1. Surgery of Penile and Urethral Carcinoma
Campbell’s Urology Chapter 32
W. Britt Zimmerman
April 15, 2009

2. Surgery of Penile & Urethral Carcinoma
Penile Cancer
Male Urethral Cancer
Female Urethral Cancer

3. Penile Cancer Typically Squamous Involves: Glans penis Coronal Sulcus
Inner preputial skin

4. Penile Cancer
Biopsy
Imperative to include area of question as well as adjacent normal tissue
Allows for evaluation of depth of invasion
May be punch or excisional
Urethral meatus involvement
Urethroscopy is mandatory

5. Penile 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

6. Laser Therapy CO2 Wavelength: 10,600 nm Skin depth: 0.01 mm
Blood vessels: 0.5 mm
33% local recurrence
Healing time: 5 – 8 weeks

7. Laser Therapy Nd:YAG Combination Most commonly reported
Skin dept: 3 – 6 mm
20% recurrence
Stage T1
Healing time: 8 – 12 weeks
Combination
Surgery and laser to the base
18% – 20% recurrence

8. Laser Therapy KTP Wavelength: 532 nm Intermediate depth
Between CO2 and Nd:YAG
Healing time: 8 – 12 weeks

9. Laser Therapy Technical improvements Final thoughts
5% Acetic acid wraps
5-aminolevulinic acid
Final thoughts
Reasonable for Tis and T1 SCC
T2 patients refusing aggressive surgery

10. Mohs Micrographic Surgery
Excision of penile cancer by thin tissue layers
Frozen sectioning with immediate pathological evaluation
Cure rates (5 years)
< 1 cm: 100%
1 – 2 cm: 83%
2- 3 cm: 75%
> 3 cm: 50%

11. Mohs Micrographic Surgery
Best suited for small superficial cancers
Comparable to partial penectomy
In the right setting

12. Conservative Surgical Excision
Local excision and Glansectomy
In the setting of low stage penile cancer
Traditionally, 2 cm margin
Grade plays a central role
Grade 1 & 2
Histologic extent 5 mm
Location also plays a role
Coronal Sulcus 50% recurrence

13. Conservative Surgical Excision
Glanular tumors
Difficult secondary inability to achieve adequate margin
Preputial skin flap or split thickness skin graft (STSG) can assist in closure
Recurrence:
Traditionally 32 – 40%
Contemporary studies 8 – 11%

14. 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.

15. Figure 32-2 Finely meshed extragenital split-thickness skin graft quilted to glans defect after superficial tumor excision.

16. Conservative Surgical Excision
Total Glansectomy
First described in 1996
Used in patients with stage T1 & T2 SCC of the glans, prepuce, and coronal sulcus
Dissassembly of glans and distal corpus spongiosum
Frozen section for margin evaluation
STSG with urethrostomy formation
Benefits
Voiding
Sexual function preservation

17. Partial Penectomy
Most common surgical procedure for treatment of patients primary SCC
Penile amputation
2 cm proximal to the tumor
Goals
Voiding
Sexual function

18. Partial Penectomy
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.

19. Partial Penectomy
1.0 to 1.5 cm distal to the cavernosal amputation site
Urethrostomy is created by approximating the urethra to the surrounding penile skin
Lengthening
Suspensory ligament division

20. Partial Penectomy Skin coverage Glans reconstruction Scrotal flaps
Z-plasty
Glans reconstruction
Skin grafts
Pedicle flaps

21. Penectomy
Local recurrence rates
0 – 8%

22. Total Penectomy At the level of the suspensory ligament
Corpra cavernosa proximally remains
Performed for large or proximal Lesions
Patients void sitting down via a perineal urethrostomy

23. Total Penectomy
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.

24. Perineal Urethrostomy

25. Perineal Urethrostomy

26. Perineal Urethrostomy

27. Perineal Urethrostomy
Foley left for 7 – 10 days

28. Radical Penectomy
The corporal bodies are dissected to the tips of the crura, which are completely excised.
Urethra is matured into a standard perineal urethrostomy.

