This document discusses tumors of the penis, including pre-malignant lesions, cancer in situ, invasive carcinoma, etiology, natural history, examination, staging, differential diagnosis, and treatment options. It provides an overview of the different types of penile tumors and lesions, from non-cancerous growths to invasive squamous cell carcinoma. Evaluation involves examination, imaging, and biopsy to determine tumor extent and stage. Treatment depends on tumor stage but may include circumcision, partial or total penectomy, lymph node dissection, and radiation therapy.

1. TUMORS OF THE PENIS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2

3. • 20% OF ALL TUMORS IN MEN
• 40% OF GENITO URINARY TUMOURS
3
Dept of Urology, GRH and KMC,
Chennai.

4. PRE- MALIGNANT LESIONS
• A. PRECANCEROUS SKIN LESIONS
– 1. LEUKOPLAKIA
• WHITE CUTANEOUS PLAQUE
– HYPERTROPHIC
– ATROPIC
– COEXIST OR PRECEDE S.C.C
– TREATMENT
» CIRCUMCISION
» EXCISION
» RADIATION
» FOLLOW UP FOR EARLY MALIGNANT CHANGE
4
Dept of Urology, GRH and KMC,
Chennai.

5. Pre cancerous lesions
Leukoplakia
Cutaneous horns
5
Dept of Urology, GRH and KMC,
Chennai.

6. PRECANCEROUS SKIN LESIONS
• 2. BALANITIS XEROTICA OBLITERANS
– GENITAL VARIATION OF LICHEN SCLEROSIS
– WHITISH PATCH OVER PREPUCE/GLANS
– MEATUS – MEATAL STENOSIS- STRICTURE
URETHRA
– ASSOCIATED WITH S.C.C
– DEVELOPMENT OF S.C.C. LONG AFTER THE
TREATMENT OF BX0
– TREATMENT
• TOPICAL STEROID CREAM
• SURGICAL EXCISION
• MEATAL STENOSIS – DILATATION -- MEATOPLASTY
6
Dept of Urology, GRH and KMC,
Chennai.

7. Balanitis xerotica obliterans
7
Dept of Urology, GRH and KMC,
Chennai.

8. PRECANCEROUS SKIN LESIONS
• 3. CONDYLOMA ACUMINATUM
– SOFT, PAPILLOMATOUS GROWTH
– BENIGN, SUPERFICIAL WART
– INFECTION WITH HPV
– GENITAL WART ASSOCIATED WITH S.C.C
– TREATMENT
• TOPICAL PODOPHYLLIN 5 F.U. CREAM
• LASER PHOTOCOAGULATION
• OR DIATHERMY
8
Dept of Urology, GRH and KMC,
Chennai.

9. Condylomata acuminata
9
Dept of Urology, GRH and KMC,
Chennai.

10. PRECANCEROUS SKIN LESIONS
• 4. BUSCHKE LOWENSTEIN TUMOR
– GIANT CONDYLOMA ACUMINATUM
– BENIGN
• TUMOR INVADE LOCALLY
• DESTROYS ADJACENT TISSUES
• NO MALIGNANT CHANGE
• NO METASTASIS
• TREATMENT
– WIDE LOCAL EXCISION
– PARTIAL PENILE AMPUTATION
10
Dept of Urology, GRH and KMC,
Chennai.

11. 11
Dept of Urology, GRH and KMC,
Chennai.

12. CANCER IN SITU (CIS)
• 1. ERTHROPLASIA OF QUEYRAT
– INVOLVES GLANS PENIS, PREPUCE
• 2. BOWENS DISEASE
– INVOLVES SHAFT, PERINEAL REGION
– RED, VELVETY, WELL MARGINATED, ULCERATE
– PAIN, DISCHARGE+
– TREATMENT
• TOPICAL 5 FU CREAM
• EXTERNAL RT
• Nd YAG LASER
• CO2 LASER
12
Dept of Urology, GRH and KMC,
Chennai.

13. Erythroplasia of Queyrat
13
Dept of Urology, GRH and KMC,
Chennai.

14. INVASIVE CARCINOMA OF
PENIS
• SQUAMOUS CELL CARCINOMA
– ORIGINATES ON THE GLANS
– NEXT PREPUCE
– NEXT SHAFT
14
Dept of Urology, GRH and KMC,
Chennai.

