# Organ-Preserving Surgery for Penile Carcinoma

Authors: Francisco E. Martins; Raul N. Rodrigues; Tomé M. Lopes
Journal: Advances in Urology
 (2008)

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## Abstract

Introduction. Penile carcinoma has traditionally been treated by either surgical
amputation or radical radiotherapy, both associated with
devastating anatomical, functional, and psychological impact on
the patient's life. Innovative surgical techniques have focused on
penile preservation in well-selected patients to minimize physical
disfigurement and consequently maximize quality of life. The
objective of this article is to define the current status of these
organ-preserving surgical options for penile carcinoma.  Materials and Methods.
An extensive review of the Pubmed literature was performed to find articles discussing only reconstructive surgery which have contributed significantly to change traditional, frequently mutilating treatments, to develop less disfiguring surgery, and to improve patients'
quality of life over the last two decades.  Results. Several articles were included in this analysis in which a major contribution to the change in therapy was thought to have occurred and was documented as beneficial. Some articles reported novel techniques of less-mutilating surgery involving different forms of glans reconstruction with the use of flaps or grafts. The issue of safe surgical margins was also addressed.  Conclusion.  The development of less-disfiguring techniques allowing phallus preservation has reduced the negative impact on functional and cosmetic outcomes of amputation without sacrificing oncological objectives in appropriately selected patients based on stage, grade, and location of the tumour. Until more prospective studies are available and solid evidence is documented, organ preservation should be offered with caution.


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## Body

## 1. Introduction

In the industrialized world,  particularly in Europe and in the USA, penile carcinoma is an
uncommon malignancy with an incidence of less than 1 per 100 000 of the male
adult population. However, its incidence may be as high as 19 per 100 000 in
parts of Asia, South America, Africa and may
even reach 50 per 100 000 males in parts of north-eastern Brazilian states [1, 2]. This different worldwide distribution varies with age, circumcision, and
hygiene patterns.Historically, the majority (90%) are
primary carcinomas, of which 95% are squamous cell carcinomas, involving the
glans, prepuce, or both in over 78% of the cases. The management of penile
carcinoma, particularly its invasive form, has changed little over the decades.
Available treatments include surgical amputation and penis-preserving
treatments, either surgical (circumcision, laser ablation, Mohs micrographic
surgery, glansectomy associated with various forms of reconstruction) or
nonsurgical (radiotherapy, immunotherapy, chemotherapy). Surgical amputation is
the oldest of all modalities [3]. It has resulted in local control rates greater than 90% of the
primary tumor and, therefore, remains the oncological “gold standard” for all
stages [4–6]. Although the radical surgical approach provides excellent local
control, it is often mutilating and is associated with urinary and sexual
dysfunction as well as dramatic psychological morbidity [7]. These negative
factors have led to a significant change in the approach to the primary penile
lesion and to the development of several surgical organ-preserving techniques.
Nowadays, the definitive treatment of penile carcinoma is stage-dependent, with
the penile-preserving options especially reserved for low-grade and low-stage
tumors. These techniques aim to remove as little of the functional anatomy as
possible, without compromising local oncological radicality [8]. However, data
from retrospective studies suggest a statistically higher local recurrence rate
following penis-preserving treatments compared with radical surgery. Most
recurrences are surgically salvageable and overall mortality is comparable to
primary amputation [9]. The objective of this article is to give an overview of
the current status and the role of these organ-preserving surgical options for
penile carcinoma and state their limitations.


