Aesthetic neo-glans reconstruction after penis-sparing surgery for benign, premalignant or malignant penile lesions

Local Therapy and Reconstruction in Penile Cancer: A Review

Local therapy for penile cancer provides robust survival and can preserve the penis functionally and cosmetically. Interventions must target the appropriate clinical stage. We reviewed studies regarding the primary therapy in penile cancer, from topical therapy to radical penectomy, and reconstructive techniques. Topical therapy (5-FU or Imiquimod) provides a robust oncologic response in patients with Ta or Tis disease. Multiple laser therapies are available for localized patients and those with low-grade T1 disease. There is a non-trivial risk of progression and nodal metastases in poorly selected patients. Wide local excision provides an oncologically sound option in patient with up to T1 disease; less evidence exists for Mohs microsurgery in the setting of penile cancer. Increasingly aggressive approaches include glansectomy and partial/radical penectomy, which provide 5- and 10-year cancer-specific survival rates of over 80%. Meticulous reconstruction is necessary for the durable function of the remaining penis. Preservation of voiding and sexual function occurs via penile skin grafting, glans resurfacing, creation of a functional penile stump, and phalloplasty with a penile implant. Perineal urethrostomy provides an alternative in pathology demanding extensive partial or radical penectomy, and a durable option for seated voiding. Clinical suspicion and timely diagnosis are paramount in terms of management as less-invasive options for earlier-stage disease develop.

Penile Glans Necrosis Following Prostatic Artery Embolization for Benign Prostatic Hyperplasia: Case Series and Review of Current Literature

PURPOSE

To report a case series of 6 patients with penile glans necrosis (PGN) following prostatic artery embolization (PAE) and review the current literature relating to PAE and PGN, including the emerging role of hyperbaric oxygen therapy (HBOT) for PGN.

MATERIALS AND METHODS

All patients have failed medical BPH therapy and chose to undergo PAE over other minimally invasive BPH surgery. Patient demographics, preoperative and postoperative validated questionnaires such as the International Prostate Symptom Severity (IPSS) and International Index of Erectile Function (IIEF) scores, treatment-related adverse events (TRAE) and subsequent treatment for PGN were reviewed. All patients were follow-up with a minimum of 12 months post-PAE.

RESULTS

Between January 2018 and June 2020, six males with a mean age of 52.3 years (44-66 y) received PAE for BPH therapy. An immediate postoperative PGN was recognised in 4 out of 6 patients with the mean penile glans pain score of 3 and 4 patients reported altered penile glans sensitivity. Comparing the mean (and median) IPSS and IIEF-5 scores were 16.5 (16) and 21.3 (21) pre-PAE, there was improvements in IPSS and IIEF-5 scores at 12.0 (12) and 18.0 (18) at 12 months review. All patients reported normal penile glans sensitivity and only 1 patient reported an on-going penile glans pain (score 2). Four patients received HBOT while 2 patients elected for conservative care. All patients reported worse erectile function scores despite complete resolution of PGN.

CONCLUSIONS

PGN is a rare but serious complication of PAE with ensuing erectile dysfunction. HBOT appears to expedite the recovery process in men with PGN related to PAE with better erection scores compared to conservative measure.

Glansectomy and Reconstruction for Penile Cancer: A Systematic Review

Penile cancer (PeCa) is a rare disease, with a global incidence of 36068 new cases reported in the 2020 GLOBOCAN database. Narrower excision margins are now acceptable without compromising survival. Glansectomy is commonly performed for invasive PeCa confined to the glans penis. The majority of data on glansectomy are from small single-centre series. We provide a contemporary update on the outcomes of glansectomy via a systematic review of glansectomy for PeCa. Overall, 20 studies were included in the analysis. The local recurrence rate was 2.6-16.7%. The incidence of salvage penectomy for positive margins and/or recurrence was 1.2-8.3%. The disease-specific survival rate was 89-96.6%. A split-thickness skin graft was commonly used to reconstruct a neoglans and the graft loss rate was 1.5-23.5%. The incidence of meatal stenosis was 2.8-14.3%. Good cosmetic outcomes and normal erections were reported in 95-100% and 50-100% of cases, respectively. Glansectomy provides acceptable oncological control without significantly compromising functional outcomes. PATIENT SUMMARY: Penile cancer invading into the head of the penis can be surgically treated with a procedure called glansectomy that has good cancer control and cosmetic outcomes. In addition, penile length can be preserved, which allows men to urinate standing up and to achieve penetrative sexual intercourse.

What Is the Most Effective Management of the Primary Tumor in Men with Invasive Penile Cancer: A Systematic Review of the Available Treatment Options and Their Outcomes

Context

The primary lesion in penile cancer is managed by surgery or radiation. Surgical options include penile-sparing surgery, amputative surgery, laser excision, and Moh’s micrographic surgery. Radiation is applied as external beam radiotherapy (EBRT) and brachytherapy. The treatment aims to completely remove the primary lesion and preserve a sufficient functional penile stump.

Objective

To assess whether the 5-yr recurrence-free rate and other outcomes, such as sexual function, quality of life, urination, and penile preserving length, vary between various treatment options.

Evidence acquisition

The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED), Google Scholar, and ClinicalTrials.gov were searched for publications from 1990 through May 2021. Randomized controlled trials, nonrandomized comparative studies (NRCSs), and case series (CSs) were included.

Evidence synthesis

The systematic review included 88 studies, involving 9578 men from 16 NRCSs and 72 CSs. The cumulative mean 5-yr recurrence-free rates were 82.0% for penile-sparing surgery, 83.9% for amputative surgery, 78.6% for brachytherapy, 55.2% for EBRT, 69.4% for lasers, and 88.2% for Moh’s micrographic surgery, as reported from CSs, and 76.7% for penile-sparing surgery and 93.3% for amputative surgery, as reported from NRCSs. Penile surgery affects sexual function, but amputative surgery causes more appearance concerns. After brachytherapy, 25% of patients reported sexual dysfunction. Both penile-sparing surgery and amputative surgery affect all aspects of psychosocial well-being.

Conclusions

Despite the poor quality of evidence, data suggest that penile-sparing surgery is not inferior to amputative surgery in terms of recurrence rates in selected patients. Based on the available information, however, broadly applicable recommendations cannot be made; appropriate patient selection accounts for the relative success of all the available methods.

Patient summary

We reviewed the evidence of various techniques to treat penile tumor and assessed their effectiveness in oncologic control and their functional outcomes. Penile-sparing as well as amputative surgery is an effective treatment option, but amputative surgery has a negative impact on sexual function. Penile-sparing surgery and radiotherapy are associated with a higher risk of local recurrence, but preserve sexual function and quality of life better. Laser and Moh’s micrographic surgery could be used for smaller lesions.

Functional and Patient Reported Outcomes Following Total Glans Resurfacing

BACKGROUND

Whilst there is a trend away from aggressive nonorgan sparing surgical treatments for malignant penile disease, a variety of penile preservation options exist but functional outcomes and patient reported outcomes (PROs) in this area are poorly reported to date.

AIM

The aim of this study is to report functional outcomes and PROs of total glans resurfacing (TGR) in a consecutive series of patients with lichen sclerosis (LS) or localized penile cancer (PC).

METHODS

From 2004 to 2018 a consecutive series of patients underwent TGR for the management of LS or localized PC in a tertiary referral network. Patient clinical records and operative notes were retrospectively reviewed. Statistical analysis was conducted with Stata 12.

OUTCOMES

Urinary and sexual outcomes were recorded utilizing both the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) validated questionnaires while PROs were extrapolated from a 5-item "ad hoc" telephone questionnaire administered at 1 year post procedure.

RESULTS

37 consecutive patients were enrolled. Histology results demonstrated LS in 16 patients, with the remaining 21 having a diagnosis of PC. The most common reasons for patient presentation were local pain (32.4%), pruritus (37.8%) and bleeding (29.7%). Median follow-up was 22 (IQR 13-77) months. Median age was 62 (IQR 55-68). Neither of the questionnaires assessing urinary and sexual function showed any significant deterioration after surgery. Glans sensitivity was fully maintained in 89.2% of cases. 94.5% of patients reported to be fully satisfied with the aesthetic appearance of the penis and would consider undergoing the same procedure again if necessary. 91.9% of patients would recommend the same procedure to someone else. An overall improvement of the quality of life was reported by 86.4% of patients.

CLINICAL IMPLICATIONS

TGR should be considered a treatment of choice for selected cases of benign or malignant penile lesions STRENGTHS AND LIMITATIONS: Our study has some limitations, the first being its retrospective nature. Furthermore, despite being one of the largest series to date, follow-up duration is somewhat limited and a control group is lacking.

CONCLUSION

TGR represents an excellent surgical option ensuring satisfactory voiding and sexual function, as well as cosmesis for selected cases of penile lesions. M. Preto, M. Falcone, G. Blecher, et al. Functional and Patient Reported Outcomes Following Total Glans Resurfacing. J Sex Med 2021;18:1099-1103.

Phallus Preservation in Penile Cancer Surgery: Patient-reported Aesthetic & Functional Outcomes

OBJECTIVE

To assess patient-reported outcomes of oncoplastic penile reconstruction using standardized questionnaires. Whilst organ-preserving penile cancer surgery has evolved, aiming to preserve genital function, reduce psychological morbidity of radical penectomy, and maximise patient quality of life, few studies have evaluated patients' final perceptions.

METHODS

Following ethical approval, patients post partial/radical glansectomy with reconstruction 2016-2019, under a single surgeon, were identified. Patients were posted a modified Index of Male Genital Image, the IIEF-5, a customised questionnaire exploring outcomes of urinary and sensory function and the EORTC QLQ-C30 to complete and return. Questionnaires were nonidentifiable, however study ID linked responses to the procedure performed.

