Resurfacing and Reconstruction of the Glans Penis

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1 european urology 52 (2007) available at journal homepage: Reconstructive Urology Resurfacing and Reconstruction of the Glans Penis Enzo Palminteri a, *, Elisa Berdondini a, Massimo Lazzeri b, Francesco Mirri c, Guido Barbagli a a Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy b Department of Urology, Santa Chiara-Firenze, Florence, Italy c Sezione di Anatomia Patologica, Ospedale S. Maria alla Gruccia, Montevarchi, Italy Article info Article history: Accepted January 12, 2007 Published online ahead of print on January 22, 2007 Keywords: Penis Carcinoma Squamous cell Lichen sclerosus Glans reconstruction Abstract Objectives: To describe the techniques and results of surgical reconstruction of glans penis lesions. Methods: Seventeen patients (mean age: 53.2 yr) were treated by resurfacing or reconstruction of the glans penis for benign, premalignant and malignant penile lesions. The aetiology of the lesions was one Zoon s balanitis, four lichen sclerosus, one carcinoma in situ, five squamous cell carcinomas, and six squamous cell carcinomas associated with lichen sclerosus. Five cases were treated by glans skinning and resurfacing; five cases by glans amputation and reconstruction of the neoglans, and seven cases by partial penile amputation and reconstruction of the neoglans. Glans resurfacing and reconstruction were performed with the use of a skin graft harvested from the thigh. Results: The mean follow-up was 32 mo. All patients were free of local premalignant/malignant recurrence. Patients who underwent glans resurfacing reported glandular sensory restoration and complete sexual ability. Patients who underwent glansectomy or partial penectomy with neoglans reconstruction maintained sexual function and activity, although sensitivity was reduced as a consequence of glans/penile amputation. Conclusions: In selected cases of benign, premalignant or malignant penile lesions, glans resurfacing or reconstruction can ensure a normal appearing and functional penis, without jeopardizing cancer control. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Center for Urethral and Genitalia Reconstructive Surgery, Via Fra Guittone 2, Arezzo, Italy. Tel ; Fax: address: enzo.palminteri@inwind.it (E. Palminteri). 1. Introduction Penile neoplasia is an uncommon malignancy affecting % per 100,000 males in Europe and % per 100,000 males in the United States. Seventy-eight percent of all tumours appear on the glans and/or prepuce [1,2]. The surgical treatment of premalignant and malignant penile lesions has changed over time [1 3]. While radical surgery can locally control the disease /$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 894 european urology 52 (2007) at a rate greater than 90%, this approach is often mutilating with a high incidence of aesthetic, physical, dysfunctional and psychological postoperative morbidity and disability, with more than 50% of patients developing mental disorders after surgical treatment for penile cancer [1,4 6]. Thus, the use of medical and surgical penis-sparing therapies has been suggested to maintain penis function and appearance [1,2,3,7,8]. Local laser ablation, for example, has shown, in patients with relatively superficial lesions, promising cosmetic and functional outcomes [3]. Brachytherapy provides, in selected cases, preservation of the penis but has a significant number of complications [3]. Despite a 6% local recurrence rate and good cosmetic results, the microscopic control of tumour excision, reported by Mohs and others [2], has failed to gain widespread acceptance by urologists. Two likely reasons for this are that urologists are not generally exposed to this highly specialised technique and that the procedure is very time consuming [2]. To date, only a limited amount of micrographic surgery for penile cancer has been reported in the literature, and no controlled trials comparing the various organ-sparing techniques have been published [2,9,10]. Partial or total penile amputation is the accepted method of treatment in patients who have invasive penile cancer involving the glans and corpora cavernosa [3]. However, in premalignant or superficial lesions, alternative forms of surgical therapy aimed at preserving the phallus without jeopardizing local cancer control have been suggested [1 3]. Recently, organ-sparing techniques have also been suggested for more advanced tumours [2]. The reluctance of many patients to undergo a mutilating penectomy has prompted the search for new reconstructive surgical techniques that can maintain or improve quality of life without compromising patient survival [3]. We herewith report our surgical experience in 17 patients suffering from benign, premalignant or malignant penile lesions, using three different techniques developed to preserve the penis and, at the same time, eradicate the primary local disease. 