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| Advances in penile-sparing surgical approaches |
Karl H. Panga,Hussain M. Alnajjara,Asif Muneera,b,c,*( )
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aInstitute of Andrology, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
bDivision of Surgery and Interventional Science, University College London, London, UK
cNIHR UCLH Biomedical Research Centre, University College London Hospital, London, UK |
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Abstract Objective: Penile cancer (PeCa) is a rare disease with a global incidence of 36 068 new cases in 2020. This accounts for 0.4% of all male malignancies. The surgical management of PeCa depends on the location of the tumour and depth of invasion. Here, we review the oncological and functional outcomes of penile-preserving surgery (PPS). Methods: A PubMed search until July 2021 on PPS for PeCa was conducted; a narrative review on different penile-sparing approaches and outcomes was performed. Results: PPS is now the standard of care in specialist centres for distal tumours not involving the corpus cavernosa. Laser therapy, glans resurfacing, and wide local excision are options for superficial lesions, whilst glansectomy is required for lesions invading into the corpus spongiosum. Conclusion: PPS aims to preserve urinary and sexual function without compromising oncological outcomes.
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Received: 14 December 2021
Available online: 20 October 2022
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Corresponding Authors:
Asif Muneer
E-mail: Asif.muneer@nhs.net
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| Laser | Author | Country | Design | Patient, n | Follow-up, month | Histology, n (%) | Oncology outcome | Complication | Functional outcome/QoL | | CO2 | Zreik et al., 2017 [10] | UK | Retro | 47 | -Mean (range): 29 (1-76) | -PeIN: 47 (100) | -Rec: 8 (17.0%);
TTR: 19.4 months;
OS: 98.0%;
DSS: 100.0% | -0 | -NR | | Colecchia et al., 2009 [11] | Italy | Retro | 56 | -Median: 66 | -pT1: 56 (100) | -Rec: 13 (23.2%);
TTR: NR;
OS: 94.6%;
DSS: 100.0% | -NR | -NR | | Bandieramonte et al., 2008 [12] | Italy | Retro | 224 | -Median (IQR): 28.6 (22.7-46.3) | -pTis: 106 (47.3); pT1: 118 (52.7) | -Rec: 32 (14.4%);
TTR: NR;
OS: NR;
DSS: NR | -0 with significant complications | -NR | | Lont et al., 2006 [13] | The Netherlands | Retro | 44 | -NR | -pT1: 19 (43.2); pT2: 25 (56.8) | -Rec: 17 (38.6%);
TTR: NR;
OS: NR;
DSS: NR | -Meatal stenosis: 3 (6.8%) | -NR | | Nd:YAG | Schlenker et al., 2010 [14] | Belgium | Retro | 54 | -Mean (range):105 (18-262) | -pTis: 11 (20.4); pT1: 39 (72.2);
pT2: 4 (7.4) | -Rec: 16 (42%);
TTR: 53.0 months;
OS: 85.2%;
DSS: 98.2% | -NR | -NR | | Meijer et al., 2007 [15] | The Netherlands | Retro | 44 | -Range: 3-192 | -pTis: 6 (13.6); pT1: 21 (47.7);
pT2: 17 (38.6) | -Rec: 29 (65.9%);
TTR: 2.3-118.0 months;
OS: NR;
