The surgical management of penile cancer at the Free State academic complex: a review
Introduction and aim Currently there exist limited data about the management of penile cancer in South Africa and there are no centres of excellence for managing this malignancy. Therefore these patients are managed by different treatment strategies at different health facilities throughout the country. The aim of this study is i. To describe the profile of men with penile cancer at our centre and compare it to the profile of men as described in the published literature ii. To evaluate the incidence of histologically node-positive patients and the early complication rate of patients undergoing simultaneous inguinal lymph node dissection (ILND) during surgery for penile carcinoma and iii. To describe the incidence of the different histological subtypes found at the Free State Academic Complex Methods Forty-one patients that presented with histologically confirmed penile cancer who were treated with surgery at the Free State Academic Complex between 2005 and 2015 were included. The data variables (that were analysed) included: Patients demographics, preoperative penile biopsy results, type of surgery performed, results of final histology of primary penile cancer and dissected lymph nodes, and early lymph node dissection complications. Primary penile surgery and lymph node management were managed according to our evolving centre protocol. Results A total of 41 patients with histologically confirmed penile cancer were surgically treated. The mean age was 50 years (range 30-86 years). Human Immunodeficiency Virus (HIV) status was known in 20 patients and revealed positive results in 16 (80%) patients. From a cohort of 41 patients, 25 patients underwent lymph node dissection for clinically palpable nodes or grade pT1 or higher disease. Of these 25 patients, eight patients (32%) had lymph node metastasis, and 17 patients (68%) showed no evidence of nodal metastasis. Of the eight patients with positive nodes, five patients had unilateral groin positive nodes and three patients had bilateral groin involvement. Out of 41 patients, 25 patients underwent primary penile surgery (glansectomy, partial (or) total penectomy with perineal urethrostomy) and inguinal lymph node dissection simultaneously. Complications associated with simultaneous penile surgery and lymph node dissection were seromas in two patients (8%), one superficial wound infection (4%) and 17 patients (68%) did not have post-operative complications. Five patients (20%) were lost to follow-up postoperatively. All 41 patients (100%) had squamous cell carcinoma (SCC), and the predominant histological subtype was classic SCC in 36 patients (87%). This was followed by warty cancer subtype in three patients (7.3%), verrucous subtype in three patients (7.3%) and one patient (2.4%) had poorly differentiated cancer with spindle cell component. Conclusion Early age of presentation and high prevalence of HIV was observed in the present study which is in line with other published literature studies. Simultaneous primary penile surgery and inguinal lymphadenectomy can be done safely in a population with a high incidence of infection and HIV-associated lymphadenopathy. In our setting, where non-compliance and lost to follow-up rates are high, simultaneous primary penile and node dissection is advisable, but the importance of serial follow-up for recurrences and distal metastases cannot be ignored. The high incidence of node negative ILND in the current study was also observed. Penile cancer histological subtypes correlates with published literature despite high prevalence of HIV infection.