Surgical and Functional Outcomes of Penile Amputation and Perineal Urethrostomy Configuration in Invasive Penile Cancer - Beyond the Abstract
Despite its rarity, a lot of risk factors can lead to the onset of this disease, such as lack of male circumcision, HPV infection, phimosis and poor hygiene, lichen sclerosus and inflammatory conditions, obesity, social factor (marital status, education, insurance status), premalignant lesions and immune compromise, UVA phototherapy. In our study, the main risk factors were the lack of circumcision and the history of lichen sclerosus.
PC has a variable clinical manifestation. It may start as an erythematous, nodular or ulcerated injury that frightened the patient. Sometimes it is associated with pain, itching, bleeding, or infection. In our court, the main symptom was pain (70%). 40% of patients has palpable nodes at the time of diagnosis.
According to the rarity of the disease, its variable clinical manifestations, and the delay in seeking medical attention due to frequent embarrassment and sense of guilt felt by the patients, as well as the misdiagnosis by the physicians, PC is often misdiagnosticated until advanced stages with poor prognosis. Because of this, it is very important to define a diagnostic and therapeutic process that includes clinical examination, biopsy of the lesion, US, MRI, and PET-CT to stage the tumor. All these instruments can lead to an early diagnosis of PC in which surgical and reconstructive techniques are possible.
Despite that, a lot of PC cases are diagnosticated in advanced stage characterized by the invasion of the corpora cavernosa with or without invasion of the urethra or invasion into adjacent structures. In these cases, total penectomy is the only surgical technique ensuring negative margins with the aim of extending patients’ life expectancy.
Even if penile amputation ensures PC control, it has important consequences on patients’ urinary and sexual function and on the overall quality of life. With perineal urethrostomy configuration, the surgeon can allow to the patient a natural voluntary urination, but amputation remains an extremely demolishing and disabling technique from a sexual and aesthetical point of view with a serious psychological impact on the patient.
From a surgical point of view, penile amputation with urinary reconstruction is a demanding surgery that required a median of three hours (IQR: 155-275 minutes). As we know, corpora cavernosa are well vascularized with an associated high risk of bleeding during the surgery (median of 70 cc in our centre). As with other surgeries, penile amputation is characterized by surgical complications such as wound infection, wound dehiscence, wound bleeding, lymphedema, and UTI. According to the complexity of this surgery, penile amputation and perineal urethrostomy configuration are burdened with greater complications such as cardiovascular disease; one of the ten patients we enrolled developed pulmonary embolism.
From a functional point of view, the urethrostomy configuration is associated with an improvement of urinary function which is demonstrated by a reduction of IPSS score in the post-operative time. In our study, the median pre-operative IPSS score was 15 (IQR: 12-19) and the median post-operative IPSS score was 6 (IQR: 5-7). From a urinary point of view, the main complications after perineal urethrostomy configuration are urethral stenosis, fistula and acute urinary retention. The incidence of these complications is variable according to numerous factors, such as the vascularization of the neo-meatus, the length of the urethra spatulation, the tissue tension, and the time of catheterization (15 days in our center). Sometimes urinary complications can require surgical revision, dilatation or permanent catheterization; the choice depends on the patient’s preference, the severity of the stenosis, the disease state, and co-morbidity. In our study, none of the patients developed urethral stenosis or fistula.
The quality of life post total penectomy is characterized by a worsening of partner relations and a sensation of loss of masculinity with increased rates of depression and suicide rate. The degree of radicality in this type of surgery and the associated life expectancy is not enough to contrast the psychological malaise of the patient.
In conclusion, penile amputation and perineal urethrostomy configuration demonstrated to be a safe and effective procedure to address invasive penile cancer. Future studies are needed to assess QoL outcomes that could further facilitate disease counseling and management of patients after treatment.
Written by: Marco Falcone, Mirko Preto, Ilaria Ferro, Lorenzo Cirigliano, Federica Peretti, Natalia Plamadeala, Martina Scavone, Federico Lavagno, Marco Oderda, Paolo Gontero
Department of Urology – “A.O.U. Città della Salute e della Scienza” Turin, Italy
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