser. First, Kaplan-Meier plots and multivariable Cox regression models tested local tumor recurrence rates. Second, Kaplan-Meier plots tested progression-free survival (≥T3 and/or N1-3 and/or M1).

RESULTS

Median (interquartile range) follow-up time was 38 (22-58) months. Overall, 33 (50.5%) patients experienced local tumor recurrence. Specifically, 19 (29%) vs 9 (14%) vs 5 (7.5%) patients had 1 vs 2 vs 3 recurrences over time. In multivariable Cox regression models, a trend for higher recurrence rates was observed for G3 tumors (hazard ratio:6.1; P = .05), relative to G1. During follow-up, 12 (18.5%) vs 4 (6.0%) vs 2 (3.0%) men were retreated with 1 vs 2 vs 3 Tm:YAG laser ablations. Moreover, 11 (17.0%) and 3 (4.5%) patients underwent glansectomy and partial/total penile amputation. Last, 5 (7.5%) patients experienced disease progression. Specifically, TNM stage at the time of disease progression was: (1) pT3N0; (2) pT2N2; (3) pTxN3; (4) pT1N1 and (5) pT3N3, respectively.

CONCLUSION

Tm:YAG laser ablation provides similar oncological results as those observed by other penile-sparing surgery procedures. In consequence, Tm:YAG laser ablation should be considered a valid alternative for treating selected penile cancer patients.

[Organ-preserving treatment as the most important option in the treatment of primary penile cancer]

The treatment of patients with penile cancer presents a significant challenge for therapists and patients alike. In this context, the focus must not only be on surgical techniques but rather on patient education and collaborative treatment planning. Consistent information about potential organ preservation and its consequences is essential. Following clinical examination and histological confirmation of the diagnosis, an organ-preserving and stage-adapted surgical procedure should be used in almost all cases. Intraoperatively, the aim should be to achieve tumour-free surgical margins through rapid pathological examination. Psycho-oncological support should be offered to all patients. Centralisation of treatment appears highly desirable for Germany, considering the excellent outcomes observed in English and Dutch centres. Until this has been achieved, following the valuable experience of the "Second Opinion Network for Testicular Tumours", the Second Opinion platform "eKonsil Urologie" (https://www.ekonsil.org) can be used as a reference.

Organ-sparing treatment for T1 and T2 penile cancer: an updated literature review

PURPOSE OF REVIEW

Penile cancer (PeCa) is an orphan disease due to its rare incidence in high-income countries. Traditional surgical options for clinical T1-2 disease, including partial and total penectomy, can dramatically affect patient's quality of life and mental health status. In selected patients, organ-sparing surgery (OSS) has the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of various OSSs currently available for men diagnosed with PeCa seeking an organ-preserving option.

RECENT FINDINGS

Patient survival largely depends on spotting and treating lymph node metastasis at an early stage. The required surgical and radiotherapy skill sets cannot be expected to be available in all centers. Consequently, patients should be referred to high-volume centers to receive the best available treatments for PeCa.

SUMMARY

OSS should be used for small and localized PeCa (T1-T2) as an alternative to partial penectomy to preserve patient's quality of life while maintaining sexual and urinary function and penile aesthetics. Overall, there are different techniques that can be used with different response and recurrence rates. In case of tumor recurrence, partial penectomy or radical penectomy is feasible, without impacting overall survival.

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.

French AFU Cancer Committee Guidelines - Update 2022-2024: penile cancer

OBJECTIVE

To update French oncology guidelines concerning penile cancer.

METHODS

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.

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 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.

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.

Guia de cáncer de pene de la Sociedad Colombiana de Urología

El cáncer de pene tiene una incidencia de 1.11 por 100.000 habitantes en Colombia, representado en el 95% por carcinoma de células escamosas el cual representa una alta morbilidad y mortalidad, La Sociedad Colombiana de Urología realizo la adaptación de la guía de cáncer de pene para el año 2021 con revisión de la literatura, esta guía permite realizar una evaluación y tratamiento del cáncer de pene, en muchas ocasiones con el objetivo de preservación de órgano utilizando la ecografía como determinante para evaluar el compromiso de la lesión a las estructuras del pene, los estudios de extensión dependerán de hallazgos al examen físico como ganglios o compromiso local de la enfermedad, de acuerdo al tipo de lesión y su estadificación puede recibir terapia con agentes tópicos, radioterapia, cirugía láser, cirugía preservadora de órgano o penectomía total; La linfadenectomía inguinal permitirá mejorar la supervivencia en tumores de riesgo intermedio y alto (>pT1G2), posteriormente la quimioterapia adyuvante esta en el grupo de pacientes en el cual la intención sea curativa, aunque en terapia paliativa de segunda línea se encuentran los platinos y texanos como alternativa pero con pobre respuesta (<30%); los esquemas de seguimiento se realiza de acuerdo al estadio y el compromiso ganglionar. Al final se presentan los resultados de actividad sexual después de cirugía preservadora de órgano; Esta guía abarca la literatura actualizada del cáncer de pene, el cual es útil para el manejo por parte de los profesionales de salud del país.

