Surgery of Penile and Urethral Carcinoma. Campbell’s Urology Chapter 32 W. Britt Zimmerman April 15, 2009. Surgery of Penile & Urethral Carcinoma. Penile Cancer Male Urethral Cancer Female Urethral Cancer. Penile Cancer. Typically Squamous Involves: Glans penis Coronal Sulcus
18% – 20% recurrence
Local excision and Glansectomy
Figure 32-1 Surgical glans defect covered with outer preputial flap as described by Ubrig and colleagues (2001). A, Superficial glans tumor. B, Outer preputial flap outlined. C, Tumor excised and circumcision performed. D, Glans defect filled with outer preputial flap.
Figure 32-2 Finely meshed extragenital split-thickness skin graft quilted to glans defect after superficial tumor excision.
Figure 32-3 Partial penectomy. A, Incision with ligation and division of dorsal penile vessels within Buck's fascia (inset). B, Corpora transected and urethra spatulated. C and D, Closure of corpora cavernosa. E, Final closure with construction of urethrostomy.
Figure 32-5 Total penectomy. A, Incision. B, Transection of the corpora near the level of the pubis. C, Mobilization of the remaining urethra off of the proximal corporal bodies. D, Transposition of the urethra through a curvilinear perineal incision. E, Completion of perineal urethrostomy.
Foley left for 7 – 10 days
Figure 32-14 Superficial inguinal lymph nodes and the branches of the saphenous vein. SEV, superficial epigastric; SEPV, superficial external pudendal; MCV, medial cutaneous; LCV, lateral cutaneous; SCIV, superficial circumflex iliac.
Figure 32-17 Limits of standard and modified groin dissection. (From Colberg JW, Andriole GL, Catalona WJ: Long-term follow-up of men undergoing modified inguinal lymphadenectomy for carcinoma of the penis. Br J Urol 1997;79:54-57.)
Figure 32-18 Modified inguinal lymphadenectomy. Lymph node packet is medial to the femoral artery and includes superficial and deep inguinal nodes.
Figure 32-19 Intraoperative photograph of right inguinal region after modified lymphadenectomy. SC, spermatic cord; V, femoral vein; S, saphenous vein; AL, adductor longus.
Figure 32-21 Ilioinguinal lymph node dissection. A, Incisions for inguinofemoral lymph node dissection (1), unilateral pelvic lymph node dissection (2), and bilateral pelvic lymph node dissection (3). B, Single incision approach for ilioinguinal lymph node dissection.
Figure 32-22 A, Incision and area of dissection for left inguinofemoral lymph node dissection with excision of adherent skin overlying nodal mass. B, Single incision approach and area of dissection for right ilioinguinal lymph node dissection with excision of overlying skin.
Figure 32-25 Inferior dissection during radical inguinofemoral lymph node dissection with removal of lymph node packet from the inferior border of the femoral triangle. After further lateral and medial dissection, the packet will remain in continuity with the pelvic dissection in the area of the femoral canal.
Figure 32-26 Intraoperative photograph after right radical inguinofemoral lymph node dissection in an obese patient. S, sartorius muscle; A, femoral artery; V, femoral vein; IL, inguinal ligament.
Figure 32-27 Sartorius muscle after detachment from the anterior superior iliac spine and 180-degree rotation medially, with suture fixation to the fascia of the inguinal ligament and the adductor longus. S, sartorius muscle; SC, spermatic cord.
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension
N2 Metastasis in a single lymph node, more than 2 cm but less than 5 cm in greatest dimension; or in multiple nodes, none greater than 5 cm
N3 Metastasis in a lymph node greater than 5 cm in greatest dimension
Distant metastasis (M)
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Prophylactic inguinal lymph node dissection (LND) offers no benefit
more in women, 4:1
Only urological malignancy with female predominance
0.2% of all GU malignancies
<1% of CA of female GU tract
85% occurs in white women ( of 1200 cases reported)
Leukoplakia, chronic irritation, caruncles, polyps, partuition, HPV, other viral infection
5% of CA
98% have symptoms
Most common obstructive
Dysuria, urethral bleeding, frequency, palpable, urethral mass, induration
Otherwise healthy middle-aged woman with new-onset UR?
Think urethral tumor (and neurolgic disease…..)
Patterns of Spread
Direct extension, may ulcerate @ skin/vulva
If proximal may extend:
Posteriorly into vagina
Proximally into bladder
1/3 @ presentation (palpable nodes)
½ of pts with advanced/proximal tumors
Lung, liver, bone, brain
Anterior (distal 1/3)
Can maintain continence with excision
Posterior (proximal 2/3)
Histology of urethra
External/internal illiac, obturator
Ant urethra/ labia
Histology of Neoplasm
Associated with diverticula
Rare: lymphoma, neuroendocrine, sarcoma, paragangliomas, melanoma, metastasis
Cysto, EUA, CT A/P, CXR
+/- MRI for extension
TNM (see male)
Pelvic LN mets:
Distant LN mets:
Confirmed malignancy: 90%
50% of proximal or advanced CA
No survival difference based on histological subtype
Local excision vs extensive surgery
Small, distal urethral tumors, superficial
5 yr DSS (disease specific survival)
24% (large urethral lesions)
Overall survival (Surgery, XRT)
Unchanged in 50yrs
Surgery, XRT, chemo, combo
Survival @ 5-6 yrs: (Early urethral CA in women, Table 32-2)
XRT (42 pts) 30%
Surgery (14 pts) 10%
Combo (3 pts) 2%