Archivio Italiano di Urologia e Andrologia 2013; 85, 124 INTRODUCTION Squamous cell carcinoma of the penis (SCC), which rep- resents a rare condition in Western Europe and North America, accounting for less than 1% of all male malig- nancies, is slightly more common in the developing coun- tries, where it has an incidence up to 20 per 100,000 peo- ple (1, 2). The traditional treatment of SCC has been radical penec- tomy, which guarantees excellent local control rates at the expense of a complete loss of sexual and urinary function with consequent severe psychological morbidity (3). Although there is little dispute that radical surgery is nec- essary for T3 and T4 disease, the need to perform this type of surgery in patients with T1 and T2 disease limit- ed to the glans penis and the prepuce and the belief that a 2 cm margin is required to guarantee an adequate onco- logical clearance have been questioned in recent studies. ORIGINAL PAPER Glans reconstruction with the use of an inverted urethral flap after distal penile amputation for carcinoma Salvatore Sansalone 1, Giulio Garaffa 2, Giuseppe Vespasiani 1, Alessandro Zucchi 3, Franklin Emmanuel Kuehhas 4, Ralf Herwig 4, Mauro Silvani 5, Stefano Pecoraro 6, Carla Loreto 7, Rosario Leonardi 8 1 Department of Experimental Medicine and Surgery, Tor Vergata University of Rome, Rome, Italy; 2 St Peter’s Andrology, University College London Hospitals, London, UK; 3 Department of Urology and Andrology, University of Perugia, Perugia, Italy; 4 Department of Urology, Medical University of Vienna, Vienna, Austria; 5 Department of Urology, General Hospital, Biella, Italy; 6 Department of Nephro-Urology, Malzoni Medical Center Avellino, Avellino, Italy; 7 Department of Bio-Medical Sciences, Anatomy Section, University of Catania, Catania, Italy; 8 Musumeci GECAS Clinic of Catania, Catania, Italy. Restoration of adequate cosmesis and preservation of sexual and urinary function are the main goals of penile reconstructive surgery following amputation for carcinoma. Split thickness skin grafts and oral mucosa grafts have been widely used for the cre- ation of a pseudoglans with excellent cosmetic and functional results. The main drawbacks associated with the use of grafts are donor site morbidity, the lack of engorgement of the pseudoglans and the risk of poor graft take, which may lead to contrac- ture and poor cosmetic results. In the present series the long term cosmetic and functional outcomes of glans reconstruction with an inverted distal urethral flap are described. KEY WORDS: Glans reconstruction; Urethral flap; Penile cancer. Submitted 12 February 2013; Accepted 28 February 2013 No conflict of interest declared Summary In particular, a more conservative organ sparing approach is suggested by the fact that more than 80% of SCC aris- es from the glans and prepuce and that margins of few millimeters may be adequate for the clearance of most tumours. Moreover, the penis is easy to inspect and there- fore local recurrences can be immediately identified and treated (4-8). Current EAU guidelines recommend a penile preserving approach for Carcinoma in situ, Ta, T1 and T2 SCC with involvement of the glans only in patients committed to a regular surveillance program (2). In particular, patients with T1 and T2 disease limited to the glans penis should be offered glansectomy with or without corporeal tips amputation followed by construc- tion of a pseudoglans (9, 10). Herein the long-term outcome of a series of patients who Sansalone_Stesura Seveso 18/04/13 11:01 Pagina 24 25Archivio Italiano di Urologia e Andrologia 2013; 85, 1 Glans reconstruction with the use of an inverted urethral flap after distal penile amputation for carcinoma heads and the distal aspect of the urethra and frozen sec- tions were collected form the corporeal heads and the distal urethral margin in all patients, as previously described by various Authors (5, 8, 10-15). Two patients presented positive corporeal margins at the frozen sec- tion and underwent distal corporectomy with recon- struction of the corporeal heads. The shaft penis was then completely degloved in all patients in order to allow a complete dissection of the ure- thra off the corpora cavernosa down to the crura (Figure 1). The distal aspect of the urethra was then spatulated ventrally for approximately 2.5 cm, everted and used to cover the corporeal heads in order to form a pseudoglans (Figure 2). The urethral edges were sutured to the under- lying corpora cavernosa with interrupted 4-0 Polyglactin sutures (Vicryl®, Ethicon, Somerville, New Jersey, USA) in order to form the ridge of the pseudoglans. The penile shaft skin was also approximated to the edge of the ure- thral flap using interrupted 4-0 Polyglactin sutures in order to recreate the coronal grove (Figure 3). A light compressive dressing was applied on the penile shaft to prevent haematoma formation and a 16 French Foley catheter left in situ for 24 hours. Patients were usu- ally discharged on postoperative day one on broad-spec- trum oral antibiotics for 1 week. Patients were reviewed on