Total or Radical Penectomy 751 Preoperative Staging

Radical penectomy is reserved for cases where extensive tumor involvement of the penile shaft necessitates complete excision of the penis and crura. Again preopera-tive MRI is useful in order to demonstrate the proximal extension of the tumor as there may be skip lesions extending proximally. Figure 7.11 shows an extensive tumor which has been imaged using MRI confirming that the tumor involves the pendulous penile shaft as well as multiple skip lesions more proximally. Therefore adequate tumor...

Penile Cancer Prognostic Index

In 2009 Chaux et al. proposed a new integrated pathological tool to predict lymph node involvement and survival in patients with penile SCC. This system included Tumor thickness Growth pattern Grade Lymphatic and or Vascular embolization Corpora cavernosa infiltration absent Corpus spongiosum infiltration Urethra infiltration Clinical lymph node stage 50 100 150 200 250 300 350 400 450 500 0.9 0.85 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.05 0.01 Fig. 10.6 Kattan Nomogram predicting 5-year...

Effects of Treatment for Penile Cancer on Quality of Life

Data regarding quality of life following surgery for penile cancer has been reviewed.17 The authors in this review identified 128 men from 6 separate studies in whom quality-of-life data had been collected, of which 5 were retrospective studies. Control groups were rarely assessed. They found that any conclusions from the data were limited by the many and varied instruments used to assess quality of life, by the methodology used to collect the data, and the small numbers of patients studied and...

Surgical Procedures to Gain Additional Penile Length

A number of techniques can be utilized in order to gain additional penile length. 1. The penis can be completely degloved and this allows division of the suspensory ligament. Reattachment to the inferior pubic bone with 2 0 ethibond sutures ensures that the penis does not retract back (Fig. 7.6). 2. Where there is a prominent peno-scrotal web, a scrotoplasty can be performed which again allows the patient to hold on to the penile shaft and direct voiding while standing.10 3. In patients with a...

Malignant Melanoma and Nonepithelial Tumors 351 Malignant Melanoma

Primary malignant melanoma of the penis is a rare disease accounting for less than 1 of all penile cancers.23,96 Preferential location is in the glans (60-80 of all cases), followed by the penile shaft and foreskin.97 Melanomas of the distal penile urethra are even rarer but have been reported and tend to affect the fossa navicularis and infrequently the pendulous urethra or meatus urethralis.23,98,99 Grossly, they present as small, brown or black, often ulcerating, lesions and the clinical...

Nanotechnology and Cancer Treatment

Nanotechnology allows the opportunity to deliver powerful cytotoxic agents to specific cancer cells without deleterious effects to other organ systems. However, lack of progress in avoiding degradation in vivo before achievement of therapeutic benefit has impeded major advances to date. Nonetheless, some examples exemplify the exception to this. Liposomal delivery systems have now overcome take-up by the reticuloendothelial system, which has historically compromised effectiveness.23...

References

Leijte JA, Gallee M, Antonini N, Horenblas S. Evaluation of current TNM classification of penile cancer. J Urol. 2008 180 933-938. 2. Hegarty PK, Kayes O, Freeman A, Christopher AN, Ralph DJ, Minhas M. A prospective study of 100 cases of penile cancer managed according to EAU guidelines. BJU Int. 2006 98 526-531. 3. Svatek RS, Munsell M, Kincaid JM, et al. Association between lymph node density and disease specific survival in patients with penile cancer. J Urol. 2009 182 2721-2727. 4. Edge SB,...

Artificial Erection Technique

We routinely use intracavernosal prostaglandin E1 (alprostadil) at a dose of 10 mg when scanning tumors with both ultrasound and MRI. This stretches the tunica albuginea, making defects or invasion easier to see, and it increases contrast between intermediate signal tumor and high signal corpus spongiosum or caverno-sum. For patients with erectile dysfunction, the dose may be increased to 20 mg (especially if it has been used before), and in young patients with normal erections it can be...

Characteristics of HPVRelated Precursor Lesions

Healthy Penile Frenulum

Characteristics of HPV-related precursor lesions are presented in Fig. 1.1. Genital Bowen's disease, erythroplasia of Queyrat (EQ), and Bowenoid papulosis (BP) are clinical presentations of high-grade PIN. Bowen's disease and EQ are usually found in elderly men, being present on the follicle bearing skin and the mucosa of the penis (i.e., glans or prepuce), respectively. Bowen's disease presents as a single, scaly plaque, located on keratinized genital skin. EQ usually presents as one or more...

