EAU 2025 Guidelines: Penile Cancer

What This Guideline Covers

The EAU 2025 Penile Cancer guideline provides evidence-based recommendations across 10 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

Pathological assessment of tumour specimens

• The pathological evaluation of penile carcinoma specimens must include the pTNM stage and an assessment of tumour grade.
• The pathological evaluation of penile carcinoma specimens must include an assessment of p16 by immunohistochemistry.
• The pathological evaluation of penile carcinoma specimens should follow the ICCR dataset synoptic report.

Diagnosis and staging

• Perform a detailed physical examination of the penis and external genitalia, recording morphology, size and location of the penile lesion, including extent and invasion of penile (adjacent) structures.
• Obtain a pre-treatment biopsy of the primary lesion when malignancy is not clinically obvious, or when non-surgical treatment of the primary lesion is planned (e.g., topical agents, laser, radiotherapy).
• Perform a physical examination of both groins. Record the number, laterality and characteristics of any palpable/suspicious inguinal nodes.
• If there are no palpable/suspicious nodes (cN0) at physical examination, offer surgical LN staging to all patients at high risk of having micro-metastatic disease (T1b or higher).
• When surgical staging is indicated, offer dynamic sentinel node biopsy (DSNB). If DSNB is not available and referral is not feasible, or if preferred by the patient after being well informed, offer inguinal lymph node dissection (ILND) (open or video- endoscopic).
• If DSNB is planned, perform inguinal US first, with fine needle aspiration cytology (FNAC) of sonographically abnormal LNs.
• If there is a palpable/suspicious node at physical examination (cN+), obtain (image- guided) biopsy to confirm nodal metastasis before initiating treatment.
• In cN+ patients, stage the pelvis and exclude distant metastases with 18FDG-PET/CT or CT of the chest and abdomen before initiating treatment.

PeIN, Ta–cT1/T2 and T3–T4 disease

• Offer a balanced and individualised discussion on benefits and harms of possible treatments options with the goal of shared decision making.
• Inform patients of the higher risk of local recurrence when using organ-sparing treatments compared to amputative surgery.
• Offer organ-sparing surgery and reconstructive techniques to patients with lesions confined to the glans and prepuce (PeIN, Ta, T1–T2) and who are willing to comply with strict follow-up.
• Offer radiotherapy to selected patients with biopsy-confirmed T1 or T2 lesions.
• Offer partial penectomy, with or without reconstruction, to patients with invasion of the corpora cavernosa (T3) and those not willing to undergo organ-sparing surgery or not willing to comply with strict follow-up.
• Offer total penectomy with perineal urethrostomy to patients with large invasive tumours not amenable to partial amputation.

CN1-2 disease

• In patients with cN1 disease offer either ipsilateral: • fascial-sparing ILND • open radical ILND; sparing the saphenous vein, if possible.
• In patients with cN2 disease offer ipsilateral open radical ILND; sparing the saphenous vein, if possible.
• Offer minimally-invasive ILND to patients with cN1–2 disease only as part of a clinical trial.

CN3 disease

• Offer surgery to patients responding to NAC in whom resection is feasible.
• Do not offer video-endoscopic inguinal lymphadenectomy.

Systemic and palliative therapies for advanced penile cancer

• Do not offer bleomycin because of the pulmonary toxicity risk.
• Offer patients with progressive disease under platinum chemotherapy the opportunity to enrol in clinical trials, including experimental therapies within phase 1 or basket trials.
• Offer radiotherapy for symptom control (palliation) in advanced disease.

Follow-up and quality of life

• Deliver penile cancer care as part of an extended multi-disciplinary team comprising of urologists specialising in penile cancer, specialist nurses, pathologists, uro-radiologists, nuclear medicine specialists, medical and radiation oncologists, lymphoedema therapists, psychologists, counsellors, palliative care teams for early symptom control, reconstructive surgeons, vascular surgeons, and sex therapists.
• Follow-up men after penile cancer treatment, initially three-monthly for two years then less frequently to assess for recurrent disease and to offer patient support services through the extended multi-disciplinary team. At discharge, recommend self-examination with easy access back to the clinic as local recurrence can occur late.
• Discuss the psychological impact of penile cancer and its treatments with the patient and offer psychological support and counselling services.
• Discuss the negative impact of treatments for the primary tumour on penile appearance, sensation, urinary and sexual function so that the patient is better prepared for the challenges he may face.
• Discuss the potential impact of lymphoedema as a consequence of inguinal and pelvic lymph node treatment with the patient and assess patients for it at follow-up and refer to lymphoedema therapists early.