PANDUAN PRAKTIS KLINIS (PPK)

SMF UROLOGI
JUDUL: KARSINOMA PENIS
No. Dokumen No. Revisi Halaman
00 1/3
RSUP SANGLAH
DENPASAR
Tanggal terbit: Ditetapkan oleh:
PPK Direktur Utama
RAWAT INAP
UROLOGI PASIEN
KARSINOMA PENIS
dr. I Wayan Sudana, M.Kes
NIP 19650409 199509 1 001
1. No.ICD 10 Karsinoma Penis : C 60
2. Pengertian Tumor ganas penis
3. Anamnesis 3.1 Anamnesis yang cermat untuk menentukan adanya keluhan
karena:
1) Pembesaran tumor/kanker penis (T): ulkus kronis, tumor
seperti bunga kol dengan/tanpa, fimosis dan gangguan
kencing
2) Pembesaran kelenjar limfe para aorta (N):
Pembengkakan tungkai
3) Metastase (M) ke hati, dan paru: Nyeri perut kanan atas,
batuk dan atau sesak nafas
3.2 Riwayat penyakit/keluarga adanya tumor saluran kencing
3.3 Riwayat pengobatan/tindakan/pembedahan saluran kencing
3.4 Status sosial-gizi keluarga/kebiasaan makan-minum/pekerjaan
4. Pemeriksaan 4.1 Umum: Kesadaran, Tekanan darah, Nadi, Tempratur aksila
Fisik dan status gisi (BMI: Obese, over weigh, Normal, Under
weigh)
4.2 Lokal pada penis (T): Luka kronis,Tumor cowly flower (bunga
kol) atau secile (datar) dan atau Phimosis
4.3 Lokal pada inguinal: Teraba tumor solid satu atau lebih,
Tumor mobil atau fixed (terfiksir)
4.4 Ektremitas bawah: Odema
5. Kriteria Diagnosis 5.1 Anamnesis
5.2 Pemeriksaan fisis
5.3 Pemeriksaan penunjang
6. Diagnosis 6.1 Condyloma acuminata/ Giant condyloma
Banding 6.2 Veruca Vulgaris penis
6.3 Limfadenopati inguinalis
6.4 Limfadenitis veneralis (STD)
7. Pemeriksaan 7.1 Laboratorium: DL, UL, dan kultur eksudat, bila klinis infeksi
Penunjang akut/kronis
7.2 Radiologi: BOF, Foto thorax dan USG abdomen dan pelvis,CT
Scan atau MRI abdomen.
7.3 Hasil PA: biopsy tumor penis dan atau inguinal (diagnosis
pasti)
8. Konsultasi 8.1 Dokter Spesialis Jantung dan Pembuluh darah, bila umur ≥ 40
tahun
8.2 Dokter Spesialis Anastesi untuk toleransi pembiusan
8.3 Dokter Spesialis lain yang terkait atas indikasi medis
9 Perawatan 9.1 Rawat inap
Rumah Sakit
10 Terapi/tindakan 10.1 Terapi medis umum:
(ICD 9 CM) 1) Infuse NaCl 0,9% pre-operative, durante-operative dan
post-operative 1,5-2 L /24 jam selama 3 hari
2) Antibiotika profilaksis Cefazolin, injeksi, 2 gram , intra
vena 30-60 menit sebelum pembiusan, dapat diulang
setiap 4 jam bila pembedahan > 4 jam
3) Antibiotika terapiutik, Apabila dengan ISK, Cefoperazon
atau sesuai kultur urin, injeksi, 1 gram/8 jam, intra vena
1 hari pre-operative dan 2 hari post-operative,
dilanjutkan dengan anti biotika oral Cefixim 200 mg 12
jam/sesuai kultur urin selama 4-7 hari.
4) Diuretikum Furosemid post-operative 20 mg intravena,
dosis tunggal
5) Analgetika post-operative: Metamizol injeksi intravena
500 mg/6 jam selama 24 jam, selanjutnya ganti dengan
metamizol tablet 500 mg oral/6 jam selama 5- 7 hari
6) Apabila ada kontra indikasi* metamizol, diganti dengan
Paracetamol injeksi intravena 500 mg/6 jam selama 24
jam, selanjutnya ganti dengan paracetamol tablet 500
mg oral/6 jam selama 5- 7 hari

