Glansectomy With Split-Thickness Skin Graft (STSG)
Glansectomy with STSG reconstruction is an organ-sparing option for penile squamous cell carcinoma (SCC) confined to the glans when local excision or resurfacing is unsuitable. It preserves penile length, but oncologic, urinary, sexual, and graft outcomes vary across selected series; the large Parnham cohort did not measure sexual or functional outcomes.[1][3][23]
For superficial / non-invasive disease and the broader spectrum of organ-sparing approaches, see Glans Resurfacing. For the underlying graft-technique detail, see Penile Skin Grafting. For the broader decision framework, see Penile Reconstruction.
Indications
| Indication | Guideline support |
|---|---|
| Invasive SCC confined to the glans (cT1–T2) | EAU-ASCO 2026 strong recommendation for suitable organ-sparing surgery in patients willing to comply with strict follow-up; glansectomy is one option when less extensive excision or resurfacing is unsuitable.[23] |
| PeIN or Ta disease | NCCN Category 2B — reserved for failed / insufficient less-invasive approaches[5] |
| pT1a disease | Not first-line — only when required for complete eradication with negative margins[5] |
| Salvage after failed prior organ-sparing | Including recurrence after RT, laser, or topical therapy[6] |
Preoperative Evaluation
- Histologic diagnosis (punch, excisional, or incisional biopsy)
- Lesion characterization — diameter, location, number, morphology (papillary / nodular / ulcerous / flat), relationship to submucosal structures
- HPV status assessment
- Cross-sectional chest / abdomen / pelvis imaging for staging
- Patient discussion of the higher local-recurrence risk vs partial amputation[4]
Surgical Technique
Performed under general or regional anesthesia with a penile tourniquet.[7][8]
1. Circumcision and degloving
- Circumferential subcoronal skin incision; deglove the penis off the shaft, exposing the glans and Buck's fascia[1][7]
2. Plane of dissection — according to corporal-tip involvement
| Variant | Plane | Indication |
|---|---|---|
| Over Buck's fascia | Separate the glans from the corpora cavernosa in the plane between glans spongiosum and Buck's | Lesion clearly away from corporal tips on clinical assessment or imaging[23] |
| Under Buck's fascia | Excise Buck's with the glans; corporal-apex resection may be required in selected cases (5 / 34 in the Falcone series) | Doubt about the deeper plane or corporal-tip proximity, not simply because treatment is salvage[7][23] |
3. Urethral transection and spatulation
- Transect the urethra at the coronal sulcus
- Spatulate ventrally 5–10 mm to prevent meatal stenosis
- Suture the spatulated stump to surrounding tissue / graft with absorbable suture[1][9]
4. Intraoperative frozen section examination (FSE)
When completeness of resection is in doubt, frozen sections may be obtained from the cavernosal bed and urethral stump; routine use is not recommended by EAU-ASCO.[5][23]
| Yunis SR data (n = 574, 7 studies)[10] | Value |
|---|---|
| Mean accuracy | 95.4% (92.9–99.4%) |
| Sensitivity | 71.4% |
| Specificity | 99.9% |
| PPV | 98.8% |
| NPV | 96.5% |
Single-center experience (Pang n = 137): sensitivity 66.7%, specificity 100%; positive / equivocal FSE prompted further resection in the same episode, 66.7% achieved negative margins.[11]
Guideline status:
- EAU-ASCO 2026: weak recommendation — in cases of doubt about complete resection, not routinely[23]
- NCCN: frozen sections to determine negative margins for both glansectomy and penectomy[5]
Margin width: negative histologic margins are required, but no universally safe fixed macroscopic width is established. A large retrospective series cited by EAU-ASCO found considerably more local recurrence at < 1 mm tumour-to-margin distance; this is not a mandate to target exactly 1 mm, and wider margins may be prudent for bulky or higher-grade lesions.[23]
5. Hemostasis
Release the tourniquet; meticulous bipolar hemostasis before graft application.
