Transcript Surgery of Penile and Urethral Carcinoma

Surgery of Penile and
Urethral Carcinoma
Campbell’s Urology Chapter 32
W. Britt Zimmerman
April 15, 2009
Surgery of Penile & Urethral Carcinoma
• Penile Cancer
• Male Urethral Cancer
• Female Urethral Cancer
Penile Cancer
• Typically Squamous
• Involves:
– Glans penis
– Coronal Sulcus
– Inner preputial skin
Penile Cancer
• Biopsy
– Imperative to include area of question as well as
adjacent normal tissue
• Allows for evaluation of depth of invasion
– May be punch or excisional
– Urethral meatus involvement
• Urethroscopy is mandatory
Penile Cancer
• Laser Therapy
– Carbon Dioxide (CO2)
– Neodymium:yttrium-aluminum-garnet (Nd:YAG)
– Potassium titanyl phosphate (KTP)
– Circumcision is usually recommended at the time
of laser surgery if not already done
Laser Therapy
• CO2
– Wavelength: 10,600 nm
– Skin depth: 0.01 mm
– Blood vessels: 0.5 mm
– 33% local recurrence
– Healing time: 5 – 8 weeks
Laser Therapy
• Nd:YAG
– Most commonly reported
– Skin dept: 3 – 6 mm
– 20% recurrence
• Stage T1
– Healing time: 8 – 12 weeks
• Combination
– Surgery and laser to the base
18% – 20% recurrence
Laser Therapy
• KTP
– Wavelength: 532 nm
– Intermediate depth
• Between CO2 and Nd:YAG
– Healing time: 8 – 12 weeks
Laser Therapy
• Technical improvements
– 5% Acetic acid wraps
– 5-aminolevulinic acid
• Final thoughts
– Reasonable for Tis and T1 SCC
– T2 patients refusing aggressive surgery
Mohs Micrographic Surgery
• Excision of penile cancer by thin tissue layers
• Frozen sectioning with immediate pathological
evaluation
• Cure rates (5 years)
–
–
–
–
< 1 cm: 100%
1 – 2 cm: 83%
2- 3 cm: 75%
> 3 cm: 50%
Mohs Micrographic Surgery
• Best suited for small superficial cancers
• Comparable to partial penectomy
– In the right setting
Conservative Surgical Excision
Local excision and Glansectomy
• In the setting of low stage penile cancer
• Traditionally, 2 cm margin
• Grade plays a central role
– Grade 1 & 2
• Histologic extent 5 mm
• Location also plays a role
– Coronal Sulcus 50% recurrence
Conservative Surgical Excision
• Glanular tumors
– Difficult secondary inability to achieve adequate
margin
– Preputial skin flap or split thickness skin graft
(STSG) can assist in closure
– Recurrence:
• Traditionally 32 – 40%
• Contemporary studies 8 – 11%
Figure 32-1 Surgical glans defect
covered with outer preputial flap as
described by Ubrig and colleagues
(2001). A, Superficial glans tumor.
B, Outer preputial flap outlined. C,
Tumor excised and circumcision
performed. D, Glans defect filled
with outer preputial flap.
Figure 32-2 Finely meshed extragenital split-thickness skin graft
quilted to glans defect after superficial tumor excision.
Conservative Surgical Excision
• Total Glansectomy
– First described in 1996
– Used in patients with stage T1 & T2 SCC of the glans,
prepuce, and coronal sulcus
– Dissassembly of glans and distal corpus spongiosum
• Frozen section for margin evaluation
• STSG with urethrostomy formation
– Benefits
• Voiding
• Sexual function preservation
Partial Penectomy
• Most common surgical procedure for
treatment of patients primary SCC
• Penile amputation
– 2 cm proximal to the tumor
– Goals
• Voiding
• Sexual function
Partial Penectomy
Figure 32-3 Partial penectomy. A, Incision
with ligation and division of dorsal penile
vessels within Buck's fascia (inset). B,
Corpora transected and urethra spatulated.
