Total Glansectomy and Split Skin Grafting

This technique involves the isolation and excision of tumors located on the glans penis (Fig. 6.2).

A circumferential incision is made in the distal shaft skin down to Buck's fascia (Fig. 6.3).

At this level a plane is developed distally to separate the glans from the underlying corporal heads. The urethra is transected and frozen-section analysis of the tunica albuginea and distal urethral margin is performed in order to ensure complete excision44 (Figs. 6.4 and 6.5).

The urethra is mobilized to allow formation of an urethrostomy at the tip of the penis. The shaft skin is sutured 2 cm from the tip leaving the corporal heads exposed. A split thickness skin graft is quilted to the exposed corpora to create a neoglans. A urethral catheter is placed and the patient remains on strict bed rest for 4 days35 (Fig. 6.6).

A novel dressing technique that allows immediate postoperative mobilization has recently been described by Malone. Rather than 'quilting' the skin graft to the

Fig. 6.2 Penile tumor located on the glans and involving the inner prepuce which can be excised by performing a glansectomy

Fig. 6.2 Penile tumor located on the glans and involving the inner prepuce which can be excised by performing a glansectomy

Fig. 6.3 Circumferential incision of the penile skin and penile fascia has been extended down to the level of Buck's fascia

Fig. 6.4 A plane can be developed between the glans and the corporal tips which allows the glans and the tumor to be dissected off

neoglans, a proflavine soaked gauze tie over dressing is sutured to the newly formed meatus distally and corona proximally, using interrupted 4-0 monofilament sutures. Twenty-four of twenty-nine patients were discharged from hospital 1 or 2 days postoperatively with a urethral catheter in situ. The patients had their catheters and dressings removed 10 days after surgery. Graft take and cosmetic outcomes were reported as excellent.45

One study has reviewed three cases of penile verrucous carcinoma, angiosarcoma, and melanoma limited to the glans.46 All patients underwent glansectomy with clear resection margins. No local recurrences were reported at 12-48 months. Erections, sexual and urinary function had normalized shortly after the operation in all cases. Hatzichristou and colleagues reported seven cases of verrucous carcinoma treated with glansectomy.47 In this series, one patient required further surgery at 3 months for a local recurrence but all patients were alive and tumor free at 18-65 months.

Table 6.3 Local recurrence following penile-preserving surgery

Local

Salvage

Mean

Patients

recurrence no

surgery

follow up

Author

Procedure

no

(%)

procedures

(months)

Bissada et al.49

Local excision

S0

S (10)

3 PPS

67.S

Shindel et al.40

Mohs procedure

SS

8/25 (S2)

7MP/1PP

-

Brown et al.50

P/T glansectomy no grafting

5

0

-

12

Pietrzak et al.S5

P/T glansectomy + grafting

S9

1 (2.5)

1 PPS

16

Smith et al.51

P/T glansectomy + resurfacing

72

S (4)

3 PPS

27

MP Mohs procedure, PP partial penectomy, PPS penile-preserving surgery, P/T partial/total

MP Mohs procedure, PP partial penectomy, PPS penile-preserving surgery, P/T partial/total

Pietrzak and coworkers documented one local recurrence in a patient who had undergone partial glansectomy and reconstruction, but all 39 patients who underwent total glansectomy and skin graft reconstruction were disease free at 2 years.35 In the largest series reported, the same group presented their medium-term outcome data. Of 72 patients (65 new tumors, 7 recurrent tumors post radiotherapy; 49% T1, 51% T2) undergoing glansectomy and reconstruction, there were three late recurrences (6%) with a mean follow-up of 27 months (range 4-68). Excellent functional and cosmetic results were described and there was no disease-specific mortality among those with local recurrence48 (Table 6.3).

In an attempt to avoid the morbidity associated with skin grafts, novel techniques of glans excision and primary closure with shaft skin advancement and eversion of the urethral mucosa have been described. Brown and colleagues described subtotal glans excision without grafting. In this study of five patients with tumor stages T1G2 (2 men), T1G3 (2 men), and T2G2, all in the absence of CIS, they were able to preserve the urethral meatus while excising the glans penis (clearance margins >5 mm on frozen sections). The urethral meatus was sutured down to the distal corpora and the penile skin advanced and approximated to it. At a mean follow-up of a year they reported no disease recurrence. The key advantage over total glansectomy was felt to be a reduction in spraying during micturition due to the preserved urethra.50 A disadvantage, however, is that this technique is inappropriate for patients with urethral invasion.

Another novel modification described by Gulino and coworkers involves mobilization of the whole urethra off the corpora, and then opening the ventral aspect of the urethra longitudinally for approximately 3 cm. This is fashioned to cover the corporal heads, thus avoiding the need for a skin graft.52 However, the final cosmetic result is inferior compared to using a split skin graft.

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