10.2 Terapi medis kemo:

1) Terapi kemo neo-adjuvant (3 cycles TPF), Cis-Platin dan
Taxane-based regimen, diikuti dengan pembedahan
radikal, bila pasien dengan metastase kelenjar getah
bening yang tidak dapat dioperasi (inoperable) atau
rekuren.
Paclitaxel 120 mg/m2/minggu (hari 1)
Cisplatin 50 mg/m2/minggu (hari 1 dan 2)
5FU 1,000 mg/m2/minggu (hari 2–5)
2) Terapi kemo adjuvant:
Adjuvant chemotherapy (3 cycles of TPF), untuk pasien
dengan tumor pN2-3

10.3 Terapi invasif tujuan kuratif

1) Menghilangkan tumor, mencegah metastase, mencegah
gangguang fungsi kencing dan mengusahakan untuk
mempertahan aktifitas sexual Sirkumsisi/Partial
penectomy/Total atau radical penectomy, Biopsi sentinal
node atau kelenjar limfe inguinal dan Diseksi kelenjar
limfe inguinalis superfisial/Diseksi kelenjar limfe
inguinalis superfisial dan profundus (satu sisi atau kedua
sisi)

10.4 Terapi invasif dan kemo tujuan paliatif

1) Penektomi, dan atau diseksi kelenjar limfe inguinalis
superfisial dan profundus (satu sisi atau kedua sisi), bila
tumor tidak resctable dan atau metastasis. Tujuan
memperbaiki kwalitas hidup
2) Chemotheraphy
3) Radiotheraphy)
4) Terapi kombinasi
11 Tempat 11.1 RSUP Sanglah Denpasar
 Pelayanan
12 Penyulit 12.1 Pendarahan
12.2 Infeksi saluran kencing dan luka operasi
12.3 Stenosis miatus uretra eksternus
12.4 Odema ekstremitas imferior
12.5 Ruptura vasa femoralis
12.6 Kambuh (residif)
13 Informed 13.1 Tertulis
Consent
14 Tenaga Standar 14.1 Dokter Spesialis Urologi Konsultan
14.2 Dokter Spesialis Urologi
14.3 Dokter PPDS (junior, madya, senior, chief)
15 Lama Perawatan 15.1. Chemotheraphy: One day care -2 hari
15.2. Penectomy: 3-5 hari
15.3. Pembedahan Urolgi Terbuka, deseksi kelenjar inguinal
sederhana : 5-7 hari
16 Masa Pemulihan 16.1. Chemotheraphy: One day care -2 hari
16.2. Penectomy: 7-14 hari
16.3. Pembedahan Urolgi Terbuka sederhana: 7-14 hari
17 Hasil 17.1. Terapi kuratif : Harapan hidup 5 tahun 50%
17.2. Terapi paliatif: Harapan hidup 1 tahun 50%
18 Patologi 18.1 Biopsi tumor penis prabedah
18.2 Tumor penis pasca bedah
18.3 Kelenjar limfe inguinalis/pelvinal pasca biopsi atau deseksi
19 Prognosis 19.1 Ad vitam: hidup
19.2 Ad functionam: fungsi organ penis kurang baik
19.3 Ad sanationam: tidak sembuh total dan dapat beraktivitas
seperti biasa.
20 Tindak Lanjut 20.1 Pascabedah di ruang rawat inap (SOAP):
1) Skor nyeri (VAS): Terapi sesuai PPK nyeri.
2) Klinis (anamnesis dan pemeriksaan fisis): Terapi sesuai
indikasi.
3) Laboratorium (DL), bila ada indikasi intervensi medis dan
atau Urologi sito/urgent
20.2 Radiologis (BOF/BNO dan atau USG Urologi), bila ada
indikasi intervensi Urologi sito/urgent
20.3 Pascabedah poliklinis: 1-4 minggu dan 4-12 minggu
1) Evaluasi infeksi, fungsi miksi dan penyulit dengan
pemeriksaan: Klinis (anamnesis dan pemeriksaan fisis):
Terapi sesuai indikasi.
2) Hasil PA: Terapi sesuai indikasi
3) Laboratorium (UL, DL dan BUN/SC), bila ada indikasi
intervensi medis
4) Efek samping khemoterapi atau radioterapi
20.1 Pasca bedah poliklinis (SOAP): 3-12 bulan dan setiap 12
bulan
1) Evaluasi T,N dan M dengan pemeriksaan Klinis
(anamnesis dan pemeriksaan fisis) : Terapi sesuai
indikasi.
2) Laboratorium (UL, DL dan BUN/SC), bila ada indikasi
intervensi medis
3) Evaluasi T,N,M atau Tumor residif/recurent dan
metastase. secara klinis dan atau CT Scan/MRI
abdomen
21 Tingkat Eviden & 21.1 Lihat tabel dibawah
Rekomendasi
22 Edukasi 22.1 Diagnosis
22.2 Terapi
22.3 Prognosis
22.4 Biaya
23 Kepustakaan 23.1 Hakenberg O.W., Compérat E., Minhas S., et.al. Guidelines
on Penile Cancer. European Association of Urology. 2014.