C and D, Closure of corpora cavernosa. E,
Final closure with construction of
urethrostomy.
Partial Penectomy
• 1.0 to 1.5 cm distal to the cavernosal
amputation site
• Urethrostomy is created by approximating the
urethra to the surrounding penile skin
• Lengthening
– Suspensory ligament division
Partial Penectomy
• Skin coverage
– Scrotal flaps
– Z-plasty
• Glans reconstruction
– Skin grafts
– Pedicle flaps
Penectomy
• Local recurrence rates
– 0 – 8%
Total Penectomy
• At the level of the suspensory ligament
– Corpra cavernosa proximally remains
• Performed for large or proximal Lesions
• Patients void sitting down via a perineal
urethrostomy
Total Penectomy
Figure 32-5 Total penectomy. A,
Incision. B, Transection of the corpora
near the level of the pubis. C,
Mobilization of the remaining urethra
off of the proximal corporal bodies. D,
Transposition of the urethra through a
curvilinear perineal incision. E,
Completion of perineal urethrostomy.
Perineal Urethrostomy
Perineal Urethrostomy
Perineal Urethrostomy
Perineal Urethrostomy
Foley left for 7 – 10 days
Radical Penectomy
• The corporal bodies are dissected to the tips
of the crura, which are completely excised.
• Urethra is matured into a standard perineal
urethrostomy.
Radical Penectomy
Regional Lymph Nodes
• SCC on the penis spreads regionally before it
spreads distantly.
– No skip lesions.
• One midline structure can metastasize to either side
or bilaterally.
• Metastatic lymph nodes confer a poorer prognosis
– Aggressive lymphadenectomy: cure in 30 – 60%
Inguinal Anatomy
• Lymph nodes
– Superficial
– Deep
• Superficial lymph nodes (5 groups)
–
–
–
–
Central (saphenofemoral junction)
Superolateral (superficial circumflex vein)
Inferolateral (lateral femoral & superficial circumflex)
Superomedial (superficial ext. pudendal & superficial
epigastric veins
– Inferomedial (greater saphenous vein)
Superficial lymph nodes (5 groups)
Figure 32-14 Superficial inguinal
lymph nodes and the branches of the
saphenous vein. SEV, superficial
epigastric; SEPV, superficial external
pudendal; MCV, medial cutaneous;
LCV, lateral cutaneous; SCIV,
superficial circumflex iliac.
Inguinal Anatomy
• Deep inguinal nodes
– Medial to femoral vein in the femoral canal
– Cloquet – most cephalad of the deep group
• Between the femoral vein and the lacunar ligament
– External iliac nodes
• Deep inguinal
• Obturator
• Hypogastric
Deep Inguinal Nodes
Inguinal Anatomy
• Skin blood supply
– Common femoral artery
• Superficial external pudendal
• Superficial circumflex iliac
• Superficial epigastric arteries
• Transverse skin incision compromises the
least amount of blood supply
Inguinal Anatomy
• Femoral nerve
– Deep to iliacus fascia
– Motor
• Pectineus
• Quadriceps femoris
• Sartorius
– Sensation
• Anterior thigh
Inguinal Anatomy
• Femoral triangle:
– Inguinal ligament – superiorly
– Sartorius muscle – laterally
– Adductor longus muscle – medially
– Floor
• Pectineus (medially) and iliopsoas (laterally)
Sentinel Node Biopsy
• First describe by
Cabanas in 1977
• Results a have
been variable
Modified Inguinal Lymphadenectomy
•
Catalona 1988
– Same therapeutic benefit
– Less morbidity
– Key aspects
1. Shorter skin incision
2. Excludes the area lateral to the femoral artery and
caudal to the fossa ovalis
3. Saphenous vein preservation
4. Elimination of sartorius muscle transposition
Modified Inguinal Lymphadenectomy
Figure 32-17 Limits of
standard and modified groin
dissection. (From Colberg
JW, Andriole GL, Catalona
WJ: Long-term follow-up of
men undergoing modified
inguinal lymphadenectomy for
carcinoma of the penis. Br J
Urol 1997;79:54-57.)
