Preoperative Preparation and Planning
Penile cancer is a relatively uncommon diagnosis among men in the United States and Europe and primarily occurs in older uncircumcised men and in locations with poor hygiene. Risk factors include human papilloma virus, poor hygiene, smoking, and number of sexual partners. Often there is a delay in diagnosis; thus, most invasive penile cancers are fairly obvious ( Fig. 132.1 ). Before total penectomy is to be undertaken, the diagnosis should be confirmed histologically with a biopsy to assess for depth of invasion and tumor grade. Excisional biopsy may also be obtained at the time of surgery on frozen section, particularly for cases when the diagnosis is not in doubt. Total penectomy is indicated when penile tumors have significant size or are in a location that prevents adequate surgical margins. In addition, it may be indicated when preservation of adequate phallus for voiding from a standing position is not achievable.
A thorough staging workup, including careful palpation of the inguinal nodes and a computed tomography scan of the chest, abdomen, and pelvis, should be performed before surgery. These studies can identify the presence and extent of lymph node metastasis or distant metastases, the most important elements for determining survival and treatment after total penectomy. In addition, laboratory evaluation should be performed with careful attention to calcium values, which may need correction before surgery in patients with advanced penile cancer. Because many advanced penile tumors are also associated with secondary infection, it is important to treat these patients with antibiotics before surgical intervention.
Patient Positioning and Surgical Incision
Place the patient in an exaggerated dorsolithotomy position (similar to that for a perineal prostatectomy). Make sure to adequately pad the leg to prevent injury to the peroneal nerve, which can result in foot drop. Isolate and drape the lesion by sewing a surgical glove in place over the penis or tumor with a silk tie or by placing a condom over the penis ( Fig. 132.2 ). Make an elliptical incision around the penis ( Fig. 132.3 ).
Dissect through the subcutaneous tissue dorsally with the electrocautery. Plan to transect the corpora near the level of the pubis.
Divide the suspensory ligaments to the penis with electrocautery and ligate the superficial dorsal vasculature of the penis with 2-0 ties.
Open the Buck fascia on the ventral aspect of the penis to identify the urethra. Dissect the urethra sharply away from the corporal bodies using Metzenbaum scissors, leaving plenty of length to reach the perineum for the eventual perineal urethrostomy. Divide the urethra sharply to maintain healthy blood supply, and tag the distal end at the 12 o’clock position with a 3-0 silk suture. Continue the dissection of the urethra off of the proximal corporal bodies back to the pubic ramus ( Fig. 132.4 ).