REKOMENDASI

Risk factors
1. Phimosis versus no phimosis (OR 11-16)
2. Chronic penile inflammation (balanoposthitis related to phimosis)
3. Balanitis xerotica obliterans (lichen sclerosus)
4. Sporalene and UV-A phototherapy for various dermatologic conditions such as psoriasis
(Incidence rate ratio 9.51 with > 250 treatments
5. Smoking 5-fold increased risk (95% CI: 2.0-10.1) versus nonsmokers
6. HPV infection condylomata acuminata 22.4% in verrucous SCC (7) 36-66.3% in
basaloid-warty
7. Rural areas, low socio-economic status, unmarried
8. Multiple sexual partners early age of first intercourse 3-5-fold increased risk of penile
cancer
(HPV = human papilloma virus; OD= odds ratio; SCC = squamous cell carcinoma; UV-A =
ultraviolet-A).

TNM clinical and pathological classification of penile cancer (Tahun 2009)

1. Clinical classification
1.1 T - Primary Tumour
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
Ta Non-invasive carcinoma
T1 Tumour invades subepithelial connective tissue
T1a Tumour invades subepithelial connective tissue without lymphovascular
invasion and is not poorly differentiated or undifferentiated (T1G1-2)
T1b Tumour invades subepithelial connective tissue with lymphovascular invasion
or is poorly differentiated or undifferentiated (T1G3-4)

T2 Tumour invades corpus spongiosum and/or corpora cavernosa

T3 Tumour invades urethra
T4 Tumour invades other adjacent structures

1.2 N - Regional Lymph Nodes

NX Regional lymph nodes cannot be assessed
N0 No palpable or visibly enlarged inguinal lymph node
N1 Palpable mobile unilateral inguinal lymph node
N2 Palpable mobile multiple unilateral or bilateral inguinal lymph nodes
N3 Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral

1.3 M - Distant Metastasis

M0 No distant metastasis
M1 Distant metastasis
2. Pathological classification
2.1 The pT categories correspond to the clinical T categories.
2.2 The pN categories are based upon biopsy or surgical excision.
pN - Regional Lymph Nodes
pNX Regional lymph nodes cannot be assessed
pN0 No regional lymph node metastasis
pN1 Intranodal metastasis in a single inguinal lymph node
pN2 Metastasis in multiple or bilateral inguinal lymph nodes
pN3 Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal
extension of any regional lymph node metastasis

pM - Distant Metastasis
pM0 No distant metastasis
pM1 Distant metastasis

G - Histopathological Grading
GX Grade of differentiation cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3-4 Poorly differentiated/undifferentiated

RECOMMENDATIONS FOR THE DIAGNOSIS AND STAGING OF PENILE CANCER

RECOMMENDATIONS GR
1. Primary tumour C
• Physical examination, recording morphology, extent and invasion of penile
structures.
• MRI with artificial erection in selected cases with intended organ preserving
surgery.
2. Inguinal lymph nodes C
Physical examination of both groins, recording number, laterality and
characteristics of inguinal nodes
• If nodes are not palpable, invasive lymph node staging in high-risk patients
• If nodes are palpable, a pelvic CT may be indicated, PET/CT is an option.
3. Distant metastases C
• In N+ patients, abdomino-pelvic CT scan and chest X-ray are required for
systemic staging. PET/CT scan is an option.
• In patients with systemic disease or with relevant symptoms, a bone scan may
be indicated.
CT = computed tomography; PET = positron emission tomography.

