Urosurgery 24 Penile carcinoma, Lichen Sclerosus

  1. Cross section of penis?
    • Image Upload 1
    • Buck's fascia is continuous with the external spermatic fascia in the scrotum, which in turn is continuous with external oblique muscle in anterior abdominal wall.
  2. Fracture penis?

    Short note on Penile fracture. [TU 2072/6]
    Penile fracture is the disruption of the tunica albuginea with rupture of the corpus cavernosum.

    Etiology - Fracture typically occurs during vigorous sexual intercourse, when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury. When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure exceeds the tensile strength of the tunica albuginea, and a transverse laceration of the proximal shaft usually results.

    Although the site of rupture can occur anywhere along the penile shaft, most fractures are distal to the suspensory ligament. Injuries associated with coitus are usually ventral or lateral.

    Clinical features - Patients usually describe a cracking or popping sound as the tunica tears, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft. If the Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical eggplant deformity. If the Buck fascia is disrupted, hematoma can extend to the scrotum, perineum, and suprapubic regions.

    Diagnosis - of penile fracture is often straightforward and can be made reliably by history and physical examination. Given that urethral injury occurs not infrequently, preoperative urethrography should be considered when urethral injury is suspected. However, because urethrography can be time consuming and inaccurate, intraoperative flexible cystoscopy is now performed routinely just before catheter placement at the time of penile exploration when urethral injury is suspected.

    Management - Suspected penile fractures should be promptly explored and surgically repaired. Closure of the tunical defect with nterrupted 2-0 or 3-0 absorbable sutures is recommended.
  3. Etiology of penile carcinoma?
    • Poor hygiene - smegma accumulation under the phimotic foreskin results in chronic inflammation leading to carcinoma.
    • Phimosis
    • Number of sexual partners
    • HPV infection - HPV-16
    • Exposure to tobacco products
  4. Prenancerous dermatological lesions?
    Leukoplakia - Histologic examination reveals acanthosis, hyperkeratosis, and parakeratosis. This lesion may precede or occur simultaneously with penile carcinoma.

    Balanitis xerotica obliterans - a white patch originating on the prepuce or glans and usually involving the meatus.

    Giant condylomata acuminata - cauliflower-like lesions arising from the prepuce or glans.
  5. Carcinoma in situ of penis?
    Carcinoma in situ (Tis) of the penis is called erythroplasia of Queyrat if it involves the glans penis and prepuce or Bowen disease if it involves the penile shaft or the remainder of the genitalia or perineal region.
  6. Pattern of spread in penile carcinoma?
    • Primary dissemination is via lymphatic channels to the femoral and iliac nodes.
    • The prepuce and shaft skin drain into the superficial inguinal nodes (superficial to fascia lata).
    • Glans and corporal bodies drain to both superficial and deep inguinal nodes (deep to fascia lata).
  7. TNM staging of penile carcinoma?
    • Tis: Carcinoma in situ
    • Ta: Noninvasive verrucous carcinoma
    • T1: Invades subepithelial connective tissue
    • T2: Invades corpus spongiosum or cavernosum
    • T3: Invades urethra or prostate
    • T4: Invades other adjacent structures

    • N1: Metastasis in single superficial inguinal node
    • N2: Metastasis in multiple or bilateral superficial inguinal nodes
    • N3: Metastasis in deep inguinal or pelvic nodes

    M1: Distant metastasis present
  8. Differential diagnosis of Penile carcinoma?
    • Syphilitic chancre - as a painless ulceration
    • Chancroid - painful ulceration of the penis
    • Condylomata acuminata - exophytic, soft, “grape cluster” lesions
  9. HPE of carcinoma of penis?
    Most tumors of the penis are squamous cell carcinomas demonstrating keratinization, epithelial pearl formation,and various degrees of mitotic activity.
  10. Treatment of Penile carcinoma?
    Biopsy is mandatory to establish the diagnosis.

    CIS - Fluorouracil cream application or neodymium:YAG laser. Patients must come for frequent follow-up examinations to monitor response.

    • Invasive carcinoma
    • Involving prepuce - simple circumcision
    • Involving the glans or distal shaft, partial penectomy with a 2-cm margin to decrease local recurrence.
    • Involving the proximal shaft or when partial penectomy results in a penile stump of insufficient length for sexual function or directing the urinary stream- total penectomy with perineal urethrostomy
  11. Management of enlarged lymph nodes in penile carcinoma?
    Up to 50% of the time the enlargement is caused by inflammation. Thus, patients who present with enlarged inguinal nodes should undergo treatment of the primary lesion followed by a 4- to 6-week course of oral broad-spectrum antibiotics. Persistent adenopathy following antibiotic treatment should be considered to be metastatic disease, and sequential bilateral ilioinguinal node dissections should be performed.

    If lymphadenopathy resolves with antibiotics, observation in low-stage primary tumors (Tis, T1) is warranted. However, if lymphadenopathy resolves in higher stage tumors, more limited lymph node samplings should be considered,such as the sentinel node biopsy or a modified (limited) dissection as suggested by Catalona. If positive nodes are encountered, bilateral ilioinguinal node dissection should be performed.

    Patients who initially have clinically negative nodes but in whom clinically palpable nodes later develop should undergo a unilateral ilioinguinal node dissection.

    Patients who have inoperable disease and bulky inguinal metastases are treated with chemotherapy (cisplatin and 5-fluorouracil). In some cases, regional radiotherapy can provide significant palliation by delaying ulceration and infectious complications and alleviating pain.
  12. What is Chimney cancer?
    Chimney sweep's cancer, also called Soot wart, is a squamous cell carcinoma of the skin of the scrotum
  13. What is Lichen sclerosus?
    Lichen sclerosus is a chronic inflammatory disorder of the skin of unknown origin. Lichen sclerosus (LS) is the preferred term for what was previously known as balanitis xerotica obliterans (BXO).

    Etiology - associated with mucous membrane pemphigoid

    • Clinical features -
    • - The most common cause of meatal stenosis
    • - Appears as a whitish plaque that may involve the prepuce, glans penis, urethral meatus, and fossa navicularis. The prepuce becomes edematous and thickened, and often may be adherent to the glans.

    Diagnosis - biopsy.

    • Treatment - 
    • - The combination of topical steroids and antibiotics may help stabilize the inflammatory process.
    • - Conservative therapy may be warranted in patients whose meatus can easily be maintained at 14 to 16 French. In these cases, intermittent catheterization with lubrication of the catheter and meatal dilator with 0.05% clobetasol may be adequate treatment.
    • - Long-term antibiotic therapy may also be helpful to improve the inflammation, because secondary infection of the inflamed tissue may occur.
    • - This nonsurgical approach to treatment is used in patients who are not good surgical candidates for other medical reasons or in older patients, and in younger patients who demonstrate stable disease.
    • - In young patients with severe meatal stenosis, surgery is indicated. Because patients with long-standing meatal stenosis often have severe proximal urethral stricture disease, retrograde urethrography should be performed before the initiation of therapy. Buccal Mucosal Graft (BMG) urethroplasty is the surgery of choice. 
    • - If only the foreskin is involved, circumcision may be curative.

    Image Upload 2

    Complications - Squamous cell carcinoma in patients with a long history of lichen sclerosus.
  14. Why is buccal mucosa flap taken in urethroplasty?
    • Strong 
    • Impermeable 
    • Ampule of graft can be harvested 
    • Easy to harvest 
    • Relatively non secretory 

    In hypospadias, we take prepuceal flap.
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Urosurgery 24 Penile carcinoma, Lichen Sclerosus
Penile carcinoma