Penile Cancer Surgery

Surgery for penile squamous cell carcinoma spans a spectrum from organ-sparing ablation through partial and total penectomy, chosen by tumour stage, grade, size, and location. The twin goals are oncological control and preserving function — glans sensation, shaft length, and the ability to void standing. Because penile-conserving options carry higher local recurrence than amputation, follow-up compliance is part of the decision. The disease, staging, and node management are covered in the Penile Cancer topic; the principal nodal operation has its own Inguinal Lymphadenectomy reference. This page covers surgery of the primary tumour.

Surgical Goals and Margins

• Cancer control is the primary goal; preserving the ability to void from a standing position is secondary. About 3 cm of residual shaft is a reasonable minimum for a functional standing stream — a stump too short to direct the stream may be better served by total penectomy with a perineal urethrostomy.
• Margin: the aim is a histologically negative margin. A 2 cm margin was advised historically, but modern penile-conserving practice accepts much smaller margins — a negative margin down to ~5 mm gives acceptable local control — individualised by tumour grade, which predicts microscopic spread. (Hinman's atlas still cites the older 2 cm / 1 cm figures; the small risk-based margin reflects current guideline practice.)

Treatment by Stage

Indications for partial or total penectomy: high grade (≥ 3), stage ≥ T2 / deep invasion into the glanular urethra or corpora cavernosa, or tumours > 4 cm. Lower-stage disease is managed by organ-sparing surgery.

Stage	Primary treatment
Tis (glans)	Laser therapy or glans resurfacing; alternative: topical therapy
Ta / Tis (foreskin, shaft skin)	Surgical excision to a negative margin; alternatives: laser, topical (Tis only)
Ta, T1 grade 1–3 (glans)	Excision, glans resurfacing, glansectomy, or radiotherapy — by size/position (RT not for Ta)
Ta, T1 (foreskin, shaft)	Complete surgical excision to a negative margin
T2 (glans, no gross cavernosal involvement)	Total glansectomy ± corpora cavernosa transection to negative margins, partial penectomy, or radiotherapy
T2 (corporeal invasion), T3	Partial or total penectomy
T4	Neoadjuvant chemotherapy with surgical consolidation in responders
Local recurrence after conservative therapy	Complete excision to negative margins (may need penectomy); select superficial low-grade recurrences may have a repeat penile-conserving procedure

Organ-Sparing Options

The goal is to preserve glans sensation and maximise shaft length. The menu is Moh's surgery, laser ablation, radiotherapy, limited excision, and glansectomy.

• Moh's micrographic surgery — the least invasive, with favourable function but high long-term recurrence; best for small, superficial, favourable-histology shaft lesions (Ta/T1, grade 1–2), not for large or high-risk tumours.
• Glansectomy — the most radical organ-sparing option, with the highest local control: the glans is separated from the corporal heads, the urethra is transected and a distal urethrostomy created, and the defect is covered by advanced/split shaft skin or a full-thickness skin graft.
• Radiotherapy — brachytherapy or external beam for select T1–T2 tumours < 4 cm of the glans/coronal sulcus in men refusing surgery; circumcision is required first, and brachytherapy preserves erectile function better than EBRT.

Laser Ablation

Laser phototherapy treats benign and malignant penile lesions, usually in the operating room. The choice of laser is set by the lesion and the depth of coagulation needed.

Laser	Wavelength	Coagulation depth	Best for
CO₂	10,600 nm (infrared)	< 1 mm (very superficial)	Condylomata, erythroplasia of Queyrat, pearly penile papules
KTP	532 nm (green)	~4 mm (mid)	Very superficial SCC (too deep for condyloma/EQ)
Nd:YAG	1064 nm (infrared)	8–10 mm (deepest)	Phallus-sparing treatment of penile SCC
Holmium:YAG	2070 nm (pulsed)	—	Not suited to penile skin lesions (use CO₂ instead)

Condylomata and Erythroplasia of Queyrat (CO₂)

• Start low — 5 W, rarely more than 10 W — with the beam slightly defocused (withdraw the handpiece 1–2 cm) into a circle, and use a painting motion with ~1 mm overlap into normal skin.
• For condylomata, "wipe off" the coagulated lesion with a damp sponge, leaving intact dermis; treat areas < 1 cm at a time and preserve viable skin bridges (returning electively for residual disease) to avoid large necrotic areas needing grafts.
• For erythroplasia of Queyrat (mucocutaneous carcinoma in situ), paint the whole lesion but do not wipe it off; stop short of char. Large areas are better managed by primary excision.

