This is a well established although now infrequently used therapy for penile carcinoma, which is most appropriate for small T1 or T2 lesions in patients unfit or unwilling for surgery. External beam radiotherapy (EBRT) or brachytherapy can be used either in the form of interstitial brachytherapy (IBRT), where the radiation source is implanted into the cancer, or plesiotherapy where the radiation source surrounds the tumor.

EBRT has been shown to offer local control rates of 60-70%. Using the Toronto technique, the whole of the penis is irradiated with the use of a rectangular wax mould to ensure even distribution of radiation around the shaft of the penis.55 A total dose of 50-70 Gy is required, given in 15-30 daily sessions over 3-8 weeks on an outpatient basis. Acute radiation reactions (mucositis, skin irritation, and tissue edema) are common and often necessitate termination of treatment. The lengthy regime is a further disadvantage.

In contrast, brachytherapy regimes are shorter but require in-patient isolation. IRBT involves the temporary implantation of radioactive wires or needles, usually iridium-192, into the penis. The wires are held in place by two external templates such as the Gerbaulet's glans applicator,5 6 the distribution of holes along them ensuring an even administration of radiation. A dose of 50-70 Gy is the aim, administered over 5-7 days (see Chap. 12 for a more detailed explanation of the technique).

Plesiotherapy can be utilized in patients with discrete, superficial lesions (<5 mm).57,58 There are two types of device. The first (high dose) uses a personalized mould containing catheters appropriately located according to the tumor position. The catheters are after-loaded with iridium-192 wires. The second (low dose) is more popular and involves the placement of two moulds around the penis. The inner

Fig. 6.7 Fibrosis of the penile skin and glans penis following treatment with radiotherapy

Fig. 6.7 Fibrosis of the penile skin and glans penis following treatment with radiotherapy

one straightens the penis and the outer is loaded with radioactive wires. Patient cooperation and dexterity are essential for success. The mould is applied for 12 h a day for a week, giving a total dose of 60 Gy.

Despite the more targeted dose of radiation with brachytherapy side effects remain common. The risks of infection, radioepidermitis, and mucositis necessitate antibiotic, anti-inflammatory and analgesic prescription. With all modes of radiotherapy, late complications occur at rates proportional to the dose delivered, with up to 40% affected.5 6,59 Urethral strictures occur in 15-40% of patients33,60 and skin changes such as telangiectasia, hypochromasia, and superficial necrosis are frequently observed.

To date there are no prospective randomized trials assessing the effectiveness of radiotherapy compared with other treatments for penile cancer but information from retrospective studies has been consistent.61,62 Recurrence rates range from 15% to 40%, higher than for both conventional and penile-preserving surgery although the vast majority of recurrences are surgically salvageable. The overall organ-preservation rates are in the region of 60-80%, with no compromise in 5 and 10-year survival. These data may appear acceptable to some, but when compared to surgical outcomes with preservation rates of 90-95%, they are less so. Functional and cosmetic impairment due to radiofibrosis of the corpora and penile skin is frequently encountered (Fig. 6.7).

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