|Year : 2006 | Volume
| Issue : 4 | Page : 341-344
Penile-preserving surgery in penile carcinoma
B Gowardhan1, D Greene2
1 Department of Urology, Sunderland Royal Hospital, Kayll Road, Sunderland, United Kingdom
2 University of Sunderland, Edinburgh Building, Chester Road, Sunderland, United Kingdom
Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Penile cancer is an uncommon cancer involving the glans, prepuce or both in over 75% cases. Historically, the standard treatment of the primary tumor has been a partial or total penectomy. Although these are still widely practiced procedures for control of the disease, as our understanding of the natural history of the disease has evolved, the treatment options have broadened, focusing more and more on penile-preserving techniques such as Mohs's micrographic surgery, wide local excision, subtotal and total glansectomy, laser, brachytherapy, external beam radiotherapy and topical application of chemotherapeutic agents such as 5-Fluorouracil. Penile-preserving options are increasingly being used as a first-line treatment, not restricted to Tis/Ta tumors, but for T1, T2 and even T3 tumors in selected cases. The metastatic stage of the tumor does not influence the treatment of the primary lesion. In this review, we discuss the various penile-preserving options currently available and their role in the management of penile carcinoma of various stages.
Keywords: Penile cancer, penile conservation
|How to cite this article:|
Gowardhan B, Greene D. Penile-preserving surgery in penile carcinoma. Indian J Urol 2006;22:341-4
The incidence of penile cancer is very low, with a geographic variation worldwide. The incidence is 0.7-0.9 per 100,000 in USA; 0.1-0.9 per 100,000 in Europe; but as high as 19 per 100,000 in parts of Asia, South America and Africa and even 50 per 100,000 in parts of northeastern Brazilian states., This low incidence accounts for the lack of good quality randomized controlled trials, which has made it difficult for the development of treatment protocols or guidelines. Up until the early 1980s, the main management of penile cancer was partial or total penectomy. These procedures are still in common practice today and although they provided good cancer control with low recurrence rates, the procedures have been deemed rather radical and patient acceptance has been poor, with a strong negative psychological impact on most men, particularly those who were sexually active prior to the procedure.,
The natural history of penile cancer is better understood now, in particular, the stepwise spread to the local and eventually distant lymph nodes. This has allowed the evolution of various techniques of lymph nodal assessment and sampling, commencing with Cabanas's initial description of sentinel node sampling in 1977. Little progress was made with regards to the treatment of the primary lesion, until Mohs described his technique of micrographic surgery for localized penile cancer in 1985. Around the same time, Laser treatment of primary lesions of the penis was being used with promising results and a low incidence of complications., Other alternatives such as External Beam Radiotherapy, Brachytherapy, Photodynamic therapy, Cryotherapy, Wide local excision and subtotal or total glansectomy with or without grafting have gained interest since then. These procedures all aim to control the disease with preservation of the penis, which has a better acceptance with patients and preserves sexual function to varying extents.
| Assessment of the primary lesion|| |
The common modality of assessing the primary lesion is clinical examination, which is very accurate (almost 100%) in determining the T stage of the disease according to the TNM classification, which interestingly has been shown to be superior to USS and even MRI scan. Despite this, MRI has a place in the assessment of the primary lesion, especially when enhanced with gadolinium. More recently, work has been done, looking at the usefulness of MRI in conjunction with an artificially induced erection of the penis, using prostaglandin E. In nine patients studied, the T stage of the disease was accurate with the final pathological stage in eight patients. The one case it did not pick up was of Tis (carcinoma in situ ). Although more studies are needed to assess the usefulness of this form of investigation, the initial impression is promising. Biopsy of the lesion is also extremely useful, since it provides information on the grade of the disease, which helps with the decision on lymph node dissection or surveillance.
| Surgical treatment options|| |
Mohs was the first to describe a local excision surgical procedure involving multiple staged procedures of excising layer by layer of the tumor area and histological assessment, to ensure negative margins. Recurrence rates of this procedure were 8% in this series. Also, it was thought that tumors larger than 3 cm should not be considered for this procedure. The procedure has been performed using frozen section in an attempt to complete the treatment in a single sitting but the results by Mohs et al have not been reproduced. As a result, the procedure has not gained wide acceptance. Frozen section is very useful in surgical procedures but has an error of around 9.5%, which can seriously affect the outcome of the procedure.
