Glans resurfacing (for CIS)
- Subdermal dissection of the skin of the glans off the underlying corpora spongiosum under GA and tourniquet.
- Marked quadrants, then circumferential coronal and perimeatal incisions, then quadrant dissection from meatus to corona
- Deep spongiosal biopsies sent separate to exclude invasion
- Split skin graft harvested from thigh – usually takes well due to well vascularised bed – 5-0 rapide
- Bed rest 48 hrs, compressive dressing for 5 days.
Allows pathological staging and assessment of invasion (as opposed to topical treatments).
Potentially higher recurrence rates (cf. amputation) but no apparent survival differences.
Glansectomy
- Circumcising or subcoronal incision down to Buck’s fascia after tourniquet placed.
- If superficial / tips of cavernosa not involved, can proceed above Bucks – if concerns for high risk of deeper invasion, open Bucks
- If proceeding above Bucks – traction on glans with Allis and scissor dissection in relatively avascular plane between Bucks and glans sponge. Intra-operative frozen sections for corporal tips.
- If opening Bucks – identification and dissection of neurovascular bundle with clip distal and ligation proximally before dividing
- Either way – circumferential mobilisation of glans off corporal tips until only urethra attaches glans to penis
- Transection of urethra (+/- frozen sections) and spatulation ventrally if needed
- Approximation of proximal penile skin to corporal bodies then covering corporal bodies with STSG (‘neo-glans’)
Partial penectomy
- Tourniquet, IDC
- Circumferential incision to Bucks then opening of Bucks down to tunica albuginea of corpora
- Corpora cavernosa divided leaving sponge and urethra intact initially
- Urethra dissected a further 1.5 cm distally then sharply transected
- Spatulate urethra dorsally (? Ventrally)
- Corpora cavernosa closed transversely with 2-0 interrupted sutures incorporating both corpora and the septum then tourniquet released and bleeders controlled
- Ventrally urethra sewn to skin and dorsally skin closed then urethral anastomosis closed over catheter
Penectomy
- Lithotomy position. Headlight
- Ellipse or circumferential incision around base of penis
- Divide suspensory ligament and superficial dorsal veins, and then expose Bucks fascia (reverse deglove)
- Open Buck’s ventrally and expose urethra – dissect urethra circumferentially off corpora cavernosa, aiming to maximise length – dissect proximally to pubic ramus
- Divide urethra and leave stay suture with long tail at 12 o’clock
- Dissect corpora as far back as able, aiming for pubic rami insertion – vascular clamp and divide and oversew – use J needle due to deep location
- Perineal incision – ellipse
- Bring urethra through perineal incision with Roberts – careful not to twist or tort.
- Divide sharply at appropriate length
- Spatulate at 12 o’clock
- Interrupted perineal urethrostomy anastomosis with 4-0 monocryl, smaller bites of urethra and bigger bites of perineum, over a 20 Fr catheter
- Close penis wound in layers with interrupted mattress sutures over a drain.
Complications – wound infections common, urethral stenosis of perineal urethrostomy.