DSS: 90.9% | -NR | -NR | | Tewari et al., 2007 [16] | India | Retro | 32 | -Median (range): 70 (6-120) | -pT1: 25 (78.1); pT2: 7 (21.9) | -Rec: 2 (6.3%);
TTR: 48.0-60.0 months;
OS: 100%;
DSS: 100% | -NR | -Normal sexual function: 23 (72.2%);
Satisfied with cosmesis: 32 (100%) | | Lont et al., 2006 [13] | The Netherlands | Retro | 60 | -NR | -pT1: 24 (40.0); pT2: 36 (60.0) | -Rec: 22 (36.7%);
TTR: NR;
OS: NR;
DSS: NR | -Meatal stenosis: 3 (6.8%) | -NR | | Frimberger et al., 2002 [17] | Germany | Retro | 29 | -Mean: 46.7 | -pTis: 17 (58.6); pT1: 10 (34.5);
pT2: 2 (6.9) | -Rec: 2 (6.9%);
TTR: NR;
OS: 100%;
DSS: 100% | -NR | -Satisfied: 29 (100%) | Combinations
Nd:YAG, CO2, KTP | Kokorovic et al., 2021 [18] (CO2 or KTP) | USA | Pros | 8 | -Whole cohort
median: 28 | -NR | -Rec: 2 (25.0%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | Tang et al., 2018 [19] (Nd:YAG or CO2) | USA, Germany, the Netherlands, UK, and China | Retro | 161 | -Median (IQR): 58 (28-900) | -pTa/Tis: 59 (37.1); pT1a: 62 (39.0);
pT1b: 17 (10.7);
pT2:18 (11.3);
pTx: 3 (1.9) | -Rec: 69 (42.9%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | Baumgarten et al., 2018 [20] (Nd:YAG or CO2 +/? WLE) | USA, Germany, the Netherlands, UK, and China | Retro | Laser only: 149 | -NR | -pTa/Tis: 57 (26.1); pT1: 77 (13.4);
pT2: 15 (3.8) | -Laser +/? WLE
Rec for pT2: 20 | -NR
-NR | -NR
-NR | | Laser+WLE: 91 | -NR | -pTa/is: 11 (5); pT1: 48 (8.3);
pT2: 32 (8.1). | | Chipollini et al., 2018 [21] (Nd:YAG or CO2 +/? WLE) | USA, Germany, the Netherlands, UK, and China | Retro | Laser only: 58 | -Median (IQR): 63.8 (20.9-95.2) | -pTis: 58 (100) | -Rec: 28 (48.3%);
TTR: NR;
OS 5-year: 100%;
DSS: NR | -NR | -NR | | Laser+WLE: 10 | -Median (IQR): 47.3 (12.8-102.6) | -pTis: 10 (100) | -Rec: 3 (30.0%);
TTR: NR;
OS 5-year: 100%;
DSS: NR | -NR | -NR | | Windahl and Andersson, 2003 [22] (Nd:YAG and CO2) | Sweden | Pros | 67 | -Median (range): 42 (12-186) | -pTis: 21 (31.3); pTa: 2 (3.0);
pT1: 23 (34.3);
pT2: 19 (28.4);
pT3: 2 (3.0) | -Rec: 13 (19.4%);
TTR: NR;
OS: 88.1%;
DSS: 97.0% | -Postop bleeding: 5 (7.5%) | -Unaltered EF: 72%;
satisfied with cosmesis: 78% | | van Bezooijen et al., 2001 [23] (Nd:YAG or CO2) | The Netherlands | Retro | 19 | -Mean (range): 32 (1-96) | -pTis: 19 (100) | -Rec: 5 (26.3%);
TTR: 25 months;
OS: NR;
DSS: NR | 0 | | | Tietjen and Malek, 1998 [24] (Nd:YAG or CO2 or KTP) | USA | Retro | 52 (44 with follow-up) | -Mean (range): 58 (12-117) | -PeIN: 22 (42.3); pTis: 13 (25.0);
pT1: 16 (30.8);
pT2: 1 (1.9) | -Rec: 5 (11.4%);
TTR: 3-12 months;
OS: 97.7%;
DSS: 97.7% | -Pain/infection: 1 (2.3%)
Preputial lymphoedema: 1 (2.3%) | -NR | | Tm:YAG | Musi et al., 2018 [25] | Italy | Pros | 23 | -Median (IQR): 24 (15-30) | -pTis: 11 (47.8); pT1a: 7 (30.4);
pT2: 3 (13.0);
pT3: 2 (8.7) | -Rec: 4 (17.4%);
TTR: 6.5 months;
OS: 100%;
DSS: 100% | -Reduced penile sensitivity: 4 (17.4%) | -Conserved penile sensitivity: 6 (26.1%)
No effect on EF; impact on sexual life: 13 (56.5%) |
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Outcomes of laser ablation for penile cancer.
