Although penile cancer is a rare malignancy, it poses a challenge for the urologist as it frequently requires surgical treatment, which can be both disfiguring and emasculating. Organ-preserving approaches to surgical treatment of the primary tumour, rather than total penectomy, exemplify a major paradigm shift in the clinical management of penile cancer. In this Review, Burnett discusses the different surgical options available for penile-preserving surgery and reconstruction, and the need for careful patient selection and monitoring.