Surgery for Penile Cancer

Surgery is the most common treatment for all stages of penile cancer. If the cancer is found when it's small and hasn't spread, the tumor can often be treated without having to remove part of the penis. If the cancer is found at a more advanced stage, part of or all of the penis might have to be removed with the tumor. Your cancer care team will talk with you about the treatment options that give you the best chance of curing the cancer while saving as much of your penis as possible.

Men with tumors that have grown deep within the penis (stage T2 or higher) usually need to have some nearby lymph nodes in the groin taken out to check for cancer spread. Instead of removing all of the groin lymph nodes to look for cancer, some doctors prefer to do a sentinel lymph node biopsy, which is covered later in this section.

Many different kinds of surgery are used to treat penile cancers. Penile-sparing techniques are used as often as possible. These include local treatments and limited surgeries, to save as much of the penis as possible to preserve sexual function, the way the penis looks, and the ability to urinate while standing up.

Circumcision

If the cancer is only on the foreskin, circumcision can often cure the cancer. This operation removes the foreskin and some nearby skin.

Circumcision is also done before radiation therapy to the penis. Radiation can cause swelling and tightening of the foreskin, which can lead to other problems.

Simple excision

In simple excision surgery, the tumor is cut out, along with some nearby normal skin. If the tumor is small, the remaining skin can then be stitched back together. This is the same as an excisional biopsy.

In a wide local excision, the tumor is removed along with a large amount of normal tissue around it (called wide margins). Removing this healthy tissue makes it less likely that any cancer cells are left behind. If there's not enough skin left to cover the area, a skin graft may be taken from another part of the body and used over the area.

Mohs surgery (microscopically controlled surgery)

This may be an option instead of wide local excision in select cases. Using the Mohs technique, the surgeon removes a layer of the skin that the tumor may have invaded and then checks the sample under a microscope right away. If it contains cancer, another layer is removed and examined. This process is repeated until the skin sample doesn't have cancer cells in it.

This process is slow, but it means that more normal tissue near the tumor can be saved. This means the penis looks and works better after surgery. This is a highly specialized technique that should only be done by doctors who have been trained in this specific type of surgery. It can be used for carcinoma in situ (CIS), where the cancer is in only the top layers of the skin, and for some early-stage cancers that haven't grown deeply into the penis.

Glansectomy

If the tumor is small and only on the glans (the tip of the penis), part or all of it may be removed. Skin grafts may be used rebuild the glans after surgery.

Partial or total penectomy

This operation removes part or all of the penis. It's the most common and best known way to treat penile cancer that has grown deeply inside the penis. The goal is to remove all of the cancer. To do this the surgeon needs to remove some of the normal looking penis as well. The surgeon will try to leave as much of the shaft as possible.

The operation is called a partial penectomy if only the end of the penis is removed (and some shaft remains).

If not enough of the shaft can be saved for the man to urinate standing up without dribbling (at least 2 to 3 cm) , a total penectomy will be done. This means the entire penis is removed, including the roots that extend into the pelvis. The surgeon creates a new opening for urine to drain from the perineum, which is the area between the scrotum (sac for the testicles) and the anus. This is called a perineal urethrostomy. Urination can still be controlled because the sphincter muscle (the “on-off” valve) in the urethra is left behind, but the man will have to sit to urinate.

For very advanced tumors, sometimes the penis is removed along with the scrotum (and testicles). This operation is called emasculation. Since this operation removes the testicles, which are the body’s main source of the male hormone testosterone, men who have this procedure must take testosterone supplements for the rest of their lives.

Any of these operations can affect a man’s self-image, as well as his ability to have sex. For more on this, see Living as a Penile Cancer Survivor.

Lymph node surgery

Men with cancer that has grown deep within the penis (stage T2 or higher) usually need to have some nearby lymph nodes in the groin removed so they can be checked for cancer spread.

Sentinel lymph node biopsy (SLNB)

This operation can sometimes help the surgeon see if the groin lymph nodes contain cancer without having to remove all of them. It's most often done when lymph nodes are not enlarged but there's a chance that the cancer reached them. See Types of Biopsies Used to Look for Cancer for details on how SLNB is done.

The surgeon finds the first lymph node that drains the tumor (called the sentinel node) and removes it. If the cancer has spread outside the penis, this lymph node is the one the cancer is most likely to go to first. If the sentinel node contains cancer, a more extensive operation, known as a lymph node dissection or inguinal lymphadenectomy, is done (see below). If the sentinel node does not have cancer cells, the surgeon doesn’t have to remove any more lymph nodes.

Using this approach, fewer patients need to have many lymph nodes removed. The more lymph nodes that are removed, the higher the risk of side effects such as lymphedema and problems with wound healing. (Side effects are covered below.)

Not all doctors agree on how useful this type of operation is for penile cancer. Early studies showed that SLNB was helpful in finding those men whose cancer had spread to their lymph nodes, but later studies did not show that it was very accurate, and some men with lymph node spread could be missed if the SLNB was used.

If your doctor is considering a SLNB, it might be useful to find out how many he/she has done. Experience is very important to the success of this procedure.

Inguinal lymphadenectomy (groin lymph node dissection)

Many men with penile cancer have swollen groin lymph nodes when they're first diagnosed. These lymph nodes need to be removed if they contain cancer cells, but sometimes, the swelling is from infection or inflammation, not cancer. If the problem might be infection, doctors may give a course of antibiotics. If the swelling goes away, it was likely caused by infection or inflammation. If it doesn’t go away, an inguinal lymphadenectomy is done to remove the lymph nodes. Higher stage and grade cancers are more likely to have spread to the lymph nodes.

If the lymph nodes are big enough to feel, most experts recommend a biopsy to check them for cancer cells in higher stage and grade cancers. Antibiotics might also be used just in case there is an infection.

This operation may also be done if cancer is found during a SLNB (see above).

In this procedure, the surgeon makes an incision about 4 inches long in your groin and carefully takes out the lymph nodes. This is a serious surgery because important muscles, nerves, and blood vessels run through the groin and the nodes can be deep inside the body. The nodes are then sent to a lab, where they're checked with a microscope to see if they have cancer cells in them.

Pelvic lymph node surgery

If cancer is found in 2 or more inguinal (groin) lymph nodes, pelvic lymph nodes will also be removed and checked. This may be done at the same time the groin nodes are removed, or later as a separate surgery.

This surgery is done through an incision (cut) in the lower belly. The risk of lymphedema goes up if these nodes are also removed.

Side effects of lymph node surgery

The groin lymph nodes help fluid drain out of the legs and back into the bloodstream. Removing many lymph nodes in an area can lead to problems with fluid drainage and cause abnormal swelling. This condition is called lymphedema. In the past, this was a common problem after treatment because the lymph nodes from groin areas on both sides were removed to check for cancer spread. Now fewer lymph nodes are usually removed, which lowers the chance that lymphedema will occur. Still, lymphedema can occur even when only one lymph node or the lymph nodes from only one part of the groin are removed. For more on this, see Lymphedema.

Other side effects, such as problems with wound healing, infection, blood clots, and skin breakdown (necrosis) can occur after lymph node surgery .