[Penile intraepithelial neoplasia]

Penile carcinogenesis can be superposed on vulvar carcinogenesis, with two pathways : with or without a link to HPV. Penile squamous cell carcinomas arise from precursor lesions: penile intraepithelial neoplasia (PeIN) defined by the presence of intraepithelial atypia, which can progress to invasive squamous cell carcinoma. Differentiated PeINs not linked to HPV, affect elderly men with inflammatory lesions, most often lichen sclerosus. PeINs linked to HPV, basaloid, condylomatous or condylomatous-basaloid growth affect younger men. Although clinically similar, their distinction is important, because the treatment differs with a greater risk of invasion for forms unrelated to HPV.

Lymph Node Dissections for T3T4 Stage Penile Cancer Patients Without Preoperatively Detectable Lymph Node Metastasis Bring More Survival Benefits: A Propensity Matching Analysis

Background and Aims

The current guidelines for the treatment of penile cancer patients with clinically non-invasive normal inguinal lymph nodes are still broad, so the purpose of this study is to determine which patients are suitable for lymph node dissection (LND).

Methods

Histologically confirmed penile cancer patients (primary site labeled as C60.9-Penis) from 2004 to 2016 in the Surveillance, Epidemiology, and Results database were included in this analysis. Univariate and multivariate Cox regression analyses were applied to determine an overall estimate of LND on overall survival and cancer-specific survival. A 1:1 propensity matching analysis (PSM) was applied to enroll balanced baseline cohort, and further Kaplan-Meier (KM) survival analysis was used to get more reliable results.

Results

Out of 4,458 histologically confirmed penile cancer patients with complete follow-up information, 1,052 patients were finally enrolled in this analysis. Age, pathological grade, T stage, and LND were identified as significant predictors for overall survival (OS) in the univariate Cox analysis. In the multivariate Cox regression, age, pathological grade, T stage, and LND were found significant. The same results were also found in the univariate and multivariate Cox regression analyses for cancer-specific survival (CSS). After the successful PSM, further KM analysis revealed that LND could bring significant OS and CSS benefits for T3T4 patients without lymph node metastasis.

Conclusion

Lymph node dissection may bring survival benefits for penile cancer patients without preoperatively detectable lymph node metastasis, especially for T3T4 stage patients. Further randomized control trial is needed.

Surgical technique and outcomes following coronal-sparing glans resurfacing for benign and malignant penile lesions

The aim of this study is to describe the outcomes for a modified glans-resurfacing technique for benign and malignant penile conditions in which the uninvolved glans corona is preserved in order to maintain glans erogenous sensation. A total of 13 patients underwent coronal-sparing glans resurfacing (CSGR), with follow-up every 3 months for ≥2 years. Positive surgical margin and local recurrence (LR) rates were evaluated. Surgical complications and cosmetic outcomes were also recorded. Patients were asked to complete the International Index of Erectile Function-5 (IIEF-5) questionnaire starting 12 months after the surgery. The median (interquartile range [IQR]) age and follow-up periods were 63 (53-68) years and 29 (14-38) months, respectively. Eight patients were diagnosed with primary penile squamous cell carcinoma (SCC), three had refractory lichen sclerosus, and two had penile intraepithelial neoplasia (PeIN). No surgical complications were recorded. All patients had a complete graft take and reported satisfactory cosmetic results with preserved erogenous sensation. Two cancer patients developed LR which was managed with further penile preserving surgery. The median (IQR) postoperative IIEF-5 value was 20 (17-23). This modified coronal-sparing technique was suitable for glans lesions that spare the coronal ridge and coronal sulcus. Preservation of the coronal ridge helps maintain sexual function and provides excellent cosmetic outcomes.

Penile-sparing surgery for patients with superficial or initially invasive squamous cell carcinoma of the penis: long-term oncological outcomes

PURPOSE

To report long-term oncological outcomes after penile-sparing surgery (PSS) for superficial (Ta-Tis) or initially invasive (T1) penile cancer patients.

