Surgery for Penile Malignancy

Total penectomy

  1. Place patient in dorsal lithotomy, prep and drape, give cefazolin or other skin flora coverage
  2. Make transverse ellipsoid incision around base of penis (easier to close than circular), ensure evenness (scrotal edge can be longer than suprapubic edge)
  3. Identify penile attachments to surrounding tissue and detach
  4. Maximize urethral length, transect from corpora and tag with silk stitch
  5. Trace corpora as far proximally as able, clamp with peon/tonsil clamp, then transect and pass off field
  6. Tie off corpora with 2-0 V-loc suture
  7. Make perineal incision and divide layers down to urethra
  8. Bring urethral stump out through perineal incision, spatulate anteriorly/ventrally and suture to skin with 4-0 interrupted sutures
  9. Place catheter to maintain urinary drainage
  10. Close scrotal incision in two layers vertically then horizontally with 2-0 vicryl, then staple skin transversely
  11. Postop: remove drain following day if minimal output, treat with antibiotics x1 week and remove staples at 2 weeks

Partial penectomy

  1. Place patient either in supine position with froglegs (to access perineum if necessary) or dorsal lithotomy, prep/drape, give cefazolin or other skin flora coverage
  2. Identify tumor and its proximal extent
  3. Create circumcising incision around penile shaft with 1-2cm margin from tumor, divide dartos and buck fascia layers to identify urethra and corpora
  4. Isolate urethra and divide, try not to cauterize edges
  5. Clamp corpora with pean clamp then divide (make sure to leave small stump to suture
  6. Pass off specimen, send for frozen margin to confirm further resection not required
  7. Run a 2-0 V-loc suture along both corpora, then unclamp and run backwards to obtain hemostasis
  8. Spatulate urethra ventrally for 3+cm (will contract during healing)
  9. Obtain hemostasis along penile stump
  10. Suture urethral mucosa to skin (can include underlying dartos) at ventral point and upper corners, using 4-0 monocryl
  11. Place interrupted 4-0 monocryl sutures to approximate edges and obtain hemostasis
  12. Place catheter via urethra, then wrap with kerlex and coban, can place bacitracin on urethra (and fibrillar if oozing)
  13. Postop: foley x1 week, antibiotics x1 week

Inguinal LND

References