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Management of the primary

Goals of management of the penile tumour:

  1. Oncological control with complete excision of the cancer
  2. Achieve accurate pathological staging and grading
  3. Preservation of the penis with sexual function, if possible
  4. Optimisation of voiding

 

Patients with favourable histological features (T1a or less, grade 2 or less) are at lower risk for metastatic disease, and best served with organ preserving treatment.

 

Minimally invasive / organ preserving options include:

  1. Topical treatment – 5-FU or imiquimod

Reserved generally for pTis disease – carcinoma in situ / PeIN confirmed on biopsy

 

  1. Wide local excision +/- circumcision +/- skin graft +/- glans resurfacing

Historically a 2 cm margin was aimed for, however this has no evidence base at 3 – 5 mm is likely to suffice.

Circumcision can be curative for foreskin tumours, and should be done concurrently with small locally excised glans tumours.

Skin grafts can be used to cover defects, and STSG can be used for glans resurfacing (often useful for high volume PeIN, or failure of topical treatment)

 

  1. Moh’s microsurgery

Layered microscopic guided surgery – good outcomes in small series but rarely practised.

 

  1. Laser ablation with CO2 or Nd:YAG

Suitable for pTa or pTis lesions.

 

  1. Radiation therapy

EBRT with minimum dose of 60 Gy combined with brachytherapy boost, or brachytherapy alone.

Recommended for T1 and T2 tumours < 4 cm, although oncological outcomes are inferior to surgery.

Unclear functional outcomes. Urethral stenosis (20-35 %) and glans necrosis (10-20 %) not uncommon.

Surgical options include:

  1. Glansectomy
  2. Partial penectomy
  3. Radical penectomy

Choice of lesion dictated by the location of the tumour and depth of invasion.

Glansectomy + resection of the corporal tips may be needed.

Patients undergoing penile preservation treatment may have higher local recurrence rates, however overall survival does not seem to be compromised as long as surveillance is maintained.

 

All cases thought to need significant surgery should be discussed at an MDT and consider centralising treatment to specialist centres.