METHODS

We retrospectively analysed 85 patients with Ta/Tis/T1cN0cM0 penile cancer (1996-2018). All patients underwent PSS: circumcision, excision or laser ablation. First, Kaplan-Meier plots and multivariable Cox regression models tested tumor recurrence rates (any local/regional/metastatic). Second, Kaplan-Meier plots depicted progression-free survival (≥T2 or N1-3 or M1 disease).

RESULTS

Median (IQR) follow-up time was 64 (48-95) months. Overall, 48 (56%) patients experienced tumor recurrence. Median (IQR) time to tumor recurrence was 34 (7-52) months. Higher recurrence rates were observed for Tis (65%) and T1 (64%), compared to Ta (40%), but these differences were not significant on multivariable Cox regression analyses (HR:2.0 with 95% CI [0.9-5.1] and HR:2.2 with 95% CI [0.9-5.9], respectively). Moreover, higher recurrence rates were observed for G2-3 tumors (74%), compared to G1 (57%), but these differences were not significant on multivariable Cox regression analyses (HR:1.6; 95% CI [0.8-3.2]). During follow-up, 15 (17.5%) vs. 18 (21.2%) vs. 10 (11.5%) patients underwent 1 vs. 2 vs. ≥3 PSS. Moreover, 26 (30.6%) and 4 (4.7%) men were treated with glansectomy and partial/total penile amputation due to local progression, tumor size or patient preference. Additionally, 24 (28%) men underwent invasive nodal staging. Last, 22 (25.9%) patients experienced disease progression. Median (IQR) time to disease progression was 51 (31-82) months.

CONCLUSION

Patients treated with PSS for newly diagnosed superficial or initially invasive squamous cell carcinoma of the penis should be informed about the non-negligible risk of tumor recurrence and disease progression over time. In consequence, strict follow-up protocols are needed.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of penile cancer

Squamous cell carcinoma of the penis (SCCP) is uncommon in some countries (including the U.S.), but is an important malignancy elsewhere. As a rare disease, progress has been slow compared to more common tumor types discussed in this anniversary issue and most often limited to single-center or retrospective datasets.  In this section we describe developments leading to the current standard approach with current research questions.

[Non-invasive precursor lesions of penile carcinoma : Differential diagnosis and treatment]

Clinical diagnosis of preinvasive malignant lesions of the penis is difficult and there are numerous differential diagnoses. Recent decades have been witness to several changes in the terminology of histopathological diagnoses. In the current World Health Organization classification, penile intraepithelial neoplasia (PeIN) is defined, of which several subtypes exist. Just like in invasive carcinoma, the principal classification of PeIN subtypes corresponds with pathogenesis and includes human papilloma virus (HPV)-related and non-HPV-related forms. Subdivision is important for prognosis. Several therapeutic options exist, including surgical and nonsurgical procedures.

Treatment Options and Outcomes for Men with Penile Intraepithelial Neoplasia: A Systematic Review

Penile intraepithelial neoplasia (PeIN) is a rare skin condition with potential to progress to invasive penile cancer. We performed a systematic review of treatment options and outcomes for PeIN. Topical agents showed response and recurrence rates of 40-100% and 20% for imiquimod, and 48-74% and 11% for 5-fluorouracil, respectively. Discontinuation of topical agents because of side effects was observed in 12% of cases. Response rates for laser therapies were 52-100%, with recurrence in 7-48% of cases and a change in penile sensitivity in 50%. Circumcision cleared preputial PeIN. Rates of recurrence after surgical treatment of glans PeIN were 25% for wide local excision, 4% for Mohs surgery, 5% for total glans resurfacing, and 10% for glansectomy. There are limited data on factors predictive of treatment response and on sequencing of treatment options. PATIENT SUMMARY: Several treatment options are available for men with precancerous lesions of the foreskin or glans. Close follow-up is necessary as lesions can recur or progress to invasive penile cancer.

Functional and Patient Reported Outcomes Following Total Glans Resurfacing

BACKGROUND

Whilst there is a trend away from aggressive nonorgan sparing surgical treatments for malignant penile disease, a variety of penile preservation options exist but functional outcomes and patient reported outcomes (PROs) in this area are poorly reported to date.

AIM

The aim of this study is to report functional outcomes and PROs of total glans resurfacing (TGR) in a consecutive series of patients with lichen sclerosis (LS) or localized penile cancer (PC).

METHODS

From 2004 to 2018 a consecutive series of patients underwent TGR for the management of LS or localized PC in a tertiary referral network. Patient clinical records and operative notes were retrospectively reviewed. Statistical analysis was conducted with Stata 12.

OUTCOMES

Urinary and sexual outcomes were recorded utilizing both the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) validated questionnaires while PROs were extrapolated from a 5-item "ad hoc" telephone questionnaire administered at 1 year post procedure.

