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Phallus Preservation in Penile Cancer Surgery: Patient-Reported Aesthetic & Functional Outcomes - Beyond the Abstract

The diagnosis of penile cancer imparts life-changing implications for a patient, inflicting a burden of both oncological concern and anticipation of organ removal, distortion, or dysfunction.  Whilst historically the treatment has been radical penectomy, the necessity for full penile amputation has been challenged in more recent times.1, 2 Organ-sparing surgery (OSS) has thus evolved.  Whilst OSS does involve acceptance of higher rates of margin positivity and an increased risk of local recurrence (LR) as compared to radical penectomy, LR is amenable to salvage surgical resection.1, 3, 4  Crucially, an organ-preserving approach in appropriately selected patients has demonstrated non-inferiority to radical penectomy in terms of metastasis-free and overall survival rates.1, 3  Accordingly, where technically and oncologically feasible, phallus-preservation now features amongst guideline recommendations for penile cancer surgery.5, 6


In tandem, oncoplastic reconstructive techniques have evolved, with the aim of optimizing ultimate aesthetic appearance and organ function and minimizing the marked psychological morbidity that has been associated with penile cancer and its treatment.7 However, little research to date has explored patients’ perceptions of the ‘end result.’  In response to this, and with the growing understanding of the importance of patient-reported outcome measures (PROMs) within oncology,8 we aimed to both assess patient perceptions of penile form and function following OSS, and to interrogate the potential role of PROMs in penile cancer surgery.

Outcome measures exploring key domains of penile reconstructive outcome were chosen. Overall quality of life was measured using the European Organization for Research and Treatment of Cancer QLQ-C30, a validated and well-renowned tool examining the day-to-day wellbeing of patients who have been diagnosed with cancer.9 A modification of the Index of Male Genital Image (IMGI)10 was used to allow a multi-dimensional evaluation of self-perceived genital appearance.  Erectile function was measured with the well-known Five Question International Index of Erectile Function (IIEF-5).11 Urinary and sensory function were explored via a customized questionnaire designed for the purposes of this study, in the absence of a pre-existing validated and appropriate instrument.  A literature review and semi-structured interviews with ten penile cancer patients and two consultant surgeons informed this.

A total of 130 questionnaires were received from a cohort of patients post penile reconstruction (n=35), yielding a response rate of 71.4% (35/49) at a mean follow-up of 22 months [4-51].  Respondents' oncological outcomes were reviewed.  One patient of the partial glansectomy (PG) cohort developed a local recurrence (pT1) requiring further surgery.  Two further members of the PG cohort had a history of local recurrence following wide local excision, however had no evidence of local recurrence to date following PG.  Due to nodal disease, a pelvic lymphadenectomy was performed for one patient in the radical glansectomy group and one partial penectomy received adjuvant chemotherapy.  All patients were disease-free at the last follow-up.  Regarding aesthetic appearance, the majority of patients (82.4%, 28/35) selected ‘very satisfied,’ ‘satisfied’ or ‘neutral’ in response to their perception of overall genital image. High satisfaction with post-procedure urinary function was reported; 85.3% (29/34) could void from a standing position and 79.4% (27/34) reported little or no spraying of urine.  Nineteen patients (55.89%) were sexually active, with mean IIEF-5 scores of 14.9 [5-25] (partial glansectomy) and 15.8 [5-25] (radical glansectomy). Mean quality of life over the previous week on a 7-point EORTC QLQ-C30 scale was 5.88 [3-7].

Subgroup analysis did not identify clear trends between patients who had and had not undergone inguinal lymph node dissection, although we expected lymphadenectomy to have a detrimental effect on outcome measures of form, function, and quality of life.  This may simply reflect an underpowered lymphadenectomy cohort.

We noticed a strong correlation between voiding from a standing position and satisfaction with current urinary function (p=0.0004).  We also observed a positive correlation between ‘better’ IIEF-5 sexual function scores and quality of life scores (p = 0.0019).

We acknowledge several limitations to the study, including its retrospective nature and the lack of an available previously validated questionnaire for urinary and sensory function.  The study may be criticized for the lack of preoperative aesthetic and functional data.  Although these are theoretically desirable, we stress the point that such variables often deviate greatly from the patient’s pre-morbid baseline when the urology referral is made, due to tumor presence, and thus the feasibility of capturing a true picture without retrospection bias is questionable.

This study confirms the ability to achieve good overall aesthetic and functional outcomes, as perceived by patients, with oncoplastic penile cancer surgery.  It also identifies the ability to void from a standing position to be important to male patients and confirms a correlation between preservation of erectile function and quality of life.  These results support uro-oncology guidelines recommending organ-sparing surgery for eligible patients with penile cancer. 

Written by: Stefanie M. Croghan & Ivor M. Cullen

Department of Urological Surgery & Andrology, University Hospital Waterford, Dunmore Road, Waterford, Ireland.

References:

  1. Baumgarten A, Chipollini J, Yan S, et al. Penile Sparing Surgery for Penile Cancer: A Multicenter International Retrospective Cohort. J Urol. 2018; 199: 1233-7.
  2. Kamel MH, Bissada N, Warford R, Farias J and Davis R. Organ Sparing Surgery for Penile Cancer: A Systematic Review. J Urol. 2017; 198: 770-9.
  3. Hakenberg OW, Drager DL, Erbersdobler A, Naumann CM, Junemann KP and Protzel C. The Diagnosis and Treatment of Penile Cancer. Dtsch Arztebl Int. 2018; 115: 646-52.
  4. Kamel MH, Tao J, Su J, et al. Survival outcomes of organ sparing surgery, partial penectomy, and total penectomy in pathological T1/T2 penile cancer: Report from the National Cancer Data Base. Urol Oncol. 2018; 36: 82 e7- e15.
  5. Hackenberg O, Compérat E, Minhas S, et al. EAU Penile Cancer Guidelines. Amsterdam: European Association of Urology, 2017.
  6. Flaig T.W. SPE, Agarwal N., et al. NCCN Clinical Practice Guidelines in Oncology. Penile cancer version 2. USA: National Comprehensive Cancer Network, 2019.
  7. Chen J, Ou L and Hollis SJ. A systematic review of the impact of routine collection of patient reported outcome measures on patients, providers and health organisations in an oncologic setting. BMC Health Serv Res. 2013; 13: 211.
  8. Field J, Holmes MM and Newell D. PROMs data: can it be used to make decisions for individual patients? A narrative review. Patient Relat Outcome Meas. 2019; 10: 233-41.
  9. Groenvold M, Klee MC, Sprangers MA and Aaronson NK. Validation of the EORTC QLQ-C30 quality of life questionnaire through combined qualitative and quantitative assessment of patient-observer agreement. J Clin Epidemiol. 1997; 50: 441-50.
  10. Davis SN, Binik YM, Amsel R and Carrier S. The index of male genital image: a new scale to assess male genital satisfaction. J Urol. 2013; 190: 1335-9.
  11. Rosen RC, Cappelleri JC, Smith MD, Lipsky J and Pena BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999; 11: 319-26.


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