Surgery of Penile andUrethral Carcinoma

Campbell’s Urology Chapter 32

W. Britt Zimmerman

April 15, 2009

Surgery of Penile & Urethral Carcinoma

• Penile Cancer

• Male Urethral Cancer

• Female Urethral Cancer

Penile Cancer

• Typically Squamous

• Involves:– Glans penis– Coronal Sulcus– Inner preputial skin

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

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

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

Laser Therapy

• Nd:YAG– 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

Laser Therapy

• KTP– Wavelength: 532 nm– Intermediate depth

• Between CO2 and Nd:YAG

– Healing time: 8 – 12 weeks

Laser Therapy

• Technical improvements– 5% Acetic acid wraps– 5-aminolevulinic acid

• Final thoughts– Reasonable for Tis and T1 SCC– T2 patients refusing aggressive surgery

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%

Mohs Micrographic Surgery

• Best suited for small superficial cancers

• Comparable to partial penectomy– In the right setting

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

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%

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.

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

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

Partial Penectomy

• Most common surgical procedure for treatment of patients primary SCC

• Penile amputation– 2 cm proximal to the tumor– Goals

• Voiding• Sexual function

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.

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

Partial Penectomy

• Skin coverage– Scrotal flaps– Z-plasty

• Glans reconstruction– Skin grafts– Pedicle flaps

Penectomy

• Local recurrence rates– 0 – 8%

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

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.

Perineal Urethrostomy

Perineal Urethrostomy

Perineal Urethrostomy

Perineal Urethrostomy

Foley left for 7 – 10 days

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.

Radical Penectomy

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%

Inguinal Anatomy

• Lymph nodes– Superficial– 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)

Superficial lymph nodes (5 groups)

Figure 32-14 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.

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

Deep Inguinal Nodes

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

Inguinal Anatomy

• Femoral nerve– Deep to iliacus fascia– Motor

• Pectineus• Quadriceps femoris• Sartorius

– Sensation• Anterior thigh

Inguinal Anatomy

• Femoral triangle:– Inguinal ligament – superiorly– Sartorius muscle – laterally– Adductor longus muscle – medially

– Floor• Pectineus (medially) and iliopsoas (laterally)

Sentinel Node Biopsy

• First describe by Cabanas in 1977

• Results a have been variable

Modified Inguinal Lymphadenectomy

• Catalona 1988– Same therapeutic benefit– Less morbidity– Key aspects

1. Shorter skin incision

2. Excludes the area lateral to the femoral artery and caudal to the fossa ovalis

3. Saphenous vein preservation

4. Elimination of sartorius muscle transposition

Modified Inguinal Lymphadenectomy

Figure 32-17 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.)

Modified Inguinal Lymphadenectomy

Figure 32-18 Modified inguinal lymphadenectomy. Lymph node packet is medial to the femoral artery and includes superficial and deep inguinal nodes.

Modified Inguinal Lymphadenectomy

Figure 32-19 Intraoperative photograph of right inguinal region after modified lymphadenectomy. SC, spermatic cord; V, femoral vein; S, saphenous vein; AL, adductor longus.

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

Radical Ilioinguinal Lymphadenectomy

Radical Ilioinguinal Lymphadenectomy

Figure 32-21 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.

Radical Ilioinguinal Lymphadenectomy

Figure 32-22 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.

Radical Ilioinguinal Lymphadenectomy

Radical Ilioinguinal Lymphadenectomy

Figure 32-25 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.

Radical Ilioinguinal Lymphadenectomy

Figure 32-27 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.

Figure 32-26 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.

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.

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.

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.

Male Urethral Cancer

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

Male Urethral Carcinoma

• Insidious onset

• 50% have stricture

• 25% have STD history

• 96% symptomatic– Palpable urethral mass– Obstructive voiding symptoms

Male Urethral Carcinoma

Pathology

• Bulbomembranous – 60%

• Penile – 30%

• Prostatic – 10%

• SCC – 80%

• TCC – 15%

• Adenocarcinoma – 5%

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

Evaluation & StagingPrimary 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 T1 Tumor invades subepithelial connective tissue 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)

Evaluation & 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

dimension

Distant metastasis (M)MX Presence of distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis

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

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

Carcinoma of the Penile Urethra

Carcinoma of the Penile Urethra

Prophylactic inguinal lymph node dissection (LND) offers no benefit

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

Carcinoma of the Bulbomemebranous Urethra

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

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

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

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.

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

Urethrectomy after Cystoprostatectomy

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

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

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.

Female Urethral Cancer

Epidemiology, Etiology, & Clinical Presentation

• Epidemiology– 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)

Epidemiology, Etiology, & Clinical Presentation

• Etiology– Leukoplakia, chronic irritation, caruncles, polyps,

partuition, HPV, other viral infection– Urethral diverticula

• 5% of CA – Predisposition?

Epidemiology, Etiology, & Clinical Presentation

• 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…..)

Epidemiology, Etiology, & Clinical Presentation

• Patterns of Spread– Local

• Direct extension, may ulcerate @ skin/vulva• If proximal may extend:

– Posteriorly into vagina

– Proximally into bladder

– Lymphatic involvement:• 1/3 @ presentation (palpable nodes)• ½ of pts with advanced/proximal tumors

– Hematogenous• Lung, liver, bone, brain

Anatomy & Physiology

• Anterior (distal 1/3)– Can maintain

continence with excision

• Posterior (proximal 2/3)

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

Anatomy & Physiology

• Histology of Neoplasm– SCC 50-70%– TCC 10%– Adenocarcinoma 25%

• Glandular origin• Associated with diverticula

– Rare: lymphoma, neuroendocrine, sarcoma, paragangliomas, melanoma, metastasis

Diagnosis & Staging

• Evaluation– 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

Treatment & Prognosis

• Prognosis– No survival difference based on histological

subtype

• Treatment– Tumor location– Clinical stage

Treatment

• Local excision vs extensive surgery– 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

Treatment

• Options– Surgery, XRT, chemo, combo– Multimodality preferred

• Survival @ 5-6 yrs: (Early urethral CA in women, Table 32-2)– XRT (42 pts) 30%– Surgery (14 pts) 10%– Combo (3 pts) 2%

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

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)

Treatment

• Complications– Meatal stenosis– SUI (DiMarco 2004)

Treatment

• Radiation– Low stage distal urethral CA– 5 yr DSS 41% (Gordon 1993)

• 74% (part of urethra involved)• 55% (entire urethra involved)

Treatment

• Delivery– XRT, Brachy, Combination– Results

• 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)

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

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

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%

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

Treatment

• Prognosis– Radiotherapy alone

• 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

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)

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

Surgery of Penile andUrethral Carcinoma

Campbell’s Urology Chapter 32

W. Britt Zimmerman

April 15, 2009