6. STSG harvest
Anterolateral thigh, dermatome at ~ 0.046 cm depth; trim to size; fenestrate for drainage of blood and seroma.[1][12][9]
7. Neoglans creation
Apply the STSG over the exposed corpora-cavernosal tips and around the spatulated meatus; ventral-to-circumferential wrap; absorbable suture.[1][9]
8. Dressing and fixation
| Technique | Detail |
|---|---|
| Quilting | Multiple interrupted sutures directly fixing the graft to the neoglans; ~ 5 days bed rest[8] |
| TODGA (Tie-Over Dressing for Graft Application) | Proflavine-soaked gauze bolster tied over the graft × 10 d; immediate mobilization; shorter LOS[8] |
In the standardized TODGA protocol (29 operations), only 1 / 29 (3.4%) required re-grafting; meatal stenosis essentially absent.
9. Catheterization and postoperative care
- Urethral catheter 5 days (TODGA) to 10 days[7][8]
- Saline washing ~ 2 weeks after bolster removal
- Discharge typically POD 2 (median LOS 2 d, IQR 1–3)[7]
Operative Parameters
| Parameter | Value |
|---|---|
| Median operative time | 150 min (IQR 105–180)[1] |
| Median hospital stay | 2 days (IQR 1–3)[1] |
| Intraoperative complication rate | 2.9%[1] |
| Positive surgical margin rate | 2.9%[2] |
Oncologic Outcomes
| Study | n | Design | Median follow-up | Local recurrence | RFS / CSS / OS |
|---|---|---|---|---|---|
| Smith 2007[6] | 72 | Prospective single-center | 27 mo | 4.2% (3 / 72) | — |
| Morelli 2009[9] | 15 | Prospective single-center | 36 mo | 0% | RFS / CSS / OS 100% |
| Parnham 2018[1] | 177 | Retrospective single-center | 41.4 mo | 9.3% (16 / 172) | CSS 89.3%, OS 83.3% |
| Tang 2017[13] | 410 | Retrospective, 5 centers | 42 mo | 7.6% | 5-yr RFS 78%; OS no difference by stage (p = 0.67) |
| Falcone 2021[7] | 34 | Prospective single-center | 12 mo | — | 1-yr RFS 88.2% / CSS 91.2% / OS 91.2% |
| Falcone 2022[2] | 34 | Retrospective single-center | 12 mo | 17.6% | 1-yr CSS / OS 91% |
| Pang 2026 SR[3] | 327 (14 studies) | Systematic review | 40.7 mo | 9.1% (0–25%) | CSS 87.5–100% |
Parnham single-center series (n = 177): local recurrence was 16 / 172 (9.3%) and 18 / 174 died of penile cancer at median 41.4 mo; denominators differ by outcome. Functional and sexual outcomes were not collected in this cohort.[1]
Largest multicenter series (Tang n = 410): RFS 98 / 94 / 78% at 1 / 2 / 5 y; no OS differences by pathologic stage (p = 0.67).[13]
Does Local Recurrence Worsen Survival? — The Evolving Debate
| Study | Finding |
|---|---|
| Roussel 2021 (n = 897, 9 centers; 26% pT1, 41% G3)[14] | In a higher-risk glansectomy cohort, local recurrence was associated with worse OS and CSS, including after adjustment (adjusted HR 2.30 and 3.82, respectively). |
| Elst 2026 (n = 550, lower-risk mixed glans-sparing cohort, 79% pT1)[15] | Across several glans-sparing procedures, 29% had local recurrence and five-year CSS was 99%; this finding should not be generalized to higher-risk glansectomy patients. |
EAU-ASCO 2026 highlights the different case mixes and does not treat recurrence as uniformly harmless; counsel according to stage, grade, margins, and follow-up capacity.[23]
Functional Outcomes
Pang 2026 SR (n = 327 across 14 studies)[3]
| Domain | Result |
|---|---|
| Preserved erectile function | 91.1% (50–100%) |
| Sexually active | 62.5% (33.3–100%) |
| Voiding while standing | 75.6% (66.7–100%) |
| Maintained glans sensation | 83.7% (63.6–91.2%) |
| Satisfaction with appearance | 86.3% (68.2–100%) |
Falcone 2022 (n = 34)[2]
- Glans sensation preserved 91.2%
- 88.2% fully satisfied with postoperative aesthetic appearance
- 91.2% would recommend the procedure
Observational IIEF-15 change at 12 mo — Falcone (99 enrolled; 44 functionally evaluable)[16]
| Procedure | IIEF-15 change | Significance |
|---|---|---|
| Total Glans Resurfacing | − 3.1 (− 6.0%) | p = 1.0 |
| Wide Local Excision | − 14.1 (− 22.9%) | p = 0.025 |
| Glansectomy | − 13.0 (− 24.1%) | p = 0.002 |
IPSS returned near baseline at 12 mo; only 18.2% reported negative voiding impact.
