Squamous cell carcinoma of the preputial sac is common in India and Africa. The patient is at least 40, and is almost always uncircumcised. He presents with a swollen and often infected preputial sac, or with phimosis secondary to it. The tumour spreads, until his whole preputial sac is involved, after which it invades his corpus spongiosum, and later his corpora cavernosa. It also spreads to his inguinal lymph nodes, which ultimately ulcerate, so that he dies from sepsis, toxaemia, or sudden haemorrhage from his femoral vessels. It does not obstruct his urethra completely, nor is it painful at first, so that he commonly presents late.
In all but the earliest lesions, which can be treated by radiotherapy if you can refer him for it, you will have to amputate his penis, either partly, or completely. A partial amputation is usually possible; and although it is not easy to do well, it is not nearly as difficult as a total amputation. This is a difficult, bloody, major operation. Partial amputation is very effective, and his prognosis is good. If a block dissection can be done, his prognosis is good, even if his inguinal nodes are involved.
After a partial amputation, he can still urinate comfortably. After a total one, he has little urinary disability, except that he now has to squat to pass his urine, if he wants to avoid soiling his perineum. If you make his perineal meatus carefully, it will function well, and is unlikely to stenose.
Complete amputation of the penis is seldom done in the industrial world, where lesions are usually treated much earlier by radiotherapy. The method described here leaves the crura of the corpora cavernosa attached to the bone, which simplifies surgery. Recurrence in the residual crura is rare. There is nothing to be gained by doing a block dissection of the inguinal nodes prophylactically.
Fig. 32-18 PARTIAL AMPUTATION for carcinoma of the penis. A, the incisions for partial and complete amputation. B, the flaps and the amputation. C, the repair. D, a cross-section of the penis.
CARCINOMA OF THE PENIS EXAMINATION. Feel the shaft of the patient's penis carefully to determine the exact extent of the growth. Feel his inguinal nodes. They will probably be enlarged by sepsis, so you may find it difficult to know if they have secondaries in them or not. If necessary, split his prepuce under general anaesthesia, so that you can examine his glans adequately.
BIOPSY. Granuloma acuminatum and donovanosis can both ulcerate the foreskin, and simulate carcinoma of the penis. So always take a biopsy, and wait for histological proof before you amputate a penis[md]it is tragic to amputate, and then find that you have done so unnecessarily! Don't amputate until you have received the report. Surgery is not urgent, because the tumour is very slow-growing.
THE DIFFERENTIAL DIAGNOSIS includes granuloma acuminatum and the following:
Suggesting primary syphilis[md]a round or oval painless ulcer, often found under the foreskin, but which does not penetrate or destroy it. Enlarged rubbery glands in the groin. Serological tests may be negative early, but are always positive later.
Suggesting venereal warts[md]small multiple lumps 1 to 3 mm in diameter, covered by epithelium.
Suggesting donovanosis (granuloma inguinale)[md]a slow-growing lesion, which may destroy the foreskin, and parts of the shaft of the penis. The lesion is usually flatter and redder than carcinoma.
MANAGEMENT If you cannot refer him, treat him like this.
If the growth is limited to his prepuce and is freely movable over his glans (unusual), excise it, preferably with diathermy if this is available, and follow him up closely.
If it has involved his prepuce and his glans, or the shaft of his penis, take a biopsy, and as soon as the diagnosis is confirmed, do a partial amputation 2 cm proximal to the lesion. If he does get a recurrence, it will probably be in his inguinal nodes, not in the stump of his penis.
If his inguinal nodes do not seem to be clinically involved, wait. ''Normal' nodes are palpable, and sepsis may cause some enlargement and tenderness.
If they are palpable, but are clinically infected, wait.
If they are palpable and clinically cancerous, biopsy the primary. When you receive the report, amputate his penis, and do a bilateral block dissection. In the developing world patients seldom return for a second operation after amputation, because they do not understand the significance of painless gland enlargement. So, if his glands are involved clinically, amputation and block dissection are best done at the same time.
PARTIAL AMPUTATION [s7]OF THE PENIS Aim to fashion his urethral orifice carefully, so that a stricture does not develop.
Cut a long ventral flap based proximally. Make its width equal to about half the circumference of his penis. Cut a shorter 2 cm dorsal one. Dissect both flaps back to their bases.
Dissect his corpus spongiosum away from his corpora cavernosa, until you reach the planned level of section. Divide his corpus spongiosum 2 cm distal to the level where you intend to section his corpora cavernosa.
