Peter Malone, Royal Berkshire NHS Foundation Trust – Harold Hopkins Department of Urology, London Road, Reading, Berkshire RG1 5AN, UK. e-mail: email@example.com
Study Type – Therapy (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
The treatment of penile cancer has been revolutionised by modern penile preserving surgery, particularly glansectomy and glans reconstruction using split skin graft. These techniques can produce a cosmetically good result but also preserve the sexual and urinary function of the penis.
Applying a split skin graft to the penis is technically difficult and most authors recommend a period of up to 5 days bed rest after surgery to maximize graft take. This is expensive in health economic terms and may increase the risk to the patient of thrombo-embolic complications. The paper describes a new technique of tie-over dressing which allows early mobilization and discharge without compromising graft viability.
• To describe a novel method of split-skin graft (SSG) fixation for neo-glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique.
• Rather than ‘quilting’ the graft onto the neo-glans, which requires up to 5 days bed rest, the tie-over method fixes the graft adequately enough to allow immediate patient mobilization.
PATIENTS AND METHODS
• In all, 41 consecutive operations, with a follow-up of ≥12 months, were performed on 40 patients (mean age 62 years, range 32–83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump.
• The protocol varied for the first 12 operations on 11 patients. The tie-over dressing was left in place for 6 (one patient) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine-soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward.
• The subsequent 29 operations used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days.
• In the original 11 patients, two required re-grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days.
• In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period.
• The cosmetic results were excellent with only one patient requiring re-grafting. The mean and median postoperative length of stay was 2 days.
• One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation.
• The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake.
Penis preserving surgery with glans reconstruction using a split-skin graft (SSG) is now considered the gold standard with distal cancers. Preservation of penile length whilst avoiding the sclerosing effects of radiotherapy has helped to preserve both sexual and urinary function whilst maintaining a cosmetically satisfactory penis .
However, applying the SSG to the distal penile stump or raw glans poses technical problems. Any movement, bleeding or seroma formation will separate the graft from its blood supply leading to graft loss. The most commonly described method of graft fixation is by suturing (‘quilting’) the SSG onto the corporal stump. Centres that use this technique recommend 3–5 days bed rest to optimize graft survival [2–4].
We have devised a tie-over dressing method of graft application, the TODGA technique, which encourages graft adherence by immobilizing the graft and minimizing the dead space between it and the corporal bodies or raw spongiosus.
PATIENTS AND METHODS
In all, 41 consecutive operations, with a follow-up of ≥12 months, were performed on 40 patients (mean age 62 years, range 32–83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump after glans resurfacing (three), glansectomy (25), or distal penectomy (13) to achieve neo-glans formation. Of the three patients who underwent glans resurfacing one had severe lichen sclerosus (LS) and two had carcinoma in situ. The remaining 38 were for distal penile cancers in 37 and a distal urethral squamous cell carcinoma (SCC) in one patient. Of the 37 men with penile cancers, one had a malignant melanoma whereas the rest were SCCs. The grade and stage of the SCCs are detailed in Table 1. One patient had two operations due to a local recurrence and another had previously received external beam radiotherapy.
Table 1. The pathological grade and stage of the 38 operations for SCC
CIS, carcinoma in situ.
Co-amoxiclav 1.2 G was given i.v. at induction followed by oral medication for 5 days (erythromycin was given if patients were allergic to penicillin).
Most of the patients had a glansectomy, where the glans was excised using the plane between the spongiosus and the corpora cavernosa. When the distal corpora were excised in patients requiring a partial penectomy, the urethra was brought to the tip by incision of the ventral corpora to allow a central neo-meatus. In the cases of glans resurfacing the glans skin was removed to leave the raw spongiosus exposed. The penile skin and subcutaneous tissue were then sutured ≈2 cm from the end of the penis to form a stable neo-corona leaving a raw surface distally as the recipient site for the skin graft to form the neo-glans (Fig. 1).
The SSG was harvested from the anterolateral right thigh using an electrical dermatome. The graft was incised from the middle of one side to the centre (Fig. 2) and placed over the neo-glans with the incision on the ventral aspect. It was sutured with interrupted 4/0 or 5/0 polyglactin to the neo-meatus distally and the neo-corona proximally (Fig. 3).
