Purpose: To describe the technique and results of penis-sparing surgery combined with a cosmetic neo-glans reconstruction for benign, premalignant or malignant penile lesions.
Material and Methods: Twenty-one patients (mean age 61 years) with penile lesions of broad-spectrum histopathology underwent organ-sparing surgery with neo-glans reconstruction using a free split-thickness skin graft (STSG) harvested from the thigh. Three cases were treated by glans-skinning and glans-resurfacing, 10 by glansectomy and neo-glans reconstruction, 4 by partial penectomy and a neo-glans reconstruction, and 4 by neo-glans reconstruction after a traditional partial penectomy.
Results: Mean follow-up was 45 months. All patients were free of primary local disease. All patients were satisfied with the phallic post-operative appearance and recovered their sexual ability, although sensitivity was reduced as a consequence of glans/penile amputation.
Conclusion: In benign, pre-malignant or malignant penile lesions, penis-sparing surgery combined with a cosmetic neo-glans reconstruction may assure a normally-appearing and functional penis, while fully-eradicating the primary local disease.
Penile neoplasm is an uncommon malignancy affecting less than 1 out of 100,000 males in Europe and in the USA. Seventy-eight percent of all tumours appear on the glans and/or prepuce [ 1, 2 ]. Many of these lesions are red, moist patches which can be misdiagnosed as either a benign skin condition (i.e. Zoon’s balanitis or lichen planus) or a premalignant lesion such as the lichen sclerosus (LS) that, if left untreated, has the risk of progression to invasive squamous cell carcinoma in 5 to 33% of the cases [ 3 ]. Above all, both benign, premalignant and malignant lesions may cause pruritus, pain, bleeding, crusting and difficulties in retracting the foreskin with overall psychosexual disability.
The treatment of the benign, premalignant and malignant penile lesions has changed over time [ 4, 5 ]. Traditional penile surgery is associated with a mutilating approach, eventually characterized by a high incidence of aesthetic, dysfunctional and psychological post-operative disorders [ 6 – 8 ]. In this context, the use of either medical or topical surgical treatments has been supported with the specific aim to maintain a good functional and aesthetic penile shaft; topical chemotherapy, laser ablation, cryotherapy, and local excisions have been thus reported in the scientific literature [ 3, 4 ]. However, these techniques are associated with high failures rates and unsightly scarring that impacts penile appearance and sexual activity.
Recently, in patients with either premalignant or malignant superficial lesions, alternative forms of surgical therapy, specifically aimed at preserving the phallus without jeopardizing local cancer control, have been extensively suggested. These organ-sparing techniques, providing the reconstruction of an aesthetic neo-glans without any impairment of patient’s survival have also been suggested for more advanced tumours [ 1 – 3, 9 ].
We herewith report our surgical experience in 21 patients suffering from either benign, pre-malignant or malignant penile lesions, using a organ-sparing surgery developed to preserve a functional and aesthetic penile shaft at the same time, while fully-eradicating the primary local disease.
2. PATIENTS AND METHODS
From 2002 through 2010, 21 patients (mean age 61 years; range 41-78) with benign, pre-malignant or malignant penile lesions have been treated at our center. Of those, 13 (62%) men had already received previous medical or surgical treatments at different hospitals. All patients underwent pre-operative biopsies in order to confirm the presence of the lesion. Likewise, patients with malignant lesions also underwent a penile magnetic resonance (MRI) to define the local extension of the tumour. Regional and metastatic disease was then clinically assessed with a physical examination and CT. Patients with suspected urethral stricture were evaluated by uroflowmetry, retrograde and voiding cystourethrography and urethroscopy. All patients underwent organ-preserving surgery with cosmetic reconstruction of a neo-glans using a free split-thickness skin graft (STSG) harvested from the thigh via 4 different surgical techniques.
2.1 Glans skinning and glans resurfacing
The penis is circumcised and the penile skin is degloved. The glandular epithelium is fully removed up to the coronal sulcus. The STSG is harvested from the thigh using manual dermatome, to be subsequently transplanted like an umbrella over the bed of the stripped glans. The graft is then tailored and quilted over the glans with multiple 6-zero polyglactin interrupted stitches. The penile skin is sutured to the graft at the coronal sulcus (fig. 1 and 2). This procedure is suitable for crippling benign and premalignant lesions, as well as for malignant lesions which appear limited to the glandular epithelium.