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| PPS | Author | Country | Design | Patient, n | Follow-up, month | Histology, n (%) | Oncology outcome | Complication | Functional outcome/QoL | | Mohs | -Machan et al., 2016 [29] | USA | Retro | 42 with 44 tumours (19 primary tumours with follow-up) | Mean: 97.4 | -pTis: 24 (54.5);
Invasive: 10 (45.5) | -Rec: 1 (3.4%);
TTR: 9 months;
OS: 67.7%;
DSS: 100.0% | -Urethral stricture: 4 (9.5%) | -Preserved: 42 (100%) | | -Shindel et al., 2007 [28] | USA | Retro | 33 (25 with follow-up) | -Mean (range): 58.0 (0.5-214.0) | -pTis: 26 (63.4); pT1: 4 (9.8);
pT2: 7 (17.1);
pT3: 4 (9.8) | -Rec: 8 (32.0%);
TTR: 36 months;
OS: 92.0%;
DSS: 96.0% | -Aborted due to: positive margins: 5 (15.2%);
wound dehiscence: 1 (3.0%);
meatal stenosis: 2 (6.1%) | -NR | | -Mohs et al., 1985 [27] | USA | Case series | 29 | ->60 | -Jackson stage:
1: 18 (62.1);
2: 9 (31.0);
3: 2 (6.9) | -Rec: (92.0%);
TTR: NR;
OS: 89.7%;
DSS: 100% | -NR | | | WLE and/or Circ | -Kokorovic et al., 2021 [18] (WLE) | USA | Pros | 36 | -Whole cohort median: 28 | -NR | -Rec: 2 (5.6%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Baumgarten et al., 2018 [20] (WLE) | USA, Germany, the Netherlands, UK, and China | Retro | 338 | -Whole cohort median (IQR): 43.0 (27.9-60.4) | -pTa/pTis: 68 (31.2); pT1: 183 (38.1);
pT2: 87 (22.1) | -Rec for pT2: 29 (33.3%)
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Baumgarten et al., 2018 [20] (Circ) | USA, Germany, the Netherlands, UK, and China | Retro | 362 | -Whole cohort median (IQR): 43.0 (27.9-60.4) | -pTa/pTis: 45 (20.6); pT1: 87 (15.1);
pT2: 5 (1.3) | -Rec: 0;
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Chipollini et al., 2018 [21] (WLE) | USA, Germany, the Netherlands, UK, and China | Retro | 61 | -Median (IQR): 35.0 (19.7-56.0) | -pTis: 61 (100) | -Rec: 15 (24.6%);
TTR: NR;
OS 5-year: 100%;
DSS: NR | -NR | -NR | | -Chipollini et al., 2018 [21] (Circ) | USA, Germany, the Netherlands, UK, and China | Retro | 44 | -Median (IQR): 40.0 (33.3-55.2) | -pTis: 44 (100) | -Rec: 0;
TTR: NR;
OS 5-year: 100%;
DSS: NR | -NR | -NR | | -Lucky et al., 2015 [30] (Circ and/or LE or 5-FU) | UK | Retro | Circ alone: 18 | -Mean: 3.5 | -pTis: 18 (100) | -Rec: 0;
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | Circ + LE: 20 | -pTis: 20 (100) | -Rec: 5 (25.0%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | Circ+5-FU: 19 | -pTis: 19 (100) | -No response: 5 (26.3%);
TTR: NR;
OS: NR;
DSS: NR | -Significant inflammation: 7 (36.8%) | -NR | | -Li et al., 2011 [31] (Circ and/or WLE | China | Pros | Circ: 8;
WLE: 18;
WLE + circ: 6 | -Median (range): 26.5 (2.0-61.0) | -Tis: 2 (6.3); pTa: 5 (15.6);
pT1: 23 (71.9);
pT2: 2 (6.2) | -Rec: 3 (9.4%);
TTR: <6 months;
OS: 96.9%;
DSS: 96.9% | -Wound dehiscence: 2 (6.2%);
