Secondary buried penis reconstruction with split‑thickness skin grafting after previous partial amputations for penile cancer – report of a case

Summary

Weibl P, Ameli G, Krauter J, Hübner W. Secondary buried penis reconstruction with split‑thