Surgical decision-making for penile cancer in the elderly

Natural history of penile cancer and impact of delayed presentation

Key risk factors for penile cancer include HPV16 and HPV18 infections, smoking, chronic inflammation (lichen sclerosus, phimosis), psoralen and ultraviolet A (PUVA) therapy for psoriasis and pre-malignant penile intraepithelial neoplasia (PeIN). Tumours typically present as raised or ulcerated forms causing local tissue damage, although early disease may be hidden beneath a phimotic foreskin [5].

In uncircumcised men, poor hygiene, phimosis and embarrassment often delay presentation [4]. Psychological distress, such as guilt, fear, neglect, or denial, also contributes to late diagnosis [6]. As a result, tumours may invade deeply and spread through lymphatic pathways to the inguinal lymph nodes.

Nodal involvement remains the most important prognostic factor in penile cancer. Contemporary series report 5-year cancer-specific survival rates of approximately 85–100%, 79–89%, 17–60% and 0–17% for pN0, pN1, pN2 and pN3 disease, respectively [7]. Early management of lymphatic spread is therefore crucial.

NHS England registry data (2013–2020) show that most cases were diagnosed through the 2-week-wait pathway (34.2%) or via GP referrals (34.6%). Nearly 10% of patients presented as emergencies, particularly men aged 70 or older or those with stage III–IV disease [2].

This case illustrates a classic delayed presentation. When the patient did seek treatment, he had locally advanced disease with regional metastasis to the groin. In such situations, treatment focuses on disease control in line with patient preferences.

Establishing the correct diagnostic pathway in frail older patients

In centres where DSNB is offered as a surgical staging option, inguinal USS is performed prior to the procedure. If suspicious nodes are detected, FNAC can be performed during the same USS assessment to confirm lymph node metastasis [8].

In frail patients, this diagnostic pathway is both safe and efficient. USS-guided FNAC can be performed under local anaesthesia, avoiding the immediate need for general anaesthesia, which carries increased risk in elderly patients with frailty and multiple comorbidities. In the vignette, this minimally invasive confirmatory step is particularly appropriate given the patient’s anticoagulation treatment for AF and mild renal impairment, both of which increase bleeding risk and complicate perioperative management.

Surgery as the primary modality: why it remains the preferred option

For locally advanced penile cancer (T4 disease), radical surgery remains the gold standard, as organ-sparing approaches are oncologically inappropriate. While partial penectomy can achieve local recurrence rates of approximately 5–10% with clear margins in earlier-stage disease, this was unsuitable here due to tumour invasion of the scrotum [9]. Radical penectomy with partial scrotectomy and perineal urethrostomy was therefore performed to achieve adequate local control. Given the large left groin mass, excision would result in a large defect and a myocutaneous flap would be needed for reconstruction. Myocutaneous flap reconstruction involves the transfer of vascularised muscle with overlying skin and subcutaneous tissue based on a defined vascular pedicle, providing robust coverage for complex defects, particularly in irradiated or infected fields. Among the available options, the vertical rectus abdominis myocutaneous (VRAM) flap is frequently utilised due to its reliable vascularity and ability to provide substantial tissue bulk [10]. These procedures are typically associated with longer operative times and require intraoperative input from plastic surgeons. Donor-site morbidity varies depending on the flap used, being generally minimal with gracilis flaps, but more significant with VRAM flaps due to the risk of abdominal wall weakness or hernia. Careful perioperative planning is essential, including patient optimisation, positioning and postoperative monitoring of flap viability to ensure adequate wound healing and minimise complications [11].

Surgical procedures pose considerable immediate risks for frail, elderly patients. Increasing physical vulnerability is associated with poorer postoperative outcomes, including both postoperative morbidity and mortality. Frailty assessment tools (such as the Rockwood Clinical Frailty Scale) assist physicians in diagnosing and classifying frailty [12]. Perioperative risk prediction tools, such as the Surgical Outcomes Risk Tool (SORT), are validated mortality prediction tools suitable for use in this patient population [13].

A Frailty Score of five indicates vulnerability to postoperative decompensation, which must be balanced against the prognosis of untreated or suboptimally treated penile cancer. Genital cancer is visible unlike other urological cancers, such as kidney, bladder or prostate, which are present in the abdomen or pelvis. Penile cancer, in particular, if advanced as in this case leads to a fungating, foul-smelling mass that affects quality of life and urination. Therefore, in the presence of a fungating mass, surgery is indicated even if the intent is non-curative, as it removes the troubling external mass that may progress to urethral obstruction.

Radiotherapy and chemoradiation: alternatives, but not equivalents

In advanced penile cancer, management depends on resectability and nodal status. In patients with resectable locally advanced disease (T3–T4), surgical management remains the standard of care, typically involving partial or radical penectomy with the aim of achieving negative margins, often requiring complex multidisciplinary planning. Overall, surgery remains the only potentially curative option in resectable disease and is associated with the most favourable long-term outcomes, particularly in patients with limited nodal involvement [14].