RESULTS

37 consecutive patients were enrolled. Histology results demonstrated LS in 16 patients, with the remaining 21 having a diagnosis of PC. The most common reasons for patient presentation were local pain (32.4%), pruritus (37.8%) and bleeding (29.7%). Median follow-up was 22 (IQR 13-77) months. Median age was 62 (IQR 55-68). Neither of the questionnaires assessing urinary and sexual function showed any significant deterioration after surgery. Glans sensitivity was fully maintained in 89.2% of cases. 94.5% of patients reported to be fully satisfied with the aesthetic appearance of the penis and would consider undergoing the same procedure again if necessary. 91.9% of patients would recommend the same procedure to someone else. An overall improvement of the quality of life was reported by 86.4% of patients.

CLINICAL IMPLICATIONS

TGR should be considered a treatment of choice for selected cases of benign or malignant penile lesions STRENGTHS AND LIMITATIONS: Our study has some limitations, the first being its retrospective nature. Furthermore, despite being one of the largest series to date, follow-up duration is somewhat limited and a control group is lacking.

CONCLUSION

TGR represents an excellent surgical option ensuring satisfactory voiding and sexual function, as well as cosmesis for selected cases of penile lesions. M. Preto, M. Falcone, G. Blecher, et al. Functional and Patient Reported Outcomes Following Total Glans Resurfacing. J Sex Med 2021;18:1099-1103.

A novel predictive model for pelvic lymph node metastasis in patients with penile cancer: A multi-institutional study

PURPOSE

We determined whether a clinicopathological nomogram is able to predict the risk of pelvic lymph node metastasis (LNM) in penile cancer patients after inguinal lymph node dissection (ILND).

METHODS

Ninety-eight patients with bilateral ILND who underwent pelvic lymphadenectomy at 10 centers were retrospectively analyzed. The most predictive features in the nomogram were selected by the stepwise logistic regression method and then tested and verified by multivariate logistic regression analyses. The nomogram was assessed using concordance indices and calibration curves.

RESULTS

Of the 181 pelvic basins, pelvic LNM was observed in 52 packages (43 patients). Bilateral pelvic LNM was present in 9 patients (9/43, 20.9%). There was no crossover metastatic spread from one inguinal side to the other pelvic side. Age, previous resection, the biopsy procedure for inguinal lymph nodes, vascular invasion, and ipsilateral inguinal lymph node status were all independent risk factors for pelvic LNM (all P < 0.05) in the multivariate logistic regression analysis. The nomogram exhibited a good probability for survival agreement, with a concordance index of 0.868 (95% CI: 0.813-0.922).

CONCLUSIONS

A novel nomogram suggests that the risk of pelvic LNM can be effectively predicted in penile carcinoma patients and may provide a useful guide for clinicians. Further external validation is needed.

Oncologic outcomes and subsequent treatment following organ sparing surgery for penile carcinoma: The University of Texas M.D. Anderson Cancer Center Experience

OBJECTIVES

To determine the oncologic outcomes of organ sparing surgery (OSS) for penile cancer and to determine the management of and risk factors for local recurrence at a tertiary referral center in the United States.

METHODS AND MATERIALS

Patients undergoing OSS from 1996 to 2018 at The University of Texas, MD Anderson Cancer Center were identified using a prospective database. Organ sparing procedures included: wide local excision (WLE; including circumcision and glans resurfacing), partial or total glansectomy, laser therapy, or OSS combined with laser ablation (i.e., laser combination). Clinical and pathologic data were collected for descriptive analysis. Recurrences (local and regional) were identified, and the association between overall and local recurrences was determined using Cox proportional hazards regression. Overall and recurrence free survival analyses were performed using Kaplan-Meier estimates.

RESULTS

A total of 129 patients undergoing OSS were identified with a median follow up interval of 28.0 months. The most common OSS was laser combination (38.8%), and 65.1% of patients presented with pTis or ≤pT1a disease. Twenty (15.5%) recurrences were identified, of which 17 (13.2%) were local and 3 (2.3%) were regional. There were no distant recurrences as the initial site of recurrence. The median time to local recurrence was 20.9 months, and 88.2% were identified within 5 years of surgery. Most (76.5%) local recurrences were successfully treated with further penile preservation without a detrimental impact on overall survival. Patients with pathologic Ta or T1a disease treated with laser or laser combination surgery were more likely to present with local recurrence.

CONCLUSION

OSS using a variety of techniques to achieve negative surgical margins provides long-term effective local control for localized penile cancer. Most local recurrences can be successfully treated with further penile preserving strategies and long follow-up is essential. Laser therapy or laser combination with OSS should be used with caution in patients with invasive penile cancer.

