Glansectomy and Reconstruction for Penile Cancer: A Systematic Review

Penile cancer treatment and sexuality: a narrative review

Penile squamous cell carcinoma is a rare malignancy that poses a significant concern to those affected due to its aggressive nature and profound impact on patients' quality of life. This review examines the evidence on the impact of penile cancer and its various treatments on the sexual health of patients. Men's post-surgical sexual functioning has mainly been assessed with the International Index of Erectile Functioning. Some studies asked men to report retrospectively on pre-surgical sexual functioning or compared surgical techniques with non-randomized samples. Studies on patient's perspectives on sexual sensations and appearance are emerging,  however reliable assessments of sexual wellbeing are missing. Penile cancer significantly impacts patients' sexual activity, sexual function, sexual sensations, cosmesis and sexual wellbeing. Considerable proportions of patients resume sexual activity following treatments, including organ-sparing procedures, partial or total penectomy, and adjuvant therapies. While organ-sparing surgeries can largely preserve sexual functioning, more invasive treatments like partial or total penectomy result in greater declines, with the impact on sexual wellbeing remaining underexplored. Rigorous prospective studies assessing valid and reliable patient reported outcome measures for sexual wellbeing besides sexual functioning are needed in order to fully understand and address the impact of penile cancer treatment on sexual health.

Functional outcomes of glansectomy to treat localised penile cancer: a systematic review

Glansectomy with or without a neoglans reconstruction is commonly performed for invasive penile cancer confined to the glans penis. The aim of penile-preserving procedures is to maintain sexual and urinary function without compromising oncological outcomes. A systematic review was performed to evaluate the functional outcomes following glansectomy. Overall, 14 studies which included 327 glansectomy procedures were analysed. At a mean follow-up of 40.7 (range, 13-52) months, the recurrence rate was 9.1% (0-25%) and the disease-specific survival rate was 87.5-100%. Partial graft loss and meatal stenosis occurred in 6.1% (0-17.6%) and 8.1% (0-14.3%) respectively. 91.1% (50-100%) had preserved erectile function and 62.5% (33.3-100%) were sexually active. 75.6% (66.7-100%) of patients were voiding whilst standing up and 83.7% (63.6-91.2%) had maintained glans sensation. Satisfaction with the overall appearance was achieved in 86.3% (68.2-100%). The reporting of functional outcomes was heterogenous with a limitation that there are no standardised guidelines on the assessment of functional outcomes following glansectomy. Further research should focus on identifying appropriate tools for reporting functional outcomes following glansectomy and standardising reporting.

Functional outcomes of organ sparing surgery for penile cancer confined to glans and premalignant lesions

The first-line treatment of penile cancer confined to the glans (Tis-T2) is based on organ-sparing approaches. Our aim is to report functional outcomes of total glans resurfacing (TGR), wide local excision (WLE) and glansectomy. A retrospective analysis was conducted from January 2013 to October 2022. Ninety-nine patients were enrolled (22 TGR, 29 WLE, and 48 glansectomy). Sexual and urinary outcomes were explored using ad hoc and validated questionnaires (IIEF-15 and IPSS). The mean follow-up was 25.28 ± 24.87 months [95% CI: 20.38; 30.18]. 44 patients (12 TGR, 10 WLE, and 22 glansectomy) were assessed for functional outcomes. Overall, 86.36% of patients were satisfied with the surgery. The mean IIEF-15 score pre-operation was 54.91 ± 21.38 [95% CI: 48.41-61.41], and at 12 months post-operation, it was 44.39 ± 23.01 [95% CI: 37.39-51.39], with the change being statistically significant (mean difference: -10.52, (-19.15), p < 0.001). During the 0-12-month interval, IIEF-15 scores decreased across all techniques. Glansectomy and WLE showed significant decreases (Glansectomy: -12.955, -24.14%, [95% CI: -21.52, -4.38], p = 0.002; WLE: -14.1, -22.92%, [95% CI: -26.8, -1.39], p = 0.025 respectively), whereas TGR experienced a non-significant decrease (-3.083, -5.97%, CI: [-14.68, 8.51], p = 1.0). Concerning urinary function, only 18.18% of overall patients reported a negative impact of surgery. At 12-months, patients returned almost to pre-intervention IPSS values. Organ-sparing surgery guarantees a decent preservation of both erectile and voiding functions. TGR seems to provide better sexual outcomes when compared to other organ sparing approaches.

Penile cancer: ESMO-EURACAN Clinical Practice Guideline for diagnosis, treatment and follow-up

•This ESMO CPG provides recommendations for diagnosis, staging, pathology, treatment and follow-up of penile cancer. •Algorithms for the management of primary penile tumours and inguinal lymph nodes are provided. •The author group encompasses a multidisciplinary group of experts from different institutions and countries in Europe. •Recommendations are based on available scientific data and the authors’ collective expert opinion. •In clinical practice, all recommendations provided need to be discussed with patients in a shared decision-making approach.

