Penile amputation for penile cancer, whether partial, subtotal or total, is a necessary step for local control of primary tumors in cases whereby penile preserving surgery is deemed inappropriate. This often has a significant functional and psychological impact on the patient and his partner with an inevitable impact on the quality of life. Whereas the majority of patients presenting with penile cancer are elderly, sexually inactive and happy to sit down in order to void, there are others who would like to regain some normality of urinary and sexual function. These patients may be candidates for a total phallic reconstruction and a discussion of this option should be undertaken with the patient at an early stage.

Patients are often devastated at the thought of penile amputation and if some comfort can be given to them by showing them examples of the long-term surgical results, or better still to see and meet other patients who have had the operation performed, then this will give them hope for the future and make the overall management less stressful. It is also important surgically, to identify early, those patients who wish to potentially have a phallic reconstruction as the decision may influence the surgical technique of the primary amputation or inguinal lymphadenectomy in order to aid the phallic reconstruction. It is much preferred to use the patient's own healthy tissues where possible than to refashion with alternative techniques. Examples of this forward thinking approach are:

• In subtotal amputation maintain as much healthy urethra by suturing it flush to the lower abdomen rather than performing a perineal urethrostomy (Fig. 11.1).

• In total amputation leave as much proximal corpora to house the rear tips of the penile prosthesis

D.J. Ralph

Department of Urology, Institute of Urology, University College Hospital, London, UK

Fig. 11.1 Subtotal penectomy with sparing of urethra ready for phalloplasty

Fig. 11.1 Subtotal penectomy with sparing of urethra ready for phalloplasty

• During inguinal lymphadenectomy, spare the long saphenous vein so that it can be used for the venous anastomosis of a subsequent free flap

• If an abdominal phalloplasty is preferred, then it may be better to do this prior to any radical lymphadenectomy in order to preserve the blood supply to the flap.

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