RECOMMENDATIONS FOR STAGE-DEPENDENT LOCAL TREATMENT OF PENILE

CARCINOMA.
Primary tumour Organ-preserving treatment is to be considered LE GR
whenever possible
1. Tis • Topical treatment with 5-fluorouracil or imiquimod for 3 C
superficial lesions with or without photodynamic
control.
• Laser ablation with CO2 or Nd:YAG laser.
• Glans resurfacing.
2. Ta, T1a (G1, • Wide local excision with circumcision CO2 or 3 C
G2) Nd:YAG laser surgery with circumcision.
• Laser ablation with CO2 or Nd:YAG laser.
 • Glans resurfacing.
• Glansectomy with reconstructive surgery, with or
without skin grafting.
• Radiotherapy by external beam or as brachytherapy
for
lesions < 4 cm.
3. T1b (G3) and • Wide local excision plus reconstructive surgery, with 3 C
T2 confined to or
the glans without skin grafting.
• Laser ablation with circumcision.
• Glansectomy with circumcision, with reconstruction.
• Radiotherapy by external beam or brachytherapy for
lesions
< 4 cm in diameter.
4. T2 with invasion • Partial amputation and reconstruction 3 C
of the corpora • Radiotherapy by external beam or brachytherapy for
cavernosa lesions < 4 cm in diameter.
5. T3 with invasion • Partial penectomy or total penectomy with perineal 3 c
of the urethra urethrostomy.
6. T4 with invasion • Neoadjuvant chemotherapy followed by surgery in 3 C
of other responders.
adjacent • Alternative: palliative external beam radiation.
structures
7. Local • Salvage surgery with penis-sparing treatment in 3 C
recurrence after small
conservative recurrences or partial amputation.
treatment • Large or high stage recurrence: partial or total
amputation.
CO2= carbon dioxide; Nd:YAG = neodymium:yttrium-aluminium-garnet.

RECOMMENDATIONS FOR TREATMENT STRATEGIES FOR NODAL METASTASES

Regional lymph nodes Management of regional lymph nodes is LE GR
fundamental in the treatment of penile
cancer
1. No palpable inguinal nodes Tis, Ta G1, T1G1: surveillance. 2a B
2. (cN0) > T1G2: invasive lymph node staging by 2a B
bilateral modified inguinal lymphadenectomy or
DSNB.
4. Palpable inguinal nodes Radical inguinal lymphadenectomy.
(cN1/cN2)
5. Fixed inguinal lymph nodes Neoadjuvant chemotherapy followed by radical
(cN3) inguinal lymphadenectomy in responders.
6. Pelvic lymphadenectomy Ipsilateral pelvic lymphadenectomy is indicated 2a B
if two or more inguinal nodes are involved on
one side (pN2) and in extracapsular nodal
metastasis (pN3).
7. Adjuvant chemotherapy Indicated in pN2/pN3 patients after radical 2b B
lymphadenectomy
8. Radiotherapy Radiotherapy is not indicated for the treatment
of nodal disease in penile cancer.
DSNB = dynamic sentinel node biopsy.
RECOMMENDATIONS FOR CHEMOTHERAPY IN PENILE CANCER PATIENTS
LE GR
1. Adjuvant chemotherapy (3-4 cycles of TPF) is an option for patients with pN2- 2b C
3 tumours.
2. Neoadjuvant chemotherapy (4 cycles of a cisplatin and taxane-based 2a B
regimen) followed by radical surgery is recommended in patients with non-
resectable or recurrent lymph node metastases.
3. Chemotherapy for systemic disease is an option in patients with limited 3 C
metastatic load.
TPF = cisplatin, 5FU plus paclitaxel or docetaxel.

RECOMMENDATIONS FOR FOLLOW-UP IN PENILE CANCER

Interval of follow-up Examinations and Minimum GR
Years 1- Years 3- investigations duration of
2 5 follow-up
1. Recommendations for follow-up of the primary tumour
Penile 3 6 Regular physician or 5 years C
preserving months months selfexamination
treatment Repeat biopsy after topical
or laser treatment for CIS.
Amputation 3 1 year Regular physician or 4 years C
months selfexamination
2. Recommendations for follow-up of the inguinal lymph nodes
Surveillance 3 6 Regular physician or 5 years C
months months selfexamination
pN0 at initial 3 1 year Regular physician or 5 years C
treatment months selfexamination.
Ultrasound with FNAB
optional.
pN+ at initial 3 6 Regular physician or 5 years C
treatment months months selfexamination
Ultrasound with FNAC
optional, CT/MRI optional.
CIS = carcinoma in situ; CT = computed tomography; FNAB = fine-needle aspiration biopsy;
FNAC = fineneedle aspiration cytology; MRI = magnetic resonance imaging.