Once surgery has taken place, the fears that initially dominated, namely the fears for recurrence and survival are gradually replaced by concerns regarding rehabilitation, particularly regarding urinary and sexual function. A number of studies have investigated sexual function following surgery for penile cancer, but the literature regarding voiding function is extremely limited.
Studies investigating patients who have undergone a partial or total penectomy for penile cancer have been limited to small retrospective studies. A Norwegian study of 30 men who had been treated for penile cancer assessed sexual function by using a semistructured interview together with a number of self-administered questionnaires.5 The median age of the patients was 57 years and all had undergone treatment at least 11 months previously (median delay 80 months). Unsurprisingly, those patients (n = 4) who had undergone the most radical surgery (namely, total penectomy) had the worst sexual function, as evidenced by a reduced sexual interest, severely limited sexual ability, markedly reduced sexual enjoyment, and markedly reduced sexual frequency. Those who had undergone radiotherapy (n = 12) or local excision or laser therapy (n=5) had the best sexual function, while those patients who had undergone partial penectomy (n=9) were in an intermediate position. There was a suggestion that the younger men had better sexual function than the older men, although comorbidities that might affect sexual function (such as diabetes) were not recorded. A subsequent Brazilian study explored sexual function in 18 men who had undergone partial penectomy by means of a structured interview and completion of the International Index of Erectile Function (IIEF).6,7 The partial penectomy procedure followed the principle that a minimum 2 cm margin of tumorfree tissue was required to achieve oncological control. The median age of the men was 52 years, and all had been sexually active prior to surgical treatment. All had a minimum residual penile stump length of at least 2.5 cm following surgery and the median time from surgery was 23.5 months. Patients were asked to retrospectively assess their sexual function before surgery and to then assess their function at the time of interview. Significant reductions in erectile function, orgasmic function, sexual desire, and intercourse satisfaction were identified. These two studies, taken together have led to a view that the more radical the penile surgery, the greater the effect on sexual function, with even partial penectomy having significant adverse effects.
The traditional view that surgery for penile cancer requires a 2-cm tumor-free margin in all cases has been challenged.8,9 Recently a more conservative approach using treatment modalities such as laser therapy, brachytherapy, or by conservative surgery such as glans resurfacing or glansectomy has been advocated.9 While the potential benefits of using a more conservative surgical approach has not been fully evaluated the effects of laser therapy for Tis, T1, and T2 tumors has been investigated in some detail.2 A cohort of 67 Swedish men were treated using a combined carbon dioxide and neodymium:YAG laser for tumor excision in a single centre between 1986 and 2000. Forty six with a median age of 63.5 years were available for follow-up and were assessed by formal interview at a median of 3 years following treatment. Of the 46 men, six had not been sexually active prior to treatment and a further 10 never resumed sexual activity following treatment. In the rest, there was maintenance of normal sexual activities, with some partners performing manual genital stimulation (17/46) and fellatio (7/46). An assessment of life satisfaction suggested that domains relating to sexual life and partner relation were comparable to Swedish men of approximately the same age. Set against this, somatic and psychological health in the patients with penile cancer was lower than might have been expected, perhaps reflecting ongoing anxiety regarding their long-term prognosis. A second smaller study explored sexual function in 14 men who had undergone glansectomy, or partial penectomy followed by glans reconstruction using urethra.10 This was a prospective study, which used the IIEF to assess sexual function up to 1 year following surgery, and appeared to show no significant loss in erectile function, orgasmic function, or sexual desire.
In summary then, there is evidence that partial and total penectomy adversely affects sexual function, with the greatest degree of dysfunction occurring in men who undergo more radical surgery and therefore lose more penile length. A general rule is that a residual postoperative penile length of 4 cm or more can still allow patients to achieve an adequate erection as well as ejaculate. Attempts at conservative therapy appear to be oncologically safe, but the evidence that they provide better sexual outcomes is at this time limited. Indeed, the quality of the evidence is relatively poor, with most publications being small and retrospective in nature.
Although radiotherapy for localized disease is rarely used nowadays, there is some evidence of maintenance of sexual interest following treatment with a minimal impact on sexual activity or coital frequency. However, the studies reporting this5,11 reported the use of radiotherapy in a younger cohort of men than those undergoing surgery which might be expected to affect the outcome. Sexual enjoyment and satisfaction remains high following radiotherapy or laser treatment indicating that therapeutic options which maintain length and appearance have the lowest impact on sexual function.51112
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