RESULTS

A total of 130 questionnaires were received from 35 patients post penile reconstruction, giving a response rate of 71.4% (35/49). Mean time from surgery was 22 months (4-51), and mean age 61 years (31-79). The majority (82.4%, n = 28) were satisfied or felt neutral about the appearance of their genitalia. High satisfaction with postprocedure urinary function was reported; 85.3% (29/34) could void from a standing position and 79.4% (27/34) reported little or no spraying of urine. Nineteen patients (55.89%) were sexually active, with mean IIEF-5 scores of 14.9 (5-25) (partial glansectomy) and 15.8 (5-25) (radical glansectomy). Mean QoL over past week on 7-point EORTC QLQ-C30 scale was 5.88 (3-7).

CONCLUSION

We report good aesthetic and functional outcomes in a unique study exploring penile cancer surgery patient-reported outcome measures. These results strongly support phallus-preserving phallic-preserving strategies as the standard of care in eligible patients undergoing penile cancer surgery.

Recent advances in understanding and managing Lichen Sclerosus

Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects the preputial skin and glans, leading to phimosis and urethral strictures if left untreated. We present a narrative review of the literature assessing its aetiology and pathogenesis and discuss its links to penile cancer and its medical and surgical management. Possible hypotheses for the development of LS include chronic exposure to trapped urine, leading to changes in the epithelial structure. This is supported by the fact that circumcision is often curative in the early stages of the disease. Although circumcision can be curative, the use of topical steroids is typically the first-line treatment and may preserve the foreskin and forgo the need for circumcision altogether. Patients should be made aware of a possible association with penile cancer. Although the majority of cases can be treated by medical therapy and circumcision, a significant number of patients may also require penile reconstructive procedures.

[Glandectomy with cutaneous thigh graft]

Penile cancer is a neoplasm that predominantly affects males in the sixth decade of life, with an incidence of .3-1 per 100,000. Traditionally, the treatment of the primary lesion has consisted of total or partial amputation of the penis. However, the psychological and functional impact has influenced the development of preservation techniques We present 2males with lesions on the glans diagnosed by biopsy of squamous cell carcinoma. The patients underwent glandectomy and reconstruction with free thigh skin graft. The pathological anatomy was superficial squamous cell carcinoma. 6 months later the patients are free of disease and satisfied with the result of the intervention In our opinion, this technique enables an adequate cosmetic and functional result without affecting oncological control and without increasing morbidity or operative time.

Utilities of scrotal flap for reconstruction of penile skin defects after severe burn injury

OBJECTIVE

In the present study, we aimed to present our experience of an effective two-stage surgical approach using scrotal skin flap for patients with penile skin defects following severe burn injury.

MATERIALS AND METHODS

A total of 17 patients with penile skin defects underwent scheduled two-stage reconstruction using scrotal skin flap from January 2004 to October 2016. Patients, who were selected as eligible candidates for scrotal flap, exhibited a wide range of indications, including iatrogenic injuries (e.g., diathermy treatment after circumcision), scalding, flame injuries and electrical burns. During the first stage, the denuded penis secondary to debridement was temporally embedded in scrotal skin flap through an intrascrotal tunnel created between the skin and darto's fascia. During the second stage, the skin around the penis was separated and divided from the scrotum after incising the scrotal skin at the ventral penile base. After a mean follow-up of 30 months, the reconstructed penises yielded satisfactory aesthetic outcomes and maintained erectile function.

RESULTS

The mean age of patients was 35 years (19-55 years), and the median follow-up was 30 months (12-60 months). No major perioperative complication occurred except for dehiscence of scrotal skin after 2nd stage in three patients, and split-thickness skin grafts were applied for recovery of scrotum. Of 17 cases, 15 patients (88.2%) were in satisfactory cosmetic appearance. All patients regained penile sensation and normal voiding function in standing position. The International Index of Erectile Function (IIEF) was used to assess sexual function, with 13 patients (76.5%) reported normal erectile function, while the rest 4 reported mild erectile dysfunction. With regards to intercourse satisfaction domain, encouraging results indicated a total of 17 patients resumed sexual intercourse after surgery. In overall satisfaction domain, 11/17 (64.7%) reported a satisfaction from "very" to "moderately" with their overall sex life and sexual relationship with their partners, while only one patient reported "moderately dissatisfied" with his overall sex life.

CONCLUSIONS

We report a series of particular cases, including rare iatrogenic injury (diathermy treatment after circumcision) and severe compound electrical injury. Meanwhile, we show our successful experience that scrotal skin flap could be used as an effective surgical alternative to cover severe burn injury wound in male genitalia. The scrotal flap, with higher anti-infection ability and flexible contexture, is available for recovering penile skin defects following severe burn injury resulting in good aesthetic and sexual outcomes.