Surgery of Penile and Urethral Carcinoma

1. Surgery of Penile andUrethral Carcinoma Campbell’s Urology Chapter 32 W. Britt Zimmerman April 15, 2009

2. Surgery of Penile & Urethral Carcinoma • Penile Cancer • Male Urethral Cancer • Female Urethral Cancer

3. Penile Cancer • Typically Squamous • Involves: • Glans penis • Coronal Sulcus • Inner preputial skin

4. Penile Cancer • Biopsy • Imperative to include area of question as well as adjacent normal tissue • Allows for evaluation of depth of invasion • May be punch or excisional • Urethral meatus involvement • Urethroscopy is mandatory

5. Penile Cancer • Laser Therapy • Carbon Dioxide (CO2) • Neodymium:yttrium-aluminum-garnet (Nd:YAG) • Potassium titanyl phosphate (KTP) • Circumcision is usually recommended at the time of laser surgery if not already done

6. Laser Therapy • CO2 • Wavelength: 10,600 nm • Skin depth: 0.01 mm • Blood vessels: 0.5 mm • 33% local recurrence • Healing time: 5 – 8 weeks

7. Laser Therapy • Nd:YAG • Most commonly reported • Skin dept: 3 – 6 mm • 20% recurrence • Stage T1 • Healing time: 8 – 12 weeks • Combination • Surgery and laser to the base 18% – 20% recurrence

8. Laser Therapy • KTP • Wavelength: 532 nm • Intermediate depth • Between CO2 and Nd:YAG • Healing time: 8 – 12 weeks

9. Laser Therapy • Technical improvements • 5% Acetic acid wraps • 5-aminolevulinic acid • Final thoughts • Reasonable for Tis and T1 SCC • T2 patients refusing aggressive surgery

10. Mohs Micrographic Surgery • Excision of penile cancer by thin tissue layers • Frozen sectioning with immediate pathological evaluation • Cure rates (5 years) • < 1 cm: 100% • 1 – 2 cm: 83% • 2- 3 cm: 75% • > 3 cm: 50%

11. Mohs Micrographic Surgery • Best suited for small superficial cancers • Comparable to partial penectomy • In the right setting

12. Conservative Surgical Excision Local excision and Glansectomy • In the setting of low stage penile cancer • Traditionally, 2 cm margin • Grade plays a central role • Grade 1 & 2 • Histologic extent 5 mm • Location also plays a role • Coronal Sulcus 50% recurrence

13. Conservative Surgical Excision • Glanular tumors • Difficult secondary inability to achieve adequate margin • Preputial skin flap or split thickness skin graft (STSG) can assist in closure • Recurrence: • Traditionally 32 – 40% • Contemporary studies 8 – 11%

14. Figure 32-1 Surgical glans defect covered with outer preputial flap as described by Ubrig and colleagues (2001). A, Superficial glans tumor. B, Outer preputial flap outlined. C, Tumor excised and circumcision performed. D, Glans defect filled with outer preputial flap.

15. Figure 32-2 Finely meshed extragenital split-thickness skin graft quilted to glans defect after superficial tumor excision.

16. Conservative Surgical Excision • Total Glansectomy • First described in 1996 • Used in patients with stage T1 & T2 SCC of the glans, prepuce, and coronal sulcus • Dissassembly of glans and distal corpus spongiosum • Frozen section for margin evaluation • STSG with urethrostomy formation • Benefits • Voiding • Sexual function preservation

17. Partial Penectomy • Most common surgical procedure for treatment of patients primary SCC • Penile amputation • 2 cm proximal to the tumor • Goals • Voiding • Sexual function

18. Partial Penectomy Figure 32-3 Partial penectomy. A, Incision with ligation and division of dorsal penile vessels within Buck's fascia (inset). B, Corpora transected and urethra spatulated. C and D, Closure of corpora cavernosa. E, Final closure with construction of urethrostomy.

19. Partial Penectomy • 1.0 to 1.5 cm distal to the cavernosal amputation site • Urethrostomy is created by approximating the urethra to the surrounding penile skin • Lengthening • Suspensory ligament division

20. Partial Penectomy • Skin coverage • Scrotal flaps • Z-plasty • Glans reconstruction • Skin grafts • Pedicle flaps

21. Penectomy • Local recurrence rates • 0 – 8%

22. Total Penectomy • At the level of the suspensory ligament • Corpra cavernosa proximally remains • Performed for large or proximal Lesions • Patients void sitting down via a perineal urethrostomy

23. Total Penectomy Figure 32-5 Total penectomy. A, Incision. B, Transection of the corpora near the level of the pubis. C, Mobilization of the remaining urethra off of the proximal corporal bodies. D, Transposition of the urethra through a curvilinear perineal incision. E, Completion of perineal urethrostomy.

24. Perineal Urethrostomy

25. Perineal Urethrostomy

26. Perineal Urethrostomy

27. Perineal Urethrostomy Foley left for 7 – 10 days

28. Radical Penectomy • The corporal bodies are dissected to the tips of the crura, which are completely excised. • Urethra is matured into a standard perineal urethrostomy.

