1. DEFINITION:
The amputation of the penis is a debulking surgery whose purpose is to remove totally or partially the organ, when it is the seat of a malignant tumor.
The inguinal lymphadenectomy is a debulking surgery to remove all of the inguinal lymph nodes, both surficial and deep ones, on both sides. The iliac lymphadenectomy allows the removal of lymph nodes located in the vicinity of the small pelvis vessels, bilaterally.
The lymphadenectomy is a completion of the amputation of the penis, which is necessary in selected cases, and may be performed either in the same surgical session, or in a subsequent session.
2. INDICATIONS
The most frequent type of penile cancer is the “squamous cell carcinoma”, which originates from the skin and affects in most cases the glans and, less frequently, the prepuce (the skin covering the glans in subjects not being subjected to circumcision).
The amputation of the penis removes the tumor with a “safety margin” of 2 cm of healthy tissue. The partial or total amputation extension should therefore be appropriate, to the area, to the size and to the tumor infiltration of the penile structures.
In selected cases, where the tumor is localized to the superficial epidermal layer (intraepithelial neoplasia) you can use a conservative treatment (local removal of the tumor) retaining the penis.
The tumor tends to metastasize through the lymphatic involvement of, in progression, the superficial inguinal lymph nodes, the deep ones and finally those inside the abdomen (iliac and shutters).
The lymphadenectomy has a dual purpose: firstly therapeutic, and secondly staging (definition of the tumor extension). The presence, number and type of the lymph nodes involvement by the tumor are the best predictive factors regarding the recovery from tumor disease.
When the lymph nodes are not palpable inguinal lymphadenectomy will be reserved for patients at high risk of lymph node involvement (tumors that demonstrate involvement of vessels or lymphatics, tumors that infiltrate deep into the structures of the penis).
When the inguinal lymph nodes are palpable (at the time of diagnosis of the tumor or in the period subsequent to the first surgery control) it is strongly recommended lymphadenectomy, which should be extended to the pelvic lymph nodes based on histological examination.
3. DESCRIPTION OF THE TECHNIQUE
PARTIAL PENECTOMY:
An hemostatic tourniquet is applied to the base of the penis. An incision is made at least 2 cm away from the tumor. Corpora cavernosa and the urethra are lanced and resected. The urethra is left 1 cm longer than the corpora cavernosa. Vessels are closed, corpora cavernosa ends are closed and the skin is sutured in order to adapt it to the urethral meatus and to cover the corpora cavernosa. A urinary catheter is put in place.
In special cases, when the tumor is confined to the penis glans and does not present a clear infiltration in depth, it is possible to confine the amputation to the glans only. In this case, the corpora cavernosa are spared maintaining a greater length of the penis.
TOTAL PENECTOMY:
An hemostatic tourniquet is applied to the base of the penis. An oval incision is done at the base of the penis. The vessels of the penis are tied. The urethra is isolated and dissected at the bulb level. The corpora cavernosa are dissected of the penis to the crura level (where they are located in the inner part). A small incision is created at the perineal level (between the base of the testicles and the anus) and the stump of the urethra is sutured at this level. A urinary catheter is placed. The previously made incision around the base of the penis is closed leaving one or two small drainage pipes.
ILIO-INGUINAL LYMPHADENECTOMY:
It comprises three incisions: one median abdominal extended from the navel to the pubis and two oblique incisions at the root of both lower limbs. Through the abdominal incision we proceed to ILIAC LYMPHADENECTOMY, removing, on both sides, the lymph node tissue which is located along the course of the vessels. The dissection is also extended to the lymph node tissue that lies in the femoral canal (where the abdominal vessels go toward the thigh). A drainage pipe is positioned on both sides. It is made to go out laterally w.r.t. the median incision. By the incisions at the root of the lower limbs we proceed to the INGUINAL LYMPHADENECTOMY. It involves the removal of all lymph tissue located in a squared area at the root of the thigh, both on the surface and more deeply, in the vicinity of the femoral vessels. A drainage tube should be left in the site of dissection. The partial penectomy can be performed under local anesthesia. All other techniques must be performed in local anesthesia (spinal) or general.
4. PREPARATION
An antibiotic prophylaxis should always be practiced.
In anticipation of a lymphadenectomy is recommended a thrombosis prophylaxis with heparin, especially for patients at risk.