Penile cancer is a rare malignancy, accounting for less than 1% of male cancers in developed countries, but its incidence is higher in certain regions of South America, Africa, and Asia. The most common type is squamous cell carcinoma, which typically arises on the glans, foreskin, or shaft of the penis. Etiology is multifactorial, with key risk factors including human papillomavirus (HPV) infection, poor hygiene, phimosis, chronic inflammation, and tobacco use.¹ Despite its rarity, penile cancer significantly impacts patients’ quality of life due to the emotional and physical consequences of traditional treatments such as partial or total penectomy. While survival rates vary based on the stage at diagnosis, the 5-year survival rate for early-stage disease is over 85%, but it drops to 30% to 50% for advanced or metastatic cases. Penile-sparing surgery (PSS) has emerged as a viable option for treating localized penile cancers while maintaining organ function, appearance, and emotional well-being. Modern advances in imaging and surgical techniques have made this approach feasible with good outcomes, allowing patients to preserve both cosmetic appearance and functionality without compromising cancer control. This article reviews the novel approaches for penile-sparing techniques, highlighting outcomes such as negative margins, quality of life, cosmesis, and emotional well-being.

Preoperative Evaluation

Assessing the extent of penile cancer is crucial for selecting appropriate candidates for PSS.

The role of MRI in assessing penile cancer is not well defined, and it is a challenging examination even for experienced radiologists. However, prior to organ preservation, MRI has 86% sensitivity and 89% specificity for identifying T1 vs T2 disease. Hence, it can be considered prior to penile preservation treatment.² Penile Doppler ultrasound with an artificial erection is another imaging modality that can provide detailed information on the depth of tumor invasion and was found similar to penile MRI for detecting infiltration of corpora cavernosa prior to penile preservation surgery.³ For superficial lesions, especially in HPV-positive patients, peniscopy combined with acetic acid (5%) staining may help delineate the tumor margins and depth preoperatively, giving the surgeon a clearer understanding of the cancer’s extent when considering organ preservation. These assessments are critical for both superficial and low-grade invasive tumors.

Penile Preservation Techniques

Penile preservation techniques fall into 2 broad categories: topical and laser treatments and surgical excision.

Topical and Laser Therapies: These are effective for superficial lesions, such as carcinoma in situ. Topical therapies include fluorouracil 5% and imiquimod 5% cream. Fluorouracil is a type of antimetabolite that interferes with the synthesis of nucleic acids and selectively targets rapidly dividing cells. Imiquimod is an immune response modifier that activates toll-like receptor 7 on immune cells, particularly macrophages and dendritic cells, leading to the release of cytokines that promote an antitumor immune response. For superficial lesions reaching the epidermis and superficial dermis layers, laser therapy (such as CO₂, Nd, or KTP lasers) has shown synergistic effects, particularly in HPV-positive patients. Acetic acid can be used before these treatments to highlight tumor borders and guide therapy.

These modalities offer excellent cosmetic results with minimal scarring. However, a recent systematic review on treatment for carcinoma in situ reported response rates for laser therapies to be 52% to 100%, with recurrences in 7% to 48% of cases, and a change in penile sensitivity in 50% of cases.⁴ Combining imiquimod and laser therapy can reduce recurrence risk, with patients reporting satisfaction in terms of both appearance and sexual function.⁵

Surgical Treatments: For low-grade invasive tumors (T1), surgical excision remains the mainstay therapy. Techniques include Mohs surgery, wedge resection (wide local excision), and partial penectomy.

1. Mohs surgery: The tumor is resected utilizing a microsurgical approach in layers. Every layer is examined in real time until no residual cancer is identified. For selected patients, this approach has good long-term recurrence-free survival rates and excellent cosmesis.⁶
2. Wedge resection: Indicated for discrete lesions on the glans or shaft, this technique allows for margin control using frozen sections. In contrast to past recommendations for a 2-cm margin, current evidence suggests that even a 1-mm tumor-free margin may be sufficient for cancer control. Skin flaps (from the foreskin or prepuce) are often used to cover defects, contributing to improved cosmesis and functionality (Figure 1). Five-year local recurrence-free survival is about 73.6%, with good cosmetic outcomes and preservation of sexual function.⁷
3. Partial penectomy: For select lesions involving the corpus spongiosum and urethral meatus, penile-sparing techniques are possible. Tumors in proximity to the urethral meatus would typically be treated using a partial penectomy/glansectomy. However, these lesions are also amenable to wide local excision with reconstructive techniques and can lead to reasonable oncological outcomes when combined with frozen sections (Figure 2).

Partial penectomy is typically reserved for more extensive disease and has very good oncological outcomes. However, it generally results in undesirable cosmesis compared to other forms of organ preservation. A partial penectomy typically leaves a penile stump of 3 to 4 cm to ensure the patient can urinate while standing upright. The emotional impact is significant, with some patients experiencing feelings of loss or decreased self-esteem due to the procedure’s more disfiguring nature.⁸

Oncological and Quality of Life Outcomes

While PSSs may carry a higher risk of local recurrence compared to radical and partial penectomy, cancer-specific survival is reasonably good in well-selected patients. In particular, combination therapies and organ-sparing surgical techniques can provide excellent functional outcomes with minimal impact on quality of life.⁹

Sexual function can be significantly impacted with radical or partial penectomy. A systematic review of the literature found that in patients undergoing partial penectomy, based on the International Index of Erectile Function domains, erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction can be decreased. Preservation of penile length was one of the significant factors that allowed for improvement in sexual function following partial penectomy. With better surgical technique and an understanding of a decreased required surgical margin, penile length can be significantly improved, and as such, function may be preserved.¹⁰ The emotional and psychological aspects of penile surgery cannot be overstated. Patient counseling is essential to help manage expectations and address concerns related to body image, sexual function, and overall quality of life. Studies suggest that men who undergo PSS report greater satisfaction with their appearance and emotional well-being compared to those who undergo partial penectomy.

Conclusion

PSSs offer a well-balanced approach to treating localized penile cancer, providing favorable oncological outcomes while maintaining cosmesis and functionality. Combined topical and laser therapies are particularly effective for superficial tumors, while wedge resection with reconstruction offers an excellent option for localized, well-selected tumors. By reducing the size of necessary surgical margins and employing reconstructive techniques, surgeons can offer patients outcomes that are not only oncologically sound, but also cosmetically and emotionally satisfactory for patients.