Surgery is the most used treatment for penile cancer and essentially involves surgical removal, varying in extent depending on the case, with possible reconstructive procedures. There are various surgical techniques for penile cancer, and the choice depends on multiple factors such as tumor size, histology, stage, location, and patient preferences.

In cases of superficial non-invasive disease, glans resurfacing is indicated, which involves the removal of the most superficial layer of the glans (mucosa) followed by reconstruction using a graft taken from the buccal mucosa, inner thigh, or abdomen. This procedure provides excellent aesthetic results and allows the patient to retain sexual functionality.
When the non-invasive lesion affects not the glans but the foreskin, circumcision is indicated.
In cases of invasive tumors confined to the glans, glandulectomy represents the surgical option. A subsequent reconstructive procedure using a full-thickness graft may follow glandulectomy.
While conservative surgery that spares the organ is possible in the previous cases, more advanced cases, in which the disease is locally advanced, require amputative surgery. Partial or total penectomy is safer against local recurrences and should always be discussed as an alternative, considering the significant impact it has on sexual functionality and quality of life.
In cases of unresectable advanced disease, neoadjuvant chemotherapy offers the possibility of reducing the disease, allowing for subsequent excision.
The management of lymph node metastases deserves a separate discussion. Penile cancer primarily metastasizes via lymphatics, first affecting the inguinal lymph nodes and then the pelvic ones. Lymph node involvement represents the most important prognostic factor and should always be considered. In clinically negative patients—those without palpable masses on physical examination—the only reliable way to exclude the presence of micrometastases is lymphadenectomy. This is, of course, an invasive procedure and is not performed arbitrarily on all patients, but only in tumors considered to be high risk, while intermediate-risk tumors are evaluated on a case-by-case basis, balancing the risk of micrometastases against the morbidity of surgical staging.

Lymphadenectomy is always performed in clinically positive patients, considering that these patients are at high risk for distant metastases.
In patients with advanced disease and the presence of a fixed inguinal mass or pelvic lymphadenopathy, chemotherapy followed by surgery is a reasonable strategy.
Patient surveillance is essential, as early diagnosis of potential recurrences increases the likelihood of curative treatment. Follow-up is vital not only from an oncological standpoint but also to assess the physical and psychological impact of treatments that can be functionally and sexually disabling, significantly negatively affecting the patient’s quality of life.

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