Comparative outcomes of partial versus total penectomy for penile carcinoma: A retrospective cohort study on demographics and postoperative complications

When feasible from an oncologic standpoint, partial penectomy (PP) is often preferred to total penectomy (TP) for penile cancer treatment, for the preservation of functional urinary outcomes. However, to date, there has not been a direct comparison of perioperative outcomes between PP and TP. Comparing treatments for penile cancer has proven difficult due to the rarity of penile cancer in the United States. We aimed to report differences in pre-operative risk factors, intra-operative outcomes, and postoperative outcomes between TP and PP for penile cancer. Using the National Surgical Quality Improvement Program database, we conducted a retrospective cohort review of penile cancer patients enlisted in the database between the years 2006-2016 using the International Classification of Diseases clinical modification 9th revision codes. A total of 260 patients, 67 TP and 193 PP patients, were included. PP patients were less likely to be transferred patients (p = 0.002), diabetic (p = 0.026), and were more likely to have preoperative laboratory values within normal limits. PP patients also had shorter lengths of stay in the hospital (p < 0.001) and operating time (p < 0.001). Significant differences were also found for inpatient stay (p < 0.001), 30-day post-surgery complications (p < 0.001), deep incisional surgical site infection (SSI) (p = 0.017), wound disruption (p = 0.017), intraoperative or postoperative transfusion (p = 0.029), and sepsis (p < 0.005). Finally, PP patients required fewer concurrent surgical procedures (p < 0.001). Demographic differences between PP and TP patients may reflect patients presenting with more advanced oncologic disease. PP is associated with fewer postoperative complications, shorter surgeries, shorter hospital stays, fewer concurrent surgical procedures, and comorbid conditions compared to TP. A gap remains in the reported data pertaining to postoperative sexual function and erectile outcomes for PP at a national level.

Long-term outcomes of penile squamous cell carcinoma in men age ≤50 years old compared with men >50 years old from a single tertiary referral centre: a propensity score matched analysis

Penile cancer (PeCa) is rare, and the oncological outcomes in younger men are unclear. We aimed to analyse and compare oncological outcomes of men age ≤50 years (y) and >50 years with PeCa. A retrospective analysis of men ≤50 y with penile squamous cell carcinoma managed at a tertiary centre was performed. A propensity score matched cohort of men >50 y was identified for comparison. Matching was according to tumour, nodal stage and the types of primary surgery. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metastasis-free survivals (MFS) were estimated using Kaplan-Meier plots and compared using log-rank tests. Between 2005-2020, 100 men ≤50 y (median (IQR) age, 46 y (40-49)) were identified and matched with 100 men >50 y (median (IQR) age, 65 y (59-73)). 10, 24, 32, 34 men age ≤50 y were diagnosed in 2005-2007, 2008-2012, 2013-2016 and 2017-2020 respectively. Median (IQR) follow-up was 53.5 (18-96) months. OS at 2 years: ≤50 y, 86%>50 y, 80.6%; 5 years: ≤50 y, 78.1%, >50 y, 63.1%; 10 years: ≤50 y, 72.3%, >50 y, 45.6% (p = 0.01). DSS at 2 years: ≤50 y, 87.2%>50 y, 87.8%; 5 years: ≤50 y, 80.9%>50 y, 78.2%; 10 years: ≤50 y, 78%, >50 y, 70.9% (p = 0.74). RFS was 93.1% in the ≤50 y group (vs. >50 y, 96.5%) at 2 year, and 90% (vs. >50 y, 88.5%) at 5 years, p = 0.81. Within the ≤50 y group, 2 years and 5 years MFS was 93% (vs. >50 y, 96.5%), and 89.5% (vs. >50 y, 92.7%) respectively, (p = 0.40). There were no statistical significance in DFS, RFS and MFS in men age ≤50 y and >50 y. PeCa in younger patients is fatal, public awareness and patient education are crucial for early detection and management.

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.

Epidemiology, Diagnosis and Management of Penile Cancer: Results from the Spanish National Registry of Penile Cancer

INTRODUCTION

Penile cancer (PC) is a rare malignancy with an overall incidence in Europe of 1/100,000 males/year. In Europe, few studies report the epidemiology, risk factors, clinical presentation, and treatment of PC. The aim of this study is to present an updated outlook on the aforementioned factors of PC in Spain.

MATERIALS AND METHODS

A multicentric, retrospective, observational epidemiological study was designed, and patients with a new diagnosis of PC in 2015 were included. Patients were anonymously identified from the Register of Specialized Care Activity of the Ministry of Health of Spain. All Spanish hospitals recruiting patients in 2015 were invited to participate in the present study. We have followed a descriptive narration of the observed data. Continuous and categorical data were reported by median (p25th-p75th range) and absolute and relative frequencies, respectively. The incidence map shows differences between Spanish regions.

RESULTS

The incidence of PC in Spain in 2015 was 2.55/100,000 males per year. A total of 586 patients were identified, and 228 patients from 61 hospitals were included in the analysis. A total of 54/61 (88.5%) centers reported ≤ 5 new cases. The patients accessed the urologist for visually-assessed penile lesions (60.5%), mainly localized in the glans (63.6%). Local hygiene, smoking habits, sexual habits, HPV exposure, and history of penile lesions were reported in 48.2%, 59.6%, 25%, 13.2%, and 69.7%. HPV-positive lesions were 18.1% (28.6% HPV-16). The majority of PC was squamous carcinoma (95.2%). PC was ≥cT2 in 45.2% (103/228) cases. At final pathology, PC was ≥pT2 in 51% of patients and ≥pN1 in 17% of cases. The most common local treatment was partial penectomy (46.9% cases). A total of 47/55 (85.5%) inguinal lymphadenectomies were open. Patients with ≥pN1 disease were treated with chemotherapy in 12/39 (40.8%) of cases.

CONCLUSIONS

PC incidence is relatively high in Spain compared to other European countries. The risk factors for PC are usually misreported. The diagnosis and management of PC are suboptimal, encouraging the identification of referral centers for PC management.

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.