Surgery for penile cancer

Most men with penile cancer will have surgery. The type of surgery you have depends mainly on the size of the tumour, stage of the cancer, depth of the tumour and type of tumour. If the cancer is found early, it can often be treated without having to remove part of the penis. If the cancer is found at a more advanced stage, part or all of the penis may have to be removed to remove the tumour. When planning surgery, your healthcare team will also consider other factors, such as your age and overall heath. The surgeon will leave as much of the penis as possible to try to keep sexual function and normal urination. Side effects of surgery depend on the type of surgery done.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• remove lymph nodes (if the cancer has spread to them)
• reduce pain or ease symptoms (called palliative surgery)

The following types of surgery are used to treat penile cancer. You may also have other treatments before or after surgery.

A circumcision removes the foreskin of the penis. This may be all that is needed for a very small tumour (less than 2 cm) located only on the foreskin.

Mohs surgery (Mohs micrographic surgery) is a specialized surgical method that may be used to treat small, early stage penile cancers. It removes the tumour and surrounding tissue layer by layer, until the tissue is completely clear of cancer cells.

Find out more about Mohs surgery.

Laser surgery is sometimes used to treat small, early stage penile cancer and precancerous conditions of the penis. Laser surgery uses an intense, narrow beam of light (called a laser beam) to destroy cancer cells.

Find out more about laser surgery.

Cryosurgery is sometimes used to treat early penile cancers (carcinoma in situ and verrucous carcinoma). Cryosurgery uses extreme cold to freeze and destroy tissue.

Find out more about cryosurgery.

Wide local excision (wide excision) is used to treat small, early stage penile cancers. The tumour is removed along with a margin of normal tissue around it. The margin size may vary depending on the grade, type and size of the tumour. The remaining skin is stitched together. The rest of the penis is left intact.

Some early stage penile cancers may be completely removed by wide local excision. But this surgery may need to be followed by external beam radiation therapy, brachytherapy, laser surgery or more surgery.

Sometimes cancer within enlarged lymph nodes can grow through the lymph nodes and invade the skin over them. A wide excision may also be used to remove the area of the skin in the groin area that contains cancer. If a large area of skin has to be removed, a skin graft may be used to cover this area.

Glansectomy is commonly used to treat penile cancer that is only on the head (glans) of the penis. This surgery involves only the head of the penis. A partial glansectomy removes only part of the head of the penis. The head of the penis can be reconstructed after surgery using skin grafts. The man can usually pass urine normally and have penetration during sex.

A partial penectomy is commonly used to treat penile cancer. This surgery removes the head of the penis and part of the shaft. It is used to treat tumours on the head or tumours on the far (distal) end of the shaft, closest to the head. A partial penectomy is done instead of a total penectomy, if possible.

During a partial penectomy, the tumour is removed along with a margin of normal tissue around it. The margin will vary depending on the grade and type of tumour. The surgeon tries to leave enough of the shaft of the penis to allow the man to urinate standing up and keep sexual function.

Depending on how much tissue is removed, the head or end of the penis can be reconstructed using skin grafts. The man can usually pass urine normally and have penetration during sex.

Some men may also be eligible for other reconstruction techniques that try to keep urination while standing up and that allow penetration during sex:

Cutting the suspensory ligament involves surgically cutting the ligament that allows the penis to “stand” when a man has an erection. When this ligament is cut, the penis usually gains about 1 cm in length, which can help a man to urinate standing up and have penetration during sex.

Removing fat above the penis so that it doesn’t get in the way of the penis can help the man urinate standing up and allow penetration during sex.

Cutting the suspensory ligament and removing suprapubic fat may both be offered to achieve the best possible results.

Total (radical) penectomy removes the entire penis. A total penectomy is used to treat:

• large penile tumours
• tumours that have grown deeply into the shaft
• tumours on the part of the shaft closest to the base of the penis (proximal shaft)
• tumours near the base of the penis

A total penectomy is done when removal of the primary penile tumour would not leave enough of the penis to allow the man to stand while urinating.

The shaft and root of the penis are removed. The remaining skin near the root of the penis is stitched together. The surgeon reroutes the urethra by making an opening between the anus and scrotum (called a perineal urethrostomy) so that the man can urinate. The man can still control urination because the muscle that keeps the bladder closed is further inside the body, above the penis. After surgery, the man must urinate sitting down.

In rare cases of advanced penile cancer, it may be necessary to have more surgery in addition to a penectomy. Men may need more surgery if they have invasive penile cancer in the proximal shaft or the root of the penis that extends to nearby tissues or structures. Surgery may include:

Scrotectomy removes the scrotum. It may be used to treat penile cancer that has spread to the scrotum.

Orchiectomy removes the testicles. It may be used to treat penile cancer that has spread to the testicles.

