Quality of life in patients treated for penile cancer. A follow-up study

A Review of Transplantation Practice of the Urologic Organs: Is It Only Achievable for the Kidney?

Transplantation is a viable treatment option for failure of most major organs. Within urology, transplantation of the kidney and ureter are well documented; however, evidence supporting transplantation of other urologic organs is limited. Failure of these organs carries significant morbidity, and transplantation may have a role in management. This article reviews the knowledge, research, and literature surrounding transplantation of each of the urologic organs. Transplantation of the penis, testicle, urethra, vas deferens, and bladder is discussed. Transplantation attempts have been made individually with each of these organs. Penile transplantation has only been performed once in a human. Testicular transplantation research was intertwined with unethical lucrative pursuits. Interest in urethra, bladder, and vas deferens transplantation has decreased as a result of successful surgical reconstructive techniques. Despite years of effort, transplantations of the penis, testicle, urethra, vas deferens, and bladder are not established in current practice. Recent research has shifted toward techniques of reconstruction, tissue engineering, and regenerative medicine.

Challenges and controversies in the management of penile cancer

Penile cancer is a rare disease, accounting for ~1% of all malignancies in men. Poor awareness of the condition among the public and clinicians often causes long delays in diagnosis and treatment, which may result in the development of advanced disease that might require extensive and emasculating surgery. In the UK, the development of supraregional penile cancer centres has pooled resources and expertise, which has led to considerable improvements in our understanding and management of this rare condition over the past decade. However, significant gaps in our knowledge still exist. Several areas of diagnosis and management remain areas of controversy, ranging from preventive strategies and treatment of premalignant disease to the assessment of lymph node involvement and the management of advanced disease.

Penile cancer: organ-sparing techniques

To compare the oncological safety of treating patients with penile cancer with conservative techniques developed to preserve function, cosmesis and psychological well-being with more radical ablative strategies. We conducted an extensive review of the literature of penile-preserving and ablative techniques and report on the oncological as well as functional outcomes. There were no randomised studies comparing penile-preserving and ablative techniques. Most studies consisted of retrospective cohorts. The quality of evidence was level 3 at best. Cancer-specific survival is similar in penile-preserving and ablative approaches for low-stage disease. Penile preservation is better for functional and cosmetic outcomes and should be offered as a primary treatment method in men with low-stage penile cancer.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Glans preservation contributes to postoperative restoration of male sexual function: a multicenter clinical study of glans preserving surgery

PURPOSE

We evaluated whether glans preserving surgery would be more helpful for patients to regain satisfactory sexual competency postoperatively than conventional partial amputation.

MATERIALS AND METHODS

From 2004 to 2012 at 4 centers a total of 135 men treated with glans preserving surgery and 36 treated with partial amputation were selected for evaluation from a total of 273 consecutive patients with penile cancer. Subjective evaluation for patient sexual performance was investigated using the IIEF-15. Objective evaluation was done using the audiovisual sexual stimulation test with the RigiScan® Plus. The degree of satisfaction with penile appearance, and patient confidence and partner acceptability for intercourse were evaluated by 5-point scales.

RESULTS

Patients treated with glans preserving surgery had better performance in 4 IIEF-15 domains (erectile function, orgasmic function, intercourse satisfaction and overall satisfaction) and 1 RigiScan parameter (tip rigidity) (each p <0.01). They also had significantly higher appearance satisfaction (64.4% vs 13.9%) and intercourse confidence (55.6% vs 5.6%) than men who underwent partial amputation. Sexual partners in the glans preserving group also showed significantly higher appearance satisfaction (51.1% vs 5.6%) and intercourse acceptability (37.8% vs 16.7%) than in the partial amputation group.

CONCLUSIONS

Glans preserving surgery effectively preserves the functional anatomy and cosmetic appearance of the glans penis. Glans preservation contributes to minimizing postoperative erectile dysfunction and negative psychological impediments, and promotes return to satisfactory sexual performance. Patients treated with glans preservation have more advantages in obtaining sexual acceptance from their partners than those who undergo amputation.

Does the width of the surgical margin of safety or premalignant dermatoses at the negative surgical margin affect outcome in surgically treated penile cancer?

AIMS

To evaluate the prognostic impact of the width of negative surgical margins (NSM) and associated and preinvasive lesions at the NSM in patients with penile squamous cell cancer (PSC).

METHODS

Enrolling 87 patients with NSM who underwent surgery for PSC, the archived margin slides and entirely wax-embedded surgical margins were retrieved from the pathology files. After step sections were cut, margins were stained with antibodies against CK5/6, p16, p53 and Ki-67 and subjected to in situ hybridisation for high-risk human papillomavirus (HPV). All NSM were histologically examined for squamous hyperplasia (SH), lichen sclerosus (LS) and subtypes of penile intraepithelial neoplasia (PeIN). Then, histological findings were correlated with cancer-specific mortality (CSM, median follow-up 34 months; IQR 6-70).

RESULTS

All NSM were negative for high-risk HPV and exhibited SH (p16 and p53 negative, Ki-67 variably positive), LS (p16 negative, variable p53 and Ki-67 positivity) and differentiated PeIN (dPeIN; p16 negative, Ki-67 positive, variable p53 positivity) in 28 (32%), 30 (34%) and 22 (25%) cases, respectively, whereas PeIN subtypes other then dPeIN did not occur. Pathological tumour stage was the only independent predictive parameter with respect to CSM in the multivariable analysis (p=0.001).

CONCLUSIONS

SH, LS and dPeIN are frequent histological findings at the NSM of surgically treated PSC. However, neither the width of the NSM nor dPeIN, LS or SH at the NSM influences prognostic outcome.

Penile cancer

OBJECTIVES

To review the risk factors, prevention, treatment, and management of the patient with penile cancer.

DATA SOURCES

Publications; clinical experience.

CONCLUSION

Penile cancer is a rare malignancy in the United States, but is more common in developing countries. The disease is so uncommon in the United States that there are oncology nurses who have never cared for a patient with this diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

With significant psychosocial implications for the patient with penile cancer and partner, it is important that the nurse have an understanding of the diagnosis, treatment, and care of these patients.

Construction of a penoid after penectomy using a transpositioned testicle

Total penectomy results in a disfiguring anatomic situation which may have a devastating effect on the patient's psychologic health. Here we report our experience with construction of a penoid by covering a transpositioned testicle with remaining penile skin after radical penectomy in 2 patients with malignant underlying disease.

Conservative surgery for squamous cell carcinoma of the penis: resection margins and long-term oncological control

PURPOSE

We assessed the oncological outcome of penile conserving surgery and identified parameters predicting local recurrence, including resection margins.

MATERIALS AND METHODS

A total of 179 patients with invasive penile cancer treated with organ sparing surgery at a tertiary center between 2002 and 2010 fulfilled our study criteria. Demographic, histopathological, management and followup data were recorded in a prospective database. Local, regional and distant recurrence rates, time to recurrence and survival rates were calculated. Survival analysis was performed by the Kaplan-Meier method. Multivariate analysis was used to identify predictors of local recurrence.

RESULTS

Mean followup was 42.8 months (range 4 to 107). Local, regional and distant metastatic recurrence developed in 16 (8.9%), 19 (10.6%) and 9 patients (5.0%) at a mean of 26.1, 26.8 and 11.7 months, respectively. The 5-year disease specific survival rate after recurrence was 54.7% (95% CI 46.1-63.3). For patients with isolated local recurrence the 5-year disease specific survival rate was 91.7% compared to 38.4% for those with regional recurrence. The overall 5-year local recurrence-free rate was 86.3% (95% CI 82.6-90.4). Tumor grade (p = 0.003), stage (p = 0.021) and lymphovascular invasion (p = 0.014) were identified as predictors of local recurrence on multivariate analysis.

CONCLUSIONS

Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.

Aesthetic neo-glans reconstruction after penis-sparing surgery for benign, premalignant or malignant penile lesions

Purpose

To describe the technique and results of penis-sparing surgery combined with a cosmetic neo-glans reconstruction for benign, pre-malignant or malignant penile lesions.

Patients and methods

Twenty-one patients (mean age 61 years) with penile lesions with a broad spectrum of histopathology underwent organ-sparing surgery with neo-glans reconstruction, using a free split-thickness skin graft harvested from the thigh. Three patients were treated by glans-skinning and glans-resurfacing, 10 by glansectomy and neo-glans reconstruction, four by partial penectomy and a neo-glans reconstruction, and four by neo-glans reconstruction after a traditional partial penectomy.

Results

The mean follow-up was 45 months; all patients were free of primary local disease. All patients were satisfied with the appearance of the penis after surgery, and recovered their sexual ability, although sensitivity was reduced as a consequence of glans/penile amputation.

Conclusion

In benign, premalignant or malignant penile lesions, penis-sparing surgery combined with a cosmetic neo-glans reconstruction can be used to assure a normally appearing and functional penis, while fully eradicating the primary local disease.

