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

The Development and Feasibility of a Novel Electronic Patient-Reported Outcome Measures (Eproms) Questionnaire in patients with penile cancer

BACKGROUND

Penile cancer (PeCa) is a rare cancer with surgical options that affect patients' quality-of-life. Patient-reported outcome measures (PROMs) are uncommonly utilized in this cohort despite their several patient-centered benefits and there are recommendations to further digitalize PROMs. This prospective, population-based study aimed to report the development and feasibility of a novel electronic patient-reported outcome measures (ePROMs) questionnaire for patients with PeCa.

MATERIALS AND METHODS

A novel ePROMs questionnaire was developed and sent to patients 3 days before outpatient clinic appointments. The questionnaire included up to 30 items on patient symptomology and quality-of-life, including a self-reported quality-of-life score (rated 0 being worst and 100 being best). Data were collected for patients followed up between August 2021 and May 2022. The primary feasibility outcomes, adherence and engagement, were measured by response and drop-out rates. Differences in responders and nonresponders were also ascertained. Secondary outcomes explored the clinical utility of the questionnaire. Responders were subcategorized into 3 groups: circumcision (Ci), partial penectomy (PP) or total penectomy (TP) and differences were analyzed. This study was approved by the local Trust Governance Panel, including for ethical considerations.

RESULTS

220 adult males were sent ePROMs questionnaires, and 141 (64%) responded initially. The mean dropout rate of subsequent questionnaires was 56%. The maximum number of questionnaires sent to and completed by a patient was 8 (n = 1). Nonresponders were older (P < .0001), with poorer performance status (P < .0001) and lower body mass index (P = .0288). TP patients reported the lowest median quality-of-life score 68.50 (8-99), followed by the Ci group (72.0, 37-94) and the PP group (76.0, 10-99).

CONCLUSIONS

Patients initially engaged and adhered to the ePROMs questionnaire but struggled to maintain this over time. Clinical data gathered by the questionnaire may be utilized to inform patient care. The questionnaire requires additional validation, research, and education.

Medical photography and the reconstructive urologist: A 6-month prospective study

Medical photography has multiple, important roles. The education of medical practitioners, documentation of disease, response to treatment, research, publication, intraoperative recording and trauma documentation all rely on medical photography. Additionally, there are important medicolegal implications pertaining to medical photography across many medical disciplines. Other than specific image use to document cases, there remains a paucity of urological literature regarding the use of medical photography in Urology. The aims of this 6-month study were to document the use of medical photography by a Reconstructive Urological Service in a tertiary referral centre and to assess the range of urological conditions photographed. A secondary aim was to specifically document intraoperative use of the medical photography.

Phallus preservation and reconstruction: 5-year outcomes of national penile cancer centralisation in the Republic of Ireland

INTRODUCTION

Penile cancer is a rare urological malignancy with an age-standardised incidence of 0.8 per 100,000 person-years [1]. Given this low incidence it has been suggested that centralised care may improve patient outcomes in relation to phallus sparing surgery and nodal assessment [2]. We aim to assess the outcomes after 5-years of national centralisation of penile cancer care.

METHODS

A retrospective analysis of prospectively collected data was performed. All patients undergoing penile cancer surgery from January 2018 to December 2022 following centralisation of care were included. The primary outcome was proportion of phallus sparing procedures performed. Secondary outcomes were patient characteristics, histologic outcomes and procedures performed.

RESULTS

124 patients underwent surgery in the study period. Mean age was 64.49 (±13.87). Overall, 82.3% of patients underwent phallus sparing surgery. This remained stable over the 5-year period from 2018 to 2022 ​at 92%, 85%, 76%, 79% and 78% respectively (p ​= ​0.534). 62.7% had reconstruction performed, including split-thickness skin graft neoglans formation, (57.8% [n ​= ​37]), preputial flap (32.8% [n ​= ​21]), glans resurfacing (4.7% [n ​= ​3]), shaft advancement flap (1.6% [n ​= ​1]), penile shaft skin graft (1.6% [n ​= ​1]), and partial penectomy with urethral centralisation (1.6% [n ​= ​1]). Phallus preservation was not affected by positive nodal status (OR 0.75 [95% CI 0.249-2.266], p ​= ​0.564) or T-stage ≥1b (OR 0.51 [95% CI 0.153-1.711], p ​= ​0.276). There has been a significant reduction in Nx nodal status from 64% in 2017 to 15% in 2021 (p ​= ​0.009).

CONCLUSION

Centralisation of treatment for rare malignancies such as penile cancer may improve oncologic outcomes and rates of phallus preservation. This study has shown centralisation to has a high rate of phallus preservation. Further long-term analysis of outcomes in Ireland is required.

