Penile Preserving Techniques and Reconstruction

Organ preservation for function and cosmesis has been the mantra which has recently guided the development of penile-preserving surgical techniques for conventional SCC of the penis. The management of superficial low-stage TCC of the urethra by transurethral resection (TUR) is well established. This applies to anterior as well as posterior urethral tumors. However, apart from using TUR for TCC, the role of TUR, fulguration, and local excision is more controversial for SCC.24 Table 8.6 illustrates the variation in the management of patients with urethral tumors in studies which have used penile-preserving techniques.

Smith et al. reported on 18 patients who underwent penile-preserving surgery for urethral carcinoma. The median follow-up was 21 months and no local recurrences were reported.12 The margin of resection was <5 mm in eight men which is compatible with similar reports defining the safe margins of resection for conventional SCC penis.23

Distal fossa navicularis tumors with invasion into the glans can be treated by performing a glansectomy and utilizing a split-skin graft in order to reconstruct a

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Years from diagnosis

Fig. 8.4 Observed and overall survival rates for 1,278 patients diagnosed with urethral cancer (Data from the National Cancer Data Base. Used with permission of the American Joint Committee on Cancer (AJCC). Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Handbook, Seventh Edition (2010) published by Springer Science and Business Media LLC, www.springerlink.com)

Table 8.6 Comparison of the surgical management of urethral tumors

Author

Number of cases

Surgical management

Smith 12

Mandler and Pool25 Baskin20

Bird27

Davis28

Kent29

Christopher30

18 SCC

Algorithm based on anatomical location

Neoadjuvant chemoradiation and distal urethrectomy Subcutaneous penectomy/urethrectomy Urethrectomy alone TUR + chemotherapy Urethrectomy, nerve-sparing radical prostatectomy and Mitrofanoff diversion + adjuvant chemoradiation neoglans (Chap 6). Depending on the distal urethral involvement, this can be combined with an anterior urethrectomy with the proximal urethra brought out as a hypospadiac opening. Excision of the adjacent ventral tunica albuginea with reconstruction using autologous or synthetic graft material in order to ensure tumor-free margins can be carried out at the time of the anterior urethrectomy (Fig. 8.5).

An algorithmic approach for the management of distal lesions has been proposed (Fig. 8.6).12 Again, there is an emphasis on achieving satisfactory cosmetic outcomes without compromising oncologic control. Surgical margins of 5 mm from the visible

Fig. 8.5 Distal urethrectomy has been performed together with excision of a segment of the adjacent tunica albuginea. The resulting defect is closed using a Pelvicol® graft

Fig. 8.5 Distal urethrectomy has been performed together with excision of a segment of the adjacent tunica albuginea. The resulting defect is closed using a Pelvicol® graft

Management of anterior urethral cancer

Lesion just visible at urethral meatus

Proven superficial T1 tumour

Tumour extends into distal corpora cavernosa

Lesion just visible at urethral meatus

Formation of hypospadias, biospy +/-topical 5-fluoruracil cream

Proven superficial T1 tumour

Two stage distal urethroplasty with buccal mucosa graft

Tumour extends into glans spongiosus but not corpora cavemosa

Glansectomy with hypospadias and partial-thickness skin graft reconstruction

Tumour extends into distal corpora cavernosa

Glansectomy and distal corporectomy with partial thickness graft and penile lengthening

Anterior urethrectomy, excision of adjacent tunica, corporeal reconstruction and perineal urethrostomy

Fig. 8.6 Management of male anterior urethral cancers (Reprinted from Smith et al.12)

edge of the tumor were used. Of the 18 patients treated using this approach, no patient experienced a local recurrence, 14 had no evidence of disease at 26 months follow-up and two of the six patients with positive nodal disease succumbed to meta-static complications. The published outcomes following surgical treatment for patients diagnosed with urethral cancer are shown in Table 8.7.

Table 8.7

Results following surgery for male urethral cancer

Number of

Mean follow-up

Overall

Disease-free

Local

Author

patients

(months)

survival (%)

survival (%)

control(%)

Eng9

10

189

70

70

100

Dalbagni7

10

125

83

Gheiler6

9

42

89

Farrer21

2

102

100

100

100

Dinney5

6

55

83

83

83

Smith12

18

21

88

67

100

Adapted from Koontz and Lee31 with permission from Elsevier

Adapted from Koontz and Lee31 with permission from Elsevier

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