The choice of surgical therapy is dictated by the primary tumor characteristics including size, location, and depth of invasion; and the surgeon’s desire to achieve effective local tumor control while at the same time retaining maximal function of the penis. In situ penile lesions, such as erythroplasia of Queryat and Bowen’s disease, are amenable to local excision, circumcision, tissue ablative techniques such as CO₂ and Nd: Yttrium Aluminum Garnet lasers (19,20), and topical 5-fluorouracil cream application (21,22). Occasionally, surgeons may use surgical excision in conjunction with laser therapy to provide an additional 4-mm margin with the intent of achieving a more cosmetically appealing result. With careful case selection and close clinical follow-up, it appears that laser therapy can effectively treat some patients. The effectiveness of laser therapy for overtly invasive penile cancers is uncertain and laser treatment should not be considered an alternative to standard resection. Wound healing after the use of the laser is by secondary intention with full re-epithelialization, usually complete after 8 to 10 weeks. Wound infections are rare following laser therapy. There are also favorable reports of Mohs micrographic surgery for carefully selected in situ and superficially invasive lesions of the glans or shaft (23,24). A specially trained dermatologist performs serial resections until the histological findings are tumor free. If the treating dermatologist or urologist selects an ablative technique to treat in situ lesions of the penis, careful physician follow-up and patient self-examinations to seek early signs of recurrence are essential.

For tumors of the prepuce, circumcision is an effective surgical treatment. Careful examination of the fully exposed glans for evidence of CIS is recommended and a low threshold for additional biopsy should exist. Local excision with adequate underlying soft tissue of invasive penile cancer without partial or total penectomy must be carefully approached. In determining which patient is a candidate for penile conservation procedures, knowledge of the true extent of the local tumor is vital. Physical examination has been shown to be quite reliable in determining the extent of disease and degree of local infiltration into the deeper structures of the penis (25). Operations must be designed to assure negative surgical margins with the goal to achieve a cosmetic result that is acceptable and not cosmetically or functionally worse than a partial penectomy. Intraoperative frozen section must assure negative margins. Local recurrence, an uncommon event following partial or total penectomy, is more common in penile-conserving operations and can be as high as 10% to 15% (26). Patients should be instructed to inspect the remaining epithelium of the glans for recurrence or a new primary, as they remain at lifelong risk for new tumor formation (27).

Most local recurrences can be treated with either a delayed partial amputation or another attempt at penile-conserving surgery. The degree to which local tumor recurrence translates
into degradation in overall survival is not known. Extensive local resections by removing a part of the corona of the glans penis can improve the tumor-free margins and can aid in decreasing local recurrences. Superficial disease covering a large part of the glans can be treated by so-called resurfacing. The epithelial layer of the glans is completely removed and replaced by a skin graft. Excellent results with this approach have been published (28). Resection of a part of the glans is also feasible. This is advisable only if the lesion does not infiltrate deeply into the cavernous tissue and does not extend more than half of the glans. Otherwise, these conservative operations can lead to serious deformation and deviation of the penis during erections with the patient clearly better served with a formal glans removal. In this approach, only the glans is removed instead of standard partial amputation, leading to minimal loss of length of the penis. This defect can be left open for secondary healing, covered with a split thickness skin graft, or partially covered by a mobilized urethra (28). Larger lesions should be managed by a formal partial penectomy (amputation). Verrucous carcinomas, which are of low to intermediate grade and have an exophytic growth pattern, are particularly amenable to local tumor excision (29). If penile conservational techniques are used, it is still necessary to frequently monitor the inguinal nodes that remain at risk for the development of metastatic disease (30).

For invasive tumors of the distal penis, partial penectomy with at least a 1-cm margin of resection is recommended (Fig. 47.1). The operation should be designed, if possible, to allow the patient to void in the upright position and without the need to push away the scrotum; otherwise, a perineal urethrostomy should be created. Partial penectomy achieves excellent tumor control with local recurrence rates as low as 6% reported (31). At the time of operation, a latex glove is placed over the primary tumor and distal shaft and is secured to the penis with a suture. A sterile marking pen is used to circumferentially outline the planned incision with care taken to provide at least a 1-cm margin. A medium Penrose drain is placed around the base of the penis and tightened to function as a tourniquet. The incision is circumferentially carried through the skin and Buck’s fascia to the tunic of the corpora. On the dorsum of the penis, the dorsal veins and arteries are individually ligated with absorbable suture. As the resection is carried ventrally, a 1-cm stump urethra is created and spatulated to prevent stenosis of the neourethra. The tunic of corpora cavernosa is closed with 2-0 absorbable sutures that provide hemostasis. The urethra is sutured to the ventral penile skin and a sterile dressing is applied. A recent study of 19 patients whose sexual function was evaluated prior to and after partial penectomy indicated that two thirds of the patients maintained the same level of sexual function and desire as they did prior to partial penectomy. However, only one third maintained the same frequency of intercourse and reported the same degree of satisfaction in their sexual lives. Factors associated with a decline in sexual function included concerns regarding the small penile size, an absence of the glans, and postsurgical complications (32). Memorial Sloan-Kettering Cancer Center (MSKCC) investigators recently reported the outcome of 34 consecutive patients treated with partial penectomy at their center from 1989 to 2005. Pathology distributions included PIS (N = 1, 3%), P1 (N = 11, 34%), P2 (N = 16, 50%), and P3 (N = 4, 13%). After a mean follow-up of 34 months, overall survival was 56%. Local tumor control was excellent in this series with only one local recurrence reported. Prognostic factors associated with a poor outcome included a poor and moderate tumor differentiation and T stage >1 (33). Kattan et al. combined partial penectomy data on 175 patients from 11 Italian centers to construct a nomogram to predict survival probabilities based on clinical and pathological variables. Important adverse prognostic factors in this study included tumor grade (2 or 3), tumor thickness (>5 mm), tumor emboli present, infiltration of the corporal cavernosa and spongiosum, and regional node involvement. After a median follow-up of 24 months, 57.7% of patients were alive free of disease and 42.3% were dead of disease (34). Taken together, these studies portray invasive penile cancer as an ominous malignancy from the time of partial penectomy.