Penile Cancer and Its Precursor Lesions 141 Penile Cancer and Adjacent Lesions

Penile cancers are thought to arise from the progression of precursor lesions and can be subdivided into HPV-positive and HPV-negative cases. The HPV prevalence differs significantly by histological subtype. Similar to vulvar and head and neck carcinomas, squamous cell carcinoma of the basaloid and warty type display the strongest association with hrHPV (ranging from 66 to 100 ) and their etiological relationship with hrHPV infection is most plausible.4 19,32,33 The remaining penile squamous...

Vascular Invasion

Several reports have established the value of vascular (either lymphatic or venous) invasion as a prognostic factor for penile cancer metastasis.133 135138 155 Lymphatic invasion is observed more frequently (Fig. 3.20b) although venous invasion can Table 3.3 2009 TNM classification of penile cancer T - primary tumor TX T0 Tis Ta NX Regional lymph nodes cannot be accessed N0 No palpable or visibly enlarged inguinal lymph node N1 Palpable mobile unilateral inguinal lymph node N2 Palpable mobile...

Malignant Epithelial Tumors with Clear Cell Features 3461 Clear Cell Carcinoma

Clear cell carcinomas of the penis are rare tumors of probably sweat gland origin characterized by the presence of neoplastic cells with intracytoplasmic prominent PAS-positive material.19 Tumors preferentially affect the foreskin inner mucosa and are consistently HPV positive, mainly genotype 16. Clear cell carcinomas are composed of solid proliferations of clear cells, sometimes with geographical areas of necrosis. Histology is of a high-grade tumor with evident nuclear atypias. Extensive...

Minimally Invasive Staging Techniques

To circumvent the above-mentioned dilemmas regarding lymphadenectomy, minimally invasive staging techniques have been developed. The basis of these techniques is to limit the morbidity in patients with pathological node-negative (pN0) groins, and to identify occult metastases at the earliest opportunity. Only patients with proven lymphatic spread undergo a completion therapeutic radical lymphadenectomy. In the last two decades, two approaches have been introduced worldwide modified inguinal...

Chemoradiotherapy

In locoregionally advanced disease (large inoperable primary tumor, N2 N3 or extra nodal extension), survival rates are poor despite extensive surgical treatment so new treatment strategies are required. As described in the previous sections surgery, radiotherapy and chemotherapy are all effective modalities in the treatment of penile cancers. Therefore, a multimodality approach with combinations of these modalities seems a logical step. Radiotherapy (RT) in combination with concurrent...

Psychological Effects in Men Who Have Undergone Treatment for Penile Cancer

The psychological effects of penile cancer surgery have been poorly researched, although it is relatively easy to speculate on the relevant issues. Mental illness has been observed in 20 of men who have undergone treatment for penile cancer, most commonly related to anxiety disorders. 1 3 The central theme relates to the patient's perception that masculinity has somehow been lost or diminished.4 There will be a notable change in the appearance of the penis, and a probable loss of length for...

Ultrasound and MR Appearance of Lymph Nodes

Liquefaction Lymph Node Ultrasound

Normal lymph nodes are usually ovoid in shape, with a fatty hilum and an organized vascular pattern radiating from the hilum57 (Fig. 4.14). Some features, such as focal areas of necrosis, are highly specific for malignancy, and in general malignant nodes tend toward roundness and may lose their fatty hilum58 (Fig. 4.15). One recent study of the use of ultrasound in 44 patients, the majority of whom had penile cancer, showed that in 42 44 patients with metastasis at least one of the following...

Sexual Experiences Following Treatment for Penile Cancer

Once surgery has taken place, the fears that initially dominated, namely the fears for recurrence and survival are gradually replaced by concerns regarding rehabilitation, particularly regarding urinary and sexual function. A number of studies have investigated sexual function following surgery for penile cancer, but the literature regarding voiding function is extremely limited. Studies investigating patients who have undergone a partial or total penectomy for penile cancer have been limited...

Genital Lichen Sclerosus Et Atrophicus LS

Lichen Sclerosus Years Old

Balanitis Xerotica Obliterans (BXO) is now better defined as the male genital variant of lichen sclerosus et atrophicus (LS). It was initially described as a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and in advanced cases, the anterior urethra and meatus, either individually or in any combination. It occurs almost exclusively in uncircumcised men. Lesions classically appear as pale, atrophic plaques, which may coalesce and...