The functional comparison includes 12 TGR, 10 WLE, and 22 glansectomy patients. The p-values describe within-group changes and do not prove a causal between-procedure advantage.[16]
Morelli 2009 (n = 15, 36-mo follow-up)[9]
All patients maintained erectile function with good vaginal penetration starting 2–6 mo postoperatively; orgasm and ejaculation preserved; all patients reported reduced glans sensitivity.
Croghan 2021 (n = 35, mean 22 mo)[17]
- IIEF-5 means: 14.9 (partial glansectomy), 15.8 (radical glansectomy)
- 82.4% satisfied or neutral about genital appearance
- 85.3% could void standing; 79.4% reported little / no spraying
- Mean EORTC QLQ-C30 QoL 5.88 / 7
Glans-preserving vs partial penectomy (Yang 2014, n = 171)[18]
Glans-preserving surgery had significantly better IIEF-15 in 4 domains (erectile, orgasmic, intercourse-satisfaction, overall) and superior RigiScan tip rigidity (all p significant).
Complications
| Complication | Pang SR | Falcone 2022 | Management |
|---|---|---|---|
| Partial graft loss | 6.1% (0–17.6%) | 17.6% | Observation or re-grafting |
| Meatal stenosis | 8.1% (0–14.3%) | 5.8% | Dilation or meatoplasty |
| Wound infection | — | 5.8% | Antibiotics / wound care |
| Postoperative phimosis | Rare | — | Circumcision revision |
| Overall complication rate | — | 29.4% | — |
| Requiring operative intervention | 9% (Parnham) | — | — |
Clavien-Dindo (Falcone 2021, n = 34)[7]
| Grade | Rate |
|---|---|
| 1 | 11.7% |
| 2 | 8.8% |
| 3a | 8.8% |
| 3b+ | 0% |
Quality of Life and Psychological Outcomes
EAU-ASCO notes very limited QoL data with heterogeneous psychometric tools.[4][19][20][21]
- Penile-preserving surgery preserves erectile function; glans sensation and orgasm can be affected
- ~ 50% experience psychological symptoms at follow-up (EORTC QLQ-C30)
- Patients describe feelings of mutilation, loss of masculinity, relationship strain
- Organ-sparing shows improved HRQoL and sexual-function measures vs amputation
- Self-image often becomes a "cancer-modified me"
- Multidisciplinary support — psychologist, sex therapist, lymphedema specialist — recommended as part of routine follow-up
- Penile prosthesis for persistent ED post-glansectomy (inflatable preferred; downsizing for corporal fibrosis; continued cancer surveillance)[22]
Surveillance (EAU-ASCO 2023)[4]
| Period | Frequency | Examination |
|---|---|---|
| Years 1–2 | q 3 months | Physical or self-examination; repeat biopsy after topical / laser for PeIN (optional) |
| Years 3–5 | q 6 months | Physical or self-examination |
| Minimum follow-up | 5 years | — |
Most local / regional recurrences occur within 2–3 y (52.3% within 2 y, 79.5% within 3 y) — supports intensive early surveillance.