Update on organ preserving surgical strategies for penile cancer

With the passage of time, there has been a major paradigm shift in the surgical management of penile cancer from radical to organ preserving penile surgical techniques, with closer surgical margins which offer good oncological, cosmetic and functional outcomes with improved physical and psychosexual well-being. This article aims to provide an update of the current organ preserving surgical strategies for penile cancer.

Penile cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer with orphan disease designation and a prevalence of 0.1-1 per 100,000 men in high-income countries, but it constitutes up to 10% of malignancies in men in some African, Asian and South American regions. Risk factors for PSCC include the absence of childhood circumcision, phimosis, chronic inflammation, poor penile hygiene, smoking, immunosuppression and infection with human papillomavirus (HPV). Several different subtypes of HPV-related and non-HPV-related penile cancers have been described, which also have different prognostic profiles. Localized disease can be effectively managed by topical therapy, surgery or radiotherapy. As PSCC is characterized by early lymphatic spread and imaging is inadequate for the detection of micrometastatic disease, correct and upfront surgical staging of the inguinal lymph nodes is crucial in disease management. Advanced stages of disease require multimodal management. Optimal sequencing of treatments and patient selection are still being investigated. Cisplatin-based chemotherapy regimens are the mainstay of systemic therapy for advanced PSCC, but they have poor and non-durable responses and high rates of toxic effects, indicating a need for the development of more effective and less toxic therapeutic options. Localized and advanced penile cancers and their treatment have profound physical and psychosexual effects on the quality of life of patients and survivors by altering sexual and urinary function and causing lymphoedema.

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.

Penile Sparing Techniques For Penile Cancer

Penile cancers are rare malignancies. Traditional surgical options, including partial and total penectomy, can dramatically affect a patient's quality of life and mental health. In select patients, penile sparing techniques (PST) have the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual function, and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of the various PST currently available for men seeking an organ-preserving option for their penile cancer.

Clinical outcomes of glansectomy with split-thickness skin graft reconstruction for localized penile cancer

INTRODUCTION

Penectomy as the traditional surgical treatment of penile cancer has substantial adverse functional and psychological impact. Glansectomy with split-thickness skin graft (STSG) reconstruction aims to provide curative resection while maximizing functional outcomes and minimizing psychological harm. We describe our outcomes of glansectomy with STSG reconstruction for penile cancer in a Canadian setting.

METHODS

We identified patients undergoing glansectomy with STSG genital reconstruction for squamous cell carcinoma of the penis from July 2006 to July 2019 at a single center. Patients undergoing glansectomy for reasons other than penile cancer were excluded. We collected clinical and pathological data, including patient demographics, 90-day complications, positive margin rate, local recurrence rate, disease-specific survival, and functional outcomes. Descriptive statistics were used to characterize our cohort and to examine outcomes.

RESULTS

Twelve men met study criteria with a median age of 62 years. Seven patients had failed prior treatment. The 90-day complication rate (Clavien >2) was 0% and graft take was excellent in all cases. The positive margins rate was 16.7% (n=2). Local recurrence occurred in two patients (16.7%), one of whom underwent a repeat organ-sparing surgery for salvage, while the other underwent radical penectomy for high-risk pathological features. Disease-free survival at a median followup of 14 months was 91.7% (11/12). Standing voiding and erectile function, as well as satisfactory cosmesis, were preserved in all patients.

CONCLUSIONS

Glansectomy with STSG reconstruction is a safe and effective treatment for men with localized penile cancer with simultaneous preservation of cosmesis, as well as urinary and sexual function.

Review of penile reconstructive techniques

Reconstructive surgery of the penis holds many unique challenges due to the unique physiological properties of the tissues. Much of the effort involved therefore goes to preserving as much of the native tissue as possible whilst novel and creative methods have been adopted to repair defects and in creation of neophallus. A search of the PubMed database was carried out using the following keywords: 'penile trauma', 'penile cancer', 'lichen sclerosus', 'glansectomy', 'glans resurfacing', 'penile-sparing surgery', 'micropenis', 'aphallia', 'female-to-male sex reassignment surgery', 'scrotal flap' and 'genital lymphoedema'. Results for glans resurfacing in treating cancer showed low local recurrence rates at 0-10% whilst 90% of lichen sclerosus patients reported complete resolutions of pain and pruritis. For repairs of penile shaft skin defects the literature supports the use of full-thickness skin graft and pedicled scrotal flaps. The radial artery-based forearm free flap remains the best option for neophallus creation in terms of function, sensation and cosmesis but unfortunately leaves a disfiguring scar and involves multiple stages. Some novel techniques have been developed to circumvent these issues and are discussed. This article presents an update on the important developments in the field of penile reconstructive surgery.