29. Radical Penectomy

30. Regional Lymph Nodes
SCC 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 prognosis
Aggressive lymphadenectomy: cure in 30 – 60%

31. Inguinal Anatomy Lymph nodes Superficial lymph nodes (5 groups)
Deep
Superficial lymph nodes (5 groups)
Central (saphenofemoral junction)
Superolateral (superficial circumflex vein)
Inferolateral (lateral femoral & superficial circumflex)
Superomedial (superficial ext. pudendal & superficial epigastric veins
Inferomedial (greater saphenous vein)

32. Superficial 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.

33. Inguinal Anatomy Deep inguinal nodes
Medial to femoral vein in the femoral canal
Cloquet – most cephalad of the deep group
Between the femoral vein and the lacunar ligament
External iliac nodes
Deep inguinal
Obturator
Hypogastric

34. Deep Inguinal Nodes

35. Inguinal Anatomy Skin blood supply
Common femoral artery
Superficial external pudendal
Superficial circumflex iliac
Superficial epigastric arteries
Transverse skin incision compromises the least amount of blood supply

36. Inguinal Anatomy Femoral nerve Deep to iliacus fascia Motor Sensation
Pectineus
Quadriceps femoris
Sartorius
Sensation
Anterior thigh

37. Inguinal Anatomy Femoral triangle: Inguinal ligament – superiorly
Sartorius muscle – laterally
Adductor longus muscle – medially
Floor
Pectineus (medially) and iliopsoas (laterally)

38. Sentinel Node Biopsy First describe by Cabanas in 1977
Results a have been variable

39. Modified Inguinal Lymphadenectomy
Catalona 1988
Same therapeutic benefit
Less morbidity
Key aspects
Shorter skin incision
Excludes the area lateral to the femoral artery and caudal to the fossa ovalis
Saphenous vein preservation
Elimination of sartorius muscle transposition

40. Modified 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.)

41. Modified Inguinal Lymphadenectomy
Figure Modified inguinal lymphadenectomy. Lymph node packet is medial to the femoral artery and includes superficial and deep inguinal nodes.

42. Modified Inguinal Lymphadenectomy
Figure Intraoperative photograph of right inguinal region after modified lymphadenectomy. SC, spermatic cord; V, femoral vein; S, saphenous vein; AL, adductor longus.

43. Radical Ilioinguinal Lymphadenectomy
Indicated in patients with resectable metastatic adenopathy and may be curative when inguinal nodes disease only.
May also be used in palliation

44. Radical Ilioinguinal Lymphadenectomy

45. Radical 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.

46. Radical 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.

47. Radical Ilioinguinal Lymphadenectomy

48. Radical 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.

49. Radical 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.

50. Key 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.

51. Key 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.

52. Key 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.

53. Male Urethral Cancer

54. Male Urethral Carcinoma
Rare and presents in the 5th decade of life.
Etiology is typically secondary to chronic inflammation.
STDs
Urethritis
Urethral stricture
HPV 16

55. Male Urethral Carcinoma
Insidious onset
50% have stricture
25% have STD history
96% symptomatic
Palpable urethral mass
Obstructive voiding symptoms

56. Male Urethral Carcinoma

57. Pathology Bulbomembranous – 60% Penile – 30% Prostatic – 10% SCC – 80%
TCC – 15%
Adenocarcinoma – 5%

58. Pathology Direct extension Lymphatic invasion
Anterior – superficial and deep inguinal, and occasionally external iliac nodes
Posterior – pelvic lymph nodes
Palpable lymph nodes are present 20% of the time and usually represent metastatic disease

59. Evaluation & Staging Primary tumor (T) (male and female)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Ta Noninvasive papillary, polypoid, or verrucous carcinoma
TisCarcinoma in situ
T1 Tumor invades subepithelial connective tissue
T2 Tumor invades any of the following: corpus spongiosum, prostate, periurethral muscle
T3 Tumor invades any of the following: corpus cavernosum, beyond prostatic capsule, anterior vagina, bladder neck
T4 Tumor invades other adjacent organs
Transitional cell carcinoma of the prostate
Tis-pu Carcinoma in situ, involvement of the prostatic urethra
Tis-pd Carcinoma in situ, involvement of the prostatic ducts
T2 Tumor invades any of the following: prostatic stroma, corpus spongiosum,
periurethral muscle
T3 Tumor invades any of the following: corpus cavernosum, beyond prostatic
capsule, bladder neck (extraprostatic extension)
T4 Tumor invades other adjacent organs (invasion of the bladder)