Outcome of glansectomy and skin grafting in the management of penile cancer

Purpose. To report outcome data for patients with penile cancer treated surgically with glansectomy and skin grafting. Materials and Methods. We retrospectively reviewed data on all patients undergoing surgical management of penile cancer by a single surgeon between 1998 and 2008. Outcomes in patients who underwent glansectomy and skin grafting were analysed. Results. Between 1998 and 2008 a total of 25 patients with a mean age 60 (39–83) underwent glansectomy and skin grafting. Six patients had carcinoma in situ (CIS); the stage in the remaining patients ranged from T1G1 to T3G3. Mean followup for patients was 28 months (range 6–66). Disease specific survival was 92% with 2 patients who had positive nodes at lymph node dissection developing groin recurrence. One patient developed a local recurrence requiring a partial penectomy. Conclusions. Penile preserving surgery with glansectomy and skin grafting is a successful technique with minimal complications for local control of penile carcinoma arising on the glans. Careful followup to exclude local recurrence is required.

Organ-preserving neodymium-yttrium-aluminium-garnet laser therapy for penile carcinoma: a long-term follow-up

OBJECTIVE

To retrospectively analyse the long-term follow-up of 54 patients treated with organ-preserving laser therapy for penile carcinoma, as such therapy provides excellent cosmetic and functional results, but recurrence rates are high, which might impair the oncological outcome and worsen tumour-related survival.

PATIENTS AND METHODS

Between 1979 and 2008, 54 patients with penile carcinoma were treated with the neodymium-doped yttrium-aluminium-garnet (Nd:YAG) laser at our institution; 11 were classified as having carcinoma in situ (Tis), 39 as T1 and four as T2.

RESULTS

There was local recurrence in 16 patients (42%); the mean (range) time to local recurrence was 53 (9-132) months. In half the patients the time to local recurrence was >53 months, with the latest recurrence at 132 months after initial therapy of primary tumour. There was no statistically significant difference in recurrence rates with Tis or invasive penile carcinoma. In lymph-node-negative patients at initial presentation, there were no newly developed positive lymph nodes during the follow-up.

CONCLUSIONS

Organ-preserving laser therapy showed a relatively high recurrence rate in patients with a long-term follow up, but the oncological outcome and survival were not compromised by local recurrence. Therefore, laser therapy appears to be appropriate for treating premalignant lesions and early stages of penile carcinoma. Patients should be informed about the potential for late recurrence.

Simple, safe, and satisfactory secondary penile enhancement after near-total oncologic amputation

After oncologic penile amputation, the penile stump may prove of insufficient length, causing poor personal hygiene and scrotal excoriation and an inability to void while standing. In these cases, penile enhancement by uncovering its subcutaneous parts may offer a simple and satisfactory solution.From August 2003 to August 2007, penile enhancement was performed in 6 patients with a mean age of 63 years (range, 51-69 years) and only 1 cm (range, 0-1.5 cm) of remaining penile length when standing up.The skin on the penile stump was used to recreate a neoglans. The subcutaneously covered penile shaft was dissected deep to Buck's fascia up into the deep suspensory ligament. Ventrally, the bulbospongeous muscle was laid bare over 1 to 2 cm. After resection of pubic subcutaneous fat, the pubic and scrotal skin edges were anchored to the suspensory ligament, bulbospongious fascia, and tunica albuginea. The resulting bare surface of the penile shaft was covered by a skin graft.Partial neoglandular skin slough was observed in 2 patients and could be treated conservatively in both. Penile lymphedema was observed in the 1 patient whom had previously undergone radiotherapy. This was treated by secondary subcutaneous resection and skin tightening. At a mean follow-up of 2.5 years (range, 1-5 years), the cosmetic appearance was acceptable in all patients and their penile length ranged from 7.5 to 9 cm. All were able to void while standing without soiling themselves.

Glansectomy with split-thickness skin graft for the treatment of penile carcinoma

Using our prospectively derived database, we identified 17 patients with squamous-cell carcinoma involving the glans penis, who were treated using organ-sparing surgery between March 2003 and January 2008. Of them, two were treated with partial glansectomy with primary glans closure, and 15 underwent total glans amputation and reconstruction of a new glans using a split-thickness skin graft (STSG). These 15 patients represent the subject of our study (mean age 51 years, range 42 to 59 years). Overall, two patients had early partial loss of the graft and of them, one required surgical regrafting. Two late complications occurred, consisting of one meatal stenosis and one postoperative phimosis. At a mean follow-up of 36 months, functional results were extremely satisfactory. All patients maintained their erectile function with good vaginal penetration starting from 3 months after surgery, with a range between 2 and 6 months. Orgasm and ejaculation were preserved in all patients, although reduced glans sensitivity was reported by all patients. No local recurrences were reported.