15. Squamous cell carcinoma
Invasive
15
Dept of Urology, GRH and KMC,
Chennai.

16. Verrucous carcinoma
16
Dept of Urology, GRH and KMC,
Chennai.

17. ETIOLOGY
• CIRCUMCISION PRACTICE
– NEONATAL CIRCUMCISION ELIMINATES
PENILE CARCINOMA. ON LATER AGE
GROUPS, IT IS INEFFECTIVE
• HYGIENIC STANDARD
• PHIMOSIS
• NUMBER OF SEXUAL PARTNERS
• H.P.V INFECTION
• CARCINOGEN - TOBACCO
17
Dept of Urology, GRH and KMC,
Chennai.

18. NATURAL HISTORY
• SMALL LESION
• GLANS
• SHAFT
• CORPORA
18
Dept of Urology, GRH and KMC,
Chennai.

19. LESIONS
• 1. PAPILLARY AND EXOPHYTIC
• 2. FLAT AND ULCERATIVE
• EARLIER LYMPHNODE METASTASIS
• POOR PROGNOSIS
• BUCK’S FASCIA
– BARRIER FOR INVASION
19
Dept of Urology, GRH and KMC,
Chennai.

20. METASTASIS
• TO REGIONAL FEMORAL – THEN TO
ILIAC NODES
• NODE METASTASIS
– SKIN NECROSIS
– CHRONIC INFECTION
– DEATH
– SEPSIS – BLEEDING – EROSION OF
FEMORAL VESSELS
20
Dept of Urology, GRH and KMC,
Chennai.

21. Fungating inguinal metastasis
21
Dept of Urology, GRH and KMC,
Chennai.

22. EXAMINATION
• SIZE
• SITE
• FIXATION
• CORPORAL BODIES
• BASE OF PENIS/SCROTUM
• P/R – PELVIC MASS
• INGUINAL AREAS (BIOPSY MANDATORY–
SCC– KERATINISATION, EPITHELIAL
PEARLS)
22
Dept of Urology, GRH and KMC,
Chennai.

23. LAB INVESTIGATION
• HB%
• TC, DC
• URINE- ALBUMIN, SUGAR, DEPOSITS
• BLOOD – UREA, SUGAR
• SERUM – CREATININE
• CXR
• USG
• CT- SCAN – INGUINAL AND PELVIC MASS
23
Dept of Urology, GRH and KMC,
Chennai.

24. JACKSON STAGING
• STAGE 1
– TUMOR CONFINED TO GLANS OR PREPUCE
• STAGE 2
– INVASION INTO SHAFT OR CORPORA
• STAGE 3
– TUMOR CONFINED TO PENIS WITH OPERABLE
INGUINAL NODE METASTASIS
• STAGE 4
– TUMOR INVOLVES ADJACENT STRUCTURE –
INOPERABLE INGUINAL NODES AND/OR DISTANT
METASTASIS
24
Dept of Urology, GRH and KMC,
Chennai.

25. TNM STAGING
• PRIMARY TUMOR (T)
– TX STAGE CANNOT BE ASSESSED
– T0 NO EVIDENCE OF PRIMARY TUMOR
– TIS CARCINOMA IN SITU
– Ta NON INVASIVE CARCINOMA
– T1 INVADES SUBEPITHELIAL CONNECTIVE
TISSUE (SIZE 2 CM)
– T2 INVADES CORPORA CAVERNOSUM OR
SPONGIOSUM (SIZE 2-5 CM)
– T3 INVADES URETHRA OR PROSTATE (SIZE >5
CM)
– T4 INVADES ADJACENT STRUCTURES
25
Dept of Urology, GRH and KMC,
Chennai.

26. TNM STAGING
• NODAL DISEASE (N)
– NX REG NODE CANNOT BE ASSESSED
– N0 NO REG NODE METASTASIS
– N1 MOBILE UNILATERAL NODE
– N2 MOBILE BILATERAL
– N3 FIXED REGIONAL LYMPH NODE
26
Dept of Urology, GRH and KMC,
Chennai.

27. TNM STAGING
• DISTANT METASTASIS (M)
– MX DISTANT METASTASIS CANNOT BE
ASSESSED
– M0 NO DISTANT METASTASIS
– M1 EVIDENCE OF DISTANT METASTASIS
27
Dept of Urology, GRH and KMC,
Chennai.

28. DIFFERENTIAL DIAGNOSIS
• CONDYLOMA ACUMINATUM
• BUSCHKE LOWENSTEIN TUMOR
• B.X.O.
• CHANCRE
• CHANCROID
• GRANULOMA INGUINALE
• TUBERCULOSIS
28
Dept of Urology, GRH and KMC,
Chennai.