## 2. Indications and Goals of Organ Preservation

Some retrospective studies have
reported good cosmetic and functional outcomes with conservative treatment
options and an overall organ preservation of 60% [9]. Because about 80% of
penile carcinomas occur distally, involving the glans and/or prepuce, they are
potentially amenable to organ-preserving surgery [10, 11].It is generally accepted that
patients with penile carcinomas associated with favourable histology (stages
Tis, Ta, T1; grades 1 and 2) are at low risk for local progression and/or
distant metastatic spread (Table1). These patients are also the best
candidates for penile-/glans-preserving treatment options [2]. Recently,
however, some series have suggested that these indications can be expanded in
order to include T2 and even some distal T3 tumors as well as recurrences
after radiotherapy [8]. Nonetheless, until more rigorous scientific evidence is
available, organ-preserving strategies should be reserved to well-selected
patients with limited low-grade, low-stage disease [11, 12]. A traditional 2 cm
excision margin has been challenged as unnecessary for patients undergoing
partial penectomy for squamous cell carcinoma. Conservative techniques
involving surgical margins of only less than 10 mm appear to offer excellent
oncological control [13, 14].Table 1
TNM classification of penile carcinoma (1997/2002).
T-Primary tumorTX Primary tumor cannot be assessedT0 No evidence of primary tumorTis Carcinomain situTa Non-invasive verrucous carcinomaT1 Tumor invades subepithelial connective tissueT2 Tumor invades corpus spongiosum or cavernosumT3 Tumor invades urethra or prostateT4 Tumor invades other adjacent structuresN-Regional lymph nodesNX Regional lymph nodes cannot be assessedN0 No evidence of lymph node metastasisN1 Metastasis in a single inguinal lymph nodeN2 Metastasis in multiple or bilateral superficial lymph nodesN3 Metastasis in deep inguinal or pelvic lymph nodes, unilateral or bilateralM-Distant metastasisMX Distant metastases cannot be assessedM0 No evidence of distant metastasesM1 Distant metastasesThe goals of penile-preserving
treatments are to maintain penile/glans sensation and to maximize penile shaft
length where possible. However, cosmetic and functional results should not
compromise long-term oncological outcomes.


## 3. Methods of Surgical Ablation for Organ Preservation

A variety of penile-preserving
therapeutic approaches have been used for low-grade and low-stage penile
carcinoma, including topical treatments (5-fluorouracil or imiquimod cream for
Tis only), radiotherapy, Mohs micrographic surgery, laser ablation or excision,
and conservative excision strategies (Table2). This article will focus
exclusively on surgical strategies to achieve organ preservation. Nonsurgical
options are beyond the scope of this review.Table 2
Organ-preserving therapeutic strategies for penile carcinoma.
A nonsurgical(1)Topical treatments5-Fluoroacil solutionImiquimol cream(2)RadiotherapyPlesiotherapyInterstitial brachytherapyExternal beam radiotherapy(3)Cryosurgery(4)Chemotherapy(5)ImmunotherapyB Surgical(1)Laser ablation or excisionCO2Nd:YAGKTP(2)Mohs micrographic surgeryCircumcision(3)Conservative surgeryGlans-preserving techniquesPartial glansectomywith primary closurewith graft reconstruction of the glansSplit-thickness skin graftsFull-thickness skin graftsBuccal mucosaGlans-removing techniquesTotal Glansectomywith split-thickness skin graftswith distal corporectomy and reconstruction


### 3.1. Mohs Micrographic Surgery

Mohs micrographic surgery (MMS)
refers to a surgical technique of excising accessible tumors under microscopic
control [15]. The tumor is excised in layers and the undersurface of each
layer is examined microscopically by systematic frozen sections in multiple sessions.
This excision is continued until the undersurface of the excised tissue is
negative, at which point another section of tissue is removed to ensure a clear
resection margin. This sequential microscopic guidance offers increased
precision and control of the negative surgical margin, while maximizing safe
organ preservation. MMS is most commonly used for skin tumors but the
accessibility of penile carcinomas (most commonly on the glans) makes it a
suitable candidate for such a procedure. In Mohs' 50-year experience with 35
cases, the success rate was stage-dependent. A percentage of 86% of stage T1
and 82% of stage T2 cases were tumor-free compared to none of stage T3 at a
followup of 5 years.This technique is attractive because
it allows reassurance of local complete excision and preservation of local
penile anatomy and function. However, because local failure rate is apparently
higher (32%) than amputation, it should be reserved to patients with penile
carcinoma in situ or with small, distal, superficially invasive tumors.
Further reports with this technique are necessary to allow comparison and
reproducibility of outcomes in order to encourage its more widespread use.
Complications may include meatal stenosis and glans disfigurement.


