Conservative surgery for penile cancer: subtotal glans excision without grafting

Authors

  • Christian T. Brown,

    1. St Peter's Andrology Centre and The Institute of Urology, University College London, London, UK
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  • Suks Minhas,

    1. St Peter's Andrology Centre and The Institute of Urology, University College London, London, UK
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  • David J. Ralph

    Corresponding author
    1. St Peter's Andrology Centre and The Institute of Urology, University College London, London, UK
      David J. Ralph, Institute of Urology, University College London, 48 Riding House Street, London, W1W 7EY, UK.
      e-mail: dralph@andrology.co.uk
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David J. Ralph, Institute of Urology, University College London, 48 Riding House Street, London, W1W 7EY, UK.
e-mail: dralph@andrology.co.uk

INDICATIONS

Penile carcinoma is an uncommon malignancy with an incidence of 0.1–0.9 per 100 000 males in Europe and 0.7–0.9 per 100 000 males in the USA, with most primary tumours on the glans and/or prepuce (in 78% of cases [1,2]). Whereas radical surgery gives excellent control of the primary tumour, it is often mutilating and perhaps unnecessary for low-grade and -stage tumours (Ta−1, G1–2). In these circumstances penis-preserving surgery should be used to maintain function and cosmesis, using techniques including laser therapy, cryotherapy, photodynamic therapy, topical 5-fluorouracil, or local excision (glansectomy) and reconstruction [3]. In selected cases, T2 tumours can be treated by glans excision with a pseudo-glans fashioned using skin or buccal mucosa as an onlay graft [4]. This technique gives excellent functional and cosmetic results, although it is often complicated by poor graft take and spraying at micturition, because it is not possible to refashion a slit-like urethral meatus. Localized tumours of the corona or central glans may be excised by the refined technique described below, which preserves the meatus and gives a better cosmetic and functional outcome.

METHODS

Five men with biopsy-confirmed localized squamous cell carcinoma of the glans penis with no surrounding carcinoma in situ or obvious erectile tissue involvement on MRI underwent the new technique of penile-conserving surgery (Fig. 1). The postoperative stage and grade was G2T1 (two patients), G3T1 (two) and G2T2 (the patient shown in Figs 1–5).

Figure 1.

Preoperative appearance of the penis with biopsy-confirmed squamous cell carcinoma of the glans.

Figure 2.

Tumour excision with macroscopic clearance of ≥ 5 mm. The suture line marks the level where the cuff of corpora was excised in a patient subsequently found to have T2 disease.

Figure 3.

The urethral meatus is spatulated and sutured to the distal glans.

Figure 4.

The penile shaft skin is sutured to the distal glans at the level of the spatulated urethra, with the catheter in situ.

Figure 5.

The appearance 3 months after surgery.

Two circumferential incisions are made: the first is a skin incision in the coronal sulcus and the second around the meatus, both with a macroscopic clearance of ≥ 5 mm and confirmed by frozen-section analysis. The tumour and glans between the incisions are then excised leaving the urethra intact (Fig. 2). The residual glans with urethral meatus is then sutured down to the distal corpora (Fig. 3) and the penile skin then closely approximated to it with absorbable sutures (Fig. 4). No skin grafting is required, a catheter remains in situ for 24 h and the patient is discharged the next day.

The mean (range) age of the patients was 61 (45–66) years and the mean follow-up 12 months. To date, no men have had a clinical recurrence, or have voiding difficulties. Those men sexually active before surgery remain so, with cosmetic and functional results acceptable to the patients (Fig. 5).

COMPARISON WITH OTHER METHODS

Conventional glans excision involves removing the whole glans and spatulating the urethra over the distal corpora; this can cause spraying of urine when voiding. The present new technique avoids this, as the distal urethra is preserved. Grafting techniques involve donor-site morbidity and a prolonged hospital stay, waiting for the graft to take. No grafts are required with the use of this new technique, and therefore complications, including graft failure and infection, are avoided. This technique is also quicker than the conventional glans reconstruction and could be performed as a day-case procedure. Short-term cosmetic results are encouraging and voiding unchanged, with no reports of spraying.

CONFLICTS OF INTEREST

None declared.

Ancillary