Abscess: 1 (3.1%). | -Worsened EF: 1 (3.4%) | | -Lont et al., 2006 [13] | The Netherlands | Retro | 24 | -NR | -pT1: 13 (54.2); pT2: 11 (45.8) | -Rec: 7 (29.2%);
TTR: NR;
OS: NR;
DSS: NR | -Urethral fistula: 1 (4.2%) | -NR | | -Bissada et al., 2003 [32] | USA | Retro | 30 | -Range: 12-360 | -NR | -Rec: 3 (10.0%);
TTR: NR;
OS: NR;
DSS: 96.7% | -NR | -NR | | Glans resurfacing | -Cakir et al., 2021 [34] | UK | Retro | 10 | -Median (IQR): 29 (14-38) | -PeIN: 2 (20); pT1: 8 (80) | -Rec: 2 (20.0%);
TTR: 7-29 months (range);
OS: 100%;
DSS: NR | -Meatal stenosis/graft loss: 0 | -Median VAS score for cosmetic satisfaction: 4;
IIEF-5 median (IQR): 20 (17-23). | | -Falcone et al., 2020 [35] | Italy | Retro | 26 | -Median (IQR): 38 (13-86) | -Cis: 11 (42.3); pT1: 14 (53.8);
pT2: 1 (3.8) | -Rec: 3 (11.5%);
TTR: 11 months;
OS: 100%;
DSS: NR | -Wound infection: 1 (3.8%) | -NR | | -Baumgarten et al., 2018 [20] | USA, Germany, the Netherlands, UK, and China | Retro | 111 | -Whole cohort median (IQR): 43.0 (27.9-60.4) | -pTa/Tis: 23 (10.6); pT1: 73 (12.7);
pT2: 15 (3.8) | -Rec for pT2: 1 (6.7%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Chipollini et al., 2018 [21] | USA, Germany, the Netherlands, UK, and China | Retro | 22 | -Median (IQR): 40.3 (34.8-66.5) | pTis: 22 (100) | Rec: 1 (4.5%);
TTR: NR;
OS: 100%;
DSS: NR | -NR | -NR | | -O'Kelly et al., 2017 [36] | UK | Pros | 19 | -Median (range): 21 (7-27) | -pTis: 8 (42.1); pTa/T1: 11 (57.9) | -Rec: 1 (5.3%);
TTR: NR;
OS: 100%;
DSS: NR | -Graft failure: 1 (5.3%) | -Preserved sexual activity: 100% | | -Veeratterapillay et al., 2012 [37] | UK | Retro | 3 | -Median (range): 40 (12-72) | -pTis: 3 (100) | -Rec: 0;
TTR: NR
OS: NR;
DSS: NR | -NR individually | -NR individually | | -Shabbir et al., 2011 [33] | UK | Retro | 25 | -Median (range): 29 (2-120) | -pTis: 25 (100) | -Rec: 1 (4.0%);
TTR: 14 months;
OS: NR;
DSS: NR | -Graft failure: 1 (4.0%) | -NR | | -Hadway et al., 2006 [38] | UK | Retro | 10 | -Median (range): 30 (7-45) | -Cis: 8 (80);
Severe dysplasia: 2 (20) | -Rec: 0;
TTR: NR;
OS: NR;
DSS: NR | -0 | -Preserved: 10 (100%) | | Glansectomy | -Falcone et al., 2021 [46] | Italy | Retro | 34 | -Median (IQR): 12 (12-41) | -NR | -Rec: 4 (11.8%)
TTR: NR
OS: 91.2%
DSS: 91.2% | -Grade 1: 4 (11.8%);
Grade 2: 3 (8.8%);
Grade 3a: 3 (8.8%) | -NR | | -Kokorovic et al., 2021 [18] (partial or total) | USA | Pros | 35 | -Whole cohort median: 28 | -NR | -Rec: 3 (8.6%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Beech et al., 2020 [47] | Canada | Retro | 12 | -Median (range): 14 (1-59) | -pT0: 2 (16.7); pTis: 2 (16.7);
pT1a: 5 (41.7);
pT1b: 1 (8.3);
pT2: 2 (16.7) | -Rec: 2 (16.7%)
TTR: NR;
OS: NR;
DSS: NR | -90-day Grade>2: 0 | -Preserved EF and standing voiding: 12 (100%) | | -Albersen et al., 2018 [49] | UK | Retro | 117 | -Median (range): 33.7 (1.9-151.9) | -Concurrent Cis: 36.8%; pT1: 26.5%;
