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Penile cancer

Key sources
The following summarized guidelines for the evaluation and management of penile cancer are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/ASCO 2023), the European Association of Urology (EAU 2018), and the European Society of Medical Oncology (ESMO 2013).
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Guidelines

1.Classification and risk stratification

Prognosis: recognize that high histological grade, perineural invasion, and lymphovascular invasion are the strongest predictors of metastasis of penile cancer.
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2.Diagnostic investigations

Physical examination
Perform a detailed physical examination of the penis and external genitalia, recording morphology, size, and location of the penile lesion, including extent and invasion of penile (adjacent) structures.
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Perform a physical examination of both groins. Record the number, laterality, and characteristics of any palpable/suspicious inguinal nodes.
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  • Imaging for staging

3.Diagnostic procedures

Biopsy and histopathology: as per EAU 2023 guidelines, perform a pretreatment biopsy of the primary lesion when malignancy is not clinically obvious or when nonoperative treatment of the primary lesion is planned (such as topical agents, laser, or radiotherapy).
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4.Medical management

General principles
Offer a balanced and individualized discussion on the benefits and harms of possible treatment options with the goal of shared decision-making.
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Provide penile cancer care as part of an extended multidisciplinary team comprising urologists specializing in penile cancer, specialist nurses, pathologists, uro-radiologists, nuclear medicine specialists, medical and radiation oncologists, lymphedema therapists, psychologists, counselors, palliative care teams for early symptom control, reconstructive surgeons, vascular surgeons, and sex therapists.
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  • Management of locoregional disease (stages Tis, Ta)

  • Management of locoregional disease (stages T1-2)

  • Management of locoregional disease (stage T3)

  • Management of advanced/metastatic disease

  • Management of lymph nodes

  • Management of recurrent disease

5.Perioperative care

Preoperative imaging: obtain a penile Doppler ultrasound or MRI with artificial erection in patients with intended organ-sparing surgery.
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  • Perioperative chemotherapy

  • Intraoperative frozen section

6.Patient education

General counseling: discuss the psychological impact of penile cancer and its treatments with the patient and offer psychological support and counseling services.
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7.Follow-up and surveillance

Follow-up
As per EAU 2018 guidelines:
Obtain clinical assessment for treatment effects after a treatment-free interval and perform a biopsy in case of doubt. Do not repeat topical treatment if it fails.
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Obtain follow-up in patients after penile cancer treatment initially every 3 months for 2 years, then less frequently to assess for recurrent disease and to offer patient support services through the extended multidisciplinary team. Advise self-examination at discharge with easy access back to the clinic, as local recurrence can occur late.
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