Purpose of review
Malignant penile lesions are uncommon but represent a challenge for reconstructive surgeons because their treatment has a profound effect on appearance and quality of life of the patient.
Partial or total penectomy remains the gold standard in the treatment of penile carcinoma. However, less invasive options that may improve quality of life are being considered, based on stage and grade of the tumor.
A variety of surgical options exists for penile cancer treatment. In this article, we review various reconstructive approaches after initial surgical management of penile carcinoma. Regardless of reconstruction method, the goals remain the same: creating a functional and aesthetically acceptable phallus with the ability to void standing and to achieve sexual function.
Penile carcinoma is an uncommon disease in the western, industrialized world. It is often devastating for the patient for its mutilating effect and frequently poses a diagnostic and therapeutic challenge for the urologist and medical oncologist. A distinction between benign and malignant tumors is essential, as the most effective treatment strategies for these two categories vary widely. Some penile tumors are considered strictly benign, whereas others express a high potential for malignant transformation. In the United States and Europe, penile carcinoma accounts for 0.4% to 0.6% of all malignant tumors in men, with an incidence of 0.3 to 1.8 per 100,000, but in gradual decline over the last 3 decades [1, 2]. However, the incidence of this malignant tumor is higher in developing countries of Africa, South America and Asia, constituting about 10% of the oncologic burden in these countries and thus posing a considerable public health concern . Arya et all  reported increase in penile cancer in England since the 1970s due to changes in sexual practice, greater exposure to sexually transmitted oncogenic human papilloma viruses, and decreasing rates of childhood circumcision. The same conclusion is found in an article on penile cancer incidence in Denmark . Last but not least, an estimated 1570 new cases of penile cancer are expected within the United States in 2013, with 310 predicted cancer-specific deaths .
Squamous cell carcinoma, which is the most common malignant penile tumor, most commonly affects men between the ages of 50 to 70, with only 19% in men under 40 and 7% in men under 30. Several etiologic risk factors have been reported in the development of penile squamous cell carcinoma, including lack of hygiene, exposure to human papilloma virus, presence of phimosis, smoking and cultural factors . Steffens et al  reported that several prognostic factors have been established for patients with penile carcinoma and concluded that early detection plays an important role in improved disease control and overall prognosis.
The treatment of the benign, premalignant and malignant penile lesions has changed over time [9*]. Traditional penile surgery is associated with mutilating effects, leading to a high incidence of aesthetic, dysfunctional and psychological post-operative disorders [10-12]. In this context, the use of either medical or topical surgical treatments has been supported with the specific aim of maintaining a good functional and aesthetically acceptable appearance of the penile shaft; topical chemotherapy, laser ablation, cryotherapy, and local excisions have been thus reported in the scientific literature. However these techniques are associated with high failures rates and unsightly scarring that impacts penis appearance and sexual activity. Radiotherapy has been used as both a primary and a palliative measure, with success in the management of primary penile tumors as well as the inguinal node disease. Current chemotherapy, either alone, or in a multimodal therapeutic combination has recently been refined. However, its role in the treatment of advanced disease is still limited. Recently, alternative forms of surgical therapy have been suggested in numerous articles, specifically aimed at preserving the phallus without compromising local cancer control in patients with either premalignant or malignant superficial lesions. These organ-sparing techniques are only indicated for patients with small lesions for which negative margins can be obtained. For patients in whom negative margins are not possible, more radical treatments are best suited.
Penile cancer should preferably be staged according to the American Joint Committee on Cancer/Union for International Cancer Control seventh edition TNM classification . According to The 2009 European Association of Urology (EAU) guidelines, patients can be prognostically stratified based on stage and/or grade into three risk groups: low-risk group (Tis, TaG1-2 or T1G1), the intermediate-risk group (T1G2) and the high-risk group (T2 or any G3) . Primary treatment options for penile cancer can be categorized based on location and extent of tumor invasion. Until 15 years ago, surgical options to treat invasive penile cancer were limited to minor procedures such as wide local excision and circumcision or more radical amputative procedures loosely divided into partial and radical penectomy. In many cases, traditional penectomy would leave the patient with a short penile stump, unsuitable for voiding while standing up and with limited or no sexual function. The psychological and psychosexual consequences were – and still remain – significant. Recently, new surgical procedures and therapeutic options have been developed to preserve a functional phallus, although some are not without major limitations.
