Editing EAU & ASCO: Penile Cancer 2023 (section)

==== Locally advanced disease (T3–T4) ====

===== Resectable disease =====

* '''Pre-operative MRI or US can assist in surgical planning'''
* '''<span style="color:#ff0000">cT2 (corpus spongiosum): g<span style="color:#ff0000">Glansectomy (partial or total), with or without reconstruction'''
** If doubt of corporeal or tunica albuginea invasion, rather than continuing the dissection over Buck’s fascia to perform glansectomy combined with distal corporectomy, dissection superficial to the tunica albuginea can be adopted after dividing the neurovascular bundle.
*** Frozen sections of the corporeal tips and urethra may be helpful in assessing the radicality of the procedure peri-operatively.

* <span style="color:#ff0000">'''cT3 (corpus cavernosum): partial amputation</span>'''
** Reconstructive options can be offered, such as (2) 
**# Urethral centralisation and/or
**# Neo-glans formation with the use of a graft
**# Total phallic reconstruction in patients undergoing total/subtotal amputation
** In patients undergoing total/subtotal amputation, a total phallic reconstruction may be offered
** Patients should be informed that a wider resection provides a lower risk of local recurrence at the cost of functionality of the penis
** '''Radical amputation and diversion of urination with a perineal urethrostomy is reserved for those patients in whom a resection with a safe margin would result in the inability to void standing upright or without wetting the scrotum.'''
** In case of locally-advanced and ulcerated cases which are resectable, composite myocutaneous flaps or advancement flaps may be needed to cover the surgical defect

* Radiotherapy for locally-advanced penile lesions should be undertaken with concurrent chemotherapy.

===== Non-resectable disease =====

* '''Induction chemotherapy''' 
** '''Offers the ability to downstage disease and may enable surgical resection among responders'''
*** Several retrospective studies have evaluated combination regimens using paclitaxel or docetaxel with cisplatin and ifosfamide or 5-FU
* If inadequate response, consider palliative chemo-radiotherapy