Advanced Penile Carcinoma : Emasculation or Testis - Sparing Surgery

ARTICLE INFO _________________________________________________________ ___________________ Vol. 38 (6): 750-759, November December, 2012 IBJU | LOCALLY ADVANCED PENILE CARCINOMA: EMASCULATION OR TESTIS-SPARING SURGERY? 751 reas 2 or 3 new cases of PC are observed every month at the Ceará Cancer Hospital in Fortaleza (Northeastern Brazil) (6), a British practicing urologist may not see more than one new case every other year. The causes of penile cancer are not always clear, but major risk factors include poor penis hygiene, phimosis, smegma retention, smoking and sexually transmitted diseases (7,8). In a recent Brazilian multicenter study, the practice of sex with animals was also identifi ed as a risk factor for this malignancy (9). Penile carcinoma metastasizes stepwise via the lymphatic system: from the inguinal nodes to the pelvic nodes to the distant nodes (10). The presence and extent of lymph node metastases are the most important predictors of survival (4). Histological grade and vascular and perineural invasion have been correlated with poor prognosis and unfavorable outcomes (11). Surgical management of malignant PC depends on the grade and stage of the disease (12). The National Institute for Clinical Excellence (U.K) recommends managing PC at centers with a catchment area of 4 million. Each center receives approximately 25 new cases annually. Advanced cases of PC are referred to a supra-regional center for multidisciplinary curative and palliative treatment, including reconstructive surgery (13). At our service, PC patients with proximal corpus cavernosum invasion and scrotal skin erosion are routinely referred to emasculation, including total penectomy (complete penis amputation), scrotectomy and bilateral orchiectomy (14). The present study evaluates the clinical and pathological fi ndings of 16 patients with locally advanced penile squamous cell carcinoma submitted to emasculation and discusses questions related to surgical technique, patient follow-up and the usefulness of bilateral orchiectomy. MATERIALS AND METHODS Between 1999 and 2010, 172 patients with penile invasive squamous cell carcinoma were submitted to surgical treatment at the Ceará Cancer Hospital in Fortaleza, Brazil. Of these, 16 advanced cases (9.3%) underwent emasculation (Table-1). Complete preoperative, operative and postoperative patient data were retrieved from the institution’s prospective database and from a review of the respective medical records. The information included patients’ age, ethnicity, date of surgery, residential setting (rural or urban), level of schooling, time from appearance of fi rst lesion to defi nitive diagnosis, type of reconstruction, duration of follow-up and date of last follow-up visit. The median follow-up time was calculated as the median observation time among patients and the overall survival time was estimated using the Kaplan-Meier method. Specimens were obtained from all patients and evaluated by a single pathologist with regard to tumor stage and grade, inguinal lymph node status, vascular and perineural invasion, invasion Table 1 Cases of penile squamous cell carcinoma submitted to surgical treatment at the Ceará Cancer Hospital between 1999 and 2009. Surgical technique Cases (n) Percent (%) Wide local excision or circumcision 5 3% Partial penectomy 125 73% Total penectomy 26 15%