2. Patients and methods From 1998 through 2004, 17 patients with benign, premalignant or malignant lesions involving the glans penis or penile shaft and requiring surgical treatment were cared for at our centre. Patient age ranged from 38 to 72 yr, with a mean age of 53.2 yr. All patients underwent preoperative multiple biopsies to confirm the presence of premalignant or malignant lesions and determine the histologic grade. A competent pathologist examined all of the samples. In patients clinically diagnosed with lichen sclerosus (LS), the patient s histology was reexamined to look for past evidence of LS, according to the accepted, strict, pathologic criteria: an epithelial-stromal lesion characterised by squamous atrophy or hyperplasia, a band-like infiltrate, hyalinization of the papillary dermis, hyperkeratosis, pigment incontinence and dermal oedema [11]. A pathologic examination showed one Zion s banalities, one carcinoma in site, four LS, four squamous cell carcinomas (Sacs), one SCC associated with carcinoma in site, six Sacs associated with LS. Squamous hyperplasia or epithelial dysplasia was associated with the lesions in 10 cases. Eleven patients with SCC underwent a penile magnetic resonance imaging (MRI) to better define the extension of the local tumour. Finally, in patients with penile malignancy, we recorded whether or not there were associated local metastatic lymph nodes following an MRI of the lower abdomen and inguinal region, or distant metastatic lymph nodes following a computed tomography (CT) scan of the abdomen and chest. All patients affected with penile malignancy were staged in accordance with the updated TNM staging system. Three cases were classified T1,N0,M0 and eight were classified T2,N0,MO. Eleven SCCs showed well histologic differentiation (G 1) in 9 cases, moderate differentiation (G 2) in 1 case, and poor differentiation (G 3) in 1 case. All patients with SCC showed no lymphovascular invasion. Of the 11 SCCs, 5 patients underwent glans amputation, and 6 patients underwent partial penile amputation. All patients underwent reconstruction of the glans penis using a free split-thickness skin graft (STSG) harvested from the thigh via three different surgical techniques. Five patients were treated by removing the glans epithelium and resurfacing the glans, specifically the one Zoon s balanitis, three LS, and one carcinoma in situ. Five patients were treated by total glans amputation and reconstruction of a new glans, specifically two SCCs and three SCCs associated with LS. Seven patients were treated by partial penile amputation and reconstruction of a new glans on the penile stump during a single surgical intervention, specifically one case of SCC, two cases of SCCs associated with LS, and one case of SCC associated with carcinoma in situ. Three patients were referred to our specialised centre for glans reconstruction after partial penile amputation for SCC previously performed in other hospitals. Two cases showed recurrence of SCC (one case was associated with LS) in the residual penile stump, and one case showed LS involving the distal part of the residual penile stump. Follow-up ranged from 12 to 60 mo (mean: 32 mo), which included a baseline colour photograph with careful examination of the genitalia every 6 mo, including groin inspection and palpation, and a biopsy of any area of penile induration or suspicious reddening. Finally, all patients with SCC underwent a chest x-ray and CT scan every 12 mo Surgical techniques Glans skinning and resurfacing The penis and glans were fully evaluated preoperatively (Fig. 1 A). A circular incision was made under the corona, degloving the penile skin. The glans epithelium was fully removed up to the coronal sulcus (Fig. 1B). In all patients, multiple frozen

3 european urology 52 (2007) Fig. 1 (A) Carcinoma in situ involving glans and coronal sulcus. (B) The glans epithelium together with the distal foreskin is removed. (C) The skin graft is sutured and quilted over the stripped glans. (D) Penile appearance 6 mo after surgery. sections of the peripheral margins were obtained and sent to the pathologist for immediate intraoperative evaluation. Following excision of the tumour, all peripheral margins were free of tumour invasion in all patients. The STSG was harvested from the thigh with the use of a manual dermatome, and then adequately tailored and transplanted like an umbrella over the bed of the stripped glans (Fig. 1C). The graft was fully quilted over the glans with multiple 6-0 Polyglactin interrupted stitches (Fig. 1C). The penile skin was sutured to the graft at the coronal sulcus (Fig. 1C). A Foley 12F silicone catheter was inserted, and a soft and humid dressing was applied, covering the penis. The dressing was left in place for 3 d, and the patient was requested to remain in bed. Four days after surgery, the patient was mobilised and discharged from the hospital if the graft was observed to be in good condition and no penile hematoma, seroma or infection were present. Six months after surgery, a follow-up study included photographing the penis (Fig. 1D). excision of the tumour, all peripheral margins were free of tumour invasion in all patients. After removing the glans (Fig. 2B), the urethra was ventrally opened and the external urethral meatus was fixed to the summit of the corpora cavernosa. The neurovascular bundle was fixed to the albuginea. The STSG was harvested from the thigh with the use of a manual dermatome, and then tailored and transplanted like an umbrella over the summit of the corpora cavernosa. The graft was fully quilted with the use of multiple 6-0 Polyglactin interrupted stitches over the top of the corpora cavernosa (Fig. 2C). A Foley 12F silicone catheter was inserted, and a soft and humid dressing was applied, covering the penis. The dressing was left in place for 3 d, and the patient was requested to remain in bed. Four days after surgery, the patient was mobilised and discharged from the hospital if the graft was observed to be in good condition and no penile hematoma, seroma or infection were present. Six months after surgery, a follow-up study included photographing the penis (Fig. 2D) Glans amputation and reconstruction of the new glans The penis and glans were fully evaluated preoperatively (Fig. 2A). A circular incision was made under the corona, degloving the penile skin. The urethra and the neurovascular bundle were isolated in their distal extremities. The neurovascular bundle was distally sectioned. The glans was dissected from the corpora cavernosa and the urethra was distally sectioned. In all patients, multiple frozen sections of the peripheral margins were obtained and sent to the pathologist for immediate intraoperative evaluation. Following Partial penile amputation and reconstruction of the new glans The distal penile amputation was made according to the current techniques: To be certain that local tumour excision was achieved, the resection was extended 2 cm over the tissue margins. In all patients, multiple frozen sections of the peripheral margins were obtained and sent to the pathologist for immediate intraoperative evaluation. Following excision of the tumour, all the peripheral margins were free of tumour invasion in all patients. The edges of the residual corpora

4 896 european urology 52 (2007) Fig. 2 (A) Squamous cell carcinoma involving glans penis. (B) Penile shaft after removal of the glans. (C) The skin graft is sutured and quilted over the summit of the corpora cavernosa. (D) Penile appearance 6 mo after surgery. cavernosa were sutured together to create a hemispheric dome-shaped stump. The urethra was spatulated and the meatus was fixed on the new tip of the corpora cavernosa. The STSG was harvested from the thigh with the use of manual dermatome, and then tailored and transplanted like an umbrella over the summit of the corpora cavernosa. The graft was fully quilted over the top of the corpora cavernosa with the use of multiple 6-0 Polyglactin interrupted stitches. A Foley 12F silicone catheter was inserted, and a soft and humid dressing was applied, covering the penis. The dressing was left in place for 3 d, and the patient was requested to remain in bed. Four days after surgery the patient was mobilised and discharged from the hospital if the graft was observed to be in good condition and no penile hematoma, seroma or infection were present. 3. Results No significant immediate intraoperative and postoperative complications were observed. Two patients showed partial graft loss and wound separation that were resolved after conservative management. Eleven patients with SCC showed no evidence of local recurrence of the primary tumour or occurrence of a new malignancy. Two patients with SCC associated with LS showed a reddened lesion 6 mo after primary excision, requiring re-excision, but the histology showed no tumour recurrence. One patient with SCC, preoperatively classified as G2,T2,NO,M0 showed bilateral inguinal node enlargement on the CT scan of the abdomen and pelvis 12 mo after surgery, and underwent bilateral groin dissection. The histologic evaluation of the lymph nodes showed inflammatory changes without recurrence of the primary tumour. Satisfaction was determined by patient self-report and photographic appearance. All patients were satisfied with the phallic postoperative appearance. Five patients who underwent glans skinning and resurfacing reported complete sexual ability. Twelve patients who underwent glansectomy or partial penectomy with reconstruction of a new

