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Radical Penectomy with Urethrostomy: Technique and Complications

Indications for Radical Penectomy

Radical penectomy is indicated in patients with advanced penile carcinoma unsuitable for partial penectomy because of inadequate surgical margin or penile length.

Contraindications

Bleeding disorders. Consider neoadjuvant chemotherapy and radiotherapy for T4 penile carcinoma with questionable resectability.

Surgical Technique

Preoperative patient preparation:

• Exclude or treat urinary tract infections.
• Perioperative antibiotic prophylaxis.
• Lithotomy position.
• Spinal or general anesthesia.
• Drape the tumor with a surgical glove to prevent wound contamination with bacteria or tumor cells.

Penectomy:

Sagittal skin incision around the base of the penis; the incision extends approximately 2cm cranially and caudally. Circular transection of the subcutaneous tissue to the level of Buck fascia.

Division of the penile ligaments:

The penile ligaments are best seen by pulling the penis caudally. The penile ligaments (fundiform ligament and suspensory ligament) can be coagulated and divided.

Mobilization of the urethra:

Open the Buck fascia and detach the urethra from the corpora cavernosa in the bulbar region. Divide the urethra at least 2 cm from the penile carcinoma, and insert a transurethral catheter 18 CH. Further proximal mobilization of the urethra is done.

Division of the crura penis:

Dissect the crura penis from the inferior ramus of the pubic bone. The mobilized crura penis are cut between Overholt clamps, and the stumps are oversewn with 2-0 sutures. The penis is now completely detached and is sent to pathology.

Perineal urethrostomy (Boutonnière):

Make a circular perineal incision for the urethrostomy of 1.5 cm diameter. The urethral stump with the catheter is brought into this opening; avoid any angulation or twisting. The excess urethra is resected, and the urethral end is spatulated. Suture the urethral end to the skin with interrupted PDS 4-0.

Wound closure:

The sagittal incision is closed in a horizontal fashion to displace the scrotum ventrally for better micturition. Fix the raphe of the scrotum to the sagittal end of the incision with the first suture. Insert redon drains into the wound bed and close the incision with interrupted sutures.

Inguinal lymphadenectomy:

See next section inguinal lymph node dissection.

Postoperative Care

Drains for 1–2 days, catheter for 7 days. Early mobilization. Thrombosis prophylaxis. Regular wound examination.

Complications of Radical Penectomy and Perineal Urethrostomy

Bleeding, hematoma, wound infection, meatal stenosis, urethral necrosis.

References

J. A. Smith, S. S. Howards, G. M. Preminger, and R. R. Dmochowski, Hinman’s Atlas of Urologic Surgery Revised Reprint. Elsevier, 2019.

  Deutsche Version: Radikale Penektomie und perineale Urethrostomie