It is apparent that for penile cancer patients as a whole, surgery as a single therapy can cure 80-90% of patients according to large or unselected series.1,2 This does not mean that surgery has reached its limit in the management of penile cancer. For example, recent data indicating that lymph node density (LND) is the strongest predictor of disease specific survival (DSS)3 imply that perhaps the quality of lymph node dissection is important in altering the natural history among patients with metastatic disease. With the limitations of surgery, novel strategies for treating both the primary tumor and the use of multimodal strategies in advanced disease are important areas requiring development. Therefore, it is important that patients are treated within a system that applies surgery (as well as other therapies) appropriately and effectively in order to maximize the cure while minimizing the morbidity.

Cancer control or cure is not the sole objective, as both the quality of life and survivorship issues frequently supervene following treatment. The patient's priorities may change as the prognosis changes with each stage of treatment. These factors should be routinely addressed in units managing penile cancer. This chapter addresses some of the gaps in our understanding of the disease, and its management. It will discuss several controversial areas and future clinical trials in order to address these gaps. We will also look at the likely impact of primary prevention on the incidence and demographics of penile cancer. Finally, we examine the rationale for changes in the delivery of penile cancer care and how this could not only impact clinical care but also potentially improve both clinical and basic science research.

Department of Urology, Guys Hospital, London, UK

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