Localized disease: types of reconstruction/plastic surgery techniques after glans resurfacing/glansectomy/partial/total penectomy

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the current literature specific to surgery for localized penile cancer including novel reconstructive techniques.Centralization of penile cancer services in many European countries and in particular the United Kingdom has resulted in an increased proportion of men undergoing organ-sparing surgery (OSS) rather than partial or total penectomy. In this review, we focus on reconstructive techniques following surgery for the primary penile tumour.

RECENT FINDINGS

The widespread adoption of penile preserving techniques in Europe and North America has shown both oncological safety as well as good cosmetic and functional outcomes. Recent evidence has suggested that narrower surgical margins do not affect overall cancer-specific survival or local recurrence rates. Therefore, excellent cosmetic and functional outcomes can be achieved using techniques such as glans resurfacing using split-thickness skin grafts, dorsal or ventral V-Y skin advancement and urethral centralization after partial penectomy. For patients requiring more radical surgery such as total penectomy, phallic reconstruction is a suitable option using free flaps or pedicled flaps.

SUMMARY

The use of OSS has transformed the lives of penile cancer patients who can avoid the significant clinical and psychological consequences of more radical surgical treatments. Careful case selection and preoperative counselling is advised prior to reconstructive techniques. Close postoperative clinical surveillance is necessary for early detection of local recurrence.

[Carbon dioxide laser treatment of genital intraepithelial neoplasia: A retrospective study]

INTRODUCTION

Genital intraepithelial neoplasias (IEN) are precursors of squamous cell carcinoma. The ideal treatment must be efficacious, conservative and well-tolerated. CO2 laser is one of the recommended therapies, but its efficacy and safety have not been extensively studied.

PATIENTS AND METHODS

This was a retrospective single-center study. Sixteen patients (8 women and 8 men) treated with CO2 laser for genital IEN, whether high-grade or differentiated, were included. Surgical lateral margins of 3 to 5mm were taken macroscopically during treatment. The CO2 laser session, assessment of therapeutic response and follow-up were undertaken by a dermatologist at the University Hospital of Caen.

RESULTS

The mean patient age was 68.1 years and mean follow-up was 52.7 months (5-130). Lesions were isolated in 87.5% of patients. The recurrence rates of genital intraepithelial neoplasia after CO2 laser treatment were 58% for women and 40% for men. No impact on quality of life or on sexual activity was reported in over 90% of patients.

CONCLUSION

Whatever the treatment recommended for intraepithelial neoplasia, recurrence is frequent. CO2 laser is an effective and well-tolerated conservative therapeutic option. It enables rapid clinical remission, but as with all currently available treatments, long-term dermatologic follow-up remains necessary.

Glans Resurfacing with Skin Graft for Penile Cancer: A Step-by-Step Video Presentation of the Technique and Review of the Literature

Introduction

Glans resurfacing has been suggested as a treatment option for the surgical management of superficial penile cancer (Tis, Ta, T1aG1, T1aG2). In this article we describe in detail the glans resurfacing technique with skin graft for penile cancer in a video presentation and we review the current knowledge of the literature.

Material and Methods

The procedure is described in a stepwise fashion. Initially the patient is circumcised. The glans is marked in quadrants and completely stripped by dissecting and removing the epithelium and subepithelium layer of the glans. Deep spongiosal biopsies are taken to exclude invasion. Each quadrant is sent separately for biopsy. The surface of the graft size needed is estimated. A partial thickness skin graft is harvested from the thigh with a dermatome. The skin graft is then fenestrated. The graft is rolled over the glans and quilted with multiple sutures. A silicone 16F Foley catheter and a suprapubic catheter are placed. The penis is dressed with multiple gauzes and compressed with an elastic band.

Results

The patient is discharged the next day. The dressing and Foley catheter are removed in 7 days. The patient continues to use the suprapubic catheter for 7 more days. The patient refrains from any sexual activity for 6 weeks and is closely followed.

Conclusions

Glans resurfacing is an emerging new appealing surgical technique that is already a recommendation in the EAU guidelines for the treatment of premalignant and superficial penile lesions. The overall satisfaction rate and recovery of the sexual function are acceptable, and it can be considered an ideal procedure to treat superficial penile cancer.

Organ-sparing procedures in GU cancer: part 2-organ-sparing procedures in testicular and penile tumors

PURPOSE

Organ-sparing surgery (OSS) is recommended in selected patients with testicular tumors and penile cancer (PC). The functional and psychological impacts of organ excision for these genital tumors are profound. In this review, we summarize the indications, techniques and outcomes of OSS for these two tumors.