60. Evaluation & Staging 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

61. Treatment Primarily a surgically treated disease process
Anterior urethral lesion is more amendable to surgical control
Posterior disease
Associated with extensive local invasion
Distant mets

62. Carcinoma of the Penile Urethra
Superficial, papillary, low-grade tumors
TUR
Local excision
Infiltrating
Lesions located to distal half of penis
Partial penectomy with 2 cm margin
Lesions proximal
Total penectomy

63. Carcinoma of the Penile Urethra

64. Carcinoma of the Penile Urethra
Prophylactic inguinal lymph node dissection (LND) offers no benefit

65. Carcinoma of the Bulbomemebranous Urethra
Poor survival figures for all recorded forms of treatment
Radical surgery offers best longer-term prognosis
Radical cystoprostatectomy
Pelvic lymphadenectomy
Total penectomy
Pubic rami resection
GU diaphragm excision

66. Carcinoma of the Bulbomemebranous Urethra

67. Radiation Therapy & Chemotherapy
XRT
Early-stage lesions of the anterior urethra
Preserves skin
Results are undetermined
Chemo
MVAC good for TCC lesions
Platinum based therapy
Results poor
Combo therapy
XRT and Chemo
Surgery and Chemo

68. Management of the Urethra after Cystectomy
General Considerations
Cancer recurrence following cystoprostatectomy
2.1 – 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 year
18 months median

69. Management of the Urethra after Cystectomy
Traditionally urethral wash was acceptable
Survival benefit has been questioned
Patients who have positive voided cytology or symptoms:
Urethral bleeding
Discharge
Palpable mass
Cystoscopy and Biopsy
Superficial recurrence can be treated with BCG via urethral perfusion

70. Total 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.

71. Total Urethrectomy after Orthotopic Diversion
Abdominal perineal approach
Can use previous bowel for diversion
Careful dissection to preserve blood supply
Commonly perform ileal conduit, but carefully selected patient may undergo a continent reservoir creation

72. Urethrectomy after Cystoprostatectomy

73. Key Points: Male Urethral Cancer
80% of male urethral cancers are SCC
Bulbomembranous urethra most common site
Anterior urethral carcinoma
More amenable to surgical control
Better prognosis
Posterior urethral carcinoma
Extensive local invasion
Distant metastasis

74. Key Points: Male Urethral Cancer
Prophylactic inguinal lymph node dissection has no benefit
Low incidence of urethral recurrence after orthotopic bladder replacement
Negative frozen-section biopsy of the distal prostatic urethral margin during surgery

75. Key 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.

76. Female Urethral Cancer

77. Epidemiology, Etiology, & Clinical Presentation
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)

78. Epidemiology, Etiology, & Clinical Presentation
Leukoplakia, chronic irritation, caruncles, polyps, partuition, HPV, other viral infection
Urethral diverticula
5% of CA
Predisposition?

79. Epidemiology, Etiology, & Clinical Presentation
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…..)

80. Epidemiology, Etiology, & Clinical Presentation
Patterns of Spread
Local
Direct extension, may skin/vulva
If proximal may extend:
Posteriorly into vagina
Proximally into bladder
Lymphatic involvement:
presentation (palpable nodes)
½ of pts with advanced/proximal tumors
Hematogenous
Lung, liver, bone, brain

81. Anatomy & Physiology Anterior (distal 1/3) Posterior (proximal 2/3)
Can maintain continence with excision
Posterior (proximal 2/3)

82. Anatomy & Physiology Histology of urethra Epithelium Proximal 1/3
Transitional urothelium
Distal 2/3
Stratified squamous
Glands
Columnar epithelium
Lymphatics
Post urethra
External/internal illiac, obturator
Ant urethra/ labia
Superficial/deep inguinal

83. Anatomy & Physiology Histology of Neoplasm SCC 50-70% TCC 10%
Adenocarcinoma 25%
Glandular origin
Associated with diverticula
Rare: lymphoma, neuroendocrine, sarcoma, paragangliomas, melanoma, metastasis