Treatment-seeking, aspects of sexual activity and life satisfaction in men with laser-treated penile carcinoma

OBJECTIVES

The aims were to assess the initial symptoms of penile carcinoma and patients' time frame in treatment seeking, and to describe the effect of laser treatment on sexual activity and life satisfaction.

PATIENTS AND METHODS

A retrospective face-to-face structured interview study of patients laser treated for localised penile carcinoma at the department of Urology in Orebro, Sweden, during 1986 to 2000. Sixty-seven was treated and 58 of them (mean age, 63 yr; range, 34-90) were alive at the time of this study. Forty-six (79%) agreed to participate.

RESULTS

Ninety-six percent of the patients recalled their first symptom of penile carcinoma. Superficial ulceration and fissures were the most common symptoms (39%). Thirty-seven percent delayed seeking treatment for more than 6 mo. The patients had a greater lifetime number of sexual partners and a greater lifetime prevalence of STIs than a Swedish representative comparator population. Some aspects of sexual life, such as manual stimulation/caressing and fellatio, decreased markedly after laser treatment. Patient satisfaction with life as a whole was approximately the same as that of the general population.

CONCLUSIONS

Patients delayed seeking treatment for a considerable period, despite awareness of the first local symptoms. Men with laser-treated localised penile carcinoma resume their sexual activities to a large extent after the treatment. Except for satisfaction with somatic health, similar-or even higher-proportions of patients than comparators are satisfied with life as a whole and with other domains of life including satisfaction with sexual life.

Organ-preserving surgery for penile carcinoma

Introduction. Penile carcinoma has traditionally been treated by either surgical amputation or radical radiotherapy, both associated with devastating anatomical, functional, and psychological impact on the patient's life. Innovative surgical techniques have focused on penile preservation in well-selected patients to minimize physical disfigurement and consequently maximize quality of life. The objective of this article is to define the current status of these organ-preserving surgical options for penile carcinoma. Materials and Methods. An extensive review of the Pubmed literature was performed to find articles discussing only reconstructive surgery which have contributed significantly to change traditional, frequently mutilating treatments, to develop less disfiguring surgery, and to improve patients' quality of life over the last two decades. Results. Several articles were included in this analysis in which a major contribution to the change in therapy was thought to have occurred and was documented as beneficial. Some articles reported novel techniques of less-mutilating surgery involving different forms of glans reconstruction with the use of flaps or grafts. The issue of safe surgical margins was also addressed. Conclusion. The development of less-disfiguring techniques allowing phallus preservation has reduced the negative impact on functional and cosmetic outcomes of amputation without sacrificing oncological objectives in appropriately selected patients based on stage, grade, and location of the tumour. Until more prospective studies are available and solid evidence is documented, organ preservation should be offered with caution.

Penile preserving surgery and surgical strategies to maximize penile form and function in penile cancer: recommendations from the United Kingdom experience

OBJECTIVES

The diagnosis of penile cancer can be devastating for a man and his partner. The fear of cancer is heightened by the prospect of penile amputation. While conventional radical surgery continues to be an effective approach to management, the emasculating nature of this treatment has serious psychological and sexual morbidity. Recent studies have challenged the traditional belief that a 2 cm margin was required for adequate oncological control.

METHODS

We review the current options and status of such penile preserving techniques in the modern day management of penile cancer, and assess the use of the different techniques according to the stage and grade of disease based upon the combined experience of two superregional centres in the United Kingdom.

RESULTS

A range of organ preserving procedures matches the clinical spectrum of patients presenting with penile cancer. These demonstrate excellent oncological control whilst maximizing penile function and form.

CONCLUSION

Innovative surgical techniques can now preserve as much penile tissue and functional integrity as possible, without compromising oncological control. This minimizes the impact of disease and its treatment on the quality of life of the patient.

Radiation therapy in the management of the primary penile tumor: an update

OBJECTIVES

Squamous carcinoma of the penis is rare but psychologically devastating and potentially fatal. Radiotherapy offers a penile-conserving treatment option without jeopardizing cure. We have used primary penile brachytherapy as the treatment of choice for T1, T2 and selected T3 patients since 1989 and present updated results for 67 patients.

METHODS

Mean age was 60 years (range 22-93). Stage was T1 in 56%, T2: 33%, T3: 8%, and Tx: 3%. Grade was moderate or poorly differentiated in 48%. In Toronto after-loading pulse dose rate (PDR) brachytherapy (n = 41) was used for all treatments while Ottawa used manually loaded Iridium(192) (n = 26). Two or three parallel planes of needles (median 6) were inserted using pre-drilled lucite templates for guidance and fixation; 60 Gy was delivered over 4-5 days.

