Carcinoma in Situ
- Topical — EAU advises circumcision before topical agents. Options: 5-fluorouracil 5% cream (BID × 6 weeks) or imiquimod 5% cream. Strict adherence and follow-up are essential, with prompt re-biopsy of non-responding lesions; failed topical therapy should not be repeated.
- Laser ablation — CO2 or Nd:YAG (efficacy for cancerous lesions is debated).
- Surgical — a foreskin lesion is treated by circumcision or excision with a 5-mm margin; a glans lesion by excisional strategies that preserve normal penile anatomy.
- Radiation — for lesions resistant to topical therapy, especially in non-surgical candidates.
Organ-sparing Approaches
The goal is to preserve glans sensation and maximize shaft length. Five options: Moh's surgery, laser ablation, radiotherapy, limited excision, and glansectomy. Because recurrence rates are higher than with amputation, follow-up compliance is a key consideration.
- Moh's micrographic surgery — the least invasive, with favourable functional outcomes but high long-term recurrence; best for small, superficial shaft lesions (favourable histology: 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.
Penectomy
Indications for partial or total penectomy: high grade (≥3), stage ≥T2 / deep invasion into the glanular urethra or corpora cavernosa, or tumours >4 cm.
Treatment by Stage
| 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 — chosen 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 if resectability is a concern |
| Local recurrence after conservative therapy | Complete excision to negative margins (may need partial/total penectomy); select superficial low-grade recurrences may have a repeat penile-conserving procedure |
Radiotherapy
An option for invasive SCC in patients refusing surgery, delivered as brachytherapy (interstitial implant) or external beam. Primary radiotherapy suits select T1–T2 tumours <4 cm involving the glans/coronal sulcus, and circumcision is required first. Brachytherapy is more likely than EBRT to preserve erectile function. Adverse effects include desquamation, meatal stenosis, and soft-tissue ulceration; salvage penectomy may be needed for persistent/recurrent disease. Inguinal nodes are managed surgically by the same criteria as for surgical primaries — radiation to the groin is less effective than surgery, prophylactic nodal radiotherapy is not recommended, and palliative radiotherapy may benefit inoperable nodes.
Self-Test
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What are the indications for partial or total penectomy? High grade (≥3), stage ≥T2 / deep invasion of the glanular urethra or corpora cavernosa, or tumours >4 cm.
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Which organ-sparing procedure offers the highest local control, and how is it done? Glansectomy — the glans is removed from the corporal heads with urethral transection and distal urethrostomy, covered by a skin graft or advanced shaft skin.
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When is primary radiotherapy appropriate, and what is required first? Select T1–T2 tumours <4 cm of the glans/coronal sulcus in patients declining surgery; circumcision must be done first. Brachytherapy preserves erectile function better than EBRT.