Surgery for penile cancer
Surgery is the primary treatment for penile cancer. Surgery is used to:
- potentially cure the cancer by completely removing it
- treat recurrent penile cancer
- remove lymph nodes (if the cancer has spread to them)
The type of surgery done depends mainly on the location of the tumour, size of the tumour, stage of the cancer and other factors, such as the depth of the tumour, type of tumour and the man’s overall health. The surgeon will try to leave as much of the penis as possible to try to preserve sexual function and normal urination. Side effects of surgery depend on the type of surgical procedure.
A circumcision removes the foreskin of the penis. This may be all that is required for a very small tumour located only on the foreskin.
Mohs surgery (Mohs micrographic surgery) is a specialized surgical method that may be used to treat small, early stage penile cancers. It is used to remove the tumour and surrounding tissue layer by layer, until the tissue is completely clear of cancer cells.
Wide local excision (wide excision) is used to treat very small, early stage penile cancers. The tumour is removed along with a margin of normal tissue around it. The remaining skin is stitched together. The rest of the penis is left intact.
The standard margin around the tumour used to be 2 cm, but recent data suggest that such a wide margin may not be necessary. Sometimes a 1 cm margin around the tumour is enough to prevent the cancer from coming back. The margin size may vary depending on the grade, type and size of the tumour.
Some early stage penile cancers may be completely removed by wide local excision. However, this surgery may need to be followed by external beam radiation therapy, brachytherapy, laser surgery or more extensive surgery.
Wide excision for cancer in lymph nodes that invades nearby skin
Sometimes cancer within enlarged lymph nodes can grow through the lymph nodes and invade the skin over them. A wide excision may also be used to remove the area of the skin in the groin area that contains cancer. If a large area of skin has to be removed, a skin graft may be used to cover this area.
A penectomy is surgery that removes part or all of the penis. It may also be referred to as a partial or total amputation of the penis. A penectomy is the most common and effective surgery done to treat cancer that has spread deeply into the tissues inside the penis.
Partial penectomy is frequently used to treat penile cancer. This surgery removes only the end of the penis. It is used to treat tumours on the glans (glans penis or head) or tumours on the far (distal) end of the shaft, closest to the glans. Partial penectomy is done instead of total penectomy, if possible.
During a partial penectomy, the tumour is removed along with a margin of normal tissue around it. A margin of least 1 cm is usually removed. The margin will vary depending on the grade and type of tumour. The surgeon tries to leave enough of the shaft of the penis to allow the man to urinate standing up and preserve sexual function.
Depending on how much of the penis is removed, the remaining skin is closed with stitches or skin is taken from another area of the body to reconstruct the head or end of the penis.
Total (radical) penectomy removes the entire penis. A total penectomy is used to treat:
- large penile tumours
- tumours that have grown deeply into the shaft
- tumours on the part of the shaft closest to the base of the penis (proximal shaft)
- tumours near the base of the penis
A total penectomy is done when removal of the primary penile tumour would not leave enough of the penis to allow the man to stand while urinating.
The shaft and root of the penis are removed. The remaining skin near the root of the penis is stitched together. The surgeon reroutes the urethra by making an opening between the anus and scrotum (called a perineal urethrostomy) so that the man can urinate. The man can still control urination because the muscle that keeps the bladder closed is further inside the body, above the penis. After surgery, the man must urinate sitting down.
It is sometimes possible to do reconstructive surgery to create a new penis, but this is rarely done.
Additional surgery for advanced penile cancer
In rare cases of advanced penile cancer, it may be necessary to have surgery in addition to penectomy. Men with invasive penile cancer in the proximal shaft (the part of the shaft of the penis that is closest to the body) or the root of the penis that extends to nearby tissues or structures may need additional surgery. Surgery may include:
- scrotectomy (surgery to remove the scrotum) and orchiectomy (surgery to remove the testicles) for penile cancer that has spread to the scrotum or testicles
- pelvic exenteration for penile cancer that has spread to the pelvis
Lymph nodes are removed so they can be checked for cancer. Lymph node dissection is done to remove lymph nodes. Sometimes a man may have a sentinel lymph node biopsy instead of a lymph node dissection.
Lymph node dissection
A lymph node dissection removes lymph nodes and checks them for cancer. This is also called a lymphadenectomy. This is considered the best way to examine the lymph nodes in men with penile cancer to see if they contain cancer cells. It is also the most effective way of getting rid of cancer in the lymph nodes and accurately staging penile cancer.
Penile cancer is most likely to spread to lymph nodes in the groin, followed by the lymph nodes in the pelvis. An inguinal lymph node dissection removes lymph nodes from the groin. A pelvic lymph node dissection removes lymph nodes from the pelvis.
Lymph nodes in the groin may be removed at the same time as a penectomy. Before surgery, the surgeon may do a fine needle aspiration (FNA) on any enlarged lymph nodes. If the lymph nodes contain cancer, they can then be removed at the time of surgery.
How doctors decide which men have a lymph node dissection
A man who has palpable inguinal lymph nodes (lymph nodes in the groin that can be felt) will have an inguinal lymph node dissection. If cancer is found in inguinal lymph nodes, a pelvic lymph node dissection will usually be done to check for cancer in these nodes as well.
About 20% of men who don’t have palpable inguinal lymph nodes will still have cancer in the lymph nodes. Therefore, about 80% of men who don’t have palpable inguinal lymph nodes won’t have cancer in the lymph nodes. Doctors have developed a risk-based approach to help them decide whether or not a man without palpable inguinal lymph nodes should proceed with a lymph node dissection.
- low risk
- Men are considered low risk if they have:
- These men have a less than 10% chance of having cancer in the lymph nodes.
- Most men with low-risk tumours can be closely followed to see if the lymph nodes become palpable or enlarged on imaging studies, such as a computed tomography (CT) scan.
- high risk
- Men are considered high risk if they have:
- a grade 3 tumour (high grade)
- invasive penile cancer (T1b–T4 tumours)
- These men have a greater than 50% chance of having cancer in their lymph nodes.
- Men with high-risk penile cancer will usually have an inguinal lymph node dissection.
- Men are considered high risk if they have:
Sentinel lymph node biopsy
Sentinel lymph node biopsy (SLNB) is also called sentinel lymph node dissection (SLND). SLNB removes the first lymph node(s) in a chain or cluster of lymph nodes in the groin (sentinel node) to which the penile cancer is likely to spread. SLNB is done to determine if a full lymph node dissection is necessary.
- If the sentinel nodes do not contain cancer (are negative), the rest of the lymph nodes are left in place.
- If the sentinel nodes contain cancer (are positive), then a complete lymph node dissection is recommended.
SLNB is a newer procedure. Researchers are studying its usefulness in penile cancer. It has been reported that SLNB for penile cancer may not be accurate and may not always show cancer even when it is present (false-negative results). Therefore, SLNB is not routinely done for penile cancer in Canada.
Doctors may also use laser surgery or cryosurgery to treat penile cancer.
Laser surgery for penile cancer
For penile cancer, laser surgery may be used to treat carcinoma in situ.
Cryosurgery delivers an extremely cold liquid or gas directly to the tissues of the penis through a metal tube called a cryoprobe. The area is allowed to thaw and then is frozen again. The freeze-thaw cycle may need to be repeated a few times. Cryosurgery is used to destroy cancer cells while avoiding nearby healthy cells. It can also be used to treat some precancerous conditions.
For penile cancer, cryosurgery may be used to treat carcinoma in situ.