Until recently, it has been believed that a minimum 2 cm margin of clearance is needed to achieve adequate cancer control. This historical view has been challenged and the current view is that a clearance of 1 cm or even a few millimeters is sufficient to achieve adequate cancer control. This supports the concept of penile-preserving surgery and as a result, procedures such as wide local excision and subtotal or total glansectomy have triggered more interest as penile-preserving surgical procedures. These achieve local tumor control with good cosmetic results. Wide local excision has had tumor recurrence rates of 7.7-50%, which are very high. Wide local excision has been assessed as a first-line treatment of the primary tumor with long-term follow-up, with three recurrences out of 30 patients treated. The recurrences were treated with further surgical resection. Subtotal or total glansectomy has been used in the treatment of disease, which is located distal to the level of the coronal sulcus. In a study looking at subtotal glansectomy as a primary treatment, the tumor over the glans was excised and the wound closed. The skin of the shaft of the penis was advanced to the level of the urethra, which was not spatulated and anastomosed. The benefit of not spatulating the urethra resulted in an even stream, with no spraying. The overall results were good in a 12-month follow-up. Another recent study looked at the role of total glansectomy for verrucous carcinoma of the glans in seven patients. Only one patient had a local recurrence at three months warranting a partial penectomy, but at a follow-up ranging from 18 to 65 months, no recurrences were noted in the remainder of the patients. The cosmetic results were very good with normal erectile function postoperatively. Pietrzak et al reported on 39 cases of partial or total glansectomy for primary disease (n=32) or failure of external beam radiotherapy (n=7). With a mean follow-up of only 16 months, their early data was very encouraging with minimal postoperative complications and a good cosmetic outcome. Only one case of recurrence was noted in a patient who had a partial glansectomy. No recurrences were noted in the patients who had total glansectomy. With these procedures, either a primary closure of the wound can be carried out as for partial glansectomy or partial or full thickness skin grafting, as in the case of a total glansectomy. Such a 'glanuloplasty', in our experience, yields much better cosmetic results as compared to a primary closure. The donor site is usually the anterior thigh, but the volar aspect of the forearm can be used and the graft is placed on the wound in a 'quilted' fashion to account for contracture of the graft.
Laser ablation of the penile lesion has been used since the 1980s. The four types of lasers used were CO 2 , Argon, Nd:YAG and Potassium Titanyl Phosphate lasers. The commonly used lasers currently are CO 2 and Nd:YAG. Since the depth of penetration of the CO 2 laser is only 0.1 mm, it makes it unsuitable for most tumors as a sole therapy, resulting in higher recurrence rates up to 50%. The Nd:YAG laser on the other hand, has a greater depth of penetration of up to 6 mm. The recurrence rates of laser treatment are dependent on the T stage of the tumor with recurrences of 7.7% for Tis, but as high as 25% for T2 tumors. Frimberger et al reported on 29 people treated with Nd:YAG laser, who also had tumor base biopsies to ensure complete treatment. Only two recurrences were noted (6.9%), which is comparable to the recurrence rates quoted for partial penectomy (0-8%). Windahl et al combined CO 2 laser with Nd:YAG to achieve better tumor control. A total of 67 patients were treated with the combination. Thirteen recurrences were noted in a median 42 months follow-up period, out of which 10 had successful repeat laser treatment. A total of eight patients died, two as a consequence of penile SCC and six from concurrent illnesses.