postoperative week 2, after 3 months and then on a 6 monthly basis and instructed to regularly inspect the genitalia in order to identify early signs of recurrence. A physical examination was routine- ly performed at each visit while a Computerized Tomography (CT) scan of chest, abdomen and pelvis with contrast was carried out on a yearly basis. Patients with histology of pT1 G3 and pT2 and/or palpable groin disease have been then managed with groin node dissec- tion according to the EAU guidelines (2). Cosmetic and functional outcome of the glans recon- struction, patients’ satisfaction, complications, recur- rence of the disease and eventual need for revision sur- gery were recorded in the postoperative follow-up visit. Figure 1. A circumferential subcoronal incision is carried out and the penile disassembly is performed. Figure 2. The urethra is divided and then spatulated ventrally. have undergone organ-sparing surgery for the manage- ment of T1 and T2 SCC of the glans penis followed by reconstruction of a pseudoglans with the use of urethral flaps is reported. MATERIALS AND METHODS In our Institution, between March 2007 and May 2011, 34 patients have undergone organ-sparing surgery for the management of T1 and T2 SCC of the glans penis followed by pseudoglans reconstruction with the use of an inverted distal urethral flap. All patients gave their informed consent prior to their inclusion in the study. Preoperatively, 22 patients reported good quality erec- tion and 19 reported to be sexually active. Prior to surgery all patients have undergone local stadia- tion based on clinical examination and on Magnetic Resonance Imaging (MRI) findings. In particular, con- trast enhanced T1 and T2 weighted MRI images in com- bination with an artificial erection with prostaglandin E1 (PGE1) were used to identify invasion of the tumour through the tunica albuginea into the corpora cavernosa. Only sexually active patients committed to a regular sur- veillance program with clinical T1 and T2 disease arising from the glans and without involvement of the corpora cavernosa were included in the series. Patients with a history of urethral stricture or of previous urethral surgery were excluded from this series and underwent glans reconstruction with split thickness skin grafts as previously described by various Authors (5, 8, 10-12). This because glans reconstruction with the use of urethral flap relies on an adequate blood supply form the proximal aspect of the urethra, and this might be severely compromised in patients with spongiofibrosis. After a circumferential subcoronal incision has been car- ried out in the shaft skin and deepened down to the level of Buck’s fascia, the glans was dissected off the corporeal Sansalone_Stesura Seveso 18/04/13 11:01 Pagina 25 Archivio Italiano di Urologia e Andrologia 2013; 85, 1 S. Sansalone, G. Garaffa, G. Vespasiani, A. Zucchi, F.E. Kuehhas, R. Herwig, M. Silvani, S. Pecoraro, C. Loreto, R. Leonardi 26 All patients who did not require further local surgery were able to maintain physiological urinary function and con- sidered the cosmetic result of the urethral flap satisfactory. All 22 patients who preoperatively had good quality erec- tions reported no reduction in rigidity after surgery. Overall, 14 of the patients who were preoperatively sex- ually active have resumed sexual activity postoperatively (74%). Of the remainder, 4 had required a delayed par- tial penectomy due to malignant infiltration of the cor- poreal heads and one, who had undergone glansectomy followed by bilateral radical lymph node dissection of the groin, had a residual penile length insufficient for penetration. It is likely that the prepubic and scrotal lym- phoedema consequence of the bilateral lymph node dis- section was the cause of the perceived loss of penile length in this patient. A ventral penile curvature during erection was noticed by 2 patients (9%) and was consequence of a relatively short urethra, which was acting as a ventral chordee. This occurred despite of a meticulous intraoperative dis- section of the urethra proximally down to its bulbar aspect. In both cases the curvature was less than 20 degrees, and, although ventral, did not interfere signifi- cantly with sexual activity. At 6 months postoperative follow up, all patients who have not required further local surgery have reported pseudo glans sensation and a degree of urethral flap engorgement. DISCUSSION Reconstruction of the glans penis following glansectomy or distal corporectomy for carcinoma of the penis repre- sents a challenge for the reconstructive surgeon. This because the aim of surgery is to achieve complete onco- logical clearance and to guarantee adequate cosmetic and functional results to allow the patient to resume sexual and urinary function with confidence (5-15). After the initial technique description in 2004, split thick- ness skin grafts, usually harvested from the inner thigh, have been widely used for glans resurfacing and pseudoglans construction for both benign and malignant conditions (5, 8-18). A recent series has also described