Reconstructive options in penile cancer surgery Surgical possibilities according to the new EAU-ASCO Collaborative Guidelines on penile cancer
Dr. Saskia Morgenstern Dept. of Urology Agaplesion Markus
Krankenhaus Frankfurt (DE)
saskia.morgenstern@ agaplesion.de
“Besides its role in sexual functioning and urination, a fully functional penis is central to a patient’s sense of wholeness, desirability and masculinity. Hence, the aims of the treatment of the primary tumour are complete tumour removal with as much organ preservation as possible, without compromising oncological control.” This quote from the newly published EAU-ASCO (American Society of Clinical Oncology) Collaborative Guidelines on penile cancer summarises the importance of reconstructive considerations when it comes to the treatment of men suffering from this often particularly burdensome cancer. The following article provides an overview of the fascinating surgical options to preserve or restore esthetical and functional aspects in penile cancer, which can be of great importance to the affected man. For each TNM stage based on the UICC/AJCC 8th edition, intra- and postoperative pictures from our centre illustrate the current guideline recommendations for surgical treatment. Nevertheless, there might be non-surgical or non-organ-sparing options better suited for some patients, thus a detailed discussion of the various treatment options taking into consideration the various individual factors of the patient should be performed with the patient prior to any treatment. Biopsies and surgical margins Biopsies (preferably as excision biopsies, Figure 1) are indicated if the nature of the lesion is uncertain, if non-surgical treatment is intended, and for surgical staging in selected cases. Despite low evidence, the current literature justifies keeping surgical margins as minimal as >1-10 mm, especially in low grade and smaller tumours.
Fig. 2: Glans resurfacing - 1st row: dividing the glans epithelium in 4 quadrants and dissection, 2nd row: partially and fully de-epithelialized glans, and grafting with split skin graft from the thigh.
Fig. 5: Partial penectomy - 1st row: view on open cavernous bodies and urethra, surrounded by spongiosum body and (3rd image) closed cavernous bodies, 2nd row: mobilisation and centralisation of urethra and grafting with split skin graft from the thigh.
Fig. 7: Penile reconstruction by resection of lymphoedema, penile anchoring and grafting - 1st row: preoperative findings, 2nd row: 1 week post op, 3rd row: placing the anchor sutures, 4th row: shaft anchoring and grafting with split skin graft from left thigh.
Fig. 8: Full penile reconstruction from top left: harvesting and tubularising the free flap for the radial forearm phalloplasty, schematic drawing of an inflatable penile implant in the phalloplasty and a 1 week post op after the glans sculpturing procedure.
Fig. 3: Variation glans resurfacing plus penoscrotal web removal in order to avoid additional donor-side morbidity. Excess of scrotal skin can be used as a graft. 1st row: pre- and intraoperative findings, 2nd row: 6 month post op, 3rd row: harvesting the full thickness skin from the penoscrotal web, 4th row: placing the graft after maximal defatting and removal of hair follicles.
Fig. 6: Penectomy with perineostomy in a patient with tumour invasion to rectum and bladder. 1st row: preoperative findings, 2nd row: partial penectomy (which later was converted to a total penectomy in the same operation), signs of stool in the urine after passing a transurethral catheter, 3rd row: flap for perineostomy, mobilising ventral bulbar urethra, 4th row: opened urethra and final aspects. Partial and total penectomy Partial penectomy is indicated in tumours invading the corpora cavernosa (T3, Figure 5), if organ-saving procedures or strict follow-ups are not desired/ possible. Total penectomy (Figure 6) with perineal urethrostomy is reserved for large invasive tumours not amenable to partial amputation and in large local recurrences with the involvement of the corpora cavernosa. Staged penile reconstruction Staged penis reconstruction in specialised centres can be offered, once no further oncological treatment is required. If surgical treatment of the primary cancer was performed without reconstruction, then in some cases operations similar to the buried penis can be sufficient to regain voiding and sexual function (Figure 7). In cases of total penectomy, a full phalloplasty with free flaps (e.g. RAP), pedicle flaps (e.g. ALT) or localised flaps can be performed (Figure 8). “If surgical treatment of the primary cancer was performed without reconstruction, then in some cases operations similar to the buried penis can be sufficient to regain voiding and sexual function.”
Key points Penis-sparing surgery with simultaneous reconstruction or staged reconstruction can lead to strong positive effects in multiple areas of the patient’s life and should be offered to suitable penile cancer patients, especially if cosmesis and sexuality are of ongoing importance to them. It is recommended to have a very clear and open discussion with the patient (and partner if applicable) to find the best individual treatment option. The patient needs to be informed that a less radical treatment despite its broad benefits has a higher risk of recurrence and requires a stricter follow-up regime. Especially if a less- organ saving approach is chosen, it could be very relieving for the patient to be informed about the possibilities of future reconstructive options in specialised centres. References EAU-ASCO Penile Cancer Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6 All pictures and surgeries by Dr. Saskia C. Morgenstern, Dept. of Urology, Agaplesion Markus Krankenhaus Frankfurt (DE) Phalloplasty by Prof. Jens Rothenberger, Dept. Plastic surgery, Agaplesion Markus Krankenhaus Frankfurt (DE)
Fig. 1: Shows a biopsy taken in a curative manner. To protect full voiding accuracy, the shape of the meatus was restored. The green dotted line shows the 5 mm macroscopic margin.
Organ-sparing options with simultaneous reconstruction
According to the present evidence, organ-sparing options are recommended in localised tumours (PeIN, penile intraepithelial neoplasia), Ta, T1-T2, (see Figures 2-4), but it requires more extensive follow- ups and leads to a higher risk of recurrence, especially in more aggressive lesions. “Have a very clear and open discussion with the patient (and partner if applicable) to find the best individual treatment option.”
Fig. 4: Local excision/partial glansectomy with reconstruction - 1st row: preoperative findings, 2nd and 3rd row: mobilising and closing remaining glans tissue, 4th row: postop findings, 5th row: 6 month postop findings.
Surgeons (ESGURS) EAU Section of Genito-Urinary Reconstructive
European Urology Today
April/May 2023
23
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