Preoperative Preparation and Planning
Partial penectomy is the surgical standard of care for invasive tumors of the mid to distal penis. A distance of 2 cm from the surgical margin of resection has been historically recommended as a primary goal to achieve optimal cancer control; however, acceptable local recurrence rates can be obtained with a surgical margin of 1 cm. Microscopic invasion of penile carcinoma has been shown to be influenced by tumor grade and should be considered when determining the final extent and margin of surgical resection.
The primary goal of partial penectomy is cancer control. A secondary goal includes preservation of the ability to void in the standing position. The length of penile shaft remaining after partial penectomy can be variable. Approximately 3 cm has been suggested as a minimal acceptable penile length for optimal functional outcomes. Voiding from a penile stump that is too short to control a urinary stream may be less desirable than voiding through a perineal urethrostomy. Total penectomy with reconstruction of a perineal urethrostomy should be considered when negative surgical margins cannot be achieved with partial penectomy or in cases when the remaining penile stump is too short to effectively direct the urinary stream.
Patient Positioning and Surgical Incision
The patient is placed in a supine position. After the area is prepped and draped in the standard fashion, the lesion may be excluded from the surgical field with a surgical glove or towel. A tourniquet is applied to the base of the penis using a Penrose drain, a red rubber catheter, or plastic tubing. A Foley catheter can be inserted at the beginning of the procedure to facilitate mobilization of the urethra during surgery.
A circumferential incision is made along the penile shaft skin 1.5 to 2 cm proximal to the lesion ( Fig. 131.1, A ). The incision is carried down from the skin to the level of the Buck fascia ( Fig. 131.1, B ). The superficial and deep dorsal veins are ligated and divided. The Buck fascia is incised to the level of the tunica albuginea of the corpora cavernosa.
The corpora cavernosa are divided, leaving the corpus spongiosum intact ( Fig. 131.2 ). The tourniquet can be temporarily released to identify bleeding vessels, which can be oversewn with absorbable suture. Tissue can be obtained from the penile stump for frozen section analysis.