RESULTS

Median follow-up is 4 years (range 0.2-16.2). At 10 years, actuarial overall survival is 59%, cause specific survival 83.6%. Nine men died of penile cancer and eight of other causes with no evidence of recurrence. Penectomy was required for eight local failures and two necroses, for an actuarial penile preservation rate at 5 years of 88% and 10 years of 67%. The soft tissue necrosis rate is 12% and the urethral stenosis rate 9%. Six of 11 regional failures were salvaged by lymph node dissection +/- external radiation. The other five all had concurrent distant failure and died of disease.

CONCLUSIONS

Brachytherapy is an effective treatment for T1, T2 and selected T3 SCC of the penis. Close follow-up is mandatory as local failures and many regional failures can be salvaged by surgery.

Partial Penectomy for Patients With Squamous Cell Carcinoma of the Penis: The Memorial Sloan-Kettering Experience

BACKGROUND

To present our institution's experience with squamous cell carcinoma (SCC) of the penis, with analysis of oncologic efficacy and survival.

METHODS

Between 1989 and 2005, we identified 32 consecutive patients (median age, 61 years) with SCC of the penis managed with partial penectomy. Clinicopathologic variables were examined, and overall and disease-specific survival were determined.

RESULTS

Pathologic stage of the primary tumor was pTis in 1 patient (3%), pT1 in 11 (34%), pT2 in 16 (50%), and pT3 in 4 (13%). Pathologic grade was well differentiated in 9 patients (28%), moderately differentiated in 20 (63%), and poorly differentiated in 2 (6%). Twenty-five patients (78%) underwent inguinal lymph node dissection, with 15 (60%) demonstrating nodal metastases. Twenty-two patients (69%) underwent pelvic lymph node dissection; 21 were negative for pelvic nodal metastases, and 1 had grossly positive nodes. One patient developed local recurrence. After a mean follow-up of 34 months, overall survival was 56%. Numbers of patients alive and disease-free were 9 and 11 in the low-stage and advanced-stage groups, and 8 and 12 in the well and moderately differentiated groups, respectively. Both patients with poorly differentiated disease died of disease within 12 months from presentation.

CONCLUSIONS

Partial penectomy for SCC of the penis provides excellent local control, with low recurrence rate, and acceptable maintenance of urinary and sexual function. Outcomes are generally poor, however, for patients with regional metastases, even in moderately differentiated disease. Future studies are needed to identify a reliable method of predicting regional metastases.

Reconstructive surgery for invasive squamous carcinoma of the glans penis

OBJECTIVES

We present medium-term outcome data for patients with invasive penile cancer treated with glansectomy and reconstruction with a split-thickness skin graft.

METHODS

A series of consecutive patients referred with penile malignancies over a 6-yr period were analyzed prospectively. A dedicated histopathologist reviewed all the specimens. After clinical staging, patients with tumours confined to the glans were offered glansectomy.

RESULTS

A total of 72 patients (32% of patients, 31% of procedures) underwent glansectomy for penile carcinoma. Of these, 65 patients were new diagnoses and seven were recurrences after radiotherapy. The mean follow-up period was 27 mo (range: 4-68 mo). There have been three late local recurrences (4%).

CONCLUSION

Glansectomy appears to be an oncologically safe and effective procedure for patients with glans-confined squamous cell tumours. It preserves maximum phallic length and results in a very satisfactory cosmetic penile appearance after reconstruction.

Resurfacing and reconstruction of the glans penis

OBJECTIVES

To describe the techniques and results of surgical reconstruction of glans penis lesions.

METHODS

Seventeen patients (mean age: 53.2 yr) were treated by resurfacing or reconstruction of the glans penis for benign, premalignant and malignant penile lesions. The aetiology of the lesions was one Zoon's balanitis, four lichen sclerosus, one carcinoma in situ, five squamous cell carcinomas, and six squamous cell carcinomas associated with lichen sclerosus. Five cases were treated by glans skinning and resurfacing; five cases by glans amputation and reconstruction of the neoglans, and seven cases by partial penile amputation and reconstruction of the neoglans. Glans resurfacing and reconstruction were performed with the use of a skin graft harvested from the thigh.

RESULTS

The mean follow-up was 32 mo. All patients were free of local premalignant/malignant recurrence. Patients who underwent glans resurfacing reported glandular sensory restoration and complete sexual ability. Patients who underwent glansectomy or partial penectomy with neoglans reconstruction maintained sexual function and activity, although sensitivity was reduced as a consequence of glans/penile amputation.

CONCLUSIONS

In selected cases of benign, premalignant or malignant penile lesions, glans resurfacing or reconstruction can ensure a normal appearing and functional penis, without jeopardizing cancer control.

