Scrotal anatomy

The skin of the scrotum can be divided into an anterior and a posterior aspect, each with distinct neurovasculature. The anterior scrotum is supplied by the deep external pudendal arteries, which branch off the femoral artery and course medially into the scrotum. The posterior scrotum is supplied by the perineal arteries, which branch off the pudendal arteries. The vessels do not cross the median raphe and this allows for a relatively bloodless incision.

The anterior scrotal skin and the posterior scrotal skin have their own dedicated venous drainage that course along with their respective arterial supplies. The anterior surface is drained via the external pudendal veins and the posterior surface by the scrotal branches of the perineal vessels. The lymphatic drainage of the scrotum is supplied by the superficial inguinal lymph nodes for both the anterior and posterior sides. This differs from testicular lymphatics, which drain into the paraortic lymph nodes. The innervation of the scrotal skin is provided by the anterior scrotal nerves, which are branches of the ilioinguinal nerve, and the posterior scrotal nerves, which are branches of the perineal nerve.

Preoperative prophylactic antibiotic and infection management

The American Urologic Association best practice policy guidelines on surgical antimicrobial prophylaxis of the scrotum recommends a single dose of preoperative antibiotics, particularly in patients with certain risk factors for infection ( Table 1 ). This is owing, in part, to the scrotal surgical infection rate being comparatively low, ranging from 0% to 10%. The recommended prophylactic antibiotic of choice is a first-generation cephalosporin or clindamycin as an alternative.

Traditionally, hair has been removed preoperatively to reduce the risk of surgical site infections, although recent studies indicated that this may not be necessary. A recent analysis of randomized, controlled trials compared hair removal with no removal, the different methods of hair removal, as well as the different times of hair removal before surgery. No significant difference in surgical site infections was found among patients who had their hair removed and those who did not. In circumstances when removal of hair is necessary, using clippers instead of a razor is associated with fewer surgical site infections.

General thoughts regarding surgical excision

• •
  

  Scrotal cancer most often presents superficially. The skin and dartos of the scrotum is thicker than the respective tissue in the penis, which contributes to the superficial nature of this disease

  
  
• •
  

  As with any surgery for resectable malignancy, the goal is to remove the disease with clear margins (both peripheral and deep). Mohs surgery and frozen sections can be used to ensure adequate margins.

General thoughts regarding reconstruction

• •
  

  The scrotal skin is extremely elastic, which helps to provide coverage for reconstruction. Factors that contribute to a larger scrotum include older age and men with hydroceles.

  
  
• •
  

  Approximately 60% of the scrotal skin can be removed with adequate tissue remaining for primary closure. Primary closure is preferred over skin grafts or flaps when possible.

  
  
• •
  

  Closed suction drains can be considered to prevent the development of fluids collections, such as seromas and hematomas.

Squamous cell carcinoma

• 1.
  

  Biopsy-proven lesions should be excised with 4- to 6-mm clinical margins. Mohs surgery can alternatively be performed.

  
  
• 2.
  

  Margins should be assessed. If positive, surgical reexcision should be performed. If unable to obtain a negative margin, which would be rare, radiation therapy is recommended.

  
  
• 3.
  

  Fine needle aspiration or core biopsy should be performed for palpable regional lymph nodes or abnormal lymph nodes identified on imaging. If positive and operable, regional lymph node dissection should be performed. Radiation therapy should be considered if multiple lymph nodes are involved or if extracapsular extension is present. If regional lymph nodes are positive and inoperable, radiation therapy with or without systemic therapy is recommended.

  
  
• 4.
  

  Excision site can be managed with tension-free primary approximation, skin graft, or flap and, seldom, with healing by secondary intention.

  
  
• 5.
  

  Nonsurgical candidates should receive radiation therapy.

  
  
• 6.
  

  Minimal evidence is available regarding systemic therapy for metastatic disease.

Extramammary Paget’s disease

• 1.
  

  Biopsy-proven lesions should be excised with a wide surgical margin and intraoperative frozen section to ensure complete resection.

  
  
• 2.
  

  The excision site can be managed with primary closure. A simultaneous reconstructive procedure, including a skin graft or flap, can be performed if the defect is unable to be closed primarily.

  
  
• 3.
  

  Imiquimod cream, 5-fluorouracil cream, and CO ₂ laser have been used with variable results. Photodynamic therapy has been used for palliative results.

  
  
• 4.
  

  Of note, traditionally extramammary Paget’s disease was thought to represent adenocarcinoma in situ, arising from the epidermis. However, more advanced disease, including deeper invasion, nodal disease, and metastatic disease have been reported, with 1 large series reporting up to 16.6% of patients with regional or distant disease. Although the role of radiation therapy and chemotherapy is not entirely clear, these modalities have been applied as primary treatment, as adjuvant therapy, and for nonsurgical candidates. It is important to assess for other malignancies, because there may be an association with other underlying malignancies in patients with extramammary Paget’s disease.

Sarcoma

• 1.
  

  Biopsy-proven lesions are treated according to stage.

  
  
  
  
  • A.
    

    For stage I sarcoma, wide local excisional surgery should be performed to obtain adequate negative oncologic margins. Although an adequate margin size is not specified, close margins may be necessary to preserve critical neurovascular and musculoskeletal structures. Failure to obtain adequate oncologic margins can be managed by re-resection or radiation therapy.

    
    
  • B.
    

