Glans Resurfacing with Skin Graft for Penile Cancer: a Step-By-Step Video Presentation of the Technique and Review of the Literature
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Hindawi BioMed Research International Volume 2019, Article ID 5219048, 6 pages https://doi.org/10.1155/2019/5219048 Review Article Glans Resurfacing with Skin Graft for Penile Cancer: A Step-by-Step Video Presentation of the Technique and Review of the Literature Athanasios Pappas ,1 Ioannis Katafigiotis,2 Marjan Waterloos,3 Anne-Francoise Spinoit ,3 and Achilles Ploumidis1 1 Department of Urology, Athens Medical Center, Athens, Greece 2Urology Andrology Center of Piraeus, Greece 3Department of Urology, Ghent University Hospital, Ghent, Belgium Correspondence should be addressed to Athanasios Pappas; athan [email protected] Received 13 February 2019; Accepted 14 April 2019; Published 9 June 2019 Academic Editor: Christian Schwentner Copyright © 2019 Athanasios Pappas et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Glans resurfacing has been suggested as a treatment option for the surgical management of superfcial penile cancer (Tis, Ta, T1aG1, T1aG2). In this article we describe in detail the glans resurfacing technique with skin graf for penile cancer in a video presentation and we review the current knowledge of the literature. Material and Methods. Te procedure is described in a stepwise fashion. Initially the patient is circumcised. Te glans is marked in quadrants and completely stripped by dissecting and removing the epithelium and subepithelium layer of the glans. Deep spongiosal biopsies are taken to exclude invasion. Each quadrant is sent separately for biopsy. Te surface of the graf size needed is estimated. A partial thickness skin graf is harvested from the thigh with a dermatome. Te skin graf is then fenestrated. Te graf is rolled over the glans and quilted with multiple sutures. A silicone 16F Foley catheter and a suprapubic catheter are placed. Te penis is dressed with multiple gauzes and compressed with an elastic band. Results. Te patient is discharged the next day. Te dressing and Foley catheter are removed in 7 days. Te patient continues to use the suprapubic catheter for 7 more days. Te patient refrains from any sexual activity for 6 weeks and is closely followed. Conclusions. Glans resurfacing is an emerging new appealing surgical technique that is already a recommendation in the EAU guidelines for the treatment of premalignant and superfcial penile lesions. Te overall satisfaction rate and recovery of the sexual function are acceptable, and it can be considered an ideal procedure to treat superfcial penile cancer. 1. Introduction such as partial amputation and total penectomy, can impair sexual function or micturition, can afect genital sensibility, Penile cancer (PeCa), though uncommon, presents a geo- and can be detrimental for the psychology and the quality graphical variation in incidence and a strong relation with oflifeofthepatient[3].Ontheotherhand,penilesparing the human papilloma virus (HPV) [1, 2]. One-third of the surgery aims at complete excision of the primary tumor, penile cancer cases are HPV-related, and even though the with or without reconstruction, with the goal of preserving peak incidence is during the sixth decade of life, it can occur sexual function and improving cosmetic outcome [4]. Glans in younger patients [2]. Surgical management and the choice resurfacing is considered a new technique described since of infltrative treatment depend on the stage and the invasive- 2000 by Depasquale and was originally used for the treatment ness of the disease with penis sparing options reserved as a of extensive balanitis xerotica obliterans. Currently it has moreoverallsuitablechoiceforthesuperfcialdiseaseupto been suggested as a valid option for the surgical management T1a (TNM Classifcation) according to the European Urology of the superfcial penile cancer (Tis, Ta,T1aG1, T1aG2) [4]. We Association (EAU) guidelines [3]. Radical surgical options, describe in detail the glans resurfacing technique with skin 2 BioMed Research International (a) (b) (c) (d) Figure 1: (a) Marking the circumcision line on the shaf of the penis. (b) Incising the marked skin, in order to perform the circumcision (sleeve technique). (c) Placing a tourniquet at the base of the penis. (d) Te glans is marked in quadrants. graf for penile cancer in a video presentation (available here) 2.3. Step 3: Marking of the Glans in Quadrants and Dissecting of and we review the current knowledge of the literature on the the Epithelium and Subepithelium Layer. Teglansismarked procedure. in quadrants from the meatus to the corona (Figure 1(d)). Te underlying spongiosum is exposed, by dissecting and removing the epithelium and subepithelium layer of the 2. Surgical Technique glans, from the meatus to the corona for each quadrant (Fig- ure 2(a)). Dissection is undertaken with tenotomy scissors for 2.1. Step 1: General Preparation. Te patient is