5 european urology 52 (2007) glans maintained sexual function and activity, although sensitivity was reduced as a consequence of glans or penile amputation. Finally, no immediate or later complications were observed at the harvesting site. 4. Discussion Recently, plastic and reconstructive surgical techniques have been developed to reduce the functional and psychological morbidity in patients who have undergone mutilating penile surgery [1,2,3,7,8,12 15]. In selected patients, the use of these plastic and reconstructive techniques provided a satisfactory aesthetic, physical, and functional outcome, without sacrificing cancer control [1 3]. Laser ablation or other conservative therapies aim to remove the diseased tissue, but recurrence of the disease may occur in unrecognised premalignant foci arising within the unstable epithelium following a partial procedure. Moreover, precancerous lesions often show recalcitrance after other conservative treatments, with transformation to SCC ranging from 5% to 33% [8,11,16 18]. In glans skinning and resurfacing, the epithelium is completely removed, thus reducing the risk of disease recurrence or progression in sites other than where the primary lesion originated [8,11,16 18]. LS involving the male genitalia often evolves into a grossly scarring disease, in which phimosis along with poor hygiene and chronic inflammatory conditions may be the etiologic factors promoting penile malignancy [8,11,16 18]. In these cases, LS is frequently associated with hyperplasia or dysplasia, thus some authors have suggested that LS should be considered a precancerous lesion [8,11,16 18]. In these patients, the excision of the dysplastic glanular epithelium probably reduces the potential risk of cancer developing [8,11,16 18] and solves the problem of discomfort during sexual intercourse, due to the scarred glans and skin around the coronal sulcus, typical in patients with aggressive genital LS. In our experience, one patient with persistent lesions due to extensive Zoon s balanitis, which conventional medical treatment was unable to cure, was able to resume sexual activity after surgical skinning and resurfacing of the glans. In patients who underwent glansectomy or partial penectomy, sensitivity was reduced as a predictable consequence of glans/penile amputation. However, the cosmetic appearance of the neoglans was similar to a true glans, and the patients were able to fully regain sexual activity with a favourable psychological impact. In these patients, the aesthetic appearance of the penis was subjectively superior to that of the patients who underwent other traditional techniques, also producing a positive psychological impact on the patient. In fact, many patients with penile cancer were reluctant to undergo partial or total penectomy [3,19]. In patients with penile carcinoma involving the corpora cavernosa, an excessively ample partial penectomy can prove overly invasive. Although a 2-cm surgical margin has been traditionally proposed, more recent data suggest that a 10-mm margin is sufficient for grade 1 2 lesions, and a 15-mm margin is sufficient for grade 3 lesions [2,20]. In these patients, the preservation of as much of the corpora cavernosa as possible can facilitate reconstruction of a new glans, thus improving the patient s quality of life: Erectile function and standup micturition are not affected, and the patient maintains complete sexual function and activity, orgasmic sensation, and good penile appearance. About 80% of penile malignancies are probably amenable to these penis-preserving techniques because the lesions occur distally, involving only the superficial epithelium of the glans [2]. The proximal tumour extension is, however, still a limitation in the use of these procedures. Moreover, in patients with superficial penile cancer associated with precancerous lesions due to LS, laser ablation or other conservative treatments do not remove these lesions, thus promoting cancer recurrence over time, arising from an unstable epithelium bordering the primary lesion. Finally, in patients with benign penile disease, the use of these techniques fully maintains sexual function and activity that would not be possible with conventional topical therapies. Certainly, a centre specialised in reconstructive genital and urologic procedures would provide the best results in the treatment of penile lesions, without jeopardizing cancer control. With regard to follow-up criteria, we realise that the European Association of Urology guidelines suggest follow-up of SCC patients who received conservative treatment with a local inspection, physical examination, and radiologic imaging every 2 mo for 2 yr, and then every 3 mo for 1 yr. Unfortunately, in our experience, these criteria are not acceptable to the patient. We thus decided to follow-up all patients every 6 mo with a baseline colour photograph and careful examination of the genitalia, including groin inspection and palpation, along with a biopsy of any area of penile induration or suspicious reddening, and a chest x-ray and CT scan every 12 mo. Finally, for glans resurfacing we prefer to not use buccal mucosa tissue. In our experience, when a