    For stage IIA sarcoma that is resectable with functional outcomes, surgery, surgery with adjuvant radiation, or neoadjuvant radiation therapy with surgery can be performed.

    
    
  • C.
    

    For stage IIB and III sarcomas that are resectable with functional outcomes, surgery, neoadjuvant radiation therapy and surgery, neoadjuvant chemoradiation and surgery, or neoadjuvant chemotherapy and surgery can be performed. Adjuvant radiation therapy with or without chemotherapy can be given.

    
    
  • D.
    

    For stage II and III sarcomas that are resectable with adverse functional outcomes or unresectable disease, radiation therapy, chemoradiation, chemotherapy, or regional limb therapy can be performed. If the lesion is subsequently resectable with acceptable functional outcomes, surgery should be performed. Adjuvant radiation therapy with or without chemotherapy can be performed.

    
    
  • E.
    

    For nodal involvement, regional lymph node dissection should be performed with or without radiation and chemotherapy.

    
    
  • F.
    

    For metastatic disease to a single organ and limited tumor bulk that is amenable to local therapy, metastasectomy with or without radiation and preoperative or postoperative chemotherapy can be performed. A marginal efficacy has been reported for the use of chemotherapy in localized resectable soft tissue sarcoma with respect to local recurrence, distant recurrence, overall recurrence, and overall survival. Ablation procedures, embolization procedures, stereotactic body radiation therapy, or observation can also be considered.

    
    
  • G.
    

    For disseminated metastatic disease, palliation should be considered. Options include chemotherapy, radiation therapy, surgery, observation, supportive care, ablation procedures, or embolization procedures.

  
  
  
  
• 2.
  

  The excision site can be managed with tension-free primary approximation, skin graft, or flap; it is seldom healed by secondary intention.

  
  
• 3.
  

  For spermatic cord sarcoma, a radical inguinal orchiectomy with high ligation of the spermatic cord is recommended. Wide circumferential margins may be difficult to obtain because of anatomic constraints. Partial scrotectomy and resection of the surrounding tissues may be necessary. The major pattern of failure for spermatic cord sarcoma is local recurrence. Combined surgery and radiation may be considered in patients who are at high risk (lesions >5 cm) for local failure.

Basal cell carcinoma

• 1.
  

  Biopsy-proven lesions should be excised with 4-mm clinical margins. Mohs surgery can be performed alternatively.

  
  
• 2.
  

  Margins should be assessed. If positive, surgical reexcision should be performed. If unable to obtain a negative margin, radiation therapy is recommended. If margins are negative but extensive perineural or large nerve involvement is present, radiation therapy is recommended.

  
  
• 3.
  

  No guidelines from the National Comprehensive Cancer Network are available for regional lymphadenopathy for basal cell carcinoma. Surgical management can be extrapolated from treatment of regional lymphadenopathy in squamous cell carcinoma. Fine needle aspiration or core biopsy should be performed for palpable regional lymph nodes or abnormal lymph nodes identified on imaging. If positive and operable, regional lymph node dissection should be performed. Radiation therapy should be considered if multiple lymph nodes are involved or if extracapsular extension is present. If regional lymph nodes are positive and inoperable, radiation therapy with or without systemic therapy is recommended.

  
  
• 4.
  

  The excision site can be managed with tension-free primary approximation, skin graft, or flap; it is seldom healed by secondary intention.

  
  
• 5.
  

  Nonsurgical candidates should receive radiation therapy.

  
  
• 6.
  

  Recent developments in systemic therapy, such as Hedgehog pathway inhibitor, may be an option for metastatic disease. Minimal evidence is available regarding chemotherapy.

Melanoma

• 1.
  

  Biopsy-proven lesions are treated according to stage. Scrotal melanoma management can be guided by the profusion of data on other skin melanoma sites, because no data specifically exist for scrotal-only melanomas.

  
  
  
  
  • A.
    

    For stage 0 or IA and IB (<0.75 mm thick), wide excision should be performed based on tumor thickness.

    
    
  • B.
    

    For stage IA (0.76–1.00 mm thick), wide excision should be performed and consider sentinel lymph node biopsy. If sentinel lymph node biopsy is positive, see stage III.

    
    
  • C.
    

    For stage IB (0.76–1.00 mm thick) or stage II (>1.00 mm thick), wide excision should be performed and consider sentinel lymph node biopsy. If sentinel lymph node biopsy is positive, see stage III. If sentinel lymph node biopsy is negative, adjuvant therapy such as clinical trials, observation, or possibly interferon alfa can be considered.

    
    
  • D.
    

    For stage III (positive sentinel node), perform complete lymph node dissection. Adjuvant therapy clinical trials, observation, interferon alfa, or high-dose ipilimumab can be considered. Newer immunotherapy agents, including PD-1 inhibitors such nivolumab and pembrolizumab, are currently being evaluated. They have preliminarily been shown to improve overall survival.

    
    
  • E.
    

    For stage IV (metastatic disease) that is resectable, surgical resection should be performed. Systemic therapy can also be considered. For metastatic disease that is unresectable, options include systemic therapy, clinical trials, intralesional injection, or palliative resection with or without radiation therapy.

  
  
  
  
• 2.
  

  Excision site can be managed with tension-free primary approximation, skin graft, or flap and seldom, with healing by secondary intention ( Table 2 ).

  
  
  
  

  Table 2

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