placed in better precision in dissection, or with a blade scalpel No 15 a supine position, with the legs slightly abducted. Te (Figure 2(b)). Te plane of dissection lies between the thick- procedure is performed under general anesthesia. Broad- ened mucosa and the underlying spongy tissue. During the spectrum antibiotics are administered preoperatively. Te dissection the surgeon must take care that no afected mucosa external genital organs and the inner thigh are shaved in the is lef on the glans especially near the meatus (Figure 2(c)). On operating room and surgical skin preparation is performed the other hand, deep dissection down to the spongy tissue using antiseptic solution. Te surgical feld is draped leaving should be avoided not to cause unnecessary bleeding or to the genitals and the thigh exposed. Usually the right thigh is compromise the aesthetic outcome. Te glans is completely preferred for a right-handed surgeon standing on the right stripped when all quadrants are removed and deep spongiosal side of the patient. biopsies can be taken to exclude invasion (Figure 2(d)). Each quadrant is sent separately for biopsy. Afer releasing the 2.2. Step 2: Circumcision and Tourniquet Appliance. Te tourniquet compression, excessive bleeding is controlled with prepuce skin is marked, just below the corona and on the bipolar diathermy. Excessive cautery should be refrained in shaf of the penis (Figure 1(a)). Te excess foreskin is removed order to avoid necrotic tissue to the graf bed. using the sleeve technique and the penis is circumcised (Fig- ure 1(b)). Glans resurfacing begins by placing a tourniquet at 2.4. Step 4: Estimating Graf Size, Harvesting and Placement the base of the penis (Figure 1(c)). of the Skin Graf. Te surface of the graf size needed is BioMed Research International 3 (a) (b) (c) (d) Figure 2: (a) Incising the epithelium and subepithelium of each quadrant of the glans. (b) Stripping the upper right quadrant of the glans, by removing the epithelium and subepithelium with tenotomy scissors (c) Te upper right quadrant is completely peeled of. Te upper lef quadrant is semidetached and rolled backwards. Te underlying spongiosum tissue is exposed. (d) Te glans epithelium and subepithelium are completely removed. estimatedbyaccuratelyplacingawhitepaperovertheglans compensate for possible stricture at the level of the meatus circumference. Blood is absorbed from the paper defning the since the skin graf is inverted and approximated directly to size of the graf bed (Figure 3(a)). Te paper is placed over the urethra (Figure 4(b)). the harvesting site, on the front or inner part of the thigh and the borders of the graf are marked taking into account graf contraction once removed (Figure 3(b)). A partial thickness 2.5. Step 5: Wound Dressing, Urinary Diversion, and Follow- skin graf is harvested from the thigh with a dermatome. Te Up. A silicone 16F Foley catheter and a suprapubic catheter graf thickness ranges from 0,02 to 0.04 cm and is carefully are placed to prevent urine extravasation to the graf. Te trimmed (Figure 3(c)). Te surgeon perforates the skin graf penis is dressed initially with a parafn gauze and further with a scalpel blade to allow blood and fuid accumulation to covered with multiple gauzes and compressed with an elastic drain, thus improving graf survival (Figure 3(d)). Te graf is band (Figure 4(d)). rolled over glans starting from the ventral side (Figure 4(a)). Te patient is discharged the next day with instructions Quilting sutures (5-0 absorbable polyglactin) are placed over for bed rest for the following two days for better immobiliza- the glans to secure the graf to its bed. In cases where a tion of the graf. Te dressing and Foley catheter are removed circumcision is performed due to the prepuce skin either in 7 days, and the graf is observed for infammation or any being part of the disease or being strongly adhered to the necrotized tissue. Te patient continues to use the suprapubic glans, the proximal end of the graf is anastomosed with the catheter for urine evacuation in order to keep the graf dry distal shaf skin by everting the edges in order to recreate the for 7 more days. Te patient is advised to avoid any friction corona sulcus (Figure 4(c)). A meatotomy is performed to to the graf and refrain from sexual intercourse for 6 weeks. 4 BioMed Research International (a) (b) (c) (d) Figure 3: (a) Estimating the graf size needed by accurately placing a white paper over the glans circumference. Blood is absorbed from the paper defning the borders. (b) Marking the size of the skin graf over the harvesting site of the thigh taking into account graf contraction once removed. (c) A dermatome is used for the harvesting of the partial thickness skin graf. (d) Perforating the skin graf, in order to improve graf survival. Te patient is examined on a 3-monthly basis for 2 years, on to preserve the phallus and improve quality of life without a 6-monthly basis for a further two years, and then annually.