Download MBBS Surgery Presentations 13 Penis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 13 Penis PPT-Powerpoint Presentations and lecture notes


Phimosis,Paraphimosis,

Peyronie's disease,

Carcinoma Penis

Phimosis


? Phimosis

? Prepuce cannot be retracted over the glans penis

? Physiologic Phimosis

? Pliant, unscarred preputial orifice

? Pathologic Phimosis

? Failure to retract secondary to distal scarring of the prepuce

Pathologic Phimosis

? Occurs mostly by forcefully pulling back the prepuce in

infancy

? Scarring after Infection

? Failure of the phimotic preputial ring to retract after

childhood

Osburn et al, Pediatrics 1981


Treatment
? No forceful retraction of the prepuce

? If no retraction at all after 5 years or scarring is present from

previous attempts

? Betamethasone dipropionate 0.05% cream (Diprolene) ? no FDA

approval under 16 years of age

? Most important: Parent education about the natural process

? Handouts

? Perform circumcision on parents request

Paraphimosis

? Tight preputial ring is trapped behind the

glans after retraction

? Very painful

? Edematous preputial skin and glans

? Urinary retention

? Requires immediate attention

? Pain

? Possible necrosis

? Management

? Compression

? Dorsal slit


Peyronie's disease

Definition

? Described by Francois Gigot

de la Peyronie in 1743

? Also known as induratio penis

plastica

? Fibrotic induration of the penis

with concurrent curvature


Clinical presentation

? Peak incidence

? 4th to 6th decades

? Pain and penile curvature during erection

? Difficult intercourse

? Impotence in some cases

? A hard fibrotic mass is felt on palpation

Etiology

? Fibrosing condition of the tunica albuginea

? Repeatitive microtrauma is most probably the inciting

event

? Dupuytran's contracture has been associated with PD

? Always examine the hands

? Possible genetic aetiology


Etiology

Clinical course

? Most cases are self limiting

? Divided into acute and chronic phase

? In the acute phase

? Pain
? Worsening of the deformity
? Enlargement of the plaque
? 12 to 18 months duration

? Chronic phase

? No pain
? Stable deformity
Treatment

? Medical

? Usual y during the acute phase

? Oral therapy

? Vitamin E

? Potassium para-amino benzoate

? Colchicine

? Tamoxifen

? Pentoxifylline

Treatment

? Transdermal therapies

? Verapamil

? Intralesional

? Verapamil
? INF alpha 2 beta
? Saline
? Intralesional therapies not for cure, but more for

prevention of progression

? Other therapies

? ESWL
Surgical treatment

? Reserved for patients with PD for at least 12 months

(chronic phase) and a stable deformity for at least 3

months

? 3 groups of surgery

? Penile shortening
? Penile lengthening
? Penile prosthesis

Surgical Treatment

ED

+

-

Penile Prosthesis

Normal length

Short penis

< 30 degrees

> 45 degrees

Penile shortening

Penile lengthening

procedure

procedure

Nesbit

Graft




Surgical treatment

Penile Shortening (Nesbit

Plication)

Surgical treatment

Penile prosthesis
Carcinoma Penis

Introduction

Uncommon malignancy in developed countries

Higher incidence rates are seen in Africa and Asia (10%

to 20%)

Commonly affects those between 50 and 70 years of

age

22% of patients are less than 40 years of age


Epidemiology
? Intact foreskin

? Phimosis (25%)

? Precancerous lesions are found in 15%-20% of patients

? Human papilloma virus(HPV 16,18)

? Chronic inflammatory conditions (eg, balanoposthitis and
lichen sclerosus et atrophicus)

Premalignant lesions
Pathology
? Primary malignancies (those that originate from either the
soft tissues, urethral mucosa, or covering epithelium)

? Secondary malignancies (ie, those that represent

metastatic disease and often affect the corpus

cavernosum

? MC: squamous cell carcinoma is found on
glans: 48%,prepuce: 21%,glans & prepuce:9%,coronal

sulcus: 6%, and shaft: <2%

? Primary, non squamous malignancies comprise <5% of

penile cancers.

