Surgical Excision

Patients developing an extensive field change or recurrent disease are best managed by surgical excision. Repeated topical therapy can result in unsightly scarring and a denuded glans that can make clinical monitoring difficult. Intractable in situ disease or non-invasive verrucous disease can be effectively treated by excising the diseased area with an adequate margin combined with split thickness skin grafting, or by underlying corpus spongiosum in quadrants

Fig. 5.12 Glans resurfacing procedure showing the glans epithelium and subepithelium sharply dissected off the

Fig. 5.12 Glans resurfacing procedure showing the glans epithelium and subepithelium sharply dissected off the

Penile Cancer Images

total glans resurfacing. This technique was first described by Bracka for the management of severe BXO, but has been adapted for Tis/Ta disease.40

5.6.3.1 Technique of Glans Resurfacing

This procedure is performed under a general or regional anesthetic with preopera-tive antibiotic cover and with the use of a tourniquet at the base of the penis. The glans and distal penis is sometimes soaked in 5% acetic acid to help highlight any dysplastic or warty changes

• The glans epithelium is marked in quadrants from the meatus to the coronal sulcus. A perimeatal and circumcoronal incision is performed, and the glans epithelium and subepithelial tissue is then completely removed off the underlying spongiosum, starting from the meatus to the coronal sulcus for each quadrant (Fig. 5.12).75

• Deep biopsies from the corpus spongiosum are taken from each quadrant for separate frozen section analysis to ensure that there is no invasive element to the lesion. Care is taken when dissecting over the coronal sulcus as the epithelium is particularly adherent at this point due to the condensation of penile fascia. A split thickness skin graft is harvested from the thigh (Fig. 5.13) using a dermatome and is placed over the denuded glans (Fig. 5.14). Graft thickness can range from 0.008 to 0.016 inch. The graft is sutured and quilted using multiple 5-0 or 6-0 interrupted absorbable sutures (Figs. 5.15-5.17).

• The patient is catheterized (14F silicone catheter) either urethrally or a suprapu-bic catheter can be inserted and the glans penis is dressed with a soft silicone-coated dressing (e.g. Mepitel®) and a gauze dressing followed by a foam dressing in order to help immobilize the graft. The dressing is left in place for 5 days with the patient remaining on strict bed rest for the first 48 h. On the 5th day the dressing and catheter are removed, and the patient is discharged with wound care advice for review in clinic the following week.

Fig. 5.13 A split thickness skin graft is harvested from the thigh using an air or electric dermatome. The exposed corpus spongiosum is then covered with the split thickness skin graft

Fig. 5.13 A split thickness skin graft is harvested from the thigh using an air or electric dermatome. The exposed corpus spongiosum is then covered with the split thickness skin graft

Fig. 5.14 Appearance following dissection of the glans epithelium and subepithelium

Penis Split From Catheter

Fig. 5.14 Appearance following dissection of the glans epithelium and subepithelium

Penile Cancer Images
Fig. 5.16 The graft is sutured to the subcoronal skin and also quilted to the glans penis. Some surgeons do not quilt the graft but ensure that the dressings applied immobilize the graft
Glans Split After

Fig. 5.17 Post operative appearance of the glans after 6 months

This approach allows preservation of maximal penile length, form, and function and combines a good cosmetic appearance with good oncological control. Graft take is excellent, and the cosmetic appearance 6 weeks after surgery is excellent. In a report of ten patients treated with total glans resurfacing for recurrent, refractory, or extensive disease, no patient had evidence of disease recurrence after a mean follow-up of 30 months,76 and over 80% were sexually active within 3 months of surgery.

Weeks After Mohs Surgery

5.6.3.2 Moh's Micrographic Surgery

An alternative surgical approach is excision using Mohs' micrographic surgery, which involves removing the entire lesion in thin sections, with concurrent histo-logical examination to ensure clear margins microscopically.77 This technique allows maximal preservation of normal penile tissue, but is difficult and time consuming, requiring both a surgeon and pathologist trained in the technique to ensure adequate oncological clearance. A recent review of outcome from this technique

Table 5.1 Treatment options available for premalignant lesions of the penis

Penile lesion

Treatment options

Giant condylomata acuminata

Penile horn

Leukoplakia

Pseudoepitheliomatous, keratotic, and

Erythroplasia of Queyrat and Bowen's disease

Bowenoid papulosis micaceous balanitis

Topical - 5-FU, Imiquimod

Ablative - Laser, PDT, cryotherapy

Surgery - Local excision with or without grafting

Topical - 5-FU, Imiquimod

Ablative - Laser, cryotherapy

Surgery - Local excision

Large lesions - Surgical excision

Surgical excision

Circumcision combined with local excision Ablative - Laser, cryotherapy Surgery - Local excision reported a high (32%) recurrence rate,7 8 and the uptake and use of the technique worldwide has been very limited.

All premalignant lesions are suitable for treatment by surgical excision. In all cases careful histological examination of the lesion and margins is essential, and close follow-up is mandatory. A summary of the treatment options is shown in Table 5.1.

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