### 3.2. Laser Ablation or Excision

Penile laser surgery has been used
since the 1980s. The four types of lasers used are carbon dioxide, argon,
neodymium yttrium aluminium garnet (Nd:YAG), and potassium titanyl phosphate
(KTP) lasers, the CO2 and Nd:YAG modes being the most commonly used in current
practice [16, 17].
CO2 laser has a very low penetration power (only 0.1 mm) and
is, therefore, unsuitable for most tumors, resulting in recurrence rates of up
to 50% [18]. Nd:YAG has a much higher penetration power of about 6 mm due to
its rather short wavelength (λ=1.06μm, i.e., 10 times less than
CO2), resulting in protein denaturation at such depth. Overall recurrence rates
after laser ablation are also stage-dependent, averaging 7.7% for Tis tumors,
and as high as 25% for T1 lesions [16]. Other authors have reported good
outcomes after Nd:YAG laser for T1 tumors with excellent cosmetic and
functional results and high satisfaction rates. Recurrences were noted in 6.9%
of the patients, which is comparable to recurrence rates after partial
amputation (0–8%) [19].The available data to date
demonstrate that laser surgery is feasible and may achieve results comparable
to those of traditional amputative surgery, particularly in highly selected
patients and in conjunction with frozen-section biopsies. Additionally, it has
significant anatomical, cosmetic, and functional advantages over traditional
amputation. However, as the local recurrence is higher, a close surveillance is
mandatory for early detection. Therefore, patient selection is extremely
important. Because in laser surgery the depth of tumor invasion is crucial,
only those invading less than 6 mm into tissues are suitable for this treatment
modality.