pT2: 59.8%;
pT3: 13.7% | -Rec: 15 (12.8%);
TTR: NR;
OS: 78.6%;
DSS: 96.6% | -Graft failure: 23 (23.5%);
Meatal stenosis: 4 (2.8%) | -NR | | -Parnham et al., 2018 [39] | UK | Retro | 172 | -Median (range): 41.4 (1.9-155) | -NR | -Rec: 16 (9.3%);
TTR: 8.7 months;
OS: 83.6%;
DSS: 89.7% | -Graft failure: 34 (19.8%) | -NR | | -Baumgarten et al., 2018 [20] | USA, Germany, the Netherlands, UK, and China | Retro | 362 | -Whole cohort median (IQR): 43 (27.9-60.4) | -pTa/pTis: 14 (6.4%); pT1: 108 (18.8%);
pT2: 240 (60.9%) | -Rec for pT2: 18 (7.5%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Chipollini et al., 2018 [21] | USA, Germany, the Netherlands, UK, and China | Retro | 10 | -Median (IQR): 28.6 (22.7-46.3) | -pTis: 10 (100) | -Rec: 1 (10%);
TTR: NR;
OS 5-year: 100%;
DSS: NR | -NR | -NR | | -Tang et al., 2017 [48] | USA, Germany, the Netherlands, UK, and China | Retro | 410 | -Median (IQR): 42 (29-56) | -pTis/pTa: 14 (3.4); pT1: 108 (26.3);
pT2: 240 (58.5);
pT3-4: 43 (10.5) | -Rec: 31 (7.6%);
TTR: NR;
OS 5-year: 82.0%;
DSS: NR. | -NR | -NR | | -Veeratterapillay et al., 2012 [37] (partial or total) | UK | Retro | 48 | -Median (IQR): 40 (12-72) | -pTis: 13 (27.1); pT1: 25 (52.1%);
pT2: 10 (20.8%) | -Rec: 4 (8.5%);
TTR: 15 months;
OS: NR;
DSS: NR. | -NR individually | -NR individually | | -O'Kane et al., 2011 [50] | UK | Retro | 25 | -Median (IQR): 28 (10-66) | -pTis: 6 (24.0); pT1: 15 (60.0)
pT2: 3 (12.0);
pT3: 1 (4.0) | -Rec: 2 (8.0%);
TTR: NR;
OS: NR;
DSS: 92.0%. | -Meatal stenosis: 2 (8.0%) | -Achieve erections: 81.8%;
Sexually active: 54.6% | | -Morelli, 2009 [43] (partial or total) | Italy | Pros | 15 | -Median (IQR): 36 (10-67) | -pTa: 2 (13.3); pT1: 7 (46.7);
pT2: 4 (26.7);
pT3: 2 (13.3) | -Rec: 0;
TTR: NR;
OS: NR;
DSS: 93.3%. | -Meatal stenosis: 1 (6.7%);
partial graft loss: 2 (13.3%) | -Preserved EF: 17 (100%);
reduced glans sensitivity: 15 (100%) | | -Smith et al., 2007 [44] | UK | Pros | 72 | -Median (range): 27 (4-68) | -pT1: 35 (48.6);
pT2: 37 (51.4) | -Rec: 3 (4.2%);
TTR: 4-28 months (range);
OS: 91.9%;
DSS: 94.6% | -Partial graft loss: 2 (2.8%);
meatal overgrowth: 1 (1.4%) | -NR | | -Pietrzak et al., 2004 [45] (partial or total and/or distal corporectomy) | UK | Pros | 39 | -Mean: 16 | -pTa: 2 (5.1);
pT1: 19 (48.7);
pT2: 17 (43.6);
pT3: 1 (2.6) | -Rec: 1 (2.6%);
TTR: NR;
OS: NR;
DSS: NR | -Partial graft loss: 1 (2.6%);
graft overgrowth: 2 (5.1%) | -NR | | PPS combined | -Menon et al., 2020 [57] (laser, LE, PP, and TP) | USA | Retro | PPS: 4407 | -Whole cohort: NR | -Whole cohort; cTis/Ta: 2348 (41.0);
cT1: 1938 (34.0);
cT2: 967 (17.0);
cT3: 475 (8.0) | -Rec: NR;
TTR: NR;
OS: 50.3 months;