? Sarcomas are the most frequent non squamous penile

cancers, followed by melanomas, basal cell carcinomas,

and lymphomas




Clinical Presentation

? Area of induration or erythema to a non healing ulcer or a

warty exophytic growth

? Palpable inguinal lymphadenopathy is present at diagnosis

in 58% of patients ( 20%-96%)

? In non palpable inguinal lymph nodes at the time of resection

of the primary tumor, 20% will found to have metastatic

disease




Staging: Two staging systems
Jackson

AJCC Cancer Staging Manual, 5th ed


TNM

Prognostic Factors

? Grade

? Depth of invasion

? Number of positive lymph nodes

? Unilateral or bilateral inguinal extension

? Pelvic nodes involvement

? Presence of lymph node extracapsular extension


Diagnosis
? Physical examination

? Cytological and/or histological diagnosis

? Chest x-ray

? CT scan/PET-CT scan

? Bone scan

PET CT scan


Treatment of the Primary Lesion

? Small tumors limited to foreskin:
? circumcision+2-cm margin

Circumcision alone, especially with tumors in the proximal

foreskin, may be associated with recurrence rates of 32%

? Small superficial penile cancers:
? Moh's micrographic surgery
? Radiation therapy (EBRT/brachytherapy)
? RT has yielded local control rates similar to surgical resection:

? Carcinomas involving the glans & distal shaft:
? partial penectomy excising 1.5 to 2 cm of

normal tissue proximal to the margin of the tumor.

This should leave a 2.5- to 3-cm stump of penis


? Bulky T3 or T4 proximal tumors involving the base of the

penis:

total penectomy with perineal urethrostomy

Lymphadenectomy in Penile Cancer

? Lymphadenectomy is indicated in patients with palpable

inguinal lymphadenopathy that persists after treatment of
the primary penile lesion following a course of antibiotic
therapy

Srinivas 1987, Ornellas 1994
N0 Groin: Treatment Options

? Fine needle aspiration cytology

? Isolated node biopsy

? Sentinel node biopsy

? Extended sentinel LN dissection

? Intraoperative lymphatic mapping

? Superficial dissection

? Modified complete dissection

Fine needle aspiration cytology

? Requires pedal / penile lymphangiograhy for node

localization & aspiration under fluoroscopy guidance

? Multiple nodes to be sampled

? Sensitivity 71% (Scappini 1986, Horenblas 1993)

? Can provide useful information to plan therapy when +ve
Sentinel Node Biopsy

? Based on penile lymphangiographic studies of

Cabanas (1977)

? Accuracy questioned: False ?ve 10=50% (Cabanas

1977, McDougal 1986, Fossa 1987)

? Extended sentinel node biopsy: 25% false ?ve

? False ?ve due to anatomic variation in position of

sentinel node

Unreliable method: Not recommended

Intraoperative Lymphatic Mapping

? Potential for precise localization of sentinel node

? Intradermal inj of vital blue dye or Tc- labeled colloid

adjacent to the lesion

? Horenblas 11/55: All +ve False ?ve in 3

? Pettaway 3/20: All +ve No false ?ve

? Tanis (2002): 18/23 +ve detected (Sensitivity 78%)

Promising technique for early localization of nodal metastases

Long-term data needed
Superficial Inguinal LND

? Removal of nodes superficial to fascia lata

? If nodes +ve on FS: Complete inguino-pelvic LND

? Rationale: No spread to deep inguinal nodes when superficial

nodes ?ve (Pompeo 1995, Parra 1996)

? No clinical evidence of direct deep node mets when corporal

invasion present

Complete Modified LND

(Catalona 1988)

? Smaller incision
? Limited inguinal dissection (superficial + fossa

ovalis)

? Preservation of saphenous vein
? Thicker skin flaps
? No sartorius transposition

Identifies microscopic mets without morbidity

(Colberg 1997, Parra 1996)
Cancer Penis: Management of N+ groin

? Surgical treatment recommended for operable inguinal

metastatic disease

? Most patients with inguinal LN mets will die if untreated.

? 20-67% patients with metastatic inguinal LN disease free 5

years after LND.

? Better survival 82-88% with single / limited mets

Pelvic Lymphadenectomy

? Staging tool
? Identifies patients likely to benefit from adjuvant chemo
? Adds to locoregional control
? No additional morbidity
? If pre-op pelvic node identified : NACT followed by

surgery in responders

Value of pelvic LND unproven

Patients with minimal inguinal disease & limited

pelvic LN mets may benefit
Inguinopelvic Lymphadenectomy:

Indications for adjuvant therapy

? >2 metastatic inguinal nodes

? Extranodal extension of disease

? Pelvic lymph node metastases

Penile Cancer

Management of fixed nodes

? Neoadjuvant chemo + surgery in responders

? Palliative chemotherapy

? Chemotherapy + radiation therapy
Complications of lymphadenectomy

? Persistent lymphorrhoea

? Wound breakdown, necrosis, infection

? Lymphocyst

? Femoral blowout

? Lymphangitis

? Lymphoedema of lower extremity

Conclusion
? Uncommon disease
? No systematic study & complete absence of RCTs
? Small no of patients over a long time

? RCTs to develop guidelines essential

This post was last modified on 08 April 2022