The Use of Chemotherapy and Chemoradiation

Penis Needle

Combination therapy in the form of chemotherapy and radiotherapy is utilized in an attempt to improve the long-term outcomes for patients diagnosed with urethral Fig. 8.7 Interstitial brachytherapy of the penile urethra using hypodermic needle and plastic template. The penis is kept away from the testicles using a sponge (From Gerbaulet et al.34. Reprinted with permission) Fig. 8.7 Interstitial brachytherapy of the penile urethra using hypodermic needle and plastic template. The penis is kept...

The Radial Artery Forearm Flap Phalloplasty

Penile Amputation

This is often considered the gold standard phalloplasty as it allows the formation of a cylindrical and sensate phallus with a urethra that reaches the tip and which is less prone to complications. The disadvantage is that it leaves a considerable donor site defect on the arm which some patients find unacceptable. The nondominant forearm is used in all patients having checked the vascular competency of the superficial and deep palmar arteries with an Allen test followed by a duplex ultrasound...

Abdominal Pubic Phalloplasty

Phalloplasty Complications

This technique is commonly used for phallus reconstruction in transsexuals but can be modified for use in penile cancer patients although no published data are available for this group.29 The advantages of this technique are that there is no donor site defect on the arm and that the operating time is shorter. The phallus however is relatively insensate, hairy, and prone to urethral complications.29 The phallus is fashioned from a flap of anterior abdominal wall skin, 12 cm wide and 12-14 cm...

Growth Factor Receptors and Tyrosine Kinases

Growth factor receptors mitigate their intracellular signal transduction pathway via intracellular tyrosine kinases that modulate cellular functions such as protein synthesis, cell turnover, cell adhesion and migration, among other processes. Several growth factor receptor inhibitors and tyrosine kinase inhibitors (TKIs) have been developed in the last decade. They have entered clinical use, notably in renal cell cancer where agents such as sunitinib, sorafenib, and bevacizumab are showing...

Penile Cancer Staging Modifications to the 6th Edition TNM Staging System

The TNM staging system is a widely accepted staging tool. However, deficiencies in the 6th edition of the American Joint Committee on Cancer (AJCC) were highlighted in a report of 513 cases treated over a 50-year period at a single center.1 They described no difference in survival between stages T2 and T3 and nodal stages N1 and N2. Importantly based upon their own data they recommended changes in the staging system (i.e., the existing sixth edition TNM) with more meaningful prognostic...

Giant Condyloma Accuminatum Bushke Lowenstein Tumor

Condyloma acuminata are warty, exophytic growths which can affect any part of the anogenital region and are generally considered benign. On the penis, lesions typically occur around the coronal sulcus and frenulum, but can also be found as flat lesions on the penile shaft. They can occasionally extend into the anterior urethra, but extension into the posterior urethra and bladder is usually only seen in immuno-compromised patients.22 They are due to infection with low-risk HPV types 6 and...

Determination of Malignancy in Hyperplasias and Extremely Low Grade Neoplasms

Squamous hyperplasias are very common penile lesions that often accompany diverse benign and malignant conditions, sometimes simulating neoplastic processes.35,36 Their morphological aspect is variegated and the surgical pathologist should be aware of their proteiform presentation and learn to separate them from significant neoplastic conditions. Squamous hyperplasias commonly are flat on the surface and on the interface between lesion and stroma, but other variants such as verrucous,...

Antero Lateral Thigh Flap Phalloplasty

The anterolateral thigh flap is another good option for phallic reconstruction.33 This is a musculocutaneous (perforator) rather than a fasciocutaneous based-flap and is based on the perforator vessels through vastus lateralis and rectus femoris from the descending branch of the lateral circumflex femoral artery (Chap. 7). The ALT flap is very reliable from a vascular point of view and is commonly used in reconstructive surgery. Rubino et al. described the ALT flap in order to create a...

Visceral and Bone Metastases

Advanced cancers can present with visceral metastases particularly to the lungs and liver. The overall prognosis in these patients is very poor and surgery is limited to palliative relief of urinary symptoms or ureteric obstruction due to extensive pelvic disease. Proximal extension of penile tumors can involve the inferior pubic rami due to local infiltration. If this is the solitary area of osseous involvement, an inferior pubectomy can be performed at the same time as the radical penectomy....