Guideline Summary
| Guideline | Recommendation | Strength |
|---|---|---|
| NCCN | Glansectomy for select PeIN / Ta / T1 distal tumors | 2A (T1); 2B (PeIN / Ta) |
| NCCN | Frozen sections of cavernosal bed and urethral stump for negative margins | 2A |
| NCCN | STSG or FTSG neoglans after glansectomy | 2A |
| EAU-ASCO | Offer organ-sparing (incl. glansectomy) for confined lesions with strict follow-up | Strong |
| EAU-ASCO | Frozen section in cases of doubt | Weak |
| EAU-ASCO | Salvage organ-sparing surgery for small recurrences not involving corpora cavernosa | Weak |
| EAU-ASCO | Inform patients of higher local-recurrence risk vs amputation | Strong |
Key Takeaways
- Glansectomy is one organ-sparing option for selected glans-confined disease when local excision or resurfacing is unsuitable; EAU-ASCO strongly supports offering suitable organ-sparing surgery with strict follow-up
- Choose over or under Buck's fascia according to tumour proximity to the corporal tips and uncertainty about deeper involvement, not a simple primary-versus-salvage label
- Aim for histologically negative margins; EAU-ASCO suggests frozen section in cases of doubt, not routinely, and establishes no universal ≥ 5 mm threshold
- In a 44-evaluable-patient observational comparison, IIEF-15 declined more within the glansectomy group than the TGR group; this does not prove comparative superiority
- Local recurrence and survival associations differ across higher-risk glansectomy and lower-risk mixed glans-sparing cohorts; discuss stage, grade, margins, and surveillance rather than assuming recurrence is harmless
- Multidisciplinary post-op support (psych / sex therapy / lymphedema) and inflatable penile prosthesis for persistent ED are part of the modern care pathway
See Also
- Glans Resurfacing — less-invasive organ-sparing alternative
- Penile Reconstruction — full decision framework
- Penile Skin Grafting — STSG / FTSG technique detail
- Penile Grafting With Tissue Substitutes
- Penile Implants — for persistent ED after glansectomy
- Foundations — Plastic Surgery Principles
Videos
References
1. Parnham AS, Albersen M, Sahdev V, et al. "Glansectomy and Split-Thickness Skin Graft for Penile Cancer." Eur Urol. 2018;73(2):284–289. doi:10.1016/j.eururo.2016.09.048
2. Falcone M, Preto M, Blecher G, et al. "The Outcomes of Glansectomy and Split Thickness Skin Graft Reconstruction for Invasive Penile Cancer Confined to Glans." Urology. 2022;165:250–255. doi:10.1016/j.urology.2022.01.010
3. Pang KH, Alnajjar HM, Muneer A. "Functional Outcomes of Glansectomy to Treat Localised Penile Cancer: A Systematic Review." Int J Impot Res. 2026;38(3):206–213. doi:10.1038/s41443-025-01062-1
4. Brouwer OR, Albersen M, Parnham A, et al. "European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update." Eur Urol. 2023;83(6):548–560. doi:10.1016/j.eururo.2023.02.027
