Management of the

Primary lesion in
Carcinoma Penis

Amudhan . D, III yr PG
Prof. R. Rajaraman's Unit
Dept. of Surgical Oncology
G.R.H.
17-12-11

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 Ca. Penis
Management of Primary

Standard Surgical Procedures

Organ Conservation Partial penectomy

Total penectomy
Emasculation
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Organ Conserving Surgical Approach
 Laser Therapy
 Mohs Micrographic Surgery
 Conservative Local Surgical Excision
 Circumcision
 Local excision

 Total glansectomy

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 Laser Therapy
 Lasers used  carbon dioxide (CO2),
neodymium:yttrium-aluminum-garnet (Nd:YAG)
potassium titanyl phosphate (KTP)
 Circumcision – recommended
 Drawbacks
 Healing time - 5 to 8 weeks for CO2 laser (8 to 12 weeks for
the Nd : YAG and KTP lasers)
 local recurrence rate - 20% (for Ca. in situ and T1 lesion)
 difficulty in determining the exact depth of laser coagulation
 inability to treat larger lesions
 careful long-term surveillance

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 Mohs Micrographic Surgery
 removal of cancer by excision of tissue in thin
layers
 Local control rate - 94%
 Best suited in- Ca. in situ, small T1

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 Local excision
 excision of lesion with negative margin
 Reconstruction- primary closure, preputial skin
flap, full-thickness graft of penile skin , SSG
 local recurrence - 8% to 11%

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Surgical glans defect covered with
outer preputial flap
 Superficial glans tumor

 Outer preputial flap

outlined

 Tumor excised and

circumcision performed

 Glans defect filled with

outer preputial flap

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Skin graft quilted to glans defect
after superficial tumor excision

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 Radiation Therapy for
the Primary Lesion
 Indications
 young patients with small (2- to 4-cm) superficial
lesions of distal penis, not willing for amputation
 patients who refuse surgery

 patients with inoperable cancer

 Patients unsuitable for major surgery.

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 Radiation Therapy for
the Primary Lesion
 EBRT 
 direct field method - only for very superficial tumors
(Tis ,T1)
 parallel opposed field method - T2, T3 (penis
irradiated by encasing the lesion in a wax mold)
 Brachytherapy 
 Interstitial brachytherapy - placement of
radioactive material within the tumor
 Plesiobrachytherapy- placement of radioactive
material molded around the tumor
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 Brachytherapy not suitable
 bulky tumors
 obese patients with short penis
 deeply infiltrating tumors

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 Radiation Therapy for
the Primary Lesion
 60 Gy to 74 Gy
 Salvage penectomy
 persistent or recurrent disease after RT
 radiation necrosis

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Penis wrapped in cellophane and taken out
through central aperture

Tele Cobalt

Locally fabricated water filled Perspex box to hold penis

Points to be well informed
to patients if RT is
selected
 Although cosmetically attractive, disadvantages
are
 Useful only in early stage (T1,T2)
 Only 65-80% success rate even in early stage
 Penile necrosis - 0% to 23%
 High chance for stricture urethra
 Penectomy required for recurrence
and necrosis
 Penile Conservation with Radiotherapy: At what cost?
Treatment Local control Penectomy Urethral
Study for necrosis
Initial stricture
Post salvage

Rozan et al
French multi-centre Implant 63Gy (185 men)
Others (75 men)
85% 94% 7% 30%
12 yrs

Delannes et al Implants - 60 Gy 82% 94% 41%

(51 patients)
16%
Toulouse, France
7 years

EBRT– 50 to 60 Gy
Ravi et al (128 patients)
Adyar Brachy – 60 to 70 Gy
65% 97% 6% 24%
12 years (28 patients)

Sarin et al EBRT - 60 Gy
Royal Marsden, UK. (56 patients) 57% 90%
5 years Implants - 60 Gy 3% 14%
(13 patients)
Chaudhary et al
TMH Ir-192 Implant – 50Gy
(23 patients)
78% 96% Nil 9%
2 years
SURGICAL MANAGEMENT
OF THE PRIMARY TUMOR

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 Partial Penectomy
 Goals
 Successful local control (at least 2 cm proximal
margin)
 preserve voiding in standing position
 possible sexual function