In unresectable disease, induction chemotherapy, commonly using cisplatin- and taxane-based combination regimens may allow downstaging and enable subsequent surgical resection in responders. Palliative chemoradiotherapy remains an option with comparatively poorer survival outcomes in advanced stages [15].

Radiation therapy may also be considered in selected patients who decline surgery or in whom the risks of surgery and anaesthesia are deemed prohibitive [16].

Management of regional lymph nodes is critical in determining outcomes: in patients with clinically evident nodal disease (cN1–cN3), treatment typically involves ILND [17], with consideration of neoadjuvant chemotherapy in selected patients with bulky or bilateral disease for downstaging.

The natural history of untreated advanced penile cancer is characterised by progressive local tumour growth, leading to ulceration, infection, bleeding, urethral obstruction (and urinary retention) and significant morbidity, with rapid clinical deterioration and markedly reduced survival. This situation highlights the importance of timely intervention and supports the need for careful risk–benefit assessment in perioperative decision-making [18].

In our case of T4N3 disease, oncological outcomes with non-surgical approaches were generally inferior to those achieved with surgical management, with higher recurrence rates and increased treatment-related toxicity. While radiotherapy can preserve penile structure in selected T1–T2 tumours using external beam radiotherapy (≥60 Gy EQD2) with or without brachytherapy, these approaches are technically demanding and have limited efficacy in locally advanced disease with corporal invasion or bulky nodal metastases, for which surgery remains the standard of care [19]. In the UK, radiotherapy is infrequently used as primary treatment. National data demonstrates that surgery alone was the primary treatment modality in around 80% of patients, whereas only 1.3% received radiotherapy and/or chemotherapy alone [2]. Following definitive surgery and staging, adjuvant chemotherapy may be indicated in N3 disease with or without the consideration of pelvic lymph node dissection [20].

Perioperative considerations: anticoagulation, cardiac disease and obstructive sleep apnoea

Perioperative assessment and shared decision-making are essential. Anticoagulation requires careful perioperative management, particularly in patients on direct oral anticoagulants. Radical ILND carries significant morbidity, highlighting the need for patient counselling and optimisation of comorbidities. Cardiac function should be assessed and optimised according to established guidelines [21], while OSA increases anaesthetic risk and necessitates appropriate perioperative respiratory and analgesic strategies [22].

Quality of life and functional considerations

Although cancer control remains essential, penile cancer surgery significantly impacts physical appearance, sexual function and urination. Elderly patients may value autonomy, avoiding extensive procedures or preserving dignity more than extended survival. Physical vulnerability can mean that even standard postoperative recoveries may lead to extended hospitalisation or require transfer to rehabilitation centres [23].

These discussions must be open, empathetic and personalised. Shared decision-making, involving family, the surgical team, perioperative physicians, geriatricians and specialist nurses, is essential to align treatment choices with patient goals.

The International Society of Geriatric Oncology (SIOG) consensus on Geriatric Oncology and Shared Decision-Making recommends:

• evaluating tumour-specific factors (biology, stage, treatment intent);

• performing a geriatric assessment in all older patients with cancer;

• eliciting patient values, preferences and goals of care;

• balancing treatment benefit against risks of toxicity, functional decline and quality-of-life impact [24].

MDT decision-making in advanced penile cancer can be conceptualised as a stepwise process. First, tumour-specific factors (stage, resectability and expected oncological benefit) are assessed. Second, patient-related factors, including frailty, comorbidities, functional status and social support are evaluated, often supported by comprehensive geriatric assessment. Third, the MDT integrates these findings to balance potential survival benefit against perioperative risk, functional decline and quality-of-life impact. Finally, management options are determined, including proceeding to surgery or selecting non-surgical or palliative strategies when risks outweigh benefits. Shared decision-making with the patient remains central throughout this process with the support from cancer nurse specialists.

In this case, a frail 78-year-old patient with multiple comorbidities presented with locally advanced T4N3 penile cancer and a fungating mass. While surgical management carried significant perioperative risk, the MDT recognised that untreated disease would probably result in rapid progression with worsening symptoms and reduced quality of life. Given the symptomatic and visible nature of the disease, surgery was considered appropriate despite limited curative potential, with the aim of improving local control and hygiene, and preventing further complications. This reflects a balance between operative risk and the morbidity of non-intervention.

Research ethics statement

Not applicable to this article.

Consent for publication statement

This narrative article is based on a fictional clinical vignette and does not describe a real patient or clinical encounter so consent for publication is not necessary. Images are used solely for illustrative purposes and are not related to the vignette. Where real patient images are included, the authors confirm that written informed consent for publication has been obtained for this purpose in accordance with the journal’s patient consent requirements.

Conflicts of interest statement

The authors declare no conflicts of interest with this work.