Pass transfixion sutures of No. 1 catgut through each of his corpora cavernosa 0.5 cm proximal to the intended level of section. Divide the corpora, dissect proximally for 0.5 cm, and then tie the sutures medially and laterally.
Cut a small circular slit in the ventral flap, and pull his urethral stump through it. Leave the end of his urethra protruding. It is less likely to stricture if you do this. Leave adequate spaces between the sutures to allow blood to drain and prevent a haematoma forming. Leave a self-retaining catheter in place for 5 days. Epithelium will grow over the raw surface of his corpus spongiosum.
Alternatively, split the distal end of his urethra longitudinally. Evert each half, and suture it to the long flap. This will prevent a terminal stricture forming. Although this is the method shown in Fig. 32-18, it is probably less satisfactory than the method above.
Warn him that, despite your efforts, he may require periodic bouginage.
Fig. 32-19 TOTAL AMPUTATION OF THE PENIS. A, passing a sound. B, make a racquet-shaped incision round the base of the patient's penis, and carry it vertically downwards in the midline of his scrotum. C, freeing his crura from his pubic bones. D, his perineum closed round the stump of his urethra.
MODIFIED TOTAL AMPUTATION [s7]OF THE PENIS INDICATIONS. Carcinoma of the penis, which cannot be excised 2 cm proximal to the lesion, by partial amputation.
If possible refer him: there are few occasions when a partial amputation is impossible. Only do a total amputation if: (1) Referral is difficult, refused, or impossible. (2) You have seen the operation done or assisted with it. (3) You have 2 units of blood ready. Several experienced contributors considered this operation too difficult to be included here.
ANAESTHESIA. (1) General anaesthesia with a tracheal tube is best. (2) Subarachnoid anaesthesia (A 7.4).
METHOD. Put him into the lithotomy position and pass a 20 to 24 Ch metal bougie to define his urethra. Wrap his penis in a sterile towel, leaving its base exposed.
Make a racquet-shaped incision round the base of his penis. Extend the arm in the midline posteriorly for about 5 cm, between the two sides of his scrotum (extend it further towards his perineum later). Dissect deeper, clamping all vessels; this area is very vascular.
Find, clamp, tie, and divide the large dorsal vein of his penis. Continue dissection until the shaft of his penis is free of subcutaneous tissue.
Extend the incision posteriorly to where his scrotum hangs from his perineum, about 4 or 5 cm in front of his anus. Separate his testes with their covering tunicae vaginales. Ask your asistant to retract them laterally with tissue forceps placed subcutaneously, first on one side and then on the other.
Dissect his corpus spongiosum on its ventral and lateral aspects, as far as the bulb which lies on his perineal membrane. Find it by feeling the expansion round the bougie. Remove the bougie, and cut his corpus spongiosum 4 cm distal to the bulb. Separate it from his corpora cavernosa and retract it.
Now free his corpora cavernosa until they diverge as the crura, at the inferior border of his symphysis pubis. Transfix each of them with a No. 1 chromic catgut suture and divide them about 0.5 cm distal to this. Only some connective tissue will now remain. Divide this and remove his penis.
Cut a transverse 1 cm hole in his perineal skin, 2 or 3 cm anterior to his anal verge. Deliver the stump of his corpus spongiosum through it, so that it protrudes about 2 cm. Suture the base to his skin, using 2/0 or 3/0 monofilament sutures. Don't try to evert the stump, or his urethra may form a stricture. Leave the stump long because it tends to retract. Epithelium from his urethra and skin will grow and cover it.
Insert corrugated rubber drains through 2 cm incisions laterally in his scrotum, to allow blood and tissue fluid to drain. Stitch these to his skin. Or, better, use suction drains.
First close the wound in the midline, using 2/0 or 1/0 monofilament. Then suture the anterior part of the wound. If his scrotum would hang down too much, trim off some skin and subcutaneous tissue before you suture it.
When you have finished, his scrotum will lie more anteriorly than usual. This allows good skin cover, and is less likely to get in the way when he urinates through his perineal urethrostomy.
POSTOPERATIVE CARE. Pass an indwelling catheter, release it 4-hourly and remove it at 7 to 10 days.
Apply much cotton wool padding, and a pressure dressing of elastic strapping. Remove the dressings and the drains on the 3rd day. Then start salt baths twice daily.