2.2 Glansectomy and neo-glans reconstruction
The penis is circumcised and the penile skin is degloved. The glans is carefully segregated from the corpora cavernosa and the urethra is then distally sectioned. After removing the glans, the urethra is ventrally opened and the external urethral meatus is fixed to the tip of the corpora cavernosa. The STSG is therefore transplanted like an umbrella over the tips of the corpora cavernosa. The graft is tailored and quilted using interrupted stitches over the top of the corpora. Finally, the graft is fixed to the penile skin in order to recreate a neo-sulcus (fig. 3). This procedure is usually suitable for malignant lesions which appear to infiltrate the glans.
2.3 Partial penectomy and neo-glans reconstruction
The partial penectomy is performed with resection margins of only few millimetres, according to the current techniques [ 10 ]. The lateral edges of the residual corpora cavernosa are sutured together to create a hemispheric dome-shaped stump. The urethra is then spatulated and the meatus is fixed on the new tip of the corpora cavernosa. The STSG is transplanted like an umbrella over the summit of the hemispheric stump where it is quilted. The graft is eventually fixed to the penile skin with the aim to recreate a glandular neo-sulcus (fig. 4). This procedure is suitable for malignant lesions which appear to involve the penile shaft.
2.4 Neo-glans reconstruction following previous traditional partial penectomy
The top of the penile stump is skinned and the tip of the residual corpora cavernosa is reconverted to a hemispheric shape. The urethra is spatulated and the meatus is fixed on the new tip of the corpora cavernosa. The STSG is transplanted like an umbrella over the summit of the hemispheric stump where it is quilted. The graft is fixed to the penile skin thus recreating a glandular neo-sulcus (fig. 5). This procedure is suitable for unaesthetic residual penile stumps following previous traditional partial penectomy.
In all cases a 12-Fr silicone Foley catheter is inserted and a soft and humid dressing is applied covering the penis. The dressing is left in place for three days and the patient is requested to remain in bed. Four days after surgery the patient is mobilised and discharged from the hospital if the graft is observed to be in good condition, without penile hematoma, seroma or infection. The current follow-up ranges from 4 to 104 mo (mean 45 mo). Practically, the follow-up assessment has included a careful examination of the external genitalia along with groin inspection and palpation, and a biopsy of any suspicious area of penile induration or reddening on a 6-mo basis. All patients with confirmed malignant tumors have been submitted to a chest x-ray and a full-body CT scan every 12 mo.
Of 21 patients, 3 (14.3%) were respectively treated by glans-skinning and glans-resurfacing, 10 (47.6%) by glansectomy and neo-glans reconstruction, 4 (19.1%) by partial penectomy along with a neo-glans reconstruction, and 4 (19.1%) by neo-glans reconstruction following previous traditional partial penectomy. Table 1 details then surgical and pathological characteristics of the whole cohort of patients. In this context, 11 (52%) patients showed urethral strictures and were eventually treated with a meatotomy or a simple derivative urethrostomy. Four (19.1%) patients came to our referral surgical centre to receive a neo-glans reconstruction after a traditional unaesthetic, partial penectomy for squamous cell carcinoma (SCC).
No significant immediate intra-operative and post-operative complications were observed. Five (23.8%) patients showed partial graft loss and wound separation that was resolved after conservative management. Patients were assessed in terms of subjective satisfaction on a self-reported basis. All men were satisfied with the postoperative aesthetic results of the penile shaft; they also reported to have recovered sexual functioning, although penile sensitivity was eventually reduced as a consequence of either the glandular skinning or glans/penile amputation. Patients who underwent neo-glans reconstruction following previous traditional partial penectomy reported an improvement of the appearance of the penile along with the recovery of their sexual ability.
Finally, no immediate or later complications were observed at the harvesting site. All patients with SCC showed no evidence of local recurrence of the primary tumour. Two (15.4%) of the 13 patients with SCC showed a reddened lesion after primary excision, requiring a biopsy, although the final histology showed no tumour recurrence. All patient with SCC had a clinical N0, M0 stage and were not submitted to a inguinal lymph node dissection at the moment of the penile surgery. In contrast, 3 (23.1%) patients showed bilateral inguinal node enlargement at the 12-mo post-operative CT scan assessment and underwent bilateral groin dissection (namely, patients #4, #7 and #16 as reported in Table 1). Final pathology of the lymph nodes showed a metastatic disease and the patients were then treated with a multimodal approach combining radio- and chemotherapy. Of those, one patient (patient #16) died because of a disease progression, while the other 2 patients are still alive at the most-recently performed follow-up assessment.
Laser ablation or other conservative therapies for penile lesions aim to remove the diseased tissue, but recurrence of the disease may eventually occur in unrecognised pre-malignant foci arising within the unstable epithelium following a partial procedure. Moreover, precancerous lesions often show recalcitrance after conservative treatments, with final evolution to a SCC in 5 to 33% of the cases [ 4, 9, 15 – 17 ]. Recently, plastic and reconstructive surgical techniques have been developed to reduce the functional and psychological morbidity in patients who have undergone mutilating penile surgery [ 1 – 3, 9, 11 – 14 ]. In selected patients, the use of these relatively-new plastic approach with total glans reconstruction provided a satisfactory aesthetic and functional outcome, without sacrificing a rigorous cancer control [ 1 – 3 ]. In this context, when performing a total glans skinning and resurfacing, the epithelium is completely removed, thus reducing the potential risk of either disease recurrence or progression in different sites as compared with the primary lesion [ 3 ].
On the other hand, the partial repair of the glans could easily create a disfiguring and dysfunctional scar.
Moreover, for LS which involves the male genitalia, a progressive crippling disease scar has been frequently described, with the subsequent phimosis which may promote poor local hygiene and chronic inflammatory conditions potentially being the etiological factors promoting penile malignancy (fig. 2) . In this case, LS is frequently associated with dysplasia, thus some authors have suggested that LS should be considered as a formal pre-cancerous lesion [ 15 – 18 ]. Particularly, in our series in 23% of cases the tumour resulted associated with LS, confirming a close correlation between these two penile pathologies. Thus, in case of LS, the total excision of the dysplastic glandular epithelium reduces the risk of cancer developing; likewise, this approach may solve the problem of discomfort during sexual intercourse, which is frequently a consequence of the scarred glans. For glans resurfacing we prefer to not use buccal mucosa (BM). This is because in our experience, when a BM graft was used in staged penile urethroplasty, desquamation of the graft was observed in some patients due to contact of the oral mucosa with air, as BM is accustomed to a humid environment, and not a dry one. In patients with LS, the use of a skin graft could lead to disease recurrence, even if it seems that excision of much of the diseased tissue by ample circumcision reduces this risk. Reconstructive surgery can also be used in benign but invalidating lesions.
For example, in our series, one patient with persistent extensive Zoon’ balanitis was able to resume sexual activity after glans skinning and glans resurfacing. In patients who underwent glansectomy or partial penectomy, length and sensitivity decreased as an inevitable and foreseeable consequence of glans/penile amputation, but the cosmetic appearance of the neo-glans was similar to that of a native glans. The patients were then able to fully regain sexual functioning, with a favourable psychological impact. In these patients, the aesthetic appearance of the penis was subjectively superior as compared with the one of the patients who underwent others traditional techniques, thus promoting a positive psychological impact.
This last aspect is of paramount importance since many patients with penile cancer are significantly reluctant to undergo partial or total penectomy due to the self-feeling of compromised masculinity [ 3 ]. It has been previously reported that roughly 80% of penile malignancies are probably amenable to these penis-preserving techniques, since most of the lesions occur distally and involve only the superficial epithelium of the glans [ 2 ]. In this context, it is important to highlight that in patients with superficial penile cancer associated to pre-cancerous lesions due to LS, any conservative treatment does not actually remove these lesions, thus potentially allowing cancer recurrence over time, which may arise from an unstable epithelium bordering the primary lesion. Therefore, a rigorous patient selection is compulsory in order to technically provide an aesthetic solution with an effective long-term cancer control. As suggested by the EAU Guidelines [ 19 ], in malignant lesions we used the MRI to define the extent of the penile lesion. This exam has been useful in defining if the lesion was limited to the glans or involved the corpora, and therefore directing toward the glansectomy or the partial penectomy. We highlight that 52% of patients with penile lesions showed an urethral stricture requiring a surgical treatment. In 11 cases of urethral stricture, the majority (6 cases) were due to the LS which involved the glans but also the urethra (see Table 1). This confirms the need of a careful urethral evaluation before to plan any genital surgery in these patients. Regarding the assessment of patient satisfaction, similarly to other leading authors [ 20 ], patients were simply interviewed during follow-up. The main limitation of this and other series is the lack of formal data on functional outcome after these techniques. Patients were assessed clinically for cosmesis and were questioned about satisfaction and sexual function but outcomes were not collated using any validated questionnaires. This remains a goal for the future and may be more effectively achieved using surgery-specific Patient Reported Outcome Measures questionnaires.
The penis-sparing surgery coupled with neo-glans reconstruction is an adequate treatment approach in rigorously selected patients with either benign, pre-malignant or malignant penile lesions. While preserving a good aesthetic appearance of the penile shaft, the goal of all these techniques is to maintain a functional penis in terms of both urination and sexual function, without jeopardizing cancer control.
The surgical techniques described in this article were developed and suggested to us by Dr. Aivar Bracka, without whose teaching and guidance it would not have been possible to obtain these positive results.