Penis carcinoma- surgical managementof primary lesion

Penis carcinoma- surgical managementof primary lesion

1. Surgical Management of
Primary lesion in Carcinoma
Penis
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. Biopsy - Histologic confirmation
•The majority - the glans penis, coronal sulcus, or inner preputial skin
•It is important to include some adjacent normal tissue with the specimen
to allow optimal evaluation of the depth of invasion of the cancer.
•the form of a punch biopsy, excisional biopsy of a relatively small tumor
of the glans or foreskin, or incisional biopsy of a larger lesion that cannot
be completely excised.
•Dorsal slit - to gain adequate exposure of the preputial cavity.
•If a lesion involves the urethral meatus, urethroscopy is indicated to
evaluate the urethra, and directed biopsies are performed.
3 Dept of Urology, GRH and KMC, Chennai.

4. 4
Ca. Penis
Management of Primary
Organ Conservation
Standard Surgical Procedures
Partial penectomy
Total penectomy
Emasculation
Dept of Urology, GRH and KMC, Chennai.

5. 5 Dept of Urology, GRH and KMC, Chennai.

6. Options
•Surgical amputation – the oldest
•Is the gold standard
•radical surgical approach provides excellent local
control
•it is often mutilating and is associated with urinary and
sexual dysfunction as well as dramatic psychological
morbidity

6 Dept of Urology, GRH and KMC, Chennai.

7. Organ preserving procedure
•80% - distal, involving the glans and/or prepuce
•stages Tis, Ta, T1; grades 1 and 2 are at low risk for local
progression and/or distant metastatic spread;

•the traditional 2 cm excision margin has been challenged
as unnecessary for patients under- going partial
penectomy.
•Conservative techniques with surgical margins of less than
10 mm appear to offer excellent oncological control
7 Dept of Urology, GRH and KMC, Chennai.

8. 8
Organ Conserving Surgical Approach
•Laser Therapy
•Mohs Micrographic Surgery
•Conservative Local Surgical Excision
–Circumcision
–Local excision
–Partial / Total glansectomy

Dept of Urology, GRH and KMC, Chennai.

9. Conservative Surgery
•Low stage – Tis, Ta, T1 Gr I&II
•N0 (no nodes)
•Glanular sensory preservation
•Void while standing
•SI
9 Dept of Urology, GRH and KMC, Chennai.

10. 10
Laser Therapy - Hofstetter and Frank

•Lasers used  CO2; Nd:YAG; KTP
•Circumcision – recommended
•Drawbacks
–Healing time - 5 to 8 weeks for CO2 laser
–(8 to 12 weeks for the Nd : YAG and KTP lasers)
–carbonisation
–local recurrence rate - 20% (for Ca. in situ and T1 lesion)
–difficulty in determining the exact depth of laser coagulation
–inability to treat larger lesions
–careful long-term surveillance
–Better for tumors < 4mm invasion [ Tis>T1]

Dept of Urology, GRH and KMC, Chennai.

11. 11
Mohs Micrographic Surgery
•removal of cancer by excision of tissue in thin
layers
•Local control rate - 94%
•Best suited in- Ca. in situ, small T1

Dept of Urology, GRH and KMC, Chennai.

12. Circumcision
•acquired phimosis secondary to preputial tumors
•symptomatic treatment of painful or haemorrhagic tumors
•before radiotherapy as it allows better targeting and definition of the tumor,
simultaneously preventing preputial radiotherapy-related adversereactions

•improves local oncological surveillance.
•circumcision alone - primary curative for small low-stage (Tis, Ta, T1) and low-
grade (grades 1 and 2) disease limited to the distal prepuce.
•proximal and close to the coronal sulcus, the circumcision margin will need to
be extended proximally to the penile shaft to ensure adequate oncological
resection, as recurrence rates may be as high as 50%
12 Dept of Urology, GRH and KMC, Chennai.

13. 13
Local excision
•excision of lesion with negative margin
•Reconstruction- primary closure, preputial skin
flap, full-thickness graft of penile skin , SSG
•local recurrence - 8% to 11%
Dept of Urology, GRH and KMC, Chennai.

14. Partial glansectomy

1. PG with primary glans
closure;
2. PG with graft
reconstruction of the
glans;
3. PG without grafting.

PG is indicated in

•
localized tumors of the
corona or central glans
with no surrounding
carcinoma in situ

•
obvious erectile tissue
involvement on MRI.

•
for small and isolated
lesions.

14 Dept of Urology, GRH and KMC, Chennai.

15. 15
Surgical glans defect covered with outer
preputial flap [ Ubrig et al]
•Superficial glans tumor

•Outer preputial flap
outlined

• Tumor excised and
circumcision performed

• Glans defect filled with
outer preputial flap
Dept of Urology, GRH and KMC, Chennai.

16. 16
Skin graft quilted to glans defect after
superficial tumor excision
Dept of Urology, GRH and KMC, Chennai.