Penile-Sparing Surgery for Tumour Recurrence after Previous Glansectomy/Partial Penectomy: Treatment Feasibility and Oncological Outcomes

We tested the feasibility and oncological outcomes after penile-sparing surgery (PSS) for local recurrent penile cancer after a previous glansectomy/partial penectomy. We retrospectively analysed 13 patients (1997-2022) with local recurrence of penile cancer after a previous glansectomy or partial penectomy. All patients underwent PSS: circumcision, excision, or laser ablation. First, technical feasibility, treatment setting, and complications (Clavien-Dindo) were recorded. Second, Kaplan-Meier plots depicted overall and local recurrences over time. Overall, 11 (84.5%) vs. 2 (15.5%) patients were previously treated with glansectomy vs. partial penectomy. The median (IQR) time to disease recurrence was 56 (13-88) months. Six (46%) vs. two (15.5%) vs. five (38.5%) patients were treated with, respectively, local excision vs. local excision + circumcision vs. laser ablation. All procedures, except one, were performed in an outpatient setting. Only one Clavien-Dindo 2 complication was recorded. The median follow-up time was 41 months. Overall, three (23%) vs. four (30.5%) patients experienced local vs. overall recurrence, respectively. All local recurrences were safely treated with salvage surgery. In conclusion, we reported the results of a preliminary analysis testing safety, feasibility, and early oncological outcomes of PSS procedures for patients with local recurrence after previous glansectomy or partial penectomy. Stronger oncological outcomes should be tested in other series to optimise patient selection.

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.

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.

Effects of partial penectomy for penile cancer on sexual function: A systematic review

Penile cancer is a rare but debilitating condition, which often requires aggressive treatment. Partial penectomy is considered as a treatment option when a sufficient portion of the penile shaft can be maintained to preserve functionality. This systematic review, which followed the PRIMSA guidelines, aimed to evaluate the effects of partial penectomy for penile cancer on sexual function—the maintenance of which is often a priority in patient groups—and to identify potential factors which may moderate these effects. A systematic search of PubMed, The Cochrane Library, and Open Grey as well as MEDLINE, CINAHL and Open Dissertations via EBSCOhost was conducted from inception through to 24^th March, 2022. Studies were required to include adults aged ≥18 years who had undergone partial penectomy for the treatment of penile cancer, with a quantitative measure of sexual function available pre- and post-surgery. Four eligible articles were identified for inclusion in this review, three of which reported a decrease in sexual function pre- to post-surgery across all domains of the International Index of Erectile Function (IIEF) questionnaire (erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction). Conversely, one study reported an increase in sexual function across IIEF domains, except for orgasmic function, which decreased, pre- to post-surgery. Greater penile length was associated with higher post-operative sexual function, whilst increasing age and higher anxiety levels were associated with lower post-operative sexual function levels in one study. Despite the overall drop in sexual function, many patients were still able to maintain satisfactory sex lives following partial penectomy. Given the limited research in this area and small sample sizes across studies, additional well-controlled investigations are warranted to provide further evidence on the effects of partial penectomy for penile cancer on sexual function.

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.

Single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy versus laparoscopic inguinal lymphadenectomy for penile cancer: A retrospective controlled study

OBJECTIVES

The main purpose of this study was to compare the surgical strategy and clinical outcomes of single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy for penile cancer.

MATERIALS AND METHODS

21 patients were diagnosis with squamous cell carcinoma and identified from March 2010 to December 2020 in our department. Ten patients were received single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy (robot-assisted group), and eleven patients underwent laparoscopic inguinal lymphadenectomy (laparoscopic group). Preoperative physical examination and related auxiliary examinations all indicated bilateral inguinal lymph node enlargement, and there was no distant metastasis patient presented during the follow-up period.

RESULTS

There was no intraoperative conversion to open surgery. The operation time under robot-assisted group was 104 ± 13 min which was significantly shorter than laparoscopic group (136 ± 11 min, P < 0.01). The average number of lymph nodes was 22.2 ± 4.5 of both sides in robot-assisted group, which was statistically different compared with laparoscopic group (15.4 ± 3.1, p < 0.01). Moreover, there was significant difference of hospitalization cost between two groups (CNY 67429 ± 5586 vs 28582 ± 3774, P < 0.01). No differences in operation time, blood loss, and length of stay were recorded.

CONCLUSIONS

The single-position robotic assisted laparoscopic anterograde bilateral inguinal lymphadenectomy reveals with shorter operating time, and better surgical effect, Moreover, we prefer to no change the trocars layout and mechanical arm system during the operation.