The choice of surgical treatment depends upon the primary tumor characteristics, including size, location, and depth of invasion, in conjunction with the oncologic need to achieve effective local tumor control while simultaneously retaining maximal penile function. As a universal oncologic principle, a tumor-free margin after resection is critical. The extent of the negative margin necessary to ensure local tumor control in penile carcinoma has been a matter of controversy. The formerly described 2-cm margin has recently been criticized by advocates of penis-conserving operations. These authors have suggested that patients treated with margins < 2 cm (e.g., 5-10 mm) also attain similar long-term recurrence-free survival rate [15-17].
Minimally invasive treatment
In situ penile lesions, such as erythroplasia of Queyrat and Bowen’s disease, can be treated conservatively by local topical therapy, local excision, circumcision, tissue ablative techniques and laser therapy . Supportive study data on topical therapy and penile–preserving surgery were reviewed by Alnajjar et al . They studied the use of 5-FU or imiquimod over a period of 10 years in the treatment of 86 patients with carcinoma in situ of the glans penis. Of the 44 men who received topical chemotherapy, 25 (57%) had a complete response. Although laser therapy has been proven effective in carefully selected patients with close follow up, it should not be considered an alternative to standard resection. Wound healing after laser therapy comprises secondary intention healing with full re-epithelialization at 8-10 weeks post-operatively. Most patients with penile lesions are uncircumcised. Indications for circumcision are preputial changes, low-grade and low-stage penile cancer. The disadvantage of circumcision is the reported recurrence rate of more than 50% after two years, indicating a need for regular close surveillance [20-21]. Mohs micrographic surgery has also shown favorable outcomes in carefully selected patients with in situ and superficially invasive lesions of the glans and shaft. The procedure involves serial tissue resections with histological evaluation to ensure that a tumor-free plane is obtained. Patients subjected to these minimally invasive, ablative techniques that are used to treat in situ or superficially invasive penile lesions should be carefully monitored for early signs of recurrence. The advantages of the Mohs technique include tumor excision without positive margins, and preservation of penile tissue with good esthetical and functional outcomes. The disadvantage is high local recurrence rate after one procedure. However, in most cases the Mohs procedure can be repeated [22-23]. The goals of penile-preserving treatments are to maintain penile/glans sensation and to maximize penile shaft length where possible. Some retrospective studies have reported good cosmetic and functional outcomes with conservative treatment options and an overall organ preservation of 60% . However, cosmetic and functional results should not compromise long-term oncologic outcomes. One study of the role of penile-preserving surgery was published by Feldman and McDougal . Sixty patients underwent this treatment and overall recurrence rate was 21%. At 5 years, about 14% had a late recurrence. Experts recommend a follow up period for these patients of at least 10 years . Because more than 80% of penile tumors arise from the glans of the penis, many patients are candidates for glansectomy .
Glans resurfacing involves excision of the epithelium and subepithelium of the entire glans or the locally affected area with a macroscopically clear margin. Although a number of patients may require a second procedure because of positive surgical margins, this does not appear to compromise overall oncologic control . The authors concluded that it appears to be a safe and effective procedure for carcinoma in situ that preserves the function of the penis .