5. National Comprehensive Cancer Network. Penile Cancer. Updated 2025-11-12.
6. Smith Y, Hadway P, Biedrzycki O, et al. "Reconstructive Surgery for Invasive Squamous Carcinoma of the Glans Penis." Eur Urol. 2007;52(4):1179–85. doi:10.1016/j.eururo.2007.02.038
7. Falcone M, Oderda M, Calleris G, Peretti F, Gontero P. "Surgical Outcomes of Glansectomy and Split Thickness Skin Graft Reconstruction for Localized Penile Cancer." Urology. 2021;152:195. doi:10.1016/j.urology.2021.03.022
8. Malone PR, Thomas JS, Blick C. "A Tie-Over Dressing for Graft Application in Distal Penectomy and Glans Resurfacing: The TODGA Technique." BJU Int. 2011;107(5):836–840. doi:10.1111/j.1464-410X.2010.09576.x
9. Morelli G, Pagni R, Mariani C, et al. "Glansectomy With Split-Thickness Skin Graft for the Treatment of Penile Carcinoma." Int J Impot Res. 2009;21(5):311–4. doi:10.1038/ijir.2009.17
10. Yunis MZ, Pang KH, Muneer A, Alnajjar HM. "Intraoperative Frozen Section Examination for Penile Cancer Surgery: A Systematic Review." Int J Impot Res. 2025;37(9):721–727. doi:10.1038/s41443-025-01024-7
11. Pang KH, Yunis M, Haider A, et al. "Outcomes of Intraoperative Frozen Section Examination of Surgical Resection Margins of the Penis in Penile Cancer." Clin Genitourin Cancer. 2024;22(5):102189. doi:10.1016/j.clgc.2024.102189
12. Palminteri E, Berdondini E, Lazzeri M, Mirri F, Barbagli G. "Resurfacing and Reconstruction of the Glans Penis." Eur Urol. 2007;52(3):893–8. doi:10.1016/j.eururo.2007.01.047
13. Tang DH, Yan S, Ottenhof SR, et al. "Glansectomy as Primary Management of Penile Squamous Cell Carcinoma: An International Study Collaboration." Urology. 2017;109:140–144. doi:10.1016/j.urology.2017.08.004
14. Roussel E, Peeters E, Vanthoor J, et al. "Predictors of Local Recurrence and Its Impact on Survival After Glansectomy for Penile Cancer: Time to Challenge the Dogma?" BJU Int. 2021;127(5):606–613. doi:10.1111/bju.15297
15. Elst L, Roussel E, Miletic M, et al. "Local Recurrence After Glans-Sparing Surgery: No Impact on Penile Cancer-Specific Survival." BJU Int. 2026 (online 2025). doi:10.1111/bju.70055
16. Falcone M, Preto M, Gül M, et al. "Functional Outcomes of Organ Sparing Surgery for Penile Cancer Confined to Glans and Premalignant Lesions." Int J Impot Res. 2024. doi:10.1038/s41443-024-00967-7
17. Croghan SM, Compton N, Daniels AE, et al. "Phallus Preservation in Penile Cancer Surgery: Patient-Reported Aesthetic & Functional Outcomes." Urology. 2021;152:60–66. doi:10.1016/j.urology.2021.02.011
18. Yang J, Chen J, Wu XF, et al. "Glans Preservation Contributes to Postoperative Restoration of Male Sexual Function: A Multicenter Clinical Study of Glans Preserving Surgery." J Urol. 2014;192(5):1410–7. doi:10.1016/j.juro.2014.04.083
19. Brouwer OR, Rumble RB, Ayres B, et al. "Penile Cancer: EAU-ASCO Collaborative Guidelines Update Q and A." JCO Oncol Pract. 2024;20(1):33–37. doi:10.1200/OP.23.00585
20. Torres Irizarry VM, Paster IC, Ogbuji V, et al. "Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review." Cancers. 2024;16(7):1309. doi:10.3390/cancers16071309
21. Törnävä M, Harju E, Vasarainen H, et al. "Men's Experiences of the Impact of Penile Cancer Surgery on Their Lives: A Qualitative Study." Eur J Cancer Care. 2022;31(1):e13548. doi:10.1111/ecc.13548
22. Rahman F, Alnajjar HM, Muneer A. "Penile Prosthesis Implantation Following Conservative Surgical Treatment for Penile Cancer: Anatomical and Surgical Considerations." Int J Impot Res. 2025. doi:10.1038/s41443-025-01213-4
23. European Association of Urology and American Society of Clinical Oncology. EAU-ASCO Guidelines on Penile Cancer: Disease Management (2026), sections 6.1.1–6.1.2 and recommendations.