Surgery of Penile and Urethral Carcinoma

1
Surgery of Penile andUrethral Carcinoma

• Campbells 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)
• Neodymiumyttrium-aluminum-garnet (NdYAG)
• 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

• NdYAG
• 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 NdYAG
• Healing time 8 12 weeks

9
Laser Therapy

• Technical improvements
• 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)
• lt 1 cm 100
• 1 2 cm 83
• 2- 3 cm 75
• gt 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
• 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.
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Perineal Urethrostomy
25
Perineal Urethrostomy
26
Perineal Urethrostomy
27
Perineal Urethrostomy
Foley left for 7 10 days
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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
• 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)

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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.
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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

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Deep Inguinal Nodes
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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

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Inguinal Anatomy

• Femoral nerve
• Deep to iliacus fascia
• Motor
• 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 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 19977954-57.)
41
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.
42
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.
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 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.
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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.
47
Radical Ilioinguinal Lymphadenectomy
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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.
49
Radical Ilioinguinal Lymphadenectomy
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.
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.
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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.

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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

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Male Urethral Carcinoma

• Insidious onset
• 50 have stricture
• 25 have STD history
• 96 symptomatic
• Palpable urethral mass
• Obstructive voiding symptoms

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Male Urethral Carcinoma
57
Pathology

• Bulbomembranous 60
• Penile 30
• Prostatic 10
• SCC 80
• TCC 15
• Adenocarcinoma 5

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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

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Evaluation Staging
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

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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

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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

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Carcinoma of the Penile Urethra
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Carcinoma of the Penile Urethra

• Prophylactic inguinal lymph node dissection (LND)
  offers no benefit

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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

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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

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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.

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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

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Urethrectomy after Cystoprostatectomy
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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

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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

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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.

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Female Urethral Cancer
77
Epidemiology, Etiology, Clinical Presentation

• Epidemiology
• more in women, 41
• Only urological malignancy with female
  predominance
• 0.2 of all GU malignancies
• lt1 of CA of female GU tract
• 85 occurs in white women ( of 1200 cases
  reported)

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Epidemiology, Etiology, Clinical Presentation

• Etiology
• Leukoplakia, chronic irritation, caruncles,
  polyps, partuition, HPV, other viral infection
• Urethral diverticula
• 5 of CA
• Predisposition?

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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..)

80
Epidemiology, Etiology, Clinical Presentation

• Patterns of Spread
• Local
• Direct extension, may ulcerate _at_ skin/vulva
• If proximal may extend
• Posteriorly into vagina
• Proximally into bladder
• Lymphatic involvement
• 1/3 _at_ presentation (palpable nodes)
• ½ of pts with advanced/proximal tumors
• Hematogenous
• Lung, liver, bone, brain

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Anatomy Physiology

• Anterior (distal 1/3)
• Can maintain continence with excision
• Posterior (proximal 2/3)

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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
• 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
• No survival difference based on histological
  subtype
• Treatment
• Tumor location
• Clinical stage

86
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

87
Treatment

• Options
• Surgery, XRT, chemo, combo
• Multimodality preferred
• Survival _at_ 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 lt 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
• 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
• XRTChemoSurg 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
• Cant 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 Cloquets node), wide vaginal
  or complete vaginal excision for (-) margins
• PRN partial vulvectomy, labial excision
• PRN pubis resection

97
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

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 andUrethral Carcinoma

• Campbells Urology Chapter 32
• W. Britt Zimmerman
• April 15, 2009