Reconstructive surgery in penile trauma and cancer

This article provides an overview of the current concepts in reconstructive surgery following penile trauma, penile fracture and penile cancer. It covers the initial management of penile trauma, with the aim of preservation of as much viable tissue as is practical, and also provides advice on dealing with penile avulsion and amputation injuries. The best treatment for penile fracture-immediate surgical exploration and repair-is outlined and discussed. Finally, penile cancer management is reviewed, from initial biopsy to definitive treatment of the penile lesion-including wide excision, partial glansectomy, total glansectomy, and partial and total penectomy. It is concluded that appropriate surgery in all these conditions reduces subsequent long-term problems in sexual function, cosmesis, psychology, and (in cancer cases) longevity. The same reconstructive techniques can be applied for different penile conditions, and it is suggested that surgeons become experienced in genital surgery as a whole, rather than in oncology or trauma alone.

Penile brachytherapy: results for 49 patients

PURPOSE

To report results for 49 men with squamous cell carcinoma (SCC) of the penis treated with primary penile interstitial brachytherapy at one of two institutions: the Ottawa Regional Cancer Center, Ottawa, and the Princess Margaret Hospital, Toronto, Ontario, Canada.

METHODS AND MATERIALS

From September 1989 to September 2003, 49 men (mean age, 58 years; range, 22-93 years) had brachytherapy for penile SCC. Fifty-one percent of tumors were T1, 33% T2, and 8% T3; 4% were in situ and 4% Tx. Grade was well differentiated in 31%, moderate in 45%, and poor in 2%; grade was unspecified for 20%. One tumor was verrucous. All tumors in Toronto had pulsed dose rate (PDR) brachytherapy (n = 23), whereas those in Ottawa had either Iridium wire (n = 22) or seeds (n = 4). Four patients had a single plane implant with a plastic tube technique, and all others had a volume implant with predrilled acrylic templates and two or three parallel planes of needles (median, six needles). Mean needle spacing was 13.5 mm (range, 10-18 mm), mean dose rate was 65 cGy/h (range, 33-160 cGy/h), and mean duration was 98.8 h (range, 36-188 h). Dose rates for PDR brachytherapy were 50-61.2 cGy/h, with no correction in total dose, which was 60 Gy in all cases.

RESULTS

Median follow-up was 33.4 months (range, 4-140 months). At 5 years, actuarial overall survival was 78.3% and cause-specific survival 90.0%. Four men died of penile cancer, and 6 died of other causes with no evidence of recurrence. The cumulative incidence rate for never having experienced any type of failure at 5 years was 64.4% and for local failure was 85.3%. All 5 patients with local failure were successfully salvaged by surgery; 2 other men required penectomy for necrosis. The soft tissue necrosis rate was 16% and the urethral stenosis rate 12%. Of 8 men with regional failure, 5 were salvaged by lymph node dissection with or without external radiation. All 4 men with distant failure died of disease. Of 49 men, 42 had an intact and tumor-free penis at last follow-up or death. The actuarial penile preservation rate at 5 years was 86.5%.

CONCLUSIONS

Brachytherapy is an effective treatment for T1, T2, and selected T3 SCC of the penis. Close follow-up is mandatory because local failures and many regional failures can be salvaged by surgery.

Cancer of the penis

Cancer of the penis is rare in Europe, accounting for less than 0.5% of all cancers. Phimosis and poor hygiene are strong risk factors whereas neonatal circumcision is a contributing factor in the prevention of this disease. More than 95% of penile carcinomas are squamous cell carcinomas. Early disease (stage I-II) is curable in most patients, who can be treated by conventional penile amputation or, in selected cases, by organ preserving techniques, including Moh's micrographic surgery, laser ablation or radiation therapy (external-beam, brachytherapy). For more advanced primary tumours, penile amputation is required. Survival of patients with penile cancer is strongly related to the presence and extent of nodal metastases. Bilateral inguinal lymphadenectomy is recommended for palpable lymph nodes that persist 3 or more weeks after removal of the primary tumour and a course of antibiotic therapy. In patients with proven inguinal lymph node metastases, bilateral ileoinguinal dissection should be performed. When the nodes are clinically negative, "prophylactic" inguinal lymphadenectomy may be a reasonable approach in patients with invasive tumours (T2 or greater), high grade tumours, or tumours exhibiting vascular invasion. The role of chemotherapy, as adjuvant and neoadjuvant or primary treatment in metastatic disease, needs to be further explored in prospective clinical trials.

Reconstructive Technique for Partial Penile Amputation

Partial or total penile amputation with resection of the corpora cavernosa and the urethra is a common and effective surgical procedure used to treat squamous cell cancer infiltrating the deep tissues of the penis. We describe an original method that allows for an aesthetic and functional restoration of the partially or total amputated penis.

