# Penile Carcinoma > NEET-PG Surgery notes on penile carcinoma covering HPV association, glans tumours, inguinal node management and staging. - Canonical URL: https://prepelephant.com/topics/neet-pg/surgery/penile-carcinoma - Exam / course: NEET-PG · Subject: Surgery - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Penile Carcinoma", PrepElephant, https://prepelephant.com/topics/neet-pg/surgery/penile-carcinoma ## Direct answer Penile carcinoma is a squamous cell carcinoma arising chiefly on the glans, prepuce or sulcus of uncircumcised men, strongly associated with high-risk human papillomavirus (type 16), chronic inflammation, phimosis, lichen sclerosus and smoking. Diagnosis is by biopsy of the lesion, and the primary is treated by organ-sparing surgery (glansectomy with reconstruction, laser or radiotherapy for small lesions) or partial penectomy ensuring histological clearance, with total penectomy for extensive tumours. Prognosis is governed by the groin: clinically node-negative groins with high-risk primaries (pT1b or worse) need dynamic sentinel node biopsy or modified inguinal lymphadenectomy, and the classic teaching that two-thirds of palpable nodes are reactive — proved by biopsy or fine-needle aspiration — before committing to block dissection. ## What you must remember - Presentation: an indurated, non-healing ulcer, exophytic mass or erythroplakia of the glans or prepuce in a man over 50 with lifelong phimosis. - Risk factors: HPV 16 (and 18) infection, phimosis with chronic smegma retention and balanitis, lichen sclerosus (BXO), smoking, and immunosuppression; neonatal circumcision is strongly protective. - Staging is clinical plus MRI of the penis for tunica albuginea or urethral involvement; groin assessment by palpation and ultrasound-guided fine-needle aspiration of suspicious nodes; CT for abdomen and pelvis once nodes are positive. - Organ-sparing options for small, low-grade distal lesions: wide local excision, glansectomy with split-skin graft, laser and brachytherapy — the tumour is radiosensitive, but local recurrence is higher and surveillance mandatory. - Partial penectomy: traditional teaching demanded a 2 cm margin; contemporary practice accepts narrower margins (about 1 cm) for distal, low-grade tumours provided frozen-section clearance, since wider margins do not improve survival and destroy function. A remnant allowing standing voiding is the goal. - Nodal rules: impalpable groins with low-risk primary (pTa, pT1a) may be observed; pT1b or higher warrants staging by dynamic sentinel node biopsy (where available) or modified inguinal lymphadenectomy; bilateral dissection for midline and lateral lesions because drainage is bilateral. - Palpable node management: fine-needle aspiration to confirm, then inguinal lymphadenectomy; a fixed or ulcerated node set may need neoadjuvant chemotherapy (taxane-cisplatin-fluorouracil, TPF) before surgery. - Pelvic node dissection when two or more inguinal nodes are positive or there is extracapsular spread — the strongest adverse prognostic factor overall. ## How to work through a case A 58-year-old labourer presents with a foul-smelling fungating ulcer of the glans and a non-retractile prepuce he has never been able to retract; both groins show 2 cm mobile nodes. Step 1: biopsy the visible lesion (or a dorsal slit to expose it) — moderately differentiated squamous carcinoma invading the corpus spongiosum, at least pT2. Step 2: image the penis (MRI for corporal and urethral involvement) and stage the groins: ultrasound-guided FNA of both nodes returns metastatic squamous carcinoma on the left, reactive on the right. Step 3: treat the primary — the tumour involves the distal glans and distal corpora: partial penectomy with frozen-section control and perineal urethrostomy if the stump is too short for forward voiding; counsel him pre-operatively about voiding and body image. Step 4: address the groins after healing — confirmed unilateral metastasis drives bilateral inguinal lymphadenectomy (drainage crosses sides), with a modified template on the clinically negative right side; saphenous-sparing modification reduces flap necrosis and lymphoedema. Step 5: if more than two nodes or extracapsular spread is found, extend to pelvic node dissection and adjuvant chemo-radiotherapy decisions, and follow up for local recurrence and groin disease. ## How the exam frames it The most repeated facts: phimosis and HPV 16 association, protective effect of circumcision, and "two-thirds of palpable inguinal nodes are reactive" — biopsy or aspirate before block dissection, but never simply observe a confirmed node. The second axis is surgical anatomy: superficial inguinal dissection above the fascia lata, the greater saphenous vein's fate (preserved in the modified operation), and complications of the dissection — flap necrosis, lymphoedema, seroma, wound infection — which explain why surgeons are cautious with prophylactic dissection and favour dynamic sentinel node biopsy in equipped centres. The third is margins: exam questions quoting "2 cm margin" reflect older Bailey & Love teaching; current practice permits narrower histologically confirmed margins, so phrase your answer as clearance by frozen section rather than a fixed centimetre. The fourth is Indian reality: advanced neglected primaries with fixed groin nodes are common, and neoadjuvant TPF chemotherapy is the accepted downstaging strategy. ## Frequently asked questions ### What are the major risk factors for penile cancer? Phimosis with chronic inflammation, high-risk HPV (types 16 and 18) infection, lichen sclerosus, smoking, immunosuppression and multiple sexual partners; neonatal circumcision is strongly protective. ### How are clinically impalpable groins managed? Risk-stratified: observation is acceptable for low-risk primaries (pTa, pT1a grade 1-2), while pT1b or higher warrants dynamic sentinel node biopsy or modified inguinal lymphadenectomy for staging. ### What margin is required at partial penectomy? Traditional teaching demanded 2 cm clearance; contemporary practice accepts about 1 cm for distal low-grade tumours with intraoperative frozen-section confirmation, preserving function without compromising local control. ### Why not simply observe a palpable inguinal node? Because roughly two-thirds prove reactive, confirmation by ultrasound-guided fine-needle aspiration or biopsy is needed first — but a proven node requires dissection, and delaying nodal surgery for proven disease is the classic fatal error. ### When is chemotherapy used in penile cancer? Neoadjuvant taxane-cisplatin-fluorouracil (TPF) for unresectable or bulky nodal disease to downstage before surgery, and palliatively in metastatic disease; responses are modest and surgery remains the mainstay when feasible.