Modified Inguinal Lymphadenectomy
Figure 32-18 Modified inguinal
lymphadenectomy. Lymph node
packet is medial to the femoral
artery and includes superficial and
deep inguinal nodes.
Modified Inguinal Lymphadenectomy
Figure 32-19 Intraoperative photograph
of right inguinal region after modified
lymphadenectomy. SC, spermatic cord;
V, femoral vein; S, saphenous vein; AL,
adductor longus.
Radical Ilioinguinal Lymphadenectomy
• Indicated in patients with resectable
metastatic adenopathy and may be curative
when inguinal nodes disease only.
• May also be used in palliation
Radical Ilioinguinal Lymphadenectomy
Radical Ilioinguinal Lymphadenectomy
Figure 32-21 Ilioinguinal lymph node
dissection. A, Incisions for inguinofemoral
lymph node dissection (1), unilateral pelvic
lymph node dissection (2), and bilateral
pelvic lymph node dissection (3). B, Single
incision approach for ilioinguinal lymph
node dissection.
Radical Ilioinguinal Lymphadenectomy
Figure 32-22 A, Incision and
area of dissection for left
inguinofemoral lymph node
dissection with excision of
adherent skin overlying nodal
mass. B, Single incision
approach and area of
dissection for right ilioinguinal
lymph node dissection with
excision of overlying skin.
Radical Ilioinguinal Lymphadenectomy
Radical Ilioinguinal Lymphadenectomy
Figure 32-25 Inferior dissection during radical
inguinofemoral lymph node dissection with
removal of lymph node packet from the
inferior border of the femoral triangle. After
further lateral and medial dissection, the
packet will remain in continuity with the pelvic
dissection in the area of the femoral canal.
Radical Ilioinguinal Lymphadenectomy
Figure 32-26 Intraoperative photograph
after right radical inguinofemoral lymph
node dissection in an obese patient. S,
sartorius muscle; A, femoral artery; V,
femoral vein; IL, inguinal ligament.
Figure 32-27 Sartorius muscle after
detachment from the anterior superior
iliac spine and 180-degree rotation
medially, with suture fixation to the
fascia of the inguinal ligament and the
adductor longus. S, sartorius muscle;
SC, spermatic cord.
Key Points of Penile Cancer
• Early meticulous surgical management with
close follow-up generally provides the best
opportunity for cure of penile SCC.
• Include some adjacent normal tissue with the
specimen to allow optimal evaluation of the
depth of invasion of the cancer during biopsy.
Key Points of Penile Cancer
• Conservative surgical approaches may be
reasonable for patients with stage Tis and small T1
SCC of the penis and for patients with manageable
T2 tumors who refuse more aggressive surgical
treatment.
• Partial penectomy with a 2-cm surgical margin
remains the most common surgical procedure for
treatment of the primary tumor in patients with
invasive SCC and affords excellent local control in
most instances.
Key Points of Penile Cancer
• In patients at risk for the development of inguinal
metastatic disease and with no palpable
adenopathy, modified inguinal lymphadenectomy
provides excellent assessment of the regional
nodes and may be converted to a full
lymphadenectomy if metastatic disease is detected.
• Penile cancer metastases to the pelvic lymph nodes
do not occur in the setting of negative ipsilateral
inguinal nodes.
Male Urethral Cancer
Male Urethral Carcinoma
• Rare and presents in the 5th decade of life.
• Etiology is typically secondary to chronic
inflammation.