Surgical technique

We performe a reconstructive technique for partial penile amputation by releasing the scarring tissue adhesions with cavernosal lysis and by advancing the penile stump with dissection of the suspensory ligament; implantation of soft but axially firm endocavernosal elastomer prostheses to maintain the corpora cavernosa extended; placement of split-thickness skin grafts to cover the shaft skin defects and glanduloplasty with oral mucosa grafting. In cases of total penile amputation, the method begins with the reconstruction of a new phallus using a rectoabdominalis flap; the new penis is then covered with split-thickness skin grafts and finally, at a later date, soft but axially firm endocavernosal elastomer prostheses are implanted.

Results

The success rate as be excellent compared with other complex reconstructive and remodelling procedures for the penis and the glans after partial or total penectomy described by several authors.

Conclusions

In cases of total or subtotal penile amputation, the use of our techniques provides satisfactory aesthetic and functional results, thus we consider it to be a simple solution since it is not too invasive, it is quick and can be carried out by urologists without recourse to sophisticated microsurgery techniques.

Organ-sparing surgery for invasive penile cancer: early follow-up data

OBJECTIVE

To present early outcome data from patients treated for invasive penile cancers with organ-sparing surgery, as the treatment of such malignancies has traditionally either been amputative surgery or radical radiotherapy, both associated with significant physical and psychosexual morbidity.

PATIENTS AND METHODS

A consecutive series of patients referred over a 3-year period for the treatment of penile malignancy were analysed prospectively. After clinical staging and grading, those patients requiring surgery were offered either a glans-preserving or a glans-removing procedure.

RESULTS

Of the 78 patients referred, 49 required surgery, with penile-preserving procedures in 39 of them; 32 were newly diagnosed tumours and seven were recurrences after radiotherapy. The tumour grade and stage were G1 in 11, G2 in 17 and G3 in 10 (one had melanoma and was not graded); and Ta in two, T1 in 19, T2 in 17 and T3 in one. The mean follow-up was 16 months, with nine patients followed for > or = 2 years. Complications included two patients who required immediate revisional surgery for positive resection margins, and one with radio-necrosis. One patient who had a glans-preserving procedure developed a recurrence, whereas none of those who had the glans removed did so.

CONCLUSION

With careful patient selection and meticulous follow-up, most patients with invasive penile carcinoma can be offered penile-preserving surgery.

Sexual function and satisfaction in men after laser treatment for penile carcinoma

PURPOSE

We evaluate sexual function, sexual satisfaction and cosmetic results after laser treatment of penile carcinoma.

MATERIALS AND METHODS

A total of 67 patients were treated at our clinic for penile cancer using combined carbon dioxide and neodymium:YAG lasers from 1986 to 2000. At the time of this study 58 men, with a mean age of 64 years were alive, of whom 46 (79%) agreed to participate in a structured face-to-face interview addressing sexual function, sexual satisfaction and cosmetic results. The length of time that had elapsed since treatment ranged from 6 months to 15 years (median 3 years).

RESULTS

Of 40 patients (87%) who had been sexually active before treatment 30 (75%) had resumed activities at the time of the interview. Unaltered erectile function after treatment was reported by 33 patients (72%), 10 patients (22%) reported decreased function and 3 (6%) reported improved function. Of the 46 patients 23 (50%) were satisfied/very satisfied with their sexual life. After treatment only 3 of 30 (10%) of the evaluable men had dyspareunia. The cosmetic results were considered satisfying/very satisfying by 36 (78%) men.

CONCLUSIONS

Laser treatment of localized penile carcinoma preserves the penis and generally provides satisfactory sexual function and cosmetic results.

Cancers of the prostate, penis, and testicles: epidemiology, prevention, and treatment