### 3.3. Conservative Surgery

Circumcision
It is the most simple and common surgical procedure in the management of penile
carcinoma. The majority of men with penile carcinoma are uncircumcised. It is
indicated for symptomatic treatment of painful or haemorrhagic tumors as well
as for acquired phimosis secondary to preputial tumors. It is always
recommended before radiotherapy as it allows better targeting and definition of
the tumor, simultaneously preventing preputial radiotherapy-related adverse
reactions, and, above all, it improves local oncological surveillance.
Noteworthy, circumcision alone is a sufficient primary curative treatment for
small low-stage (Tis, Ta, T1) and low-grade (grades 1 and 2) disease limited to
the distal prepuce [20]. If the tumor is more proximal and close to the
coronal sulcus, the circumcision margin will need to be extended proximally to
the penile shaft to ensure adequate oncological resection, as recurrence rates
may be as high as 50% [21]. Therefore, case selection is critical to reduce
local recurrence rates.Glansectomy
It can be done either partial or total, has recently been introduced for the
local excision of distal tumors on the glans and prepuce [8, 12, 22, 23].
Frozen sections from the cavernosal bed and urethral stump should be carried
out during the procedure to ensure negative surgical margins followed by an
end-shaft urethrostomy. Glansectomy is usually combined with grafting
procedures to create a neoglans. Basically, there are 2 forms of glansectomy: (i)
partial glansectomy, which removes the portion of the glans affected by the tumor,
leaving behind remaining glanular epithelium with malignant potential, and (ii)
total glansectomy, which removes all the glans tissue, thus preventing ‘de
novo' tumor growth.
Traditionally, amputative surgery
has been based on the assumption that a 2 cm resection margin is required to
achieve local oncological clearance [24]. However, the scientific value of a
2 cm margin has not been supported uniformly and several authors have recently
questioned it [13, 14, 25], concluding in their studies that a 2 cm surgical
margin was not only unnecessary but also overtreatment in many cases. About 80%
of the penile carcinomas arise distally, which render them potential candidates
for penile-preserving surgery. This type of surgery includes an extirpative
component leaving in some cases a simple defect amenable to primary closure. If
the defect is larger and primary closure is not possible or safe, various
techniques have been suggested to cover or reconstruct the area [8, 12, 22, 23, 26–33]. Ubrig described a simple technique in 2001 in which an outer preputial
skin flap was used to cover the glans defect if primary closure was impossible.
However, the tumor should not be too deep (Figure 1). Pietrzak et al. have
suggested the use of a full-thickness flap of penile skin or extragenital
(lateral aspect of the thigh) split-thickness skin graft to reconstruct the
glans associated with partial or total glans removal. In cases of invasion of
tunica albuginea by distal tumors, distal corporectomy was included [8]. In glans-preserving
procedures, partial glansectomy with primary glans closure was essentially an
excisional biopsy of a small distal tumor. Larger lesions necessitated partial
glansectomy followed by glans reconstruction which was performed with the use
of split-thickness or full-thickness grafting. In glans-removing procedures,
total glansectomy was performed followed by either split-thickness skin graft
reconstruction or reconstruction of cavernosal tips and grafting, if a distal
corporectomy was required. In some cases, a penile-lengthening procedure was
added to the reconstruction to maintain as much cavernosal tissue as possible.
In all forms of penile-preserving surgery, a frozen biopsy of the surgical bed
is mandatory to confirm tumor clearance (negative margins). A subtotal glans
excision without grafting has been described as a simple and cosmetically
attractive alternative to other forms of conservative surgery for penile
carcinoma [23]. This procedure involves excision of the tumor and glans
between 2 incision lines leaving the urethra intact. The residual glans and
urethral meatus is sutured down to the distal corpora and the penile skin is
advanced to be sutured to the distal glans at the level of spatulated urethra.
A urethral catheter is left indwelling for 24 hours. No skin or any other
source of grafting is required and the patient is discharged the next day.
Apparently, patients maintain their voiding characteristics unchanged (e.g., no
spraying) and avoid graft-related complications (e.g., donor-site morbidity,
graft failure, and infection). However, this technique should be avoided in
patients with penile tumors very close to (less than 5 mm) or invading the
urethral meatus. Other forms of glansectomy without glans reconstruction have
also been described [22, 33]. These usually create a new urethral stoma and
attach the residual urethra to the foreskin with acceptable cosmetic and
functional outcomes. However, some authors have reported that these procedures
only partially resolve aesthetic and psychological problems associated with
surgery. Also, they do not resolve the question of penile sensation, and
consequently ejaculation and orgasm, as well as penile length and appearance.
To overcome these pitfalls, they suggested a technique of glans reconstruction
using the distal urethra [27].
More recently, an alternative
approach to organ-sparing surgery for penile carcinoma based on a penile
disassembly technique has been utilized by Djordjevic et al. with good results
[28]. Penile disassembly was first described by Perovic in the early 1990s as a
surgical technique to treat most congenital and acquired penile deformities in
paediatric and adult male populations, such as hypospadias, extrophy-epispadias
complex, penile curvature, and Peyronie's disease. This technique has been
employed in low-grade and low-stage tumors, mostly T1G1-2
lesions. The procedure begins with urethral mobilization together with Bucks
fascia (Figure 2). Dorsally, the neurovascular bundle is dissected off by blunt
and sharp manoeuvres. Glans with urethra ventrally and neurovascular bundle
dorsally are completely separated from the corpora cavernosa. The neurovascular
bundle is divided 2 cm proximal to the glans cap. The glans is removed after
division of the urethra. Biopsies of the surgical margins are performed
routinely to confirm oncological clearance. The urethra is spatulated 4 cm in
length and sutured to the corpora cavernosa. The spatulated urethra is used for
neoglans construction. The corpora cavernosa are fixed to the skin proximally
using U-shaped sutures to avoid penile retraction. Reconstruction of the penile
skin is performed as in circumcision. The authors believe that penile
disassembly represents a radical but very useful approach to organ-preserving surgery
in penile carcinoma with excellent cosmetic, functional, and oncological
outcomes.
Some authors have long reported on a
surgical strategy for refashioning of phallus stumps to make them longer and
more natural in appearance. Where this was not feasible, a neophallus was
performed. Perineal urethrostomy was avoided completely [29, 33]. This was even
considered to reflect a failure of surgical skill [29].
Total glansectomy for penile tumors
was first described by Austoni in 1996 [34]. Since that time, enormous efforts
have been made in the development of more refined and appealing surgical
alternatives to improve both function and cosmesis, as well as local
oncological control. Early results have been encouraging but more reproducible
studies and longer followup are still required to consider organ preservation as
the gold standard treatment of penile carcinoma. Until then, it should be used
with caution.Outer preputial full-thickness skin flap as described by Ubrig et al. (2001) to
cover surgical glans defects.
(a)
Superficial glans carcinoma(b)
outer preputial flap outlined(c)
glans lesion has been excised and circumcision performed(d)
surgical glans defect covered by preputial flapPenile disassembly for the conservative treatment of penile carcinoma.
(a)
Glans tumor(b)
Total disassembly of the penis(c)
Glans is completely dissected from the corpora cavernosa(d)
Glans removal and urethral spatulation for glans
reconstruction(e)
Glans has been reconstructed and urethra sutured to the corporal
tips(f)
Appearance at the end of the surgery(g)
Appearance at 6 months after surgery