– STDs
– Urethritis
– Urethral stricture
– HPV 16
Male Urethral Carcinoma
• Insidious onset
• 50% have stricture
• 25% have STD history
• 96% symptomatic
– Palpable urethral mass
– Obstructive voiding symptoms
Male Urethral Carcinoma
Pathology
• Bulbomembranous – 60%
• Penile – 30%
• Prostatic – 10%
• SCC – 80%
• TCC – 15%
• Adenocarcinoma – 5%
Pathology
• Direct extension
• Lymphatic invasion
• Anterior – superficial and deep inguinal, and occasionally
external iliac nodes
• Posterior – pelvic lymph nodes
• Palpable lymph nodes are present 20% of the time and
usually represent metastatic disease
Evaluation & Staging
Primary tumor (T) (male and female)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Ta Noninvasive papillary, polypoid, or verrucous carcinoma
TisCarcinoma in situ
T1 Tumor invades subepithelial connective tissue
T2 Tumor invades any of the following: corpus spongiosum, prostate,
periurethral muscle
T3 Tumor invades any of the following: corpus cavernosum, beyond prostatic
capsule, anterior vagina, bladder neck
T4 Tumor invades other adjacent organs
Transitional cell carcinoma of the prostate
Tis-pu Carcinoma in situ, involvement of the prostatic urethra
Tis-pd Carcinoma in situ, involvement of the prostatic ducts
T1 Tumor invades subepithelial connective tissue
T2 Tumor invades any of the following: prostatic stroma, corpus spongiosum,
periurethral muscle
T3 Tumor invades any of the following: corpus cavernosum, beyond prostatic
capsule, bladder neck (extraprostatic extension)
T4 Tumor invades other adjacent organs (invasion of the bladder)
Evaluation & Staging
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension
N2 Metastasis in a single lymph node, more than 2 cm but less than 5 cm in
greatest dimension; or in multiple nodes, none greater than 5 cm
N3 Metastasis in a lymph node greater than 5 cm in greatest dimension
Distant metastasis (M)
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Treatment
• Primarily a surgically treated disease process
• Anterior urethral lesion is more amendable to
surgical control
• Posterior disease
– Associated with extensive local invasion
– Distant mets
Carcinoma of the Penile Urethra
• Superficial, papillary, low-grade tumors
– TUR
– Local excision
• Infiltrating
– Lesions located to distal half of penis
• Partial penectomy with 2 cm margin
– Lesions proximal
• Total penectomy
Carcinoma of the Penile Urethra
Carcinoma of the Penile Urethra
Prophylactic inguinal lymph node dissection
(LND) offers no benefit
Carcinoma of the Bulbomemebranous Urethra
• Poor survival figures for all recorded forms of
treatment
– Radical surgery offers best longer-term prognosis
•
•
•
•
•
Radical cystoprostatectomy
Pelvic lymphadenectomy
Total penectomy
Pubic rami resection
GU diaphragm excision
Carcinoma of the Bulbomemebranous Urethra
Radiation Therapy & Chemotherapy
• XRT
– Early-stage lesions of the anterior urethra
– Preserves skin
– Results are undetermined
• Chemo
– MVAC good for TCC lesions
– Platinum based therapy
• Results poor
• Combo therapy
– XRT and Chemo
– Surgery and Chemo
Management of the Urethra after Cystectomy
• General Considerations
– Cancer recurrence following cystoprostatectomy
• 2.1 – 11.1% recurrence (cutaneous diverison)
• 0.5 – 4% recurrence (orthotopic neobladder)
• Frozen section of apical margins of prostatic urethra
during surgery should be NEGATIVE.
• 40% of recurrence within 1 year
– 18 months median
Management of the Urethra after Cystectomy
• Traditionally urethral wash was acceptable
– Survival benefit has been questioned
• Patients who have positive voided cytology or
symptoms:
– Urethral bleeding
– Discharge
– Palpable mass
• Cystoscopy and Biopsy
– Superficial recurrence can be treated with BCG via urethral perfusion
Total Urethrectomy after Cutaneous Diversion
• Care must be exercised in completing the proximal
dissection, in view of the possible postcystectomy
adherence of intestine to the superior surface of the
urogenital diaphragm.