29. Radical Penectomy

30. Regional Lymph Nodes • SCC on the penis spreads regionally before it spreads distantly. • No skip lesions. • One midline structure can metastasize to either side or bilaterally. • Metastatic lymph nodes confer a poorer prognosis • Aggressive lymphadenectomy: cure in 30 – 60%

31. Inguinal Anatomy • Lymph nodes • Superficial • Deep • Superficial lymph nodes (5 groups) • Central (saphenofemoral junction) • Superolateral (superficial circumflex vein) • Inferolateral (lateral femoral & superficial circumflex) • Superomedial (superficial ext. pudendal & superficial epigastric veins • Inferomedial (greater saphenous vein)

32. Superficial lymph nodes (5 groups) Figure 32-14 Superficial inguinal lymph nodes and the branches of the saphenous vein. SEV, superficial epigastric; SEPV, superficial external pudendal; MCV, medial cutaneous; LCV, lateral cutaneous; SCIV, superficial circumflex iliac.

33. Inguinal Anatomy • Deep inguinal nodes • Medial to femoral vein in the femoral canal • Cloquet – most cephalad of the deep group • Between the femoral vein and the lacunar ligament • External iliac nodes • Deep inguinal • Obturator • Hypogastric

34. Deep Inguinal Nodes

35. Inguinal Anatomy • Skin blood supply • Common femoral artery • Superficial external pudendal • Superficial circumflex iliac • Superficial epigastric arteries • Transverse skin incision compromises the least amount of blood supply

36. Inguinal Anatomy • Femoral nerve • Deep to iliacus fascia • Motor • Pectineus • Quadriceps femoris • Sartorius • Sensation • Anterior thigh

37. Inguinal Anatomy • Femoral triangle: • Inguinal ligament – superiorly • Sartorius muscle – laterally • Adductor longus muscle – medially • Floor • Pectineus (medially) and iliopsoas (laterally)

38. Sentinel Node Biopsy • First describe by Cabanas in 1977 • Results a have been variable

39. Modified Inguinal Lymphadenectomy • Catalona 1988 • Same therapeutic benefit • Less morbidity • Key aspects • Shorter skin incision • Excludes the area lateral to the femoral artery and caudal to the fossa ovalis • Saphenous vein preservation • Elimination of sartorius muscle transposition

40. Modified Inguinal Lymphadenectomy Figure 32-17 Limits of standard and modified groin dissection. (From Colberg JW, Andriole GL, Catalona WJ: Long-term follow-up of men undergoing modified inguinal lymphadenectomy for carcinoma of the penis. Br J Urol 1997;79:54-57.)

41. Modified Inguinal Lymphadenectomy Figure 32-18 Modified inguinal lymphadenectomy. Lymph node packet is medial to the femoral artery and includes superficial and deep inguinal nodes.

42. Modified Inguinal Lymphadenectomy Figure 32-19 Intraoperative photograph of right inguinal region after modified lymphadenectomy. SC, spermatic cord; V, femoral vein; S, saphenous vein; AL, adductor longus.

43. Radical Ilioinguinal Lymphadenectomy • Indicated in patients with resectable metastatic adenopathy and may be curative when inguinal nodes disease only. • May also be used in palliation

44. Radical Ilioinguinal Lymphadenectomy

45. Radical Ilioinguinal Lymphadenectomy Figure 32-21 Ilioinguinal lymph node dissection. A, Incisions for inguinofemoral lymph node dissection (1), unilateral pelvic lymph node dissection (2), and bilateral pelvic lymph node dissection (3). B, Single incision approach for ilioinguinal lymph node dissection.

46. Radical Ilioinguinal Lymphadenectomy Figure 32-22 A, Incision and area of dissection for left inguinofemoral lymph node dissection with excision of adherent skin overlying nodal mass. B, Single incision approach and area of dissection for right ilioinguinal lymph node dissection with excision of overlying skin.

47. Radical Ilioinguinal Lymphadenectomy

48. Radical Ilioinguinal Lymphadenectomy Figure 32-25 Inferior dissection during radical inguinofemoral lymph node dissection with removal of lymph node packet from the inferior border of the femoral triangle. After further lateral and medial dissection, the packet will remain in continuity with the pelvic dissection in the area of the femoral canal.

49. Radical Ilioinguinal Lymphadenectomy Figure 32-26 Intraoperative photograph after right radical inguinofemoral lymph node dissection in an obese patient. S, sartorius muscle; A, femoral artery; V, femoral vein; IL, inguinal ligament. Figure 32-27 Sartorius muscle after detachment from the anterior superior iliac spine and 180-degree rotation medially, with suture fixation to the fascia of the inguinal ligament and the adductor longus. S, sartorius muscle; SC, spermatic cord.

50. Key Points of Penile Cancer • Early meticulous surgical management with close follow-up generally provides the best opportunity for cure of penile SCC. • Include some adjacent normal tissue with the specimen to allow optimal evaluation of the depth of invasion of the cancer during biopsy.