Patient Preparation

The procedure is performed with the patient supine. If inguinal lymphadenectomy is to be performed at the same time, the patient is draped with the inguinal regions exposed. Antibiotics are administered preoperatively and continued postoperatively as these lesions are often associated with concomitant infection.

Figure 7.2 shows a penile SCC in a 65 year-old man. In order to prevent tumor spillage into the operative field the tumor is covered with either a condom, gauze swab, or a surgical glove. The resection limit is marked with a pen ensuring that an adequate tumor-free margin is maintained (Fig. 7.3).

Fig. 7.2 Penile tumor involving the glans penis and distal corpus cavernosum

Fig. 7.2 Penile tumor involving the glans penis and distal corpus cavernosum

The common surgical techniques use a circumcoronal incision of the penile shaft skin with partial degloving of the penis. This is useful if a neoglans is to be reconstructed using a split skin graft. Alternatively, if a graft is not going to be used for reconstruction, the penile skin is brought forward and used to cover the corporal tips. Once the skin and superficial fascial layers are dissected, Bucks fascia is identified (Fig. 7.4). This distinct tough shiny layer is then marked at the area where the corpus cavernosum is going to be transected. The neurovascular bundle is mobilized, ligated, and divided prior to transection of the penis (Fig. 7.5). A tourniquet placed at the penile base will minimize the bleeding prior to transection of the corpus cav-ernosum. In cases where penile lengthening is required, the suspensory ligament can also be divided (Fig. 7.6). Once transected, the corpora are mobilized off the non-involved urethra and the urethra is then divided ensuring that it is approximately 1.5-2 cm longer than the corporal margins in order to enable adequate spatulation of

Fig. 7.4 The skin and penile fascia are dissected to the level of Buck's fascia

Fig. 7.4 The skin and penile fascia are dissected to the level of Buck's fascia

Fig. 7.5 The neurovascular bundle is ligated and the penis transected leaving the urethra protruding by 1.5 cm. Further biopsies of the proximal margin can be taken in order to ensure that the margins are clear of tumor

Fig. 7.5 The neurovascular bundle is ligated and the penis transected leaving the urethra protruding by 1.5 cm. Further biopsies of the proximal margin can be taken in order to ensure that the margins are clear of tumor

the urethra. Further biopsies from the proximal corporal margin and urethra are sent for frozen-section analysis in order to ensure that the margins are clear of tumor.

The corpora are oversewn with 2/0 absorbable sutures and the tourniquet can then be released (Figs. 7.7 and 7.8). The urethra is spatulated dorsally and sutured to the corporal margin (Figs. 7.9 and 7.10).

The alternative options available in order to construct a neoglans are:

1. Suture the skin longitudinally and then circumferentially to the urethra.

2. Suture the skin just proximal to the corporal margin and construct a neoglans using a split thickness skin graft.9

3. Button hole the skin flap and bring the urethra through the button hole followed by primary closure of the skin.

A 14Ch or 16Ch Foley catheter is left in situ and removed after 1 week. If a split skin graft is used, we prefer to harvest the graft from the anterior or anteromedial thigh with a graft thickness between 0.012 and 0.016 in. harvested using an air or

Fig. 7.6 Division of the suspensory ligament allows penile mobilization in order to gain additional length

Fig. 7.6 Division of the suspensory ligament allows penile mobilization in order to gain additional length

Fig. 7.7 The corpus cavernosum is oversewn

Fig. 7.9 The penile shaft skin is drawn forward and sutured to the urethra
Fig. 7.10 Final appearance of the penis

electric dermatome. This is sutured to the neoglans using a combination of 4/0 and 5/0 absorbable sutures. The dressings are applied in order to immobilize the graft and then subsequently removed on day 5.

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