Total Urethrectomy after Orthotopic Diversion
• Abdominal perineal approach
• Can use previous bowel for diversion
– Careful dissection to preserve blood supply
• Commonly perform ileal conduit, but carefully
selected patient may undergo a continent
reservoir creation
Urethrectomy after Cystoprostatectomy
Key Points: Male Urethral Cancer
• 80% of male urethral cancers are SCC
– Bulbomembranous urethra most common site
• Anterior urethral carcinoma
– More amenable to surgical control
– Better prognosis
• Posterior urethral carcinoma
– Extensive local invasion
– Distant metastasis
Key Points: Male Urethral Cancer
• Prophylactic inguinal lymph node dissection
has no benefit
• Low incidence of urethral recurrence after
orthotopic bladder replacement
– Negative frozen-section biopsy of the distal
prostatic urethral margin during surgery
Key Points: Male Urethral Cancer
• Converting a patient to cutaneous conduit
urinary diversion, bowel from the existing
orthotopic neobladder can often be
reconfigured with its blood supply intact and
used for this purpose.
Female Urethral Cancer
Epidemiology, Etiology, & Clinical
Presentation
• Epidemiology
– more in women, 4:1
– Only urological malignancy with female
predominance
– 0.2% of all GU malignancies
– <1% of CA of female GU tract
– 85% occurs in white women ( of 1200 cases
reported)
Epidemiology, Etiology, & Clinical
Presentation
• Etiology
– Leukoplakia, chronic irritation, caruncles, polyps,
partuition, HPV, other viral infection
– Urethral diverticula
• 5% of CA
– Predisposition?
Epidemiology, Etiology, & Clinical
Presentation
• Clinical Presentation
– 98% have symptoms
• Most common obstructive
• Dysuria, urethral bleeding, frequency, palpable,
urethral mass, induration
• Otherwise healthy middle-aged woman with new-onset
UR?
– Think urethral tumor (and neurolgic disease…..)
Epidemiology, Etiology, & Clinical
Presentation
• Patterns of Spread
– Local
• Direct extension, may ulcerate @ skin/vulva
• If proximal may extend:
– Posteriorly into vagina
– Proximally into bladder
– Lymphatic involvement:
• 1/3 @ presentation (palpable nodes)
• ½ of pts with advanced/proximal tumors
– Hematogenous
• Lung, liver, bone, brain
Anatomy & Physiology
• Anterior (distal 1/3)
– Can maintain
continence with excision
• Posterior (proximal 2/3)
Anatomy & Physiology
• Histology of urethra
– Epithelium
• Proximal 1/3
– Transitional urothelium
• Distal 2/3
– Stratified squamous
– Glands
• Columnar epithelium
– Lymphatics
• Post urethra
– External/internal illiac, obturator
• Ant urethra/ labia
– Superficial/deep inguinal
Anatomy & Physiology
• Histology of Neoplasm
– SCC 50-70%
– TCC 10%
– Adenocarcinoma 25%
• Glandular origin
• Associated with diverticula
– Rare: lymphoma, neuroendocrine, sarcoma,
paragangliomas, melanoma, metastasis
Diagnosis & Staging
• Evaluation
– Cysto, EUA, CT A/P, CXR
– +/- MRI for extension
• Staging
– TNM (see male)
– Pelvic LN mets:
• 20%
– Distant LN mets:
• 15%
– Palpable nodes:
• 30% overall
• Confirmed malignancy: 90%
• 50% of proximal or advanced CA
Treatment & Prognosis
• Prognosis
– No survival difference based on histological
subtype
• Treatment
– Tumor location
– Clinical stage
Treatment
• Local excision vs extensive surgery
– Small, distal urethral tumors, superficial
• Survival facts
– 5 yr DSS (disease specific survival)
• 71% (distal)
• 48% (proximal)
• 24% (large urethral lesions)
– Overall survival (Surgery, XRT)
• 30-40%
• Unchanged in 50yrs
Treatment
• Options
– Surgery, XRT, chemo, combo
