Treating penile cancer

If the cancer is located only on the foreskin, it may be possible to treat it by the surgical removal of the foreskin (circumcision). This treatment can usually be carried out as a day case procedure. It can be performed under local or general anaesthetic, depending on individual circumstances.

If the cancer is small or only a small surface is involved with cancer and it has not spread elsewhere then it can usually be treated by removing only the affected area and a small area around it.

This means removing the cancer with a rim of healthy tissue around it to reduce the risk of the cancer coming back in the future. The operation is performed under general anaesthetic and will involve a short stay in hospital.

Occasionally you may require a small skin graft (taken from the thigh) to cover the treated area.

For superficial (surface) pre malignant disease or superficial early cancers it may be possible to remove the top layer of the mucosa lining the glans (tip of penis) and use a skin graft from the thigh in order to cover the treated area.

To help the wound heal and produce a good cosmetic result, following surgery, a urethral catheter will be left in place and special dressing. This will be left untouched for approximately ten days while the wound heals. You do not need to stay in hospital for this period, but you will attend clinic for your nurse specialist to remove the dressing and catheter.

For larger cancers involving just the head of the penis, the bulbous part (the glans) will be removed. This is called a glansectomy. In order to make the penis look as normal as possible a layer of skin is taken from the thigh (skin graft) and placed onto the treated area. This aims to give a good cosmetic and functional result.

To help the wound heal and produce a good cosmetic result, following surgery, a urethral catheter will be left in place and a special dressing applied. This will be left untouched for approximately 12 days whilst the wound heals. You do not need to stay in hospital for this period, but you will attend clinic for you nurse specialist to remove the dressing and catheter.

This procedure should not affect normal sexual function (erections) as it removes only the head of the penis, although the sensitivity of the head of the penis is likely to be affected.

This may be advised if the cancer is large and is involving a large area of the penis. Amputation may be partial (where only part of the penis is removed) or total (removal of the whole penis). This depends on the position of the tumour. If the tumour extends to near the base of the penis then total amputation may be the only option. This operation is now much less common, as doctors try to preserve as much penis as possible.

UCLH is the only centre in the country that currently offers total penile reconstruction (radial artery phalloplasty).

If there are no signs that the cancer has spread it may be possible to have a penis reconstructed after amputation. This will require more surgery and will be performed at a later stage once you have recovered from the amputation and once the doctors are sure that there is no cancer spread. The techniques that may be used include taking a flap of skin and muscle from the arm and using this to make a new penis. Sometimes, it is also possible for surgeons to reconnect some of the nerves in order to provide sensation.

The surgeon may remove a small number of lymph nodes from your groin to find out if the cancer has spread. If the nodes in your groin are obviously enlarged you will usually have all the glands in your groin removed (radical groin dissection). However, there is a higher risk of developing lymphoedema the more lymph nodes are removed. This results in the lymphatic fluid accumulating in the soft tissues (for example in the legs, scrotum or abdomen) instead of being carried back into the central circulation. This results in swelling, a feeling of tightness and sometimes redness and pain in the affected area.

This surgery is less invasive than radical lymph node dissection. It can be done if the lymph nodes cannot be felt on examination by your doctor.

A sentinel lymph node is the very first node that is reached by lymph fluid from the site of a penile cancer and so it is the first lymph node to which cancer (if present) is likely to spread from the primary site of malignancy.

When cancer spreads, the malignant cells may appear first in the sentinel node before spreading to other lymph nodes which are more distant.

Sentinel lymph node dissection is carried out to find and remove the sentinel lymph node. The idea behind this surgery is to remove and analyse the one node that is most likely to have malignant cells in it instead of removing ten or more lymph nodes and investigate all of them for cancer from the primary tumour.

In cases where sentinel lymph node biopsy is not possible, or recommended, you may be offered superficial lymph node dissection. This is where a smaller ‘packet’ of lymph nodes are removed from the groin and analysed under a microscope. Should cancer be found, then you surgeon will proceed to remove all the remaining lymph nodes.

Radiotherapy treats cancer using high-energy rays to destroy cancer cells, while doing as little harm as possible to healthy cells.

Radiotherapy is no longer recommended as a treatment for the primary penile tumour. Radiotherapy will only be offered if disease has spread to the lymph nodes in the groin or pelvis and shown signs of spreading outside of the lymph node (extra capsular spread).

It may also be used to treat affected lymph nodes in the groin after surgery to help reduce the risk of the cancer spreading.

It may also be given to treat symptoms, such as pain, if the cancer has spread to other parts of the body, like the bones. Radiotherapy can be given externally (from outside the penis). External radiotherapy is normally given as a series of short daily treatments in the hospital’s radiotherapy department.

High energy X-rays are directed at the area of the cancer by using a special machine. The number of treatments will depend on the type and size of the cancer, but the whole course of treatment for early cancer will usually last up to six weeks. Your doctor will discuss the treatment and possible side effects with you.

External radiotherapy is not painful, but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

There are sometimes side effects from radiotherapy treatment to the penis. Towards the end of your treatment, the skin on your penis can become sore and may break down. Long-term, radiotherapy can cause thickening and stiffening of healthy tissues (fibrosis).

In some men, this can result in narrowing of the tube that carries urine through the penis (the urethra) and so can cause difficulty in passing urine. If narrowing of the urethra does develop, it can usually be relieved by an operation to stretch (dilate) the area. This is done by passing a tube into the urethra and is performed under a general anaesthetic.

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It can be one drug or several drugs used together. It is not commonly used in the initial treatment of penile cancer.

Pre-cancers on the foreskin or end of the penis may sometimes require topical chemotherapy cream (5-FU). This cream only destroys the abnormal cells near the surface of the skin, so is not used to treat deeper cancers. Chemotherapy may also be given as tablets, or by injection, into a vein for more advanced cancer. It may be given along with surgery or radiotherapy (or both).

Side effects are more severe and more common with chemotherapy given by injection or into a vein. Many of these side effects can be controlled with drugs and almost all are only short-term and will gradually disappear once the treatment has stopped.

Different chemotherapy drugs cause different side effects. Everyone is different and will react to chemotherapy treatment in a different way. Some people may have very few side effects while others will have a lot.

If prescribed topical chemotherapy cream the skin may become sore, red and inflamed. Other creams and pain killers may also be prescribed to reduce any pain and inflammation. These side effects should wear off within a couple of weeks after stopping treatment.

If having chemotherapy as injection or into a vein, the main areas of your body that may be affected are those where normal cells which rapidly divide and grow, such as the lining of your mouth, the digestive system, your skin, hair and bone marrow (the spongy material that fills the bones and produces new blood cells).

Common side effects of chemotherapy may include:

• Lowered resistance to infection
• Bruising or bleeding – the production of platelets which make blood clot can drop causing bruising or bleeding
• Anaemia (a lack of iron in the body that leads to a reduction in the number of red blood cells)
• Nausea and vomiting – anti sickness drugs can help this
• Sore mouth – may cause small ulcers
• Poor appetite
• Hair loss – hair should grow back within three to six months of finishing treatment.

Your doctor or clinical nurse specialist (CNS) will be able to tell you what side effects may be caused by your chemotherapy treatment. Although the side effects of chemotherapy can be unpleasant, they need to be weighed against the benefits of the treatment.

It is important to tell your doctor or chemotherapy nurse if the treatment is making you feel unwell. You may be able to have medicines to help you, or changes can be made to your treatment to lessen any side effects.