DSS: NR | -NR | -NR | | -Lindner et al., 2020 [52] (laser, LE, glansectomy, resurfacing, PP, and TP) | Austria | Retro | PPS: 26 | -Whole cohort mean (SD): 63.7 (11.9) | -pTis: 7 (26.9); pTa: 7 (26.9);
pT1a: 8 (30.8);
pT1b: 1 (3.8);
pT2: 3 (11.5) | -Rec: 11 (42.3%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Kamel et al., 2018 [53] (organ-sparing, PP, and TP) | USA | Retro | PPS: 1211 | -Whole cohort mean (SD): 3.5 (2.7) | -pT1: 1069 (90.3); pT2: 115 (9.7) | -Rec: NR;
TTR: NR;
OS 5-year: 88%;
DSS: NR | -NR | -NR | | -Djajadiningrat et al., 2014 [54] (laser, WLE, glans resurfacing, and glansectomy) | The Netherlands | Retro | 451 | -Whole cohort median (IQR): 65 (41-101) | -pT1a: 191 (42.4); pT1b: 61 (13.5);
pT2: 189 (41.9);
pT3: 9 (2.0);
pT4: 1 (0.2) | -Rec: 185 (41.0%) (local only, 27);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Philippou et al., 2012[9] (Circ, WLE, and glansectomy) | UK | Retro | 179 | -Whole cohort median (range): 42.8 (4-107) | -pT1-3: 179 (100) | -Rec: 8.9%;
TTR: 26.1 months;
OS: 96.1%;
DSS: 98.3% | -Infection: 0.6%;
necrosis: 0.6%;
partial graft failure: 1.8% | -NR | | -Feldman and McDougal, 2011 [55] (Mohs, circumcision, LE, and partial glansectomy) | USA | Retro | 56 | -Whole cohort mean (SD): 65.6 (46.6) | -Cis: 28 (50); pT1: 28 (50) | -Rec: 12 (21.4%);
TTR: 51 months;
OS: NR;
DSS: NR | -Meatal stenosis/stricture: 0 | -Maintained sexual activity: 56 (100%); standing voiding: 56 (100%) | | -Leijte et al., 2008 [56] (laser, LE, and radiation) | The Netherlands | Retro | 415 | -Median (range): 60.6 (3.0-358.0) | -pTis: 95 (22.9); pTa: 9 (2.2);
pT1: 168 (40.5);
pT2: 111 (26.7);
pT3: 8 (1.9);
pT4: 1 (0.2);
pTx: 23 (5.5) | -Rec: 115 (27.7%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR | | -Minhas et al., 2005[8] (WLE, glansectomy, and PP) | UK | Retro | 51 | -Median (range): 26 (5-55) | -pTis: 3 (5.9); pT1: 20 (39.2);
pT2: 26 (51.0);
pT3: 2 (3.9) | -Rec: 2 (3.9%);
TTR: NR;
OS: NR;
DSS: NR | -NR | -NR |
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Outcomes of penile-preserving surgical procedures for penile cancer.
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Glans resurfacing. (A) Refractory PeIN and lichen sclerosis before glans resurfacing; (B) STSG being used to cover the denuded glans; (C) Appearance following glans resurfacing. PeIN, penile intraepithelial neoplasia; STSG, split thickness skin graft. Intraoperative pictures taken from Institute of Andrology, University College London Hospital, Courtesy of Mr Asif Muneer.
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Glansectomy and neoglans formation. (A) Glans dissected off corporal heads; (B) Neoglans reconstruction following glansectomy. Pictures taken from Institute of Urology, University College London Hospital, Courtesy of Mr. Asif Muneer.
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