## 3.1. Mohs Micrographic Surgery

Mohs micrographic surgery (MMS)
refers to a surgical technique of excising accessible tumors under microscopic
control [15]. The tumor is excised in layers and the undersurface of each
layer is examined microscopically by systematic frozen sections in multiple sessions.
This excision is continued until the undersurface of the excised tissue is
negative, at which point another section of tissue is removed to ensure a clear
resection margin. This sequential microscopic guidance offers increased
precision and control of the negative surgical margin, while maximizing safe
organ preservation. MMS is most commonly used for skin tumors but the
accessibility of penile carcinomas (most commonly on the glans) makes it a
suitable candidate for such a procedure. In Mohs' 50-year experience with 35
cases, the success rate was stage-dependent. A percentage of 86% of stage T1
and 82% of stage T2 cases were tumor-free compared to none of stage T3 at a
followup of 5 years.This technique is attractive because
it allows reassurance of local complete excision and preservation of local
penile anatomy and function. However, because local failure rate is apparently
higher (32%) than amputation, it should be reserved to patients with penile
carcinoma in situ or with small, distal, superficially invasive tumors.
Further reports with this technique are necessary to allow comparison and
reproducibility of outcomes in order to encourage its more widespread use.
Complications may include meatal stenosis and glans disfigurement.


## 3.2. Laser Ablation or Excision

Penile laser surgery has been used
since the 1980s. The four types of lasers used are carbon dioxide, argon,
neodymium yttrium aluminium garnet (Nd:YAG), and potassium titanyl phosphate
(KTP) lasers, the CO2 and Nd:YAG modes being the most commonly used in current
practice [16, 17].
CO2 laser has a very low penetration power (only 0.1 mm) and
is, therefore, unsuitable for most tumors, resulting in recurrence rates of up
to 50% [18]. Nd:YAG has a much higher penetration power of about 6 mm due to
its rather short wavelength (λ=1.06μm, i.e., 10 times less than
CO2), resulting in protein denaturation at such depth. Overall recurrence rates
after laser ablation are also stage-dependent, averaging 7.7% for Tis tumors,
and as high as 25% for T1 lesions [16]. Other authors have reported good
outcomes after Nd:YAG laser for T1 tumors with excellent cosmetic and
functional results and high satisfaction rates. Recurrences were noted in 6.9%
of the patients, which is comparable to recurrence rates after partial
amputation (0–8%) [19].The available data to date
demonstrate that laser surgery is feasible and may achieve results comparable
to those of traditional amputative surgery, particularly in highly selected
patients and in conjunction with frozen-section biopsies. Additionally, it has
significant anatomical, cosmetic, and functional advantages over traditional
amputation. However, as the local recurrence is higher, a close surveillance is
mandatory for early detection. Therefore, patient selection is extremely
important. Because in laser surgery the depth of tumor invasion is crucial,
only those invading less than 6 mm into tissues are suitable for this treatment
modality.


