Current concepts of organ-sparing surgery in penile cancer.

The report by Palminteri et al. on penis-preserving surgery (PPS) in various benign and malignant penile lesions is interesting. The authors describe their technique of the use of the split-thickness skin graft (STSG) for neo-glans reconstruction after glansectomy, partial penectomy and in patients in whom all the glanular skin is removed and replaced by STSG. They confirm the feasibility of optimal functional outcome and oncological control in their 21 patients. The basic concepts of PPS in penile cancer involve excision of the lesion with an adequate safety margin, and taking multiple frozen-section biopsies from the base and edges [1-3]. With strict adherence to these requirements, a few millimetres of normal surrounding tissue is enough as a surgical margin. Similar to partial nephrectomy, where contemporary reports support that a much smaller safety margin than historically reported is enough for oncological control, PPS follows in the same footsteps.

The techniques of PPS were first described by Bissada [1] in the 1980s and were later recommended by several authors. In the original description, tailored excision of the lesion was performed, followed by multiple deep and lateral frozen-section biopsies [1,2]. The ‘tailored’ excision means excising the lesion with a surrounding few millimetres of normal tissue as a safety margin. How deep this tailored excision depends on how deep the tumour is, with excision of underlying Buck’s fascia, tunica albuginea or corporal tissue as needed. This principle is applied irrespective of the tumour location, whether in the glans or the penile shaft. Corporeal involvement can be easily identified by careful clinical examination. Recently MRI was advocated for accurate local tumour staging and postoperative follow-up [4]. The defect is closed either by primary suturing or the application of skin grafts (partial or full thickness). Skin grafts can be harvested from the thigh or the inner side of the forearm. When using skin grafts, it is wise to take a graft larger than the defect, as it has a tendency to contract. It is our opinion that all patients should have a preoperative biopsy of the penile lesion. This can be easily done in the office under local anaesthesia. In complex cases multiple biopsies with careful mapping of the extent of the lesion is used.

An interesting technique in patients where the glans is completely excised is to advance the urethra, split it and use it to cover the tips of the exposed corpora cavernosa, with or without penile shaft skin advancement [5,6]. Another occasion to use PPS is when a patient presents with glanular lesion extending to the penile skin. Tailored excision in this case includes partial/complete glansectomy with excision of the involved penile skin, underlying Buck’s fascia and rarely the tunica. If the tunica is excised, a synthetic graft is used to cover the tunical defect. In this case a vascularised penile/scrotal flap is used rather than a skin graft. Finally, in lesions involving parts of the corpora cavernosa, the urethra can be preserved and later used during subsequent reconstructive surgery. In this case, the preserved urethra is used to create a temporary perineal urethrostomy. At the time of penile reconstruction, the preserved urethra can be used to construct a neo-meatus in the normal position at the tip of the reconstructed penis [7]. Regardless of the tumour location or method of excision in PPS, oncological control remains mandatory and is ensured by obtaining multiple frozen sections from the margins and deeper tissues and close follow-up.

Oncological outcome

The longest follow-up on patients with PPS was reported by Bissada et al. [3]. In that report the local recurrence rate in 26 patients followed for up to 360 months was 7.7%. In another smaller study, there was local recurrence in one of five patients treated with PPS and skin grafting/proximal penile skin advancement [5]. What is important is that these local recurrences were treated with local excision, with no effect on survival.

Quality of life

PPS provides the highest patient satisfaction rate. Patients with a reasonable erection before surgery will continue to have the same. Obviously the ability to have meaningful sexual ability also depends on the penile length left after PPS. Many patients are also able to have a normal urinary stream.

Conflict of interest

The authors declare no conflict of interest.