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 Partial Penectomy- Steps
 lesion initially excluded from surgical field by small towel
 skin incised circumferentially at the line of amputation to Buck fascia
 Buck fascia incised laterally, plane dissected between tunica albuginea and
neurovascular structures
 dorsal penile vessels ligated and divided
 corpora cavernosa sharply divided
 urethra dissected 1.5 cm distally and transected
 corpora closed transversely
 penile skin closed in midline over corporeal ends
 urethrostomy constructed by approximating urethra to the adjacent penile
skin
 indwelling urethral catheter is left in place for 3 to 5 days

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Partial penectomy

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Partial penectomy

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Partial penectomy

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Partial penectomy + Rt. IIBD with
TFL flap + Lt. SIBD

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 Total Penectomy with Perineal
Urethrostomy
 Indication  After adequate surgical
margin – if remnant not sufficient for
upright voiding

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Emasculation

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Emasculation + Rt. IIBD with
extended TFL flap + Lt. SIBD

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Emasculation Specimen

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 Emasculation + Rt. IIBD with
extended TFL flap + Lt. IIBD with
Primary closure

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 Radical Penectomy
 Excision of the corporeal bodies in their entirety

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 Comparing Surgery & RT
 Surgery
 local recurrence after
partial or total penectomy -
0% to 8%
 rapid tumor control
 Meatal stenosis- 6%
 RT
 urethral fistula, stricture,
stenosis, penile necrosis,
pain, edema
 Penile necrosis - 0%
to 23%
 Urethral stenosis - 10% to
45%
 6 weeks of therapy in EBRT
 several months of
morbidity
 Close follow-up – must
 distinguishing post
irradiation ulcer, scar, and
fibrosis from recurrent
carcinoma - impossible
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 Comparing Surgery & RT
 Surgery  RT
 Complications of block
dissection
 5-year local control -
70% to 87%
(Brachytherapy)
 5-year local control -
44% to 69.7% (EBRT)
 sexual QOL - not
studied with validated
instruments
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Treatment of Primary lesion Stage by
Stage
 Tis ( options after confirmatory biopsy)
 Lesion prepuce  circumcision
 Lesion glans 
 Topical5FU cream
 Laser Excision

 Mohs Micrographic Surgery

 RT

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 Treatment of Primary lesion- Ta
 Laser Excision
 Mohs
Micrographic
Surgery

 RT-
contraindicated

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 Treatment of Primary lesion- Options

 T1,T2,T3 
 Partial penectomy
 Total penectomy
 Emasculation

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 Treatment of Primary lesion- Options

 T4
 Emasculation
 Hemipelvectomy

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 Sexual function after partial penectomy

 66.7% sustained the same frequency and level of sexual desire as

before surgery, and 72.2% continued to have ejaculation and
orgasm every time they had sexual stimulation or intercourse.
Only 33.3% maintained their preoperative sexual
intercourse frequency and were satisfied with their
sexual relationship with their partners and their
overall sex life.

*Urology. 2005 Dec;66(6):1292-5. Romero et al

 Prospective evaluation of Sexual Functions - TMH
Prospective study of PCT using accelerated External RT
1996-2003
23 men with Stage I – II Penile SCC

Pre Radiotherapy Post Radiotherapy

Sexual function Sexual function

Erection Normal in **17/18 Unchanged in 15/17 (88%)

Mild dysfunction in 2 (12%)

Sexually Active ***15/18 15/18

Coitus Frequency 5 per month in 15 sexually Unchanged in13/15 (87%)
(median) active men (Range 2-15) Reduced in 2 men

Coital Satisfaction Normal in 15/15 sexually Unchanged in 13/15 (87%)

active men Reduced in 2 men

5 patients ( 21.7%) who underwent penectomy for residual / recurrent disease not included
** 1 patient had loss of erectile function before starting Radiotherapy
***2 patients with normal erection were not sexually active (single and advanced age)
Pizzocaro G, et al. EAU Penile Cancer Guidelines 2009
Eur Urol 2010

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 Total Penile Reconstruction
 Originally developed for treatment of victims of
war injuries
 micro vascular free-flap reconstruction for
phallic construction
 Forearm flap

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 Configuration of the flap
(modified Biemer design)

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 Appearance of the phallus after it is
totally configured and transposed to the
area of the “penis.”

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 Summary
 Definite role for Organ preservation- Tis, Ta,
T1a
 RT – only in selected cases ( local recurrence,
complications common)
 2cm proximal margin, adequate penile stump for
upright micturition - Partial Penectomy
 2cm proximal margin , if inadequate penile stump
for upright micturition- Total Penectomy

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Thank you