## 3.3. Conservative Surgery

Circumcision
It is the most simple and common surgical procedure in the management of penile
carcinoma. The majority of men with penile carcinoma are uncircumcised. It is
indicated for symptomatic treatment of painful or haemorrhagic tumors as well
as for acquired phimosis secondary to preputial tumors. It is always
recommended before radiotherapy as it allows better targeting and definition of
the tumor, simultaneously preventing preputial radiotherapy-related adverse
reactions, and, above all, it improves local oncological surveillance.
Noteworthy, circumcision alone is a sufficient primary curative treatment for
small low-stage (Tis, Ta, T1) and low-grade (grades 1 and 2) disease limited to
the distal prepuce [20]. If the tumor is more proximal and close to the
coronal sulcus, the circumcision margin will need to be extended proximally to
the penile shaft to ensure adequate oncological resection, as recurrence rates
may be as high as 50% [21]. Therefore, case selection is critical to reduce
local recurrence rates.Glansectomy
It can be done either partial or total, has recently been introduced for the
local excision of distal tumors on the glans and prepuce [8, 12, 22, 23].
Frozen sections from the cavernosal bed and urethral stump should be carried
out during the procedure to ensure negative surgical margins followed by an
end-shaft urethrostomy. Glansectomy is usually combined with grafting
procedures to create a neoglans. Basically, there are 2 forms of glansectomy: (i)
partial glansectomy, which removes the portion of the glans affected by the tumor,
leaving behind remaining glanular epithelium with malignant potential, and (ii)
total glansectomy, which removes all the glans tissue, thus preventing ‘de
novo' tumor growth.
Traditionally, amputative surgery
has been based on the assumption that a 2 cm resection margin is required to
achieve local oncological clearance [24]. However, the scientific value of a
2 cm margin has not been supported uniformly and several authors have recently
questioned it [13, 14, 25], concluding in their studies that a 2 cm surgical
margin was not only unnecessary but also overtreatment in many cases. About 80%
of the penile carcinomas arise distally, which render them potential candidates
for penile-preserving surgery. This type of surgery includes an extirpative
component leaving in some cases a simple defect amenable to primary closure. If
the defect is larger and primary closure is not possible or safe, various
techniques have been suggested to cover or reconstruct the area [8, 12, 22, 23, 26–33]. Ubrig described a simple technique in 2001 in which an outer preputial
skin flap was used to cover the glans defect if primary closure was impossible.
However, the tumor should not be too deep (Figure 1). Pietrzak et al. have
suggested the use of a full-thickness flap of penile skin or extragenital
(lateral aspect of the thigh) split-thickness skin graft to reconstruct the
glans associated with partial or total glans removal. In cases of invasion of
tunica albuginea by distal tumors, distal corporectomy was included [8]. In glans-preserving
procedures, partial glansectomy with primary glans closure was essentially an
excisional biopsy of a small distal tumor. Larger lesions necessitated partial
glansectomy followed by glans reconstruction which was performed with the use
of split-thickness or full-thickness grafting. In glans-removing procedures,
total glansectomy was performed followed by either split-thickness skin graft
reconstruction or reconstruction of cavernosal tips and grafting, if a distal
corporectomy was required. In some cases, a penile-lengthening procedure was
added to the reconstruction to maintain as much cavernosal tissue as possible.
In all forms of penile-preserving surgery, a frozen biopsy of the surgical bed
is mandatory to confirm tumor clearance (negative margins). A subtotal glans
excision without grafting has been described as a simple and cosmetically
attractive alternative to other forms of conservative surgery for penile
carcinoma [23]. This procedure involves excision of the tumor and glans
between 2 incision lines leaving the urethra intact. The residual glans and
urethral meatus is sutured down to the distal corpora and the penile skin is
advanced to be sutured to the distal glans at the level of spatulated urethra.
A urethral catheter is left indwelling for 24 hours. No skin or any other
source of grafting is required and the patient is discharged the next day.
Apparently, patients maintain their voiding characteristics unchanged (e.g., no
spraying) and avoid graft-related complications (e.g., donor-site morbidity,
graft failure, and infection). However, this technique should be avoided in
patients with penile tumors very close to (less than 5 mm) or invading the
urethral meatus. Other forms of glansectomy without glans reconstruction have
