Joniau_EU Urology 17/03/2010 15:13 Page 28
Penile Cancer
Table 3: Local Recurrence Rates and Disease-specific Survival of Laser Surgery for Penile Carcinoma
Study, Year n FU (mo) Modality Stage LR (%) DSS (%)
Van Bezooijen, 2001
41
19 25 Nd:YAG or CO
2
Tis 26 100
Frimberger, 2002
42
29 47 Nd:YAG Tis–T2 6.8 100
Windahl, 2003
38
67 42 Nd:YAG and CO
2
Tis–T3 19 97
Lont, 2006
18
60 106 Nd:YAG T1–T2 37 NR
44 CO
2
29
Meijer, 2007
26
44 53 Nd:YAG Tis–T2 48 91
Tewari, 2007
32
32 70 Nd:YAG T1, T2 6.25 100
Leijte, 2008
24
415 60 PE (25%) Tis–T2 27.7* NR
Laser (70%)
Radiation (5%)
Bandieramonte, 2008
33
244 120 Peniscopy and CO
2
Tis, T1 17.5
†
100
Colecchia, 2009
43
56 66 Peniscopy and CO
2
T1 20 100
DSS = disease-specific survival; FU = follow-up; LR = local recurrence; Nd:YAG = neodymium:yttrium–aluminum–garnet laser; NR = not reported; PE = primary excision.
*27.7% overall local recurrence in penile-conserving surgery, including PE, laser and radiotherapy.
†
40 patients underwent neo-adjuvant cytoreductive chemotherapy.
al., these investigators were unable to find a clear correlation penile cancers, superficial spreading lesions and even pre-malignant
between tumour size and disease progression. In spite of the conditions. Bandieramonte et al. recently reported on the use of
relatively high local recurrence rate, with repeat procedures and peniscopically controlled CO
2
laser excision for the treatment of in situ
vigilant follow-up the disease-specific survival rate was 96%, and T1 penile cancer in 244 patients. They used excisional surgery alone
comparable to the other two series, and progression rates were low for in situ or initially invasive flat tumours, and reductive chemotherapy
(see Table 2). Shindel et al. further looked at complications of Mohs followed by surgery for the exophytic lesions.
33
Although of proven
surgery and found wound dehiscence in one patient and meatal efficacy in more advanced stages of the disease, the use of neoadjuvant
stenosis in two patients, of whom one had a meatoplasty at the first chemotherapy in early penile carcinoma is not standard therapy, and its
procedure. One patient suffered from a pulmonary embolism.
31
use carries the risk of serious adverse effects.
34–36
The authors justified
the use of chemotherapy for downsizing to render penile-conserving
Overall, it seems that Mohs surgery is an excellent treatment option therapy possible. With this treatment schedule the authors reported an
for patients with penile tumours that are restricted in size and do not overall recurrence rate of 17.5% in a follow-up period of 10 years, in
show deep infiltration in the corpora or penile shaft. There is a which the majority of patients could be treated with conservation of
relatively high local recurrence rate compared with conventional penile form and function.
33
partial penectomy with a 2cm resection margin, which warrants
vigilant surveillance in patients undergoing Mohs surgery. Oncological Earlier, the same group at the Milan Institute presented their findings
control in the case of local recurrence can apparently easily be with CO
2
laser-assisted resection of the total glans surface in 15
achieved by repeat Mohs procedures and did not seem to influence patients, consisting mainly of superficial SCC and in situ SCC of
progression or death rates in the few series published. the penis. Of these, flat tumours occupied more than half the
circumference of the organ in eight patients, and the remaining seven
Laser Surgery patients had superficial lesions after chemotherapy for exophytic
Since its introduction, laser surgery has been increasingly adopted for lesions. The authors found satisfactory results with one case with
the treatment of malignant and pre-malignant diseases of the penis. Two persisting cancer in the perimeatal area four months after initial
types of laser are currently used: the neodymium:yttrium–aluminium– treatment, and one patient required post-operative radiotherapy
garnet (Nd:YAG) laser and the carbon dioxide (CO
2
) laser. The Nd:YAG because of microscopically invasive cancer.
37
laser has a deep penetrating wavelength and can be used in a non-
contact laser irradiation mode to achieve uniform coagulation of tissue Some authors have also investigated the combined use of different
for 3–4mm. Tewari and colleagues used this technique for the treatment types of laser. Windahl et al. reported the results of 67 men treated by a
of 32 patients, of whom seven had T2 penile carcinoma and the combination of excision of macroscopically visible lesions with the CO
2
remainder had T1 disease. They reported excellent cosmesis and sexual laser with a margin of 3–5mm, followed by coagulation of the tumour
function following surgery with the Nd:YAG laser, and observed one bed with the Nd:YAG laser. This strategy resulted in a local recurrence
patient with systemic recurrence after 48 months and one patient with rate of 19% and a disease-specific survival of 97% at a median follow-up
local recurrence after 60 months, both of whom had high-grade primary of 42 months.
38
Erectile function and satisfaction with sexual life are
tumours and inguinal nodal involvement.
32
Similar results have been generally good following laser treatment of penile carcinoma.
38–40
achieved by other groups investigating the Nd:YAG laser (see Table 3).
Follow-up
The CO
2
laser has a minimal penetration wavelength allowing only In a large multicentre retrospective study, Leijte et al. found an overall
resection of tumours with a maximal penetrating depth of 2–2.5mm, local recurrence rate of 27.7% in patients treated with organ-
where it loses bleeding control and surgical accuracy. However, excision preserving modalities.
24
However, despite the high number of local
capability at the surface is virtually unlimited, and the CO
2
laser provides recurrences after penile-preserving treatment, there is little impact on
correct evaluation of the resection margins by the pathologist.
7,33
This survival. Local recurrence can be easily recognised by the patient and
makes the CO
2
laser an excellent option for the treatment of early-stage his partner; therefore, regular self-examination is mandatory in
28
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