– Multimodality preferred
• Survival @ 5-6 yrs: (Early urethral CA in
women, Table 32-2)
– XRT (42 pts) 30%
– Surgery (14 pts) 10%
– Combo (3 pts)
2%
Treatment
• Distal Urethral CA
– Small, exophytic, superficial tumor from urethral
meatus:
• Options:
– Circumferential excision of distal urethra & portion of anterior
vaginal wall
– Laser coag described (small, distal tumors)
– Urethrectomy & diversion
» Anterior vaginal wall, periurethral tissues to bladder neck
» Ileovesicostomy, appendicovesicostomy to native bladder
Treatment
• Facts, surgical data:
– Distal tumor
• Low stage
• Cure rate 70-90% with local excision
– 21 % with < T2 treated with partial urethrectomy
had a local recurrence (Dimarco et al 2004)
– 0-50% recurrence with partial urethrectomy +/rads (Hahn 1991, Ghelier 1998)
Treatment
• Complications
– Meatal stenosis
– SUI (DiMarco 2004)
Treatment
• Radiation
– Low stage distal urethral CA
– 5 yr DSS 41% (Gordon 1993)
• 74% (part of urethra involved)
• 55% (entire urethra involved)
Treatment
• Delivery
– XRT, Brachy, Combination
– Results
• Combo
– Fewer failures (14%) than all radiation Rx patients (36%) &
surgery alone (60%) (University of Iowa)
– Complications
• 20-40%
• UI, strictures, necrosis, fistulas, cystitis, cellulitis
– Prognosis
• 5 yr survival: surgery, radiation “similar” (Foens, 1991)
Treatment
• Various Rx: Advanced stage urethral CA
(Table 32-3)
– Radiation: 25 people, 28% survival, 5-6 yrs
– Surgery: 13 people, 15% survival, 5-6 yrs
– XRT + Surgery: 20 people, 5% survival, 5-6 yrs
– XRT+Chemo+Surg: 6 people, 50% survival, 2 yrs
Treatment
• Ilioinguinal lymphadenectomy
– Significant morbidity
– Systemic spread without regional LN involve
– No improved survival after pelvic, inguinal LADN
– Can’t predict micrometastatic LN involvement
– Recommend: no prophylactic or diagnostic LND
– Candidates for LND
• (+) inguinal, pelvic LAD on presentation without distant
mets
• Pts who develop regional LAD during surveillance
Treatment
• Proximal female urethral CA
– Facts
• More likely high stage
• Advanced female urethral CA involves:
– Proximal location, entire urethra
– Locally invasive lesion: external genitalia, vagina or bladder
• Multimodal Rx is the rule
• Prognosis
– With anterior exenteration: 10-17% (5 yrs)
– Local recurrence 67%
Treatment
• Proximal female urethral CA
– Anterior exenteration, pelvic LN dissection
(standard bladder + Cloquet’s node), wide
vaginal or complete vaginal excision for (-)
margins
• PRN: partial vulvectomy, labial excision
• PRN: pubis resection
Treatment
• Prognosis
– Radiotherapy alone
• 0-57% survival (5 yrs)
– Combo (XRT + surgery)
• Mean survival 54% (5 yrs)
– Chemo + XRT + surgery
• Local, distant control in advanced CA
– SCC
» 5 FU + Mitomycin C
– TCC
» MVAC or Gemcitabine
Urethral recurrence after
Cystectomy in women
• Facts
– Incidence of CA involving urethra in females
undergoing cystectomy for CaB 1-13%
– Bladder neck involvement and urethral sparing
surgery (controversial)
– Few reported cases of urethral CA despite
increasing # of orthotopic neobladders (urethral
preservation)
Urethral recurrence after
Cystectomy in women
• Limited data No conclusive treatment Rec.
– Options (in the absence of mets):
• Urethrectomy, resection of anastomosis with
conversion to continent cutaneous diversion
• Conversion to cutaneous urinary conduit with bowel
from orthotopic diversion
Surgery of Penile and
Urethral Carcinoma
Campbell’s Urology Chapter 32
W. Britt Zimmerman
April 15, 2009