Cancer is a disease that most people fear. Nurses are required to provide information on how to avoid cancer, and, once the diagnosis is made, how to cope with it. Prevention and early detection of the cancers described in this article are in the very early stages of knowledge development, but general health promotion guidance can be offered on how to avoid most cancers (ie, no tobacco use, a high-fiber and low fat diet, exercise, and maintaining a normal weight). Nurses also can advise patients to be screened for colorectal cancer at the appropriate ages and time intervals and to be aware as new developments occur in the scientific base for screenings in the areas of prostate, penile, and testicular cancer. Finally, coping with these forms of cancer often requires the patient to make major lifestyle and psychological changes, especially if surgery in the genital area occurs. Decreased libido, incontinence, and impotence are major complications that can occur with these illnesses. The male cancers described vary tremendously in their prevalence, incidence, mortality, treatment, and survival rates. Within this group, there are remarkably positive outcomes and outcomes much in need of improvement. Penile and testicular cancers are the bright spots in this picture; both are uncommon, and both are eminently treatable. Prostate cancer, on the other hand, is quite common, difficult to screen, difficult to treat without major sexual problems, and yet receives relatively little funding from the NIH. Although as many men die from prostate cancer as women die from breast cancer, NIH funds breast cancer research at much higher levels than prostate cancer. According to the latest data available at the NIH Web site, during the 1990s, the amount of NIH funding varied from four times more for breast cancer (1993) to 2.9 times more in 1999. For fiscal year 2002, NIH is providing $522 million in funding for breast cancer and $278 million for prostate cancer. Private foundation funds for prostate cancer are much smaller than those available for breast cancer. Both types of cancer are extremely important to address, and both should receive adequate research attention. Nurses can advocate for more funding for prostate cancer, from basic science approaches to behavioral science strategies.

Penile carcinoma. Is Nd:YAG laser therapy radical enough?

PURPOSE

Penile carcinoma is a difficult disease to treat due to its aggressive nature and the psychological effects of amputation, which is often the recommended therapy. Outcome data from the last 13 years on patients with penile carcinoma treated with Nd:YAG laser coagulation were evaluated and compared with outcome data on conventional organ sparing techniques.

MATERIALS AND METHODS

For the last 13 years 29 patients were treated with Nd:YAG laser coagulation, including 17 with carcinoma in situ, and 10 with stage T1 and 2 with T2 cancer. Mean patient age was 55.1 years and mean followup was 46.7 months.

RESULTS

All patients are alive. Disease recurred in 1 patient with T1 tumor and 1 with carcinoma in situ. All patients were satisfied with the cosmetic and functional result.

CONCLUSIONS

Recurrence rates after Nd:YAG laser treatment for T1 tumors are comparable to those after partial amputation. Excellent cosmetic and functional results can be achieved without compromising oncological principles. For patients with metastasis prognosis is limited by the distant disease and, therefore, amputation is only necessary to achieve local control.

Treatment of localized carcinoma of the penis: a survey of current practice in the UK

Consensus opinion from published reports on the management of localized carcinoma of the penis recommends that patients with small, distal, non-poorly differentiated lesions should be offered penis-conserving treatment, while those with larger or more advanced lesions should be considered for amputative surgery. A questionnaire survey was sent to 289 urologists and 237 oncologists in the UK to assess their practice for the treatment of localized carcinoma of the penis. Consultants were asked to choose between penis-conserving surgery, amputation or radiotherapy as their preferred treatment for four examples of localized disease. Oncologists were also asked to indicate their preferred radiation modality (external beam radiotherapy or brachytherapy). For treating a small lesion situated distally on the glans penis, 56.7% of urologists and 94.5% of oncologists preferred penis-conserving methods; 28.8% of urologists and one oncologist preferred partial or total amputation. In total, 43.2% of urologists would consider amputative surgery for this lesion compared with only 5.5% of oncologists. Only 23.3% of oncologists considered using brachytherapy. For a 4 cm lesion situated distally, the majority of urologists surveyed (82.0%) preferred amputative surgery, while the majority of oncologists (68.5%) preferred conservative treatment. For a 1.5 cm lesion extending on to the penile shaft, 68.5% of urologists preferred amputative surgery while 85.0% of oncologists preferred penis-conserving options. For a 4 cm lesion extending on to the shaft, the vast majority of urologists (86.5%) preferred amputation as treatment compared with only 36.9% of oncologists. The results of the survey suggested that clinicians tended to favour the treatment modality of which they have most experience. As such, urologists tended to prefer surgery while clinical oncologists tended to prefer radiotherapy, irrespective of the size and position of the primary tumour or consensus opinion. These results emphasize the importance of multidisciplinary clinics and site specialization, so that both clinicians and patients can make informed choices about optimal treatment, based on the knowledge of all available treatment options.

Squamous cell carcinoma of the penis

Squamous cell carcinoma of the penis is a rare disease in Western countries. In geographical locations where infantile circumcision is not routinely practised and genital hygiene is poor, penile cancer may comprise 10-20% of all malignancies. Superficial tumours (Ta-Tl) should be treated with organ-preserving therapy. Partial of total penectomy is recommended for invasive penile carcinoma (stage T2 or higher). Currently, management of the ilioinguinal lymph nodes is controversial. The value of radiation therapy and chemotherapy is still uncertain; these treatments are only palliative therapy modalities.

Conservative surgical therapy for penile and urethral carcinoma

OBJECTIVES

Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery.

METHODS

Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data.

RESULTS

Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months.

CONCLUSIONS

Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.