Penile SCC (Nd:YAG, phallus-sparing)

• A phallus-sparing option with the patient understanding the primary may be under-treated — recurrence up to 30%, without compromising eventual cancer control after further surgery. Most invasive SCC is still treated by primary excision to a negative margin.
• Moisten the tissue to limit char, then paint the lesion plus a 2–5 mm border of normal tissue with continuous-wave Nd:YAG at ~10 W, overlapping ≥ 2 mm into normal tissue.

Pearly Penile Papules

Benign coronal papules (1–3 mm) that mimic condylomata; treat with pinpoint 5 W CO₂ (no wipe-off, preserve skin bridges) or Er:YAG laser (400–500 mJ/pulse, 8–10 Hz, 1.5–3 mm spot).

Aftercare

Healing tracks the depth of injury: CO₂ areas re-epithelialise within ~2–3 weeks (de-pigmented but contour-normal "white spots"), whereas the deep Nd:YAG burn can take ~6 weeks and leaves a mild divot. Expect serous weeping until re-epithelialisation; no special wound care is needed.

Partial Penectomy

The standard of care for invasive tumours of the mid-to-distal penis, when a negative margin leaves a functional standing stump.

Technique

1. Position and isolate — supine; exclude the lesion with a glove or towel; apply a base tourniquet (Penrose, red rubber, or tubing) and place a Foley to aid urethral mobilisation.
2. Incision — a circumferential skin incision 1.5–2 cm proximal to the lesion, carried to Buck fascia; ligate and divide the superficial and deep dorsal veins; incise Buck fascia onto the tunica albuginea.
3. Divide the corpora — transect the corpora cavernosa, leaving the corpus spongiosum intact; briefly release the tourniquet to oversew bleeders with absorbable suture; send a stump frozen section.
4. Urethra — dissect the urethra off the spongiosum for 1–1.5 cm, transect it, and spatulate dorsally to prevent neomeatal stenosis.
5. Close the corpora — close both corporal ends transversely with interrupted 2-0 absorbable suture incorporating the septum, and place 2-0/3-0 sutures in the spongiosum around the urethra.
6. Reconstruct the meatus — close penile skin ventrally in the midline (3-0/4-0 absorbable) and approximate the spatulated urethra to the skin as an oblique meatus open at 12 o'clock; close remaining skin dorsally. Leave an 18-Fr Foley for 3–5 days.

Complications

Infection, bleeding, and meatal stenosis are the early problems — reduce stenosis with a long elliptical suture line, and reduce infection/tumour spillage with perioperative antibiotics and glove exclusion of the tumour.

Total Penectomy

Indicated when tumour size or location prevents an adequate margin with partial penectomy, or when too little phallus would remain to void standing.

Preoperative Workup

Confirm the diagnosis histologically (depth and grade); stage with inguinal node palpation and CT of the chest, abdomen, and pelvis (nodal/distant disease drives survival); check and correct calcium in advanced disease; and treat any secondary infection with antibiotics beforehand.

Technique

1. Position — exaggerated dorsolithotomy (as for perineal prostatectomy); pad the leg to protect the peroneal nerve (foot drop). Isolate the tumour with a sewn-on glove or condom and make an elliptical incision around the penis.
2. Mobilise — dissect dorsally, plan to transect the corpora near the pubis, divide the suspensory ligaments, and ligate the superficial dorsal vasculature with 2-0 ties.
3. Urethra — open Buck fascia ventrally, sharply dissect the urethra off the corpora leaving ample length to reach the perineum, divide it sharply (preserving blood supply), and tag the distal end at 12 o'clock with 3-0 silk.
4. Corpora — dissect the corporal bodies back to the pubic rami, divide them, and oversew each stump with running 2-0 polyglactin (a UR-6 needle helps in the deep hole).
5. Perineal urethrostomy — make a 1–2 cm elliptical or inverted-Y perineal incision; pass a tonsil clamp through to deliver the urethra (grasp the silk tag, never the urethra, to protect its blood supply; avoid twisting). Spatulate at 12 o'clock and mature the urethrostomy with interrupted 4-0 poliglecaprone (small urethral bites, larger skin bites). Place an 18- or 20-Fr Foley.
6. Close — approximate scrotal to suprapubic skin with interrupted 2-0 nylon vertical mattress (non-absorbable, given the infection risk), close dead space, and leave a Penrose drain brought out laterally.

Postoperative Care

Admit for IV antibiotics; remove the Penrose the next morning if dressings are dry; keep the Foley until the urethrostomy is well healed (1–2 weeks), with triple antibiotic ointment to the stoma until catheter removal.

Complications

• Meatal stenosis is the most common complication — manage with sounds/meatal dilators at the first sign of a weaker stream.
• Bleeding from a postoperative erection (rare; the Penrose helps detect it), wound infection (commoner in obesity/diabetes — superficial → antibiotics, deep → I&D and healing by secondary intent), and urethral necrosis (debride; drop skin darts back to the urethral edge later to prevent stenosis).