Surgery for Penile Cancer

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

If radiation therapy is going to be used to treat a tumor on the penis of an uncircumcised man, circumcision is typically done first. This is because radiation can cause swelling and tightening of the foreskin, which can lead to other problems.

This might be an option for some very early-stage cancers on the glans (head) of the penis. In this procedure, the entire thin outer layer of skin over the glans, including the tumor, is removed.

The removed skin is then quickly frozen and checked under a microscope to make sure the cancer hasn’t grown any deeper into the penis. If it has, a more extensive operation, such as a glansectomy (see below), will be needed.

Once the skin has been removed, a skin graft from another part of the body (often the thigh) is used to replace it.

These operations remove just the tumor and some surrounding normal tissue to help make sure all of the cancer has been removed.

For a simple excision, the tumor and a small amount of surrounding tissue are cut out. If the tumor is small, the remaining skin can then be stitched back together. This surgery is the same as an excisional biopsy, and it’s rarely used by itself to treat penile cancer.

In a wide local excision, the tumor is removed along with a larger amount of normal tissue around it (called wide margins). If there's not enough skin left to cover the area, a skin graft might be taken from another part of the body and used over the area.

Mohs surgery (also known as Mohs micrographic surgery, or MMS) might be an option instead of wide local excision for some early-stage penile cancers.

In this technique, the surgeon removes a thin layer of the skin containing the tumor. The sample is then frozen and checked under a microscope right away. If cancer is seen, the surgeon removes and examines another layer. This process is repeated until a 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, which can help the penis look and work better after surgery.

This is a highly specialized technique that is only done by doctors who have been trained in this specific type of surgery.

If the tumor is only on the glans (the head of the penis) but has grown deeper than just the top layer of skin, just the glans can be removed in an operation called a glansectomy. Skin grafts may be used rebuild the glans after surgery.

This operation removes part or all of the penis. It's the most common 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 to keep urinating while 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 then creates a new opening for urine to drain from the perineum, 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 urination will have to be done while sitting.

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 need to 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 After Penile Cancer Treatment.

This operation, also known as dynamic sentinel node biopsy (DSNB), can help the surgeon see if the inguinal (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 has reached them. See How Is a Biopsy Done? for details on how an SLNB is done.

In this procedure, the surgeon finds and removes the first lymph node that drains the tumor (called the sentinel node). 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 cells, the cancer might have spread farther, so a more extensive operation known as an inguinal lymph node dissection (ILND) 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 because the cancer is unlikely to have spread farther.

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

If your doctor is considering an SLNB, it might be useful to find out how many they have done. Experience is very important to the success of this procedure.

Many people with penile cancer have swollen inguinal (groin) lymph nodes when the cancer is found. These lymph nodes will need to be removed if they contain cancer cells. But sometimes the swelling might be from an infection or inflammation, not cancer.

If the problem might be an infection, doctors may give a course of antibiotics first. If the swelling goes away, it was likely caused by infection or inflammation. If it doesn’t go away, an ILND (also known as an inguinal lymphadenectomy) is done to remove these 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 given just in case there is an infection.

An ILND may also be done if cancer is found in the sentinel node during an SLNB (see above).

There are different ways an ILND might be done:

• During an open ILND, which is used in many medical centers, the surgeon makes an incision about 4 inches long in your groin and carefully takes out the lymph nodes.
• During a robotic-assisted inguinal lymphadenectomy (RAIL), the operation is done through several small incisions. The surgeon sits at a panel that controls very precise robotic arms with long, thin surgical tools that are put in through the small incisions.

Because the RAIL procedure uses smaller incisions, recovery is quicker and there's less pain. But this is a complex operation that is best done by an experienced surgeon. It is more likely to be an option if you are being treated at a major medical center.

Regardless of which technique is used, the lymph nodes are then sent to a lab, where they're checked to see if they have cancer cells in them.

If cancer is found in 2 or more inguinal (groin) lymph nodes, pelvic lymph nodes, which are slightly higher up in the body, 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.

As with removal of inguinal lymph nodes, removing the pelvic nodes can be done with either an open technique (through a long incision in the lower belly), or with the use of precise robotic arms (known as a robotic-assisted pelvic lymph node dissection (RAPLND). RAPLND is a complex procedure that is not done very often, especially outside of major medical centers. It is best done by an experienced surgeon.

The risk of lymphedema (see below) is higher if pelvic lymph nodes are also removed.