the use of oral mucosa grafts for glans reconstruction.18 Although glans reconstruction with the use of grafts yields adequate cosmetic and functional results in the hands of experienced surgeons, it is associated with donor site morbidity and the risk of poor graft take, which can lead to contracture and poor cosmesis. Despite a good cosmetic result, the pseudoglans fashioned with this technique does not engorge like the native one (8). Furthermore, oral infection with human papillomavirus (HPV), which can have a prevalence as high as 31%, can lead to the development of HPV related carcinomas aris- ing from the oral mucosa grafts, although the literature has not provided any indication of the actual risk after genital reconstruction (20). This series confirms that a distal urethral flap is a good alternative to a split thickness skin graft for the recon- struction of the glans penis following amputation for car- cinoma, as previously described in 1 series of 14 patients (21). This technique is not associated with donor site Sensation of the urethral flap and patient’s satisfaction were assessed by direct questioning the patient and no objective test or validated questionnaire has been employed. RESULTS Mean age at the time of surgery was 60 years (range 36- 73) and the final histo-pathological results are reported in Table 1. Infiltration of the proximal surgical margin, which had resulted clear in the initial frozen section, was present in 4 patients with pT2 disease (17%) and was managed with a distal corporectomy followed by glans recon- struction with the use of split thickness skin grafts, as the distal urethra had already been used (5). After a median follow-up of 27 months (range 6-48 months) none of the patients has succumbed because of the disease. The urethral flap survived in all patients and a penile hematoma occurred in 2 (6%) patients and required sur- gical evacuation in one case. A local recurrence occurred in one of the patients who had pT2 disease (3%) and was noticed at the 6 months follow up visit. Eventually the patient was managed with partial penectomy and was local recurrence free at the 18 months follow up visit. Figure 3. The final results after the eversion of the urethral flap and the creation of the pseudoglans Table 1. Histology results. Histology result N. of patients G2 pT1 12 G3 pT1 15 pT2 7 Sansalone_Stesura Seveso 18/04/13 11:01 Pagina 26 27Archivio Italiano di Urologia e Andrologia 2013; 85, 1 Glans reconstruction with the use of an inverted urethral flap after distal penile amputation for carcinoma morbidity, as it does not require the harvesting of a graft, and as the spongy tissue engorges during the erection, it leads to tumescence of the pseudo glans and therefore produces a more physiological outcome. Regardless to the reconstructive technique used, glansec- tomy and distal corporectomy needs to be carried out as previously described in the literature.8 In particular, frozen sections of the corporeal and urethral margins are required to assess whether a complete clearance of the malignancy has been achieved (8, 22). Only patients with a good blood supply to the distal ure- thra can be offered glans reconstruction with the use of distal urethral flap and therefore in presence of history of urethral strictures and/or previous urethral surgery recon- struction should be performed with the use of skin grafts. Patients need to be warned that even with adequate prepa- ration of the urethra, which should be dissected proximal- ly down to its bulbar portion, a minor ventral penile cur- vature during erection is not an uncommon finding. CONCLUSIONS The present series confirms that urethral flaps represent an excellent alternative to split thickness skin grafts for pseudoglans reconstruction following glansectomy and partial corporectomy for penile carcinoma in carefully selected patients. REFERENCES 1. Mistry T, Jones RW, Dannat E, Pet al. A 10-year retrospective audit of penile cancer management in the UK. BJU Int. 2007; 100:1277-81. 2. Pizzocaro G, Algaba F, Horenblas S, et al. 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Correspondence Salvatore Sansalone, MD (Corresponding Author) salvatore.sansalone@yahoo.it Giuseppe Vespasiani, MD Department of Experimental Medicine and Surgery Tor Vergata University of Rome - 00133 Rome, Italy Giulio Garaffa, MD St Peter’s Andrology - University College London Hospitals W1G 6BJ London, UK Alessandro Zucchi, MD Department of Urology and Andrology University of Perugia - 06123 Perugia, Italy Franklin Emmanuel Kuehhas, MD Ralf Herwig, MD Department of Urology - Medical University of Vienna 1040 Vienna, Austria Mauro Silvani, MD Department of Urology – Biella General Hospital 13900 Biella 13900, Italy Stefano Pecoraro, MD Department of Nephro-Urology, Malzoni Medical Center Avellino, 83100 Avellino, Italy Carla Loreto, MD Department of Bio-Medical Sciences - Anatomy Section University of Catania - 95100 Catania, Italy Rosario Leonardi, MD Musumeci GECAS Clinic of Catania - 95100 Catania. Italy Sansalone_Stesura Seveso 18/04/13 11:01 Pagina 27