Presentation on theme: "Surgery of Penile and Urethral Carcinoma"— Presentation transcript:
1Surgery of Penile and Urethral Carcinoma Campbell’s Urology Chapter 32W. Britt ZimmermanApril 15, 2009
2Surgery of Penile & Urethral Carcinoma Penile CancerMale Urethral CancerFemale Urethral Cancer
3Penile Cancer Typically Squamous Involves: Glans penis Coronal Sulcus Inner preputial skin
4Penile CancerBiopsyImperative to include area of question as well as adjacent normal tissueAllows for evaluation of depth of invasionMay be punch or excisionalUrethral meatus involvementUrethroscopy is mandatory
5Penile Cancer Laser Therapy Carbon Dioxide (CO2) Neodymium:yttrium-aluminum-garnet (Nd:YAG)Potassium titanyl phosphate (KTP)Circumcision is usually recommended at the time of laser surgery if not already done
6Laser Therapy CO2 Wavelength: 10,600 nm Skin depth: 0.01 mm Blood vessels: 0.5 mm33% local recurrenceHealing time: 5 – 8 weeks
7Laser Therapy Nd:YAG Combination Most commonly reported Skin dept: 3 – 6 mm20% recurrenceStage T1Healing time: 8 – 12 weeksCombinationSurgery and laser to the base18% – 20% recurrence
8Laser Therapy KTP Wavelength: 532 nm Intermediate depth Between CO2 and Nd:YAGHealing time: 8 – 12 weeks
9Laser Therapy Technical improvements Final thoughts 5% Acetic acid wraps5-aminolevulinic acidFinal thoughtsReasonable for Tis and T1 SCCT2 patients refusing aggressive surgery
10Mohs Micrographic Surgery Excision of penile cancer by thin tissue layersFrozen sectioning with immediate pathological evaluationCure rates (5 years)< 1 cm: 100%1 – 2 cm: 83%2- 3 cm: 75%> 3 cm: 50%
11Mohs Micrographic Surgery Best suited for small superficial cancersComparable to partial penectomyIn the right setting
12Conservative Surgical Excision Local excision and GlansectomyIn the setting of low stage penile cancerTraditionally, 2 cm marginGrade plays a central roleGrade 1 & 2Histologic extent 5 mmLocation also plays a roleCoronal Sulcus 50% recurrence
13Conservative Surgical Excision Glanular tumorsDifficult secondary inability to achieve adequate marginPreputial skin flap or split thickness skin graft (STSG) can assist in closureRecurrence:Traditionally 32 – 40%Contemporary studies 8 – 11%
14Figure 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.
15Figure 32-2 Finely meshed extragenital split-thickness skin graft quilted to glans defect after superficial tumor excision.
16Conservative Surgical Excision Total GlansectomyFirst described in 1996Used in patients with stage T1 & T2 SCC of the glans, prepuce, and coronal sulcusDissassembly of glans and distal corpus spongiosumFrozen section for margin evaluationSTSG with urethrostomy formationBenefitsVoidingSexual function preservation
17Partial PenectomyMost common surgical procedure for treatment of patients primary SCCPenile amputation2 cm proximal to the tumorGoalsVoidingSexual function
18Partial PenectomyFigure 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.
19Partial Penectomy1.0 to 1.5 cm distal to the cavernosal amputation siteUrethrostomy is created by approximating the urethra to the surrounding penile skinLengtheningSuspensory ligament division
22Total Penectomy At the level of the suspensory ligament Corpra cavernosa proximally remainsPerformed for large or proximal LesionsPatients void sitting down via a perineal urethrostomy
23Total PenectomyFigure 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.
30Regional Lymph NodesSCC on the penis spreads regionally before it spreads distantly.No skip lesions.One midline structure can metastasize to either side or bilaterally.Metastatic lymph nodes confer a poorer prognosisAggressive lymphadenectomy: cure in 30 – 60%
32Superficial lymph nodes (5 groups) Figure 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.
33Inguinal Anatomy Deep inguinal nodes Medial to femoral vein in the femoral canalCloquet – most cephalad of the deep groupBetween the femoral vein and the lacunar ligamentExternal iliac nodesDeep inguinalObturatorHypogastric
38Sentinel Node Biopsy First describe by Cabanas in 1977 Results a have been variable
39Modified Inguinal Lymphadenectomy Catalona 1988Same therapeutic benefitLess morbidityKey aspectsShorter skin incisionExcludes the area lateral to the femoral artery and caudal to the fossa ovalisSaphenous vein preservationElimination of sartorius muscle transposition
40Modified Inguinal Lymphadenectomy Figure 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.)
41Modified Inguinal Lymphadenectomy Figure Modified inguinal lymphadenectomy. Lymph node packet is medial to the femoral artery and includes superficial and deep inguinal nodes.
42Modified Inguinal Lymphadenectomy Figure Intraoperative photograph of right inguinal region after modified lymphadenectomy. SC, spermatic cord; V, femoral vein; S, saphenous vein; AL, adductor longus.