The neo-glans was then covered by the proflavine-soaked gauze dressing and the SSG immobilized by tie-over sutures attached to the neo-meatus distally and the corona proximally (Fig. 4). Initially we left the polyglyctin sutures long enough to tie over the gauze but later found it quicker and easier to use separate 4/0 nylon tie-over sutures (Fig. 5). A 16 F silicone urethral catheter was then inserted into the splayed urethral opening (Fig. 6).
The protocol varied for the first 12 operations on 11 patients performed between December 2000 and July 2005. The pressure dressing was left in place for 6 (one) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine-soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward.
The subsequent 29 operations, performed in the subsequent 3 years, used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days. After this period the dressing was taken down and the catheter removed at the same time. The tie-over sutures were cut allowing the dressing to be removed from the neo-glans without anaesthetic. The graft was assessed at this stage and subsequently in the outpatient clinic at routine follow-up.
The mean (range) follow-up is 19.6 (12–105) months. In the original 11 patients, two required re-grafting where a patch on the dorsum of the neo-glans had failed to take. In one of these patients, where the dressing was tied on using 5/0 polyglactin, the dressing failed to stay in place for the whole week. The other patient’s graft looked viable when the dressing was taken down 1 week after surgery, but a dorsal patch was subsequently lost requiring a further SSG to be applied. After this initial development period, we amended the technique to use stronger sutures, initially 2/0 polyglycin but more recently 4/0 nylon, and left the dressing undisturbed for 10 days. In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period.
The length of stay has fallen over this 7-year period (Table 2) but our current routine involves 1 postoperative night in hospital when the patients are fit enough to go home with the dressing and catheter in situ. In all, 24/29 (82.7%) have been discharged after 1 or 2 postoperative nights in hospital.
Table 2. Length of stay and re-graft rate
First 12 operations
Subsequent 29 operations
Length of stay and re-graft rate in the initial 11 patients and in the subsequent 29 where the proflavine-soaked gauze dressing was left in place for 10 days.
Length of stay, days
Required re-grafting, n (%)
At 10 days after surgery, 22/29 patients had excellent graft uptake, six of 29 patients had minor areas of graft loss that healed to give a good or excellent cosmetic outcome by 6 weeks after surgery and one required re-grafting. One patient required evacuation of a haematoma from the shaft of his penis 14 days after his initial procedure; however, the graft was satisfactory. No patient had a symptomatic meatal stenosis. The patient with the urethral SCC associated with urethral LS required urethral dilatation 12 months after surgery to pass the cystoscope at check urethroscopy, and in another patient the meatus was dilated with a spigot in the outpatient clinic soon after surgery as it looked a little tight but the patient did not go on to develop meatal stenosis. No patient required regular meatal dilatation and even the patient with the urethral SCC has a urinary flow rate of >20 mL/s at 12 months after his dilatation. There were no other complications (Figs 7,8).
The surgical treatment of carcinoma of the penis has been revolutionized by the advent of organ-preserving surgery. Until recently, the standard operation for penile cancer has been either total or partial amputation based on the concept that a 2-cm resection margin was necessary to obtain safe tumour clearance . Radiotherapy, although allowing a chance of penile preservation, has a high rate of complications such as painful ulceration, urethral stenosis, penile necrosis, radiation skin changes, erectile dysfunction and local recurrence . More recently techniques of organ-sparing surgery have been developed challenging the ‘2 cm rule’ but the premise that such a wide clearance was unnecessary has been advocated for a long time. Mohs technique of local excision coupled with contemporaneous microscopic proof of complete excision has been used since the 1930s , but the degree of technical expertise required coupled with a high recurrence rate limited its widespread acceptance . In the 1990s, Bissada  and Davis et al.  reported their experience of conservative penile amputation where they showed acceptable oncological control with a much smaller margin than 2 cm allowing the preservation of length and function. Although this work showed that it was possible and safe to preserve penile length, the cosmetic aspects were poor. Skin cover was provided by local skin flaps with a spatulated urethral anastomosis giving little resemblance to the normal anatomy.
The first report the authors have found of the application of split skin to a penile stump dates back to 1976  but the concept of using split skin to mimic the appearance of the glans penis is a more recent development first described by Bracka  in 1996. Pietrzak et al. (2004)  reported 34 patients undergoing penis preserving surgery and glans ‘reconstruction’ using a SSG. They reported that two of 34 patients (6%) required re-grafting or debridement and two patients (6%) developed meatal stenosis. This technique has now been deservedly adopted by other centres confirming the oncological safety whilst, at the same time reproducing the functional and cosmetic outcome [3,4,13,14]. There is little doubt that now it should become the standard for patients with penile cancer suitable for organ-preserving surgery.