For bulky T3 or T4 proximal tumors involving the base of the penis, total penectomy with perineal urethrostomy is done (Fig. 47.2). Total penectomy for proximal tumors that are locally advanced and associated with agonizing local symptoms and bulky regional metastatic disease can provide effective palliation for these patients. Psychiatric input is recommended for patients undergoing total penectomy to be certain that the patient has the necessary emotional capacity to endure the operation and its postoperative implications. During total penectomy, an incision is outlined circumferentially at the base of the penis with extension into the median raphe of the scrotum. At the base of the penis, the suspensory ligament of the penis is identified and divided. The urethra and corpora spongiosum are mobilized from the corpora between clamps and divided. A 2-cm margin of perineal urethra is preserved for construction of a perineal urethrostomy. The urethral remnant
is passed through the scrotum to the midline perineum and the urethrostomy is performed. An 18-French Foley catheter is left in the urethrostomy. In rare cases, the site of attachment of the corpus cavernosum to the pubic bone may need to be resected in order to achieve a clear margin.

Like all squamous cell carcinomas, penile cancer has a propensity for locoregional dissemination, whereas hematogenous dissemination in the absence of lymphatic invasion is uncommon. Metastases in penile carcinoma occur in a sequential manner with tumor cells embolizing through firstechelon regional inguinal nodes and then on to second-echelon deep pelvic nodes (35). Using pooled data from 11 Italian centers involving 175 patients, Ficarra and colleagues generated a nomogram of clinical and pathological features which estimated the risk of inguinal nodal metastases. Features associated with regional metastatic disease at presentation included palpable groin nodes, vascular or lymphatic embolization, and poorly differentiated primary tumors (36). Some surgeons advocate a conservative approach to the groin nodes at the time of presentation in order to avoid the potential morbidity of groin dissection (cellulitis, flap necrosis, lymph edema) without the certainty of a therapeutic dissection. Others advocate an immediate, preemptive surgical approach toward the regional nodes at a point earlier in the course of the disease when a potential survival advantage may be realized, even at the expense of perioperative morbidity or the finding of negative nodes. Approximately 30% to 60% of patients presenting with squamous cell carcinoma of the penis have enlarged lymph nodes in the groin. There are no reported cases of patient with pelvic node involvement without concomitant inguinal node involvement first (37,38,39,40,41,42,43,44,45,46,47,48).

Nodal metastasis will develop in approximately 20% of patients presenting without any clinical sign of lymphadenopathy, and unfortunately, physical examination and contemporary imaging with CT scan or MRI are not able to reliably detect minimal metastatic nodal disease. The management of this group of patients with invasive penile cancer who are initially node negative remains controversial and may be improved by the evolving use of radionuclide-based lymphoscintigraphy of the sentinel nodes (SNs) or dynamic sentinel lymph node biopsy (DSLNB). This technique has the potential to identify early metastatic disease while at the same time spare the side effects of groin dissection in patients who are node negative. Unlike other genitourinary tumors (e.g., prostate, renal), in which nodal involvement is usually synonymous with incurable disease, nodal metastases in penile cancer are highly curable and therapeutic nihilism is not justified, even in patients with locally advanced lymphatic involvement.

The regional lymph nodes of the penis are located in the inguinal region (Fig. 47.3) (49,50,51). Some urologic oncologists have divided the inguinal nodes into two groups, a superficial group and a deep group. The superficial nodes are located beneath the subcutaneous fascia and above the fascia lata covering the muscles of the upper leg. Eight to twenty-five nodes can be found. The deep inguinal nodes are those around the fossa ovalis, the opening in the fascia lata in which the saphenous vein drains into the femoral vein. Three to five nodes are usually found there. These nodes intercommunicate with one another and then drain to the pelvic nodes. From a clinical point of view, this distinction is meaningless, because at the time of operation, the superficial inguinal nodes cannot be distinguished from the deep nodes. This point of anatomic confusion has led some surgeons to perform operations that are incomplete and can contribute later to regional nodal recurrence. Therefore, complete groin dissection should be performed in all cases to remove both of these inguinal nodal drainage basins. The most constant and usually largest node is the node found medial to the femoral vein and just underneath the inguinal ligament, the so-called node of Cloquet or Rosenmuller. This node may be missed during either incomplete groin or pelvic dissection and can represent a common site of local recurrence following lymphadenectomy. It is customary to divide the inguinal region into four sections by drawing a horizontal and a vertical line through the point where the saphenous vein drains into the femoral vein. The nodes that are involved primarily in
penile cancer are mainly located in the superomedial segment. However, individual variation exists, and therefore all groin nodes should be removed. The penis drains to both inguinal sides in at least 85% of the patients, as evidenced by lymphangiographic studies, and in 60% of patients as evidenced by studies utilizing lymphoscintigraphy (52,53). The pelvic nodal package consists of nodes around the iliac artery and vein as well as the obturator fossa, above and below the obturator nerve, and contains between 12 and 20 nodes. Crossover from one pelvic nodal basin to the other has not been observed clinically or by lymphoscintigraphy.