43Radical Ilioinguinal Lymphadenectomy Indicated in patients with resectable metastatic adenopathy and may be curative when inguinal nodes disease only.May also be used in palliation
45Radical Ilioinguinal Lymphadenectomy Figure 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.
46Radical Ilioinguinal Lymphadenectomy Figure 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.
48Radical Ilioinguinal Lymphadenectomy Figure 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.
49Radical Ilioinguinal Lymphadenectomy Figure 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 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.
50Key Points of Penile Cancer Early meticulous surgical management with close follow-up generally provides the best opportunity for cure of penile SCC.Include some adjacent normal tissue with the specimen to allow optimal evaluation of the depth of invasion of the cancer during biopsy.
51Key Points of Penile Cancer Conservative surgical approaches may be reasonable for patients with stage Tis and small T1 SCC of the penis and for patients with manageable T2 tumors who refuse more aggressive surgical treatment.Partial penectomy with a 2-cm surgical margin remains the most common surgical procedure for treatment of the primary tumor in patients with invasive SCC and affords excellent local control in most instances.
52Key Points of Penile Cancer In patients at risk for the development of inguinal metastatic disease and with no palpable adenopathy, modified inguinal lymphadenectomy provides excellent assessment of the regional nodes and may be converted to a full lymphadenectomy if metastatic disease is detected.Penile cancer metastases to the pelvic lymph nodes do not occur in the setting of negative ipsilateral inguinal nodes.
58Pathology Direct extension Lymphatic invasion Anterior – superficial and deep inguinal, and occasionally external iliac nodesPosterior – pelvic lymph nodesPalpable lymph nodes are present 20% of the time and usually represent metastatic disease
59Evaluation & Staging Primary tumor (T) (male and female) TX Primary tumor cannot be assessedT0 No evidence of primary tumorTa Noninvasive papillary, polypoid, or verrucous carcinomaTisCarcinoma in situT1 Tumor invades subepithelial connective tissueT2 Tumor invades any of the following: corpus spongiosum, prostate, periurethral muscleT3 Tumor invades any of the following: corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neckT4 Tumor invades other adjacent organsTransitional cell carcinoma of the prostateTis-pu Carcinoma in situ, involvement of the prostatic urethraTis-pd Carcinoma in situ, involvement of the prostatic ductsT2 Tumor invades any of the following: prostatic stroma, corpus spongiosum,periurethral muscleT3 Tumor invades any of the following: corpus cavernosum, beyond prostaticcapsule, bladder neck (extraprostatic extension)T4 Tumor invades other adjacent organs (invasion of the bladder)
60Evaluation & Staging Regional lymph nodes (N) NX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in a single lymph node, 2 cm or less in greatest dimensionN2 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 cmN3 Metastasis in a lymph node greater than 5 cm in greatest dimensionDistant metastasis (M)MX Presence of distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis
61Treatment Primarily a surgically treated disease process Anterior urethral lesion is more amendable to surgical controlPosterior diseaseAssociated with extensive local invasionDistant mets
62Carcinoma of the Penile Urethra Superficial, papillary, low-grade tumorsTURLocal excisionInfiltratingLesions located to distal half of penisPartial penectomy with 2 cm marginLesions proximalTotal penectomy
64Carcinoma of the Penile Urethra Prophylactic inguinal lymph node dissection (LND) offers no benefit
65Carcinoma of the Bulbomemebranous Urethra Poor survival figures for all recorded forms of treatmentRadical surgery offers best longer-term prognosisRadical cystoprostatectomyPelvic lymphadenectomyTotal penectomyPubic rami resectionGU diaphragm excision
67Radiation Therapy & Chemotherapy XRTEarly-stage lesions of the anterior urethraPreserves skinResults are undeterminedChemoMVAC good for TCC lesionsPlatinum based therapyResults poorCombo therapyXRT and ChemoSurgery and Chemo
68Management of the Urethra after Cystectomy General ConsiderationsCancer recurrence following cystoprostatectomy2.1 – 11.1% recurrence (cutaneous diverison)0.5 – 4% recurrence (orthotopic neobladder)Frozen section of apical margins of prostatic urethra during surgery should be NEGATIVE.40% of recurrence within 1 year18 months median
69Management of the Urethra after Cystectomy Traditionally urethral wash was acceptableSurvival benefit has been questionedPatients who have positive voided cytology or symptoms:Urethral bleedingDischargePalpable massCystoscopy and BiopsySuperficial recurrence can be treated with BCG via urethral perfusion
70Total Urethrectomy after Cutaneous Diversion Care must be exercised in completing the proximal dissection, in view of the possible postcystectomy adherence of intestine to the superior surface of the urogenital diaphragm.