Pelvis exenteration removes certain reproductive organs along with lymph nodes in the pelvis. It may be used to treat penile cancer that has spread to the pelvis. Find out more about pelvic exenteration.

Skin grafts and skin flaps may be used to reconstruct the penis after surgery. Skin grafts may also be used when cancer in the lymph nodes of the groin has spread to the overlying skin. In this case, a skin graft is needed because a large area of skin is removed. Skin and muscle is often taken from the outer part of the thigh or abdomen.

A skin graft is a piece of skin taken from another part of your body (called the donor site) and placed over the area where the cancer was removed.

A skin flap is a thick piece of tissue with its own blood supply. Like a skin graft, a skin flap covers the area where the cancer was removed.

It may be possible to reconstruct the penis after a total penectomy using skin grafts and skin flaps, although this surgery is very rare. Various techniques may be used to create a penis. Skin grafts and tissue flaps used to reconstruct the penis are often taken from the leg, abdomen, forearm, scrotum or groin area. Sometimes as many as 6 operations are needed to get the desired results. Sometimes it may be possible for a surgeon to reconnect nerves so a man has feeling in the reconstructed penis. The reconstructed penis may also be able to get an erection if the surgeon can reconnect blood vessels.

Men with high-grade cancer, cancer that has grown deeper in the penis or cancer that has grown into the blood vessels or lymph vessels often need to have nearby lymph nodes in the groin or pelvis removed to check for cancer. The doctor will examine the lymph nodes to check if they look or feel swollen. If the doctor cannot feel the lymph nodes, they are called clinically uninvolved lymph nodes. If the lymph nodes are large and firm to the touch, they are called clinically involved lymph nodes.

If the lymph nodes cannot be felt, the doctor may monitor the lymph nodes using imaging tests (CT, MRI or PET scan) or may do a sentinel lymph node biopsy (SLNB).

If the lymph nodes are large and firm to the touch, the doctor will do a fine needle aspiration (FNA) biopsy to check for cancer.

In some cases, the lymph nodes are not checked with an SLNB or FNA but instead through surgery to remove a few lymph nodes from an area (called lymph node sampling).

Sentinel lymph node biopsy (SLNB) may be used to find out whether cancer has spread to the lymph nodes and if removing lymph nodes is necessary. An SLNB is usually only used in centers where there are doctors who specialize in this technique. The sentinel node is the first lymph node or cluster of lymph nodes that receives fluid from the area around a tumour. Cancer cells will most likely spread to these lymph nodes first. An SLNB removes the sentinel lymph node so it can be examined to see if it contains cancer cells. There may be more than one sentinel lymph node, depending on the drainage route of the lymph vessels around the tumour.

• If the results of the SLNB are negative (cancer cells are not present), it is unlikely that other lymph nodes are affected and no more surgery is needed.
• If the results of the SLNB are positive (cancer cells are present), lymph nodes will be removed from the groin (called a lymph node dissection).

Fine needle aspiration (FNA) may be used to remove some fluid from an enlarged lymph node to check for cancer cells. An FNA is sometimes used instead of removing lymph nodes to see if they contain cancer. If the biopsy shows that cancer cells are present, surgery may be done to remove all the lymph nodes in the area. The doctor may use an ultrasound or a CT scan to guide the needle into the lymph node if it is too deep to be felt.

• If the results of the FNA are negative (cancer cells are not present), the biopsy may be repeated and the doctor may monitor the lymph nodes using imaging tests.
• If the results of the FNA are positive (cancer cells are present), all of the lymph nodes in the area may be removed (called a lymph node dissection).

Lymph node dissection is surgery to remove an area of lymph nodes. This is also called a lymphadenectomy. Penile cancer is most likely to spread to lymph nodes in the groin, followed by the lymph nodes in the pelvis. Lymph nodes in the groin may be removed at the same time as surgery to remove the penile cancer.

Inguinal lymph node dissection (ILND) may be used to remove lymph nodes in the groin. This is often the first type of lymph node dissection done for penile cancer.

Pelvic lymph node dissection (PLND) may be used to remove lymph nodes from the pelvis. If the lymph nodes are positive following an ILND, a PLND may be done.

Find out more about fine needle aspiration (FNA), sentinel lymph node biopsy, inguinal lymph node dissection and pelvic lymph node dissection.

Side effects can happen with any type of treatment for penile cancer, but everyone’s experience is different. Some men have many side effects. Other men have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health.

Surgery for penile cancer may cause these side effects:

• pain
• infection
• scarring
• wound separation
• bleeding
• lymphedema (if you have lymph nodes removed)
• seroma
• blood clot
• hematoma
• narrowing of the urethra
• changes to how a man urinates
• skin reactions
• change in colour and texture of the skin of the penis

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.