6 898 european urology 52 (2007) buccal mucosal graft was used in two-stage penile urethroplasty, desquamation of the graft was observed in some patients because of contact of the oral mucosa with air, as buccal mucosa is accustomed to a humid, not a dry, environment. In patients with LS, the use of a skin graft could lead to disease recurrence, even if it seems that excision of much of the diseased tissue by ample circumcision reduces this risk. 5. Conclusions The resurfacing or reconstruction of the glans penis is a safe and effective treatment modality in selected patients with benign, premalignant, or malignant penile lesions. The goal of these techniques is to maintain a functional penis for urination and perhaps intercourse, without jeopardizing cancer control. The preservation of full sexual ability with good penile appearance and sensation guarantees a satisfying functional and psychosexual quality of life for the patient, thus encouraging more urologists to adopt a more conservative approach in the surgical removal of penile cancer. Conflicts of interest The authors do not have any commercial relationships such as: consultancies, stock ownership or other equity interests, patents received and/or pending, or any commercial relationship that might be in any way considered related to this article. Acknowledgements The surgical techniques described in this article were developed and suggested to us by Dr Aivar Bracka (West Midlands Regional Plastic and Reconstructive Surgery Unit, Stourbridge, UK), without whose teaching and guidance it would not have been possible to obtain these positive results. References [1] Brown CT, Minhas S, Ralph DJ. Conservative surgery for penile cancer: subtotal glans excision without grafting. BJU Int 2005;96: [2] Pietrzak P, Corbishley C, Watkin N. Organ-sparing surgery for invasive penile cancer: early follow-up data. BJU Int 2004;94: [3] McDougal WS. Phallic preserving surgery in patients with invasive squamous cell carcinoma of the penis. J Urol 2005;174: [4] Opjordsmoen S, Fossa SD. Quality of life in patients treated for penile cancer. A follow-up study. Br J Urol 1994; 74: [5] D Ancona CA, Botega NJ, De Moraes C, et al. Quality of life after partial penectomy for penile carcinoma. Urology 1997;50: [6] Romero FR, Pereira Dos Santos Romero KR, Elias De Mattos MA, et al. Sexual function after partial penectomy for penile cancer. Urology 2005;66: [7] Kroon BK, Horenblas S, Nieweg OE. Contemporary management of penile squamous cell carcinoma. J Surg Oncol 2005;89: [8] Micali G, Nasca MR, Innocenzi D, et al. Invasive penile carcinoma: a review. Dermatol Surg 2004;30: [9] Mohs FE, Snow SN, Larson PO. Mohs micrographic surgery for penile tumors. Urol Clin North Am 1992;19: [10] Nash PA, Bihrle R, Gleason PE, et al. Mohs micrographic surgery and distal urethrectomy with immediate urethral reconstruction for glanular carcinoma in situ with significant urethral extension. Urology 1996;47: [11] Barbagli G, Palminteri E, Mirri F, et al. Penile carcinoma in patients with genital lichen sclerosus: a multicentric survey. J Urol 2006;175: [12] Fonseca AG, Rabelo GN, Vidal KS, et al. Glandectomy with preservation of corpora cavernosa in the treatment of penile carcinoma. Int Braz J Urol 2003;29: [13] Bissada N. Organ-sparing surgery for invasive penile carcinoma. BJU Int 2005;95: [14] Greenberger ML, Lowe BA. Penile stump advancement as an alternative to perineal urethrostomy after penile amputation. J Urol 1999;161: [15] Parkash S, Ananthakrishnan N, Roy P. Refashioning of phallus stumps and phalloplasty in the treatment of carcinoma of the penis. Br J Surg 1986;73: [16] Cubilla AL, Velazquez EF, Young RH. Epithelial lesions associated with invasive penile squamous cell carcinoma: a pathologic study of 288 cases. Int J Surg Pathol 2004;12: [17] Nasca MR, Innocenzi D, Micali G. Penile cancer among patients with genital lichen sclerosus. J Am Acad Dermatol 1999;41: [18] Powell J, Robson A, Cranston D, et al. High incidence of lichen sclerosus in patients with squamous cell carcinoma. Br J Dermatol 2001;145:85 9. [19] Seyam RM, Bissada NK, Mokhatar AA, et al. Outcome of penile cancer in circumcised men. J Urol 2006;175: [20] Hoffman M, Renshaw A, Loughlin K. Squamous cell carcinoma of the penis and microscopic pathologic margins. How much margin is needed for local cure? Cancer 1999;85:

7 european urology 52 (2007) Editorial Comment on: Resurfacing and Reconstruction of the Glans Penis David J. Ralph St. Peter s Hospital and the Institute of Urology, London, United Kingdom dralph@andrology.co.uk The paper by Palminteri et al describes the important issue of penile preservation in the management of penile cancer and the use of the glans resurfacing technique to also treat benign destructive conditions such as balanitis xerotica obliterans (BXO) [1]. Because >80% of penile tumours are sited distally, the techniques described should be able to deal with the majority of cancers [2]. The cosmetic results with the use of skin grafts to fashion a pseudo-glans are uniformly excellent and have been reported by others [3]. One important message from this paper is the method of partial amputation by performing a hemispherical incision, thereby creating a domeshaped stump to apply the skin graft, which gives excellent cosmetic results [1]. Hopefully, the guillotine method of amputation is now an historical operation. The paper still states that a 2-cm margin is taken and this is not necessary. In a study of 51 men with penile cancer, excellent tumour control was obtained with surgical margins of <5mmwith only two patients developing a local recurrence [3]. The follow-up of the patients for lymph node metastases was by physical examination and an annual computed tomography scan. This does not follow the recommendation of the European Association of Urology, whose guidelines advocate more frequent radiologic imaging [4]. Clearly only longer term follow-up of these patients will determine if this management policy is correct. The biggest change in the management of penile cancer in the last 30 yr is penile conservation and the more urologists publish their results of these techniques then the less likely that patients will have mutilating surgery in the future. References [1] Palminteri E, Berdonolini E, Lazzeri M, Mirri F, Barbagli G. Resurfacing and reconstruction of the glans penis. Eur Urol 2007;52: [2] Sufrin G, Huben R. Benign and malignant lesions of the penis. In: Gillenwater JY, editor. Adult and paediatric urology. 2nd ed. Chicago: Year Book Medical Publishers; p [3] Minhas S, Kayes O, Hegarty P, Kumar P, Freeman A, Ralph DJ. What surgical resection margins are required to achieve oncological control in men with primary penile cancer? BJU Intl 2005;96: [4] Solsona E, Algaba F, Horenblas S, et al. EAU guidelines on penile cancer. Eur Urol 2004;46:1 8 DOI: /j.eururo DOI of original article: /j.eururo Reply to Editorial Comment on: Resufacing and Reconstruction of the Glans Penis Enzo Palminteri Center for Urethral and Genitalia Reconstructive Surgery, Casa di Cura, Arezzo, Italy enzo.palminteri@inwind.it The comment by Ralph has focused on the article s main message of the penile cosmetic preservation in the management of the invasive penile cancer [1]. The paper follows the recent literature stream, which proposes the penis-sparing surgical strategy for penile lesions [2,3]. Furthermore, we wanted to stress the problem regarding the treatment of some premalignant and malignant but superficial glandular diseases. The latter represent an uncertain area regarding the therapy of penile lesions in which non-resolution solutions such as the wait and watch by repeated biopsies, laser, or other techniques have been proposed. This strategy is dangerous because of the potential unpredictable malignant development of the lesions. In these cases the glans resurfacing would aim at being a more radical but at the same time cosmetic solution; for the first time, to the best of our knowledge, the glans skinning of the mucosa only and the subsequent glans resurfacing is illustrated in such a detailed fashion. In the last decade we have observed an increase in destructive conditions such as lichen sclerosus, which causes sexual inability. In these patients the glans resurfacing re-establishes sexual life compromised for a long time and also reduces the risk of the development of cancer by 8% [4]. Given the rarity of the penile tumours, in the future it will be difficult to carry out controlled trials

8 900 european urology 52 (2007) that should effectively compare the various organsparing techniques with traditional treatments. We agree with Ralph that our follow-up for lymph node metastases was not what is recommended by the European Association of Urology where more frequent radiologic imaging is usually performed [5]. However, due to the psychological impact of the disease, we had to consider the patients reluctance to undergo all these investigations. References [1] Palminteri E, Berdondini E, Lazzeri M, Mirri F, Barbagli G. Resurfacing and reconstruction of the glans penis. Eur Urol 2007;52: [2] Minhas S, Kayes O, Hegarty P, Kumar P, Freeman A, Ralph DJ. What surgical resection margins are required to achieve oncological control in men with primary penile cancer? BJU Intl 2005;96: [3] Pietrzak P, Corbishley C, Watkin N. Organ-sparing surgery for invasive penile cancer: early follow-up data. BJU Int 2004;94: [4] Barbagli G, Palminteri E, Mirri F, Guazzoni G, Turini D, Lazzeri M. Penile carcinoma inpatientswith genital lichen sclerosus: a multicentric survey. J Urol 2006;175: [5] Solsona E, Algaba F, Horenblas S, et al. EAU guidelines on penile cancer. Eur Urol 2004;46:1 8. DOI: /j.eururo DOI of original article: /j.eururo