METHODS

PubMed^® was searched for relevant articles up to December 2018. For Testicular sparing surgery (TSS) search, keywords used were; testicular tumors alone and in combination with "testicular sparing surgery", "partial orchiectomy" and outcomes. For penile conserving surgery (PCS), keywords used were: penile cancer alone and in combination with "penile conserving surgery", "partial penectomy" and outcomes. Because of the low quality of available evidence, a narrative rather that systematic review has been performed.

RESULTS

Indications of TSS are tumors ≤ 2 cm in solitary testis or bilateral tumors and no rete testis invasion. Prerequisites include normal testosterone and luteinizing hormone levels and patient compliance with follow-up. Indications for PCS are distal penile lesions with clinical stage ≤ T1. Adequate penile stump (3 cm) is required after surgery to maintain forward urine stream. Frozen section helps to reduce the risk of recurrence. Local recurrence after PCS is not associated with reduced survival and can be managed with another PCS in selected patients. The reported oncological and functional outcomes following TSS and PCS are adequate.

CONCLUSIONS

In properly selected patient OSS in testicular and penile tumors has a comparable oncological outcome to total organ excision with added advantages of preserving organ function and psychological well-being.

The Diagnosis and Treatment of Penile Cancer

BACKGROUND

The incidence of penile cancer in Europe lies in the range of 0.9 to 2.1 cases per 100 000 persons per year. Carcinogenesis is associated with human papilloma virus (HPV) infection and with chronic inflammation.

METHODS

This review is based on publications (2010-2017) retrieved by a selective search in PubMed and EMBASE and on the guidelines of the European Association of Urology, the European Society of Medical Oncology, the National Comprehensive Cancer Network, and the National Institute for Health and Care Excellence (NICE).

RESULTS

95% of cases of penile cancer are accounted for by squamous cell carcinoma, whose numerous subtypes have different clinical courses. Chronic preputial inflammation due to phimosis or lichen sclerosus is often associated with penile cancer. Circumcision lowers the risk of penile cancer (hazard ratio: 0.33). Maximally organ-preserving surgery with safety margins of no more than a few millimeters is the current therapeutic standard, because a local recurrence, if it arises, can still be treated locally with curative intent. Local radiotherapy can be performed in early stages. Lymphogenic metastasis must be treated with radical lymphadenectomy and adjuvant chemotherapy. Patients with clinically unremarkable inguinal lymph nodes nonetheless need invasive lymph node staging because of the high rate of lymphogenic micrometastasis.

CONCLUSION

Penile cancer is curable in all early stages with the appropriate treatment, but its prognosis depends crucially on the proper management of the regional (i.e., inguinal) lymph nodes. In many countries, the treatment of this rare disease entity has been centralized.

[Assessment of scar satisfaction and quality of sexual life after conservative surgical treatment. Our experience]

The aim of the present study was to evaluate the overall scar satisfaction and quality of life in the conservative surgical treatment of penis cancer with reconstruction according to the Bracka technique. In order to do this, we passed out the questionnaire «Patient Scar Assessment Questionnaire» and the IIEF-15 questionnaire. From 2015 to 2017, 5 conventional glandectomy and reconstruction according to the Bracka technique were performed. 100% of the patients were very satisfied with the result, were slightly aware of the presence of the wound and lacked discomfort in relation to the scar. Regarding the quality of sexual life, an average improvement of 18 points was observed in the IIEF-15. We observed improvement in satisfaction of the sexual relationship (P6-8), orgasmic function (P9-10), overall satisfaction (P13-14) and confidence to maintain sexual intercourse (P15). Lesions at the level of the penis represent an important alteration in quality of sexual life. By performing a minimally invasive surgery with subsequent reconstruction, the patient presents a significant improvement in the quality of sexual life.

[Penile intra-epithelial neoplasia]

INTRODUCTION

Penile intra-epithelial neoplasia (PIN) are precancerous lesions, characterized by architectural and cytological abnormalities of the genital epithelium, from which can arise squamous carcinomas.

METHODS

A literature review was performed on the Medline database, considering the articles listed between October 2007 and October 2017 dealing with PIN, using the following keywords "intraepithelial neoplasia" or "Bowen's disease" or "erythroplasia of Queyrat" or "bowenoid papulosis" and "penis ». Papers were selected according to their language (English and French) and their relevance.

RESULTS

One hundred seventy four articles related to PIN were listed. Twenty-five of them were selected for their relevance. The analysis of the references of these articles identified 6 relevant papers published before October 2007, which were considered for this review based on a total of thirty-one articles. We describe clinical and pathological characteristics of PIN, emphasizing treatment modalities.