Interstitial radiotherapy has been used for the last two decades, being the treatment of choice in France. Radium 226, Iridium 192 and Cesium 137 are the radioisotopes which have been used for penile brachytherapy. Rozan et al reported data on 259 men with five and 10-year disease-free survival of 78 and 67%, respectively. Urethral strictures and penile necrosis are the common side-effects at 45 and 23%, respectively, consistent with other reports. The incidence of side-effects is thought to be lower with Iridium 192, with good local control. More recently, Crook et al reported on 49 patients with T1 to T3 tumors treated with brachytherapy. They reported a recurrence rate of 15% and side-effect incidence of 16 and 12% for urethral stenosis and penile necrosis, respectively. Most studies quoted in the literature, have used a total radiation dose of 50 to 70Gy.
External beam radiotherapy (EBRT)
Penile SCC is a relatively radio-resistant tumor requiring high doses of radiation to render the tumor sterile. The risk of urethral stenosis, fistulae, penile necrosis and pain is therefore high with this treatment. Also, the radiation changes including ulcers that can occur after EBRT can be difficult to distinguish from recurrent disease, warranting repeat biopsies. Local recurrence rates of 22-50% have been quoted for small tumors and low stages Ta - T3. pT2 - T3 tumors larger than 3 cm, however, had local recurrences as high as 66%. The long-term survival of patients treated with EBRT is comparable to penectomy.
| Discussion|| |
Penile cancer is a rare cancer with a natural history of a stepwise spread to the lymph nodes. The mainstay of treatment of the primary lesion has been partial or total penectomy up until the last 20 years. Both these procedures result in excellent cancer control, but have significant detrimental effects psychologically and psycho-sexually. The historic concept of a 2 cm margin as an essential requirement for adequate cancer control has been challenged and the current view is that 1 cm or even a few millimeters would provide adequate cancer control. With this view, it would seem that partial or total penectomy might be an over-treatment in most cases of localized disease, albeit with excellent results. Over the last 20 years, with the advent of various laser techniques, brachytherapy and microsurgical techniques, the possibility of penile preservation has become a reality. A number of groups have reported on their experience of various techniques, including Mohs's micrographic surgery, wide local excision, subtotal and total glansectomy, laser, brachytherapy and EBRT. All these procedures aim for adequate cancer control, cosmetically acceptable results with preservation of as much penile length as possible and preservation of sexual function, the latter being of variable importance to patients.
Despite the advent of imaging modalities such as USS and MRI to stage primary lesion, it is interesting to note that clinical examination has a near 100% accuracy in staging the disease, emphasizing its importance. The relevance of accurate staging is in choosing the appropriate therapeutic option. Although penile-preserving strategies are still to an extent in their infancy, based on the current literature, it would seem that larger tumors >4 cm and most T3 and all T4 tumors have a high recurrence rate, irrespective of the penile-preserving option used. In these cases, partial or total penectomy is still the treatment of choice.
Apart from recurrence rates for the various treatment options, the side-effects need to be taken into consideration when choosing a penile preserving option. In case of EBRT, the difficulty in accurately judging recurrence at clinical examination is a realistic one, which may lead to the need for repeated biopsies of the suspected areas. Additionally, side-effects such as urethral stricture, fistulae and penile necrosis can lead to additional problems for the patient and clinician alike. It would seem, looking through the literature, that EBRT is not as commonly used as a first-line treatment of penile carcinoma. Similarly, Brachytherapy has side-effects in the form of penile induration and loss of penile sensation, which, similar to EBRT, can make follow-up, challenging to rule out recurrences. Additionally, the preservation of sexual function is poor. The side-effects for surgical options such as wide local excision, glansectomy and laser, on the other hand, are lower.
In our centre, total glansectomy coupled with glanuloplasty, is the treatment of choice for tumors [Figure - 1]. For more locally advanced cancers, it is possible to remove the distal portion of the corpora cavernosa and to reconstruct a neo-glans with a partial thickness skin graft as described above.
| Conclusion|| |
It is evident that penile-preserving strategies such as Glansectomy, Laser, Brachytherapy and EBRT have an important place in the management of penile carcinoma. Although we have nearly 20 years of experience in this field, with the low incidence of the disease, indications for individual therapeutic procedures are lacking, but will hopefully become clear in the years to come. It is our opinion, a penile- preserving option is suitable for most patients with a primary tumor <4 cm in size and a stage
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[Figure - 1]