17. Total Glansectomy
•Austoni in 1996
•circular incision in the distal shaft skin down to Buck fascia.
•At this level, a plane is developed to separate the glans from corporal tips.
•The urethra and the neurovascular bundle are isolated in their distal extremities.
•The glans is dissected from the corpora cavernosa and the urethra is distally
sectioned.
•The use of multiple frozen sections of the surgical margins is strongly suggested.
•After removing the glans, the urethra is ventrally opened and the neomeatus
fixed to the tip of the corpora cavernosa.
•The neurovascular bundle is fixed to the albuginea proximally to the neoglans
with absorbable sutures.

17 Dept of Urology, GRH and KMC, Chennai.

18. 18 Dept of Urology, GRH and KMC, Chennai.

19. Amputational surgery
•> 4cm
•Gr III
•Deep into glans / urethra / corpora
19 Dept of Urology, GRH and KMC, Chennai.

20. 20
Partial Penectomy
•Goals
–Successful local control (at least 1-2 cm proximal
margin)
–preserve voiding in standing position
–possible sexual function

Dept of Urology, GRH and KMC, Chennai.

21. 21
Partial Penectomy- Steps
•lesion initially excluded from surgical field by small towel
•skin incised circumferentially at the line of amputation to Buck
fascia
•Buck fascia incised laterally, plane dissected between tunica
albuginea and neurovascular structures
•dorsal penile vessels ligated and divided
• corpora cavernosa sharply divided
•urethra dissected 1.5 cm distally and transected
•corpora closed transversely
•penile skin closed in midline over corporeal ends
•urethrostomy constructed by approximating urethra to the
adjacent penile skin
•indwelling urethral catheter is left in place for 3 to
5 days

Dept of Urology, GRH and KMC, Chennai.

22. 22
Partial penectomy
Dept of Urology, GRH and KMC, Chennai.

23. Remaining
Stump
of atleast 3cm
23 Dept of Urology, GRH and KMC, Chennai.

24. 24
Total Penectomy with Perineal
Urethrostomy
•Indication  After adequate surgical
margin – if remnant not sufficient for
upright voiding
Dept of Urology, GRH and KMC, Chennai.

25. TOTAL PENECTOMY
25 Dept of Urology, GRH and KMC, Chennai.

26. 26 Dept of Urology, GRH and KMC, Chennai.

27. Radical Penectomy
•Rare
•Total amputation + corporosectomy
27 Dept of Urology, GRH and KMC, Chennai.

28. Complications
•Early – bleeding / infection
•The most common complication of partial and total
penectomy is meatal stenosis.
•The V inlay technique has been used to decrease the
stenosis at the urethral opening
•Patients with partial or total penectomy suffer serious
psychological and physical trauma with major changes in
their quality of life.
28 Dept of Urology, GRH and KMC, Chennai.

29. 29
Comparing Surgery & RT
Surgery
local recurrence after
partial or total penectomy -
0% to 8%
rapid tumor control
Meatal stenosis- 6%


•RT
–urethral fistula, stricture,
stenosis, penile necrosis,
pain, edema
–Penile necrosis - 0%
to 23%
–Urethral stenosis - 10% to
45%
–6 weeks of therapy in EBRT
–several months of
morbidity
–Close follow-up – must
–distinguishing post
irradiation ulcer, scar, and
fibrosis from recurrent
carcinoma - impossible
Dept of Urology, GRH and KMC, Chennai.

30. 30
Comparing Surgery & RT
Surgery
Complications of block
dissection
RT
5-year local control -
70% to 87%
(Brachytherapy)
5-year local control -
44% to 69.7% (EBRT)
sexual QOL - not studied
with validated
instruments
Dept of Urology, GRH and KMC, Chennai.

31. 31
Treatment of Primary lesion Stage by Stage
•Tis ( options after confirmatory biopsy)
–Lesion prepuce  circumcision
–Lesion glans 
•Topical 5FU cream
•Laser Excision
•Mohs Micrographic Surgery
•RT

Dept of Urology, GRH and KMC, Chennai.

32. 32
Treatment of Primary lesion- Ta
Laser Excision
Mohs Micrographic
Surgery

RT-
contraindicated


Dept of Urology, GRH and KMC, Chennai.

33. 33
Treatment of Primary lesion- Options
•T1,T2,T3 
–Partial penectomy
–Total penectomy
–Emasculation

Dept of Urology, GRH and KMC, Chennai.

34. 34
Treatment of Primary lesion- Options
•T4
–Emasculation
–Hemipelvectomy

Dept of Urology, GRH and KMC, Chennai.

35. Sexual function after partial penectomy

•66.7% sustained the same frequency and level of sexual desire as
before surgery, and 72.2% continued to have ejaculation and
orgasm every time they had sexual stimulation or intercourse.
Only 33.3% maintained their preoperative sexual
intercourse frequency and were satisfied with their
sexual relationship with their partners and their
overall sex life.

*Urology. 2005 Dec;66(6):1292-5. Romero et al
35 Dept of Urology, GRH and KMC, Chennai.

36. Pre Radiotherapy
Sexual function
Post Radiotherapy
Sexual function
Erection Normal in **17/18 Unchanged in 15/17 (88%)
Mild dysfunction in 2 (12%)
Sexually Active ***15/18 15/18
Coitus Frequency
(median)
5 per month in 15 sexually
active men (Range 2-15)
Unchanged in13/15 (87%)
Reduced in 2 men
Coital Satisfaction Normal in 15/15 sexually
active men
Unchanged in 13/15 (87%)
Reduced in 2 men
5 patients ( 21.7%) who underwent penectomy for residual / recurrent disease not included
** 1 patient had loss of erectile function before starting Radiotherapy
***2 patients with normal erection were not sexually active (single and advanced age)
Prospective evaluation of Sexual Functions - TMH
Prospective study of PCT using accelerated External RT
1996-2003
23 men with Stage I – II Penile SCC


36 Dept of Urology, GRH and KMC, Chennai.

37. 37
Pizzocaro G, et al. EAU Penile Cancer Guidelines 2009
Eur Urol 2010
Dept of Urology, GRH and KMC, Chennai.

38. 38
Total Penile Reconstruction
•Originally developed for treatment of victims of
war injuries
•micro vascular free-flap reconstruction for
phallic construction
•Forearm flap
Dept of Urology, GRH and KMC, Chennai.

39. 39
Configuration of the flap
(modified Biemer design)
Dept of Urology, GRH and KMC, Chennai.

40. 40
Appearance of the phallus after it is totally
configured and transposed to the area of the
“penis.”
Dept of Urology, GRH and KMC, Chennai.

41. 41
Radiation Therapy for
the Primary Lesion
•Indications
–young patients with small (2- to 4-cm) superficial lesions
of distal penis, not willing for amputation
– patients who refuse surgery
– patients with inoperable cancer
–Patients unsuitable for major surgery.



Dept of Urology, GRH and KMC, Chennai.

42. 42
Radiation Therapy for
the Primary Lesion
•EBRT 
–direct field method - only for very superficial tumors
(Tis ,T1)
–parallel opposed field method - T2, T3 (penis
irradiated by encasing the lesion in a wax mold)
•Brachytherapy 
–Interstitial brachytherapy - placement of
radioactive material within the tumor
–Plesiobrachytherapy- placement of radioactive
material molded around the tumor
Dept of Urology, GRH and KMC, Chennai.

43. 43
Brachytherapy not suitable
•bulky tumors
•obese patients with short penis
•deeply infiltrating tumors
Dept of Urology, GRH and KMC, Chennai.

44. 44
Radiation Therapy for
the Primary Lesion
•60 Gy to 74 Gy
•Salvage penectomy
–persistent or recurrent disease after RT
–radiation necrosis
Dept of Urology, GRH and KMC, Chennai.

45. Locally fabricated water filled Perspex box to hold penis
Penis wrapped in cellophane and taken out
through central aperture
Tele Cobalt
45 Dept of Urology, GRH and KMC, Chennai.

46. 46 Dept of Urology, GRH and KMC, Chennai.

47. Points to be well informed to
patients if RT is selected
•Although cosmetically attractive, disadvantages
are
–Useful only in early stage (T1,T2)
–Only 65-80% success rate even in early stage
–Penile necrosis - 0% to 23%
–High chance for stricture urethra
–Penectomy required for recurrence
and necrosis
47 Dept of Urology, GRH and KMC, Chennai.

48. Study

Treatment Local control
Initial Post salvage
Penectomy
for necrosis
Urethral
stricture
Rozan et al
French multi-centre
12 yrs

Implant 63Gy (185 men)
Others (75 men)


85%

94%

7%

30%

Delannes et al
Toulouse, France
7 years

Implants - 60 Gy
(51 patients)

82%

94%

16%

41%

Ravi et al
Adyar
12 years

EBRT– 50 to 60 Gy
(128 patients)
Brachy – 60 to 70 Gy
(28 patients)


65%


97%


6%


24%

Sarin et al
Royal Marsden, UK.
5 years


EBRT - 60 Gy
(56 patients)
Implants - 60 Gy
(13 patients)


57%


90%


3%


14%
Chaudhary et al
TMH
2 years

Ir-192 Implant – 50Gy
(23 patients)

78%

96%

Nil

9%
Penile Conservation with Radiotherapy: At what cost?
48 Dept of Urology, GRH and KMC, Chennai.

49. 49
Summary
•Definite role for Organ preservation- Tis, Ta, T1a
•RT – only in selected cases ( local recurrence,
complications common)
• 2cm proximal margin, adequate penile stump for upright
micturition - Partial Penectomy
• 2cm proximal margin , if inadequate penile stump for
upright micturition- Total Penectomy

Dept of Urology, GRH and KMC, Chennai.

50. 50 Dept of Urology, GRH and KMC, Chennai.

51. Thank you

51 Dept of Urology, GRH and KMC, Chennai.