Glansectomy, either partial or total, has recently been introduced for the local excision of distal tumors on the glans and prepuce [30, 31, 32*, 33]. Partial glansectomy should include the collection of frozen sections of the cavernosal bed and urethral stump, if involved, to confirm negative margins before reconstruction. Closure of the defect can be performed in three ways: (i) primary closure, (ii) closure with preputial or penile/scrotal skin flap, or (iii) grafting technique. Primary closure is recommended if the lesion is small and not too close to the urethral meatus. Otherwise, it might lead to tilting of the glans and affect the direction of micturition. The grafting procedure is commonly performed by split-thickness skin graft [34**]. In patients with lichen sclerosus, use of a skin graft could lead to disease recurrence, even if it seems that excision of much of the diseased tissue by ample circumcision reduces this risk. A recent series of articles has also described the use of oral mucosa for glans reconstruction. The buccal mucosa seems to be an unsuitable tissue for resurfacing because of graft-desquamation due to the contact of oral mucosa with air, being that it is adapted to a humid, not a dry, environment . Although this reconstruction with grafts yields adequate cosmetic and functional results, it is associated with risk of poor graft take, which can lead to contracture and poor cosmesis. Decreased penile sensitivity has also been described; in addition, in men with total glansectomy, a loss of penile length is a common complaint [35*]. Sansalone et al  reported good alternative to split-thickness skin and oral grafts. They used distal urethral flap for glans reconstruction in selected cases with negative sections of the corporeal and urethral margins. This is based on penile disassembly technique in the treatment of penile carcinoma previously reported by Djordjevic et al  (Fig. 3).
Partial penectomy remains the most common surgical procedure for men with distal penile cancer. It remains the standard option for invasive distal penile cancers that are not amenable to more conservative measures and for locally recurrent cancers after organ-sparing management has been attempted. It is also indicated in cases in which the disease extends into the urethra or corpora cavernosa. This technique seems to be oncologically safe with a 100% recurrence-free follow-up reported by different authors . Minhas  reported a recurrence rate of 12.5%, treated successfully with repeat partial penectomy. Conversely, the study of Lont  states that the local recurrence after partial penectomy carries a poor prognosis. In general, partial penectomy offers excellent local control with low recurrence rates (< 10%) and allows for preservation of urinary function and, possibly, sexual function.
Total penectomy is indicated for tumors whose size or location would not permit excision with an adequate surgical margin and preservation of a remnant sufficient for voiding while standing. It requires the creation of a perineal urethrostomy. According to European guidelines  for the treatment of penile carcinoma, penile reconstruction is recommended after cancer management. Although different techniques for phalloplasty have been published, there is no ideal procedure. Regardless of the method of phalloplasty, the goals of this surgery remain the same. These include creating a functioning and aesthetically acceptable phallus with the ability to void standing and to achieve sexual function. Hence, microsurgical free flap reconstruction has become the method of choice for total phalloplasty. The ideal flap should be one that is sensate and hairless, with sufficient tissue to allow tubularization, as well as a long pedicle. The radial forearm flap fulfills these requirements, and is by far the most commonly used flap for phalloplasty . In an effort to improve the donor site scar, the latissimus dorsi musculocutaneous flap has been used for phallic reconstruction. This flap has been described by the Belgrade team in the treatment of transsexuals and patients with severe penile trauma . Advances in tissue engineering promise new options for penile reconstruction. Even though the research is still in the phase of animal studies, progress has been made in recent years .
A literature study revealed only few studies of quality of life in patients with penile carcinoma. None of these used a specific standardized tool, but they did show that penile cancer and its management can affect patient’s psychosocial and psychosexual life [43, 44]. Many patients delay seeking medical attention due to embarrassment, fear, and/or ignorance. The ideal outcome involves the preservation of normal sexual and urinary function while eradicating the disease. However, this is not always possible due to extent of disease. It is understandable why patients often are reluctant to undergo radical treatment due to devastating effect it has both physically and psychologically [45*]. New reports are necessary to gain a greater insight into the impact of penile cancer surgery on men’s physical and mental health and well-being and broader quality of life [46**,47,48].
The penis-sparing techniques are a safe and effective treatment option in select patients with benign, pre-malignant or malignant penile lesions. The goal of these techniques is to maintain a functional penis for urination and intercourse, without compromising cancer control. The preservation of sexual ability with good penile appearance and sensation guarantees a satisfying functional and psychosexual quality of life for the patient. However, in patients with a more aggressive disease, partial or total penectomy is indicated and should be followed by some form of neophalloplasty.
- Penile cancer causes significant morbidity and mortality in patients throughout the world.
- Patients with lower tumor stage can be treated with a minimally invasive approach such as circumcision, local excision, glans resurfacing or glansectomy.
- More aggressive surgical treatment, such as partial or total penectomy, is necessary for tumors of higher stages.
- Patient’s preference must be considered in selecting the treatment option.