CONCLUSION

Urologists should distinguish HPV-related and non HPV-related PIN, both of them sharing clinical presentation, but needing different management.

[Local treatment of penile cancer]

In recent decades, the local treatment of penile cancer has focused primary on the removal of the primary tumor. Due to the significant psycho-oncological effects of treating the primary tumor, the guidelines on penile cancer now contain a clear recommendation for preserving the target organ and prior to each surgical procedure histological examination should be performed to confirm the penile cancer. For more advanced tumors, reconstructive plastic surgery should also be considered. The treatment of the primary tumor should be based on the stage and the local extent and size of the tumor. The aim of this article is to highlight current standards in the local treatment of penile cancer.

Penile-sparing modalities in the management of low-stage penile cancer

Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.

Contemporary role of radiotherapy in the management of penile cancer

Penile cancer is a rare clinical entity that contributes to significant patient morbidity and mortality. Human papilloma virus (HPV) plays an important role in the carcinogenesis of penile squamous cell carcinoma (SCC), is associated with improved clinical outcomes, and is predictive for response to treatment with chemotherapy and radiotherapy. Historically, treatment consisted of radical surgery with partial or total penectomy. While effective for local control, surgical resection can impart significant physical, psychological and sexual dysfunction for afflicted men. Organ preservation strategies offer significant quality of life advantages over standard surgery and can be utilized without compromising oncological control. As an alternative or adjunct to surgical resection, radiation therapy can be used for organ preservation strategies successfully in up to 70% of patients. A variety of treatment techniques can be employed depending on the location and burden of disease. Limited disease can be amenable to treatment with interstitial brachytherapy, surface mold plesiotherapy or external beam radiotherapy. For locally advanced presentations, or for patients not amenable to surgical resection, excellent clinical outcomes can be achieved using a combination of chemotherapy and radiation therapy. Here, we discuss the management of penile SCC using modern radiation therapy treatment techniques, the expected clinical outcomes for organ preservation, as well as the management of side-effects and toxicities. While large randomized trials are being developed, the management of penile cancer is informed from the management of other of other anogenital malignancies, which we also review.

National Trends and Predictors of Organ-sparing for Invasive Penile Tumors: Expanding the Therapeutic Window

INTRODUCTION

The purpose of this study was to analyze contemporary trends and predictors in the use of organ-sparing treatment (OST) for low-stage invasive penile tumors as well as to ascertain its impact on overall mortality (OM) in those with high-risk (pT2) disease.

PATIENTS AND METHODS

The National Cancer Data Base was queried for patients with clinically nonmetastatic penile cancer and available pathologic tumor (pT) and treatment data from 1998 to 2012. Independent predictors for performance of OST were analyzed. Multivariable Cox proportional hazard regression was used to identify factors of OM in a subset of patients with pT2 disease.

RESULTS

A total of 4231 patients with ≤ pT2cN0cM0 primary penile cancer were identified over a median follow-up of 39.6 months. Approximately 49% of patients received OST over the study period (P = .009). Older age, Hispanic ethnicity, urban counties, academic facilities, and pT2 disease were negative predictors for OST (all P < .05), whereas grade and years of diagnosis where associated with increased performance (P < .01). In subgroup analysis of pT2 patients, older age, black race, comorbidity, node status, and grade were associated with higher OM (all P < .05). When compared with radical penectomy, partial penectomy was associated with decreased OM (hazard ratio, 0.67; 95% confidence interval, 0.52-0.87; P = .002), whereas organ-sparing did not affect survival (hazard ratio, 0.83; 95% confidence interval, 0.52-1.31; P = .419) in these patients.

CONCLUSION

Ethnic and socioeconomic differences exist in the local management of penile tumors. No impact on OM was observed for those with high-risk cases treated with organ-sparing at intermediate follow-up. More studies are needed to evaluate oncologic efficacy of organ-sparing in carefully selected invasive penile tumors.

Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer

This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.

Organ Preservation Surgery for Carcinoma Penis

Carcinoma of the penis is not uncommon in India. A sizeable number of patients do not report to the doctors in fear of mutilation to the organ and hence subsequently end up with advanced disease. Many patients with T1 or T2 disease when carefully selected are amenable to organ-preserving penile procedures including surgery, topical therapy, laser, and radiation therapy. Identification of appropriate patients and institution of these treatments has been noted to produce oncologically comparable results to extirpative surgeries. In this article, we review the criteria to identify patients qualifying for organ-preserving treatments and also review outcomes with a variety of penile-preserving procedures.