29. TREATMENT OF PRIMARY
LESION
• BIOPSY WITH DEEP MARGIN IMPORTANT –
ENSURE PROPER STAGING
• PREPUCE – CIRCUMCISION
• GLANS AND DISTAL SHAFT
– PARTIAL AMPUTATION OF PENIS WITH 2 CM
MARGIN
– SUFFICIENT STUMP OF LENGTH PRESERVED
FOR
• SEXUAL FUNCTION
• DIRECTING URINARY STREAM
29
Dept of Urology, GRH and KMC,
Chennai.

30. TREATMENT
• STUMP INVOLVED WITH INSUFFICIENT
LENGTH FOR SEXUAL FUNCTION AND
URINARY STREAM
– 1. TOTAL AMPUTATION WITH PERINEAL
URETHROSTOMY
– INVERTED U SHAPED PERINEAL FLAP
– BLANDY URETHROPLASTY
– VERTICAL ELLIPTICAL INCISION
– 2. TOTAL PENECTOMY
30
Dept of Urology, GRH and KMC,
Chennai.

31. Perineal urethrostomy
31
Dept of Urology, GRH and KMC,
Chennai.

32. TREATMENT
• INGUINAL LYMPH NODES
– 50% ENLARGED LYMPH NODES ARE DUE
TO INFLAMMATION
– SHOULD UNDERGO – ANTIBIOTICS 4-6
WEEKS
– 1.. PERSISTANT DISEASE
• METASTATIC DISEASE
• SEQUENTIAL BILATERAL ILIO INGUINAL NODE
DISSECTION even if the metastasis is unilateral
(due to cross over of lymphatics)
32
Dept of Urology, GRH and KMC,
Chennai.

33. TREATMENT
– 2.. IF LYMPH ADENOPATHY RESOLVES
WITH ANTIBIOTICS
• OBSERVATION IN LOW STAGE PRIMARY
TUMOR (TIS,T1)
• MORE LIMITED LYMPH NODE (SENTINEL
NODE BIOPSY) OR
• MODIFIED DISSECTION
– 29% +VE
– DUE TO MICRO METASTASIS
33
Dept of Urology, GRH and KMC,
Chennai.

34. TREATMENT
• IF PATIENTS WHO INITIALLY HAVE
CLINICALLY –VE BUT LATER
DEVELOPS CLINICALLY PALPABLE
NODES
– UNILATERAL ILIO INGUINAL NODE
DISSECTION
– RADIOTHERAPY
34
Dept of Urology, GRH and KMC,
Chennai.

35. INDICATIONS FOR RT
• YOUNG PATIENTS WITH SMALL (2-4 CM)
SUPERFICIAL, EXOPHYTIC, NON-INVASIVE
LESIONS ON THE GLANS OR CORONAL
SULCUS
• PATIENTS REFUSING SURGERY
• PATIENTS WITH INOPERABLE TUMOR OR
DISTANT METASTASIS – REQUIRES LOCAL
THERAPY TO THE PRIMARY TUMOR BUT
WHO WISH TO RETAIN THE PENIS
35
Dept of Urology, GRH and KMC,
Chennai.

36. DISADVANTAGES OF RT
• RADIORESISTANT S.C.C.
• DOSE 6000 RAD EXT RT
• CAUSES URETHRAL
FISTULA/STRICTURES
• PAIN
• EDEMA
36
Dept of Urology, GRH and KMC,
Chennai.

37. RT TO INGUINAL AREA
• NOT IDEAL
– INACCURACY OF STAGING
– LACK OF HISTOLOGICAL CONFIRMATION
– INGUINAL AREAS TOLERATE POOR FOR
RT
• SKIN MACERATION
• ULCERATION
37
Dept of Urology, GRH and KMC,
Chennai.

38. CHEMOTHERAPY
• RESPONSE
– PARTIAL AND SHORT IN DURATION
38
Dept of Urology, GRH and KMC,
Chennai.

39. ANATOMY OF INGUINAL NODES
• SUPERFICIAL AND DEEP GROUPS
• NODES SEPARATED BY FASCIA LATA
• SUPERFICIAL 4-25
• SENTINAL NODE – CABANAS
– LOCATED SUPEROMEDIAL TO THE
JUNCTION OF THE SAPHENOUS AND
FEMORAL VEINS
– FOR TUMOR NO METASTASIS TO OTHER
NODES
39
Dept of Urology, GRH and KMC,
Chennai.