also been described [22, 33]. These usually create a new urethral stoma and
attach the residual urethra to the foreskin with acceptable cosmetic and
functional outcomes. However, some authors have reported that these procedures
only partially resolve aesthetic and psychological problems associated with
surgery. Also, they do not resolve the question of penile sensation, and
consequently ejaculation and orgasm, as well as penile length and appearance.
To overcome these pitfalls, they suggested a technique of glans reconstruction
using the distal urethra [27].
More recently, an alternative
approach to organ-sparing surgery for penile carcinoma based on a penile
disassembly technique has been utilized by Djordjevic et al. with good results
[28]. Penile disassembly was first described by Perovic in the early 1990s as a
surgical technique to treat most congenital and acquired penile deformities in
paediatric and adult male populations, such as hypospadias, extrophy-epispadias
complex, penile curvature, and Peyronie's disease. This technique has been
employed in low-grade and low-stage tumors, mostly T1G1-2
lesions. The procedure begins with urethral mobilization together with Bucks
fascia (Figure 2). Dorsally, the neurovascular bundle is dissected off by blunt
and sharp manoeuvres. Glans with urethra ventrally and neurovascular bundle
dorsally are completely separated from the corpora cavernosa. The neurovascular
bundle is divided 2 cm proximal to the glans cap. The glans is removed after
division of the urethra. Biopsies of the surgical margins are performed
routinely to confirm oncological clearance. The urethra is spatulated 4 cm in
length and sutured to the corpora cavernosa. The spatulated urethra is used for
neoglans construction. The corpora cavernosa are fixed to the skin proximally
using U-shaped sutures to avoid penile retraction. Reconstruction of the penile
skin is performed as in circumcision. The authors believe that penile
disassembly represents a radical but very useful approach to organ-preserving surgery
in penile carcinoma with excellent cosmetic, functional, and oncological
outcomes.
Some authors have long reported on a
surgical strategy for refashioning of phallus stumps to make them longer and
more natural in appearance. Where this was not feasible, a neophallus was
performed. Perineal urethrostomy was avoided completely [29, 33]. This was even
considered to reflect a failure of surgical skill [29].
Total glansectomy for penile tumors
was first described by Austoni in 1996 [34]. Since that time, enormous efforts
have been made in the development of more refined and appealing surgical
alternatives to improve both function and cosmesis, as well as local
oncological control. Early results have been encouraging but more reproducible
studies and longer followup are still required to consider organ preservation as
the gold standard treatment of penile carcinoma. Until then, it should be used
with caution.Outer preputial full-thickness skin flap as described by Ubrig et al. (2001) to
cover surgical glans defects.
(a)
Superficial glans carcinoma(b)
outer preputial flap outlined(c)
glans lesion has been excised and circumcision performed(d)
surgical glans defect covered by preputial flapPenile disassembly for the conservative treatment of penile carcinoma.
(a)
Glans tumor(b)
Total disassembly of the penis(c)
Glans is completely dissected from the corpora cavernosa(d)
Glans removal and urethral spatulation for glans
reconstruction(e)
Glans has been reconstructed and urethra sutured to the corporal
tips(f)
Appearance at the end of the surgery(g)
Appearance at 6 months after surgery


## 4. Conclusion

Historically, amputative surgery and
radical radiotherapy were the only options to treat penile carcinoma. Over the
last two decades, several innovative techniques have been described and
proposed for organ-preserving surgery in penile carcinoma. These should avoid
complications and maximize both cosmetic and functional outcomes,
simultaneously not compromising local oncological long-term control. At
present, definitive management of penile carcinoma remains stage-dependent.
Penile amputation has been challenged by more recent conservative surgical
techniques and should perhaps be considered overtreatment in low-stage disease.
Glansectomy appears to offer good local control rates. Glans reconstruction
with or without grafting procedures have offered excellent cosmetic results
where applicable. However, until further studies are available and sufficient
evidence reproducible in common day practice, and until the surgical margin
issue is safely addressed in prospective studies, penile amputation (partial or
total) with all its attendant anatomical, psychosocial, and sexual disabilities
should still be regarded as the gold standard treatment for all stages of
penile carcinoma, even for Tis, Ta and T1 tumors.



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*Source: 634216-2008-11-04.xml*