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Glansectomy With Split-Thickness Skin Graft (STSG)

Glansectomy with STSG reconstruction is the most widely studied organ-sparing technique for invasive penile squamous cell carcinoma (SCC) confined to the glans, providing reliable oncologic control with preservation of penile length, urinary function, and sexual function.[1][2][3]

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​

IndicationGuideline support
Invasive SCC confined to the glans (cT1–T2)EAU-ASCO 2023 strong recommendation for organ-sparing in compliant follow-up patients[4]
PeIN or Ta diseaseNCCN Category 2B — reserved for failed / insufficient less-invasive approaches[5]
pT1a diseaseNot first-line — only when required for complete eradication with negative margins[5]
Salvage after failed prior organ-sparingIncluding 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 — standard vs salvage​

VariantPlaneIndication
Standard glansectomyOver Buck's fascia — separate the glans from the corpora cavernosa in the plane between glans spongiosum and Buck'sConfined invasive disease without suspicion of deeper involvement
Salvage glansectomyUnder Buck's fascia — Buck's excised en bloc with the glans; transection of corporal apices in selected cases (5 / 34 in Falcone series)Suspected deeper invasion; post-RT / post-laser / post-topical failure[7]

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)​

Obtain from the cavernosal bed and urethral stump.[5]

Yunis SR data (n = 574, 7 studies)[10]Value
Mean accuracy95.4% (92.9–99.4%)
Sensitivity71.4%
Specificity99.9%
PPV98.8%
NPV96.5%

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 2023: weak recommendation — when margins uncertain[4]
  • NCCN: frozen sections to determine negative margins for both glansectomy and penectomy[5]

Margin threshold: local recurrence rises considerably when distance from tumor to margin is < 5 mm.[4]

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​

TechniqueDetail
QuiltingMultiple 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​

ParameterValue
Median operative time150 min (IQR 105–180)[1]
Median hospital stay2 days (IQR 1–3)[1]
Intraoperative complication rate2.9%[1]
Positive surgical margin rate2.9%[2]

Oncologic Outcomes​

StudynDesignMedian follow-upLocal recurrenceRFS / CSS / OS
Smith 2007[6]72Prospective single-center27 mo4.2% (3 / 72)—
Morelli 2009[9]15Prospective single-center36 mo0%RFS / CSS / OS 100%
Parnham 2018[1]177Retrospective single-center41.4 mo9.3% (16 / 172)CSS 89.3%, OS 83.3%
Tang 2017[14]410Retrospective, 5 centers42 mo7.6%5-yr RFS 78%; OS no difference by stage (p = 0.67)
Falcone 2021[7]34Prospective single-center12 mo—1-yr RFS 88.2% / CSS 91.2% / OS 91.2%
Falcone 2022[2]34Retrospective single-center12 mo17.6%1-yr CSS / OS 91%
Pang 2026 SR[3]327 (14 studies)Systematic review40.7 mo9.1% (0–25%)CSS 87.5–100%

Largest single-center series (Parnham n = 177): local recurrence 9.3%, cancer-specific mortality 10.7% at median 41.4 mo.[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).[14]

Does Local Recurrence Worsen Survival? — The Evolving Debate​

StudyFinding
Roussel 2021 (n = 897, 9 centers)[15]Local recurrence after glansectomy associated with significantly worse OS (HR 2.89, p significant)
Elst 2025 (n = 550, lower-risk glans-sparing cohort, 79% pT1)[16]Despite 29% local recurrence, 5-yr CSS 99%; none of the 3 cancer-specific deaths had experienced local recurrence; PeIN at margin predicted local recurrence (HR 2.28, p = 0.02)

EAU-ASCO 2023 acknowledges the tension — the limits of organ-sparing surgery are not fully defined, and the higher local-recurrence risk vs partial amputation must be discussed with patients.[4]

Functional Outcomes​

Pang 2026 SR (n = 327 across 14 studies)[3]​

DomainResult
Preserved erectile function91.1% (50–100%)
Sexually active62.5% (33.3–100%)
Voiding while standing75.6% (66.7–100%)
Maintained glans sensation83.7% (63.6–91.2%)
Satisfaction with appearance86.3% (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

Comparative IIEF-15 change at 12 mo — Falcone 2024 (n = 99)[17]​

ProcedureIIEF-15 changeSignificance
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.

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)[18]​

  • 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)[19]​

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​

ComplicationPang SRFalcone 2022Management
Partial graft loss6.1% (0–17.6%)17.6%Observation or re-grafting
Meatal stenosis8.1% (0–14.3%)5.8%Dilation or meatoplasty
Wound infection—5.8%Antibiotics / wound care
Postoperative phimosisRare—Circumcision revision
Overall complication rate—29.4%—
Requiring operative intervention9% (Parnham)——

Clavien-Dindo (Falcone 2021, n = 34)[7]​

GradeRate
111.7%
28.8%
3a8.8%
3b+0%

Quality of Life and Psychological Outcomes​

EAU-ASCO notes very limited QoL data with heterogeneous psychometric tools.[4][20][21][22]

  • 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)[23]

Surveillance (EAU-ASCO 2023)[4]​

PeriodFrequencyExamination
Years 1–2q 3 monthsPhysical or self-examination; repeat biopsy after topical / laser for PeIN (optional)
Years 3–5q 6 monthsPhysical or self-examination
Minimum follow-up5 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​

GuidelineRecommendationStrength
NCCNGlansectomy for select PeIN / Ta / T1 distal tumors2A (T1); 2B (PeIN / Ta)
NCCNFrozen sections of cavernosal bed and urethral stump for negative margins2A
NCCNSTSG or FTSG neoglans after glansectomy2A
EAU-ASCOOffer organ-sparing (incl. glansectomy) for confined lesions with strict follow-upStrong
EAU-ASCOFrozen section in cases of doubtWeak
EAU-ASCOSalvage organ-sparing surgery for small recurrences not involving corpora cavernosaWeak
EAU-ASCOInform patients of higher local-recurrence risk vs amputationStrong

Key Takeaways​

  • First-line for invasive SCC confined to the glans (cT1–T2) — strong EAU-ASCO recommendation
  • Standard (over Buck's) vs salvage (under Buck's, sometimes corporal-apex transection) plane is the key intraoperative decision
  • Frozen section of cavernosal bed and urethral stump is the dominant strategy for margin control (mean accuracy 95.4%); ensure ≥ 5 mm tumor-to-margin distance
  • Glansectomy IIEF-15 falls ~ 24% vs only ~ 6% with glans resurfacing — counsel patients on the functional trade-off vs disease control
  • Local recurrence 7.6–17.6% in modern series; the Roussel vs Elst data leave the impact on survival genuinely debated — depends on patient risk profile and PeIN-at-margin
  • Multidisciplinary post-op support (psych / sex therapy / lymphedema) and inflatable penile prosthesis for persistent ED are part of the modern care pathway

Cross-references​

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. Swallow T, Summerton D. "Penis and Urethra Neoplasm." Chapter 33.

14. 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

15. 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

16. Elst L, Roussel E, Miletic M, et al. "Local Recurrence After Glans-Sparing Surgery: No Impact on Penile Cancer-Specific Survival." BJU Int. 2025. doi:10.1111/bju.70055

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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