84. Diagnosis & Staging Evaluation Staging Cysto, EUA, CT A/P, CXR
+/- MRI for extension
Staging
TNM (see male)
Pelvic LN mets:
20%
Distant LN mets:
15%
Palpable nodes:
30% overall
Confirmed malignancy: 90%
50% of proximal or advanced CA

85. Treatment & Prognosis Prognosis Treatment
No survival difference based on histological subtype
Treatment
Tumor location
Clinical stage

86. Treatment Local excision vs extensive surgery Survival facts
Small, distal urethral tumors, superficial
Survival facts
5 yr DSS (disease specific survival)
71% (distal)
48% (proximal)
24% (large urethral lesions)
Overall survival (Surgery, XRT)
30-40%
Unchanged in 50yrs

87. Treatment
Options
Surgery, XRT, chemo, combo
Multimodality preferred
5-6 yrs: (Early urethral CA in women, Table 32-2)
XRT (42 pts) 30%
Surgery (14 pts) 10%
Combo (3 pts) 2%

88. Treatment Distal Urethral CA
Small, exophytic, superficial tumor from urethral meatus:
Options:
Circumferential excision of distal urethra & portion of anterior vaginal wall
Laser coag described (small, distal tumors)
Urethrectomy & diversion
Anterior vaginal wall, periurethral tissues to bladder neck
Ileovesicostomy, appendicovesicostomy to native bladder

89. Treatment Facts, surgical data: Distal tumor
Low stage
Cure rate 70-90% with local excision
21 % 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)

90. Treatment
Complications
Meatal stenosis
SUI (DiMarco 2004)

91. Treatment Radiation Low stage distal urethral CA
5 yr DSS 41% (Gordon 1993)
74% (part of urethra involved)
55% (entire urethra involved)

92. Treatment Delivery XRT, Brachy, Combination Results Complications
Combo
Fewer failures (14%) than all radiation Rx patients (36%) & surgery alone (60%) (University of Iowa)
Complications
20-40%
UI, strictures, necrosis, fistulas, cystitis, cellulitis
Prognosis
5 yr survival: surgery, radiation “similar” (Foens, 1991)

93. Treatment Various Rx: Advanced stage urethral CA (Table 32-3)
Radiation: 25 people, 28% survival, 5-6 yrs
Surgery: 13 people, 15% survival, 5-6 yrs
XRT + Surgery: 20 people, 5% survival, 5-6 yrs
XRT+Chemo+Surg: 6 people, 50% survival, 2 yrs

94. Treatment Ilioinguinal lymphadenectomy Significant morbidity
Systemic spread without regional LN involve
No improved survival after pelvic, inguinal LADN
Can’t predict micrometastatic LN involvement
Recommend: no prophylactic or diagnostic LND
Candidates for LND
(+) inguinal, pelvic LAD on presentation without distant mets
Pts who develop regional LAD during surveillance

95. Treatment Proximal female urethral CA Facts More likely high stage
Advanced female urethral CA involves:
Proximal location, entire urethra
Locally invasive lesion: external genitalia, vagina or bladder
Multimodal Rx is the rule
Prognosis
With anterior exenteration: 10-17% (5 yrs)
Local recurrence 67%

96. Treatment Proximal female urethral CA
Anterior exenteration, pelvic LN dissection (standard bladder + Cloquet’s node), wide vaginal or complete vaginal excision for (-) margins
PRN: partial vulvectomy, labial excision
PRN: pubis resection

97. Treatment Prognosis Radiotherapy alone Combo (XRT + surgery)
0-57% survival (5 yrs)
Combo (XRT + surgery)
Mean survival 54% (5 yrs)
Chemo + XRT + surgery
Local, distant control in advanced CA
SCC
5 FU + Mitomycin C
TCC
MVAC or Gemcitabine

98. Urethral recurrence after Cystectomy in women
Facts
Incidence 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)

99. Urethral 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 diversion
Conversion to cutaneous urinary conduit with bowel from orthotopic diversion

100. Surgery of Penile and Urethral Carcinoma
Campbell’s Urology Chapter 32
W. Britt Zimmerman
April 15, 2009