40. Anatomy of inguinal nodes
40
Dept of Urology, GRH and KMC,
Chennai.

41. RADICAL ILIO INGUINAL NODE
DISSECTION
• POSITION
– THIGH – FLEXED, ABDUCTED, EXTL ROTATED
– KNEE - FLEXES
• INCISION
– FOR BILATERAL DISSECTION
• OBLIQUE INCISION BELOW AND PARALLEL TO INGUINAL
LIGAMENT
• LOWER MIDLINE EXTRA PERITONEAL
– FOR UNILATERAL DISSECTION
• SINGLE OBLIQUE INGUINAL INCISION
• SUPERIORLY – EXTERNAL OBLIQUE APO
• LATERAL – SARTORIUS
• MEDIALLY – ADDUCTOR LONGUS
– 4-5 CM ABOVE THE LEVEL OF INGUINAL LIGAMENT
41
Dept of Urology, GRH and KMC,
Chennai.

42. RADICAL ILIO INGUINAL NODE
DISSECTION
– FOR UNILATERAL DISSECTION
• SINGLE OBLIQUE INGUINAL INCISION
• SUPERIORLY – EXTERNAL OBLIQUE APO
• LATERAL – SARTORIUS
• MEDIALLY – ADDUCTOR LONGUS
– 4-5 CM ABOVE THE LEVEL OF INGUINAL LIGAMENT
– FEMORAL TRIANGLE DISSECTED
– SARTORIUS MOBILISED FROM ITS ORIGIN
– LONG SAPHENOUS VEIN DIVIDED
– ROLLED MEDIALLY TO COVER THE FEMORAL
VESSELS
42
Dept of Urology, GRH and KMC,
Chennai.

43. PELVIC LYMPHADENECTOMY
• INCLUDES
– COMMON ILIAC
– EXT ILIAC
– OBTURATOR GROUP
43
Dept of Urology, GRH and KMC,
Chennai.

44. MODIFIED GROIN LYMPHADENECTOMY
BY CATALONA
• INDICATIONS
– CLINICALLY –VE NODES
– MINIMALLY ENLARGED NODES
– WITH EQUIVOCALLY
INCISIONS
10 CM, 1.5 CM BELOW GROIN CREASE
LIMITED DISSECTION
MEDIAL ADDUCTOR LONGUS
LATERAL FEMORAL ARTERY
CAUDAL FOSSA OVALIS
SUPERIOR SPERMATIC CORD
44
Dept of Urology, GRH and KMC,
Chennai.

45. MODIFIED GROIN LYMPHADENECTOMY
BY CATALONA
• REMOVAL OF SUPERFICIAL INGUINAL
NODES ANDTERIOR AND MEDIAL
ASPECT OF SAPHENO FEMORAL
JUNCTION.
• ALL FIBRO FATTY TISSUE REF.
LOCKED AS ‘ PACKAGE’
• DEEP ING NODES AROUND THE
FEMORAL VESSELS DEEP TO FASCIA
LATA
45
Dept of Urology, GRH and KMC,
Chennai.

46. MODIFIED GROIN LYMPHADENECTOMY
BY CATALONA
• ADVANTAGES
– SHORTER INCISION
– PRESERVES SAPHENOUS VEIN
– NO TRANSPOSITION OF SARTORIUS
MUSCLES
– LIMITED DISSECTION
46
Dept of Urology, GRH and KMC,
Chennai.

47. Nodal dissection
47
Dept of Urology, GRH and KMC,
Chennai.

48. Catalona
modified inguinal lymphadenectomy
Catalona WJ.
Modified inguinal
lymphadenectomy fo
carcinoma of the pen
with preservation of
saphenous veins:
technique and
preliminary results.
J Urol. 1988;140:306-
48
Dept of Urology, GRH and KMC,
Chennai.

49. NON- SQUAMOUS MALIGNANCY
• BASAL CELL CARCINOMA
• MELANOMA
• SARCOMA
• PAGET’S DISEASE
• METASTATIC
• PRIAPISM
• PENILE SWELLING
• NODULARITY
• ULCERATION
49
Dept of Urology, GRH and KMC,
Chennai.

50. 5 YEAR SURVIVAL – 80%
• MINIMAL NODAL DISSECTION(UPTO 2
NODES)
• UNILATERAL +VE NODES
• NO EXTRA NODAL EXTENSION
• ABSENCE OF PELVIC NODE INVASION
50
Dept of Urology, GRH and KMC,
Chennai.

51. 51
Dept of Urology, GRH and KMC,
Chennai.