71Total Urethrectomy after Orthotopic Diversion Abdominal perineal approachCan use previous bowel for diversionCareful dissection to preserve blood supplyCommonly perform ileal conduit, but carefully selected patient may undergo a continent reservoir creation
73Key Points: Male Urethral Cancer 80% of male urethral cancers are SCCBulbomembranous urethra most common siteAnterior urethral carcinomaMore amenable to surgical controlBetter prognosisPosterior urethral carcinomaExtensive local invasionDistant metastasis
74Key Points: Male Urethral Cancer Prophylactic inguinal lymph node dissection has no benefitLow incidence of urethral recurrence after orthotopic bladder replacementNegative frozen-section biopsy of the distal prostatic urethral margin during surgery
75Key Points: Male Urethral Cancer Converting a patient to cutaneous conduit urinary diversion, bowel from the existing orthotopic neobladder can often be reconfigured with its blood supply intact and used for this purpose.
77Epidemiology, Etiology, & Clinical Presentation more in women, 4:1Only urological malignancy with female predominance0.2% of all GU malignancies<1% of CA of female GU tract85% occurs in white women ( of 1200 cases reported)
78Epidemiology, Etiology, & Clinical Presentation Leukoplakia, chronic irritation, caruncles, polyps, partuition, HPV, other viral infectionUrethral diverticula5% of CAPredisposition?
79Epidemiology, Etiology, & Clinical Presentation 98% have symptomsMost common obstructiveDysuria, urethral bleeding, frequency, palpable, urethral mass, indurationOtherwise healthy middle-aged woman with new-onset UR?Think urethral tumor (and neurolgic disease…..)
80Epidemiology, Etiology, & Clinical Presentation Patterns of SpreadLocalDirect extension, may skin/vulvaIf proximal may extend:Posteriorly into vaginaProximally into bladderLymphatic involvement:presentation (palpable nodes)½ of pts with advanced/proximal tumorsHematogenousLung, liver, bone, brain
81Anatomy & Physiology Anterior (distal 1/3) Posterior (proximal 2/3) Can maintain continence with excisionPosterior (proximal 2/3)
84Diagnosis & Staging Evaluation Staging Cysto, EUA, CT A/P, CXR +/- MRI for extensionStagingTNM (see male)Pelvic LN mets:20%Distant LN mets:15%Palpable nodes:30% overallConfirmed malignancy: 90%50% of proximal or advanced CA
85Treatment & Prognosis Prognosis Treatment No survival difference based on histological subtypeTreatmentTumor locationClinical stage
86Treatment Local excision vs extensive surgery Survival facts Small, distal urethral tumors, superficialSurvival facts5 yr DSS (disease specific survival)71% (distal)48% (proximal)24% (large urethral lesions)Overall survival (Surgery, XRT)30-40%Unchanged in 50yrs
88Treatment Distal Urethral CA Small, exophytic, superficial tumor from urethral meatus:Options:Circumferential excision of distal urethra & portion of anterior vaginal wallLaser coag described (small, distal tumors)Urethrectomy & diversionAnterior vaginal wall, periurethral tissues to bladder neckIleovesicostomy, appendicovesicostomy to native bladder
89Treatment Facts, surgical data: Distal tumor Low stageCure rate 70-90% with local excision21 % with < T2 treated with partial urethrectomy had a local recurrence (Dimarco et al 2004)0-50% recurrence with partial urethrectomy +/- rads (Hahn 1991, Ghelier 1998)
94Treatment Ilioinguinal lymphadenectomy Significant morbidity Systemic spread without regional LN involveNo improved survival after pelvic, inguinal LADNCan’t predict micrometastatic LN involvementRecommend: no prophylactic or diagnostic LNDCandidates for LND(+) inguinal, pelvic LAD on presentation without distant metsPts who develop regional LAD during surveillance
95Treatment Proximal female urethral CA Facts More likely high stage Advanced female urethral CA involves:Proximal location, entire urethraLocally invasive lesion: external genitalia, vagina or bladderMultimodal Rx is the rulePrognosisWith anterior exenteration: 10-17% (5 yrs)Local recurrence 67%
96Treatment Proximal female urethral CA Anterior exenteration, pelvic LN dissection (standard bladder + Cloquet’s node), wide vaginal or complete vaginal excision for (-) marginsPRN: partial vulvectomy, labial excisionPRN: pubis resection
97Treatment Prognosis Radiotherapy alone Combo (XRT + surgery) 0-57% survival (5 yrs)Combo (XRT + surgery)Mean survival 54% (5 yrs)Chemo + XRT + surgeryLocal, distant control in advanced CASCC5 FU + Mitomycin CTCCMVAC or Gemcitabine
98Urethral recurrence after Cystectomy in women FactsIncidence of CA involving urethra in females undergoing cystectomy for CaB 1-13%Bladder neck involvement and urethral sparing surgery (controversial)Few reported cases of urethral CA despite increasing # of orthotopic neobladders (urethral preservation)
99Urethral recurrence after Cystectomy in women Limited data No conclusive treatment Rec.Options (in the absence of mets):Urethrectomy, resection of anastomosis with conversion to continent cutaneous diversionConversion to cutaneous urinary conduit with bowel from orthotopic diversion
100Surgery of Penile and Urethral Carcinoma Campbell’s Urology Chapter 32W. Britt ZimmermanApril 15, 2009