The same technique has also been modified for patients with urethral cancers  and with carcinoma in situ of the glans, where the glans skin is removed and the raw glans resurfaced by split skin. Hadway et al. (2006)  reported a series of 10 patients where all the grafts took successfully with excellent cosmetic results and Palminteri et al. (2007)  recorded a series of five patients mainly with benign disease where the same technique was used.
The age-proven method of securing a skin graft is by a ‘tie-over’ dressing aiming to apply direct pressure on the graft to keep it in contact with the source of its future blood supply, reducing the chance of graft separation by haematoma or seroma formation . Although this technique has been used in most areas of the body , the anatomical difficulties of applying this technique to the tip of the penis led to the concept of ‘quilting’ the graft into place with small ‘criss-cross’ sutures to secure the graft to the tips of the corpora [2,12]. The sutures are time-consuming to place and, in their original reports, Bracka , Pietrzak et al.  and Hadway et al.  advised that patients should be on bed rest for 5 days after surgery to maximize the chances of graft take. Although, in a later article from the same institution this had been reduced to 4 days  and Palminteri et al. (2007)  only felt the need for 3 days. In an age of cost consciousness when patients after radical prostatectomy are increasingly only kept in hospital for ≤2 days , it seems extravagant to occupy a hospital bed for so long after such minor surgery. In addition, such a protracted period on bed rest poses some risk to the patient. Immobility is known to increase the risk of thrombo-embolic events  and a proportion will face further major surgery to their inguinal and pelvic lymph nodes, which is known to carry a significant chance of deep vein thrombosis and pulmonary embolism [21,22]. It must also be remembered that bed rest does not stop men from getting erections, which might disturb and separate the graft.
We used a 0.1% proflavine-soaked dressing which has been used for many years as a bolster for tie-on dressings due to its non-stick properties and antibacterial action  (and, perhaps, for its beautiful yellow colour). The antibacterial action may reduce the risk of graft loss due to infection, particularly by haemolytic streptococci, which is well known to cause this . It is for this reason that we also gave co-amoxiclav as prophylaxis at induction of anaesthesia and for 5 days postoperatively . Although the dressing has worked well, there may well be alternative or superior dressings to use as a bolster . More recently Morelli et al. (2009)  have reported a series of 15 patients who were mobilized soon after surgery and discharged on day 2. They, like us, used a ‘soft humid compressive dressing’ sewn onto the graft (although the technique used to do this was not recorded) but, unlike us, also used multiple graft incisions and quilting sutures.
Meatal stenosis, so common a complication of a standard penile skin flap  has not been such a problem when split-skin glans reconstruction has been performed, possibly due to the avoidance of genital skin, which is often affected by LS in patients with penile cancer . In the present series, the patient with a verrucous SCC of the urethra, associated with LS, developed a stricture proximal to the meatus requiring dilatation and another patient was noticed to have a tight meatus and was dilated in the clinic with a spigot without recurrence. No other patient has had obstruction secondary to surgery.
In the present study, we have shown that it is possible to produce similar results to those in other reported series, whilst, at the same time avoiding the need for the time-consuming quilting technique, mobilizing patients immediately after surgery and discharging them the next day. Overall, three of 41 (7.3%) required re-grafting but only in one of 29 (3.4%) after standardization of the technique. No patient developed symptomatic meatal stenosis although two patients underwent meatal dilatation, one as an outpatient without anaesthetic. No patient has required regular dilatation or has recurred after the dilatation showing results at least as good as in other major series.
In conclusion, the TODGA technique has overcome the difficulties in applying a traditional tie-over dressing for glans reconstruction after glansectomy, distal penectomy and glans resurfacing. All the patients in our series mobilized immediately without diminishing graft survival or having a detrimental effect on the eventual cosmetic appearance. It was cost effective by reducing operative time and hospital stay. Taking the dressing down and trial without catheter can be performed as an outpatient procedure. Although we did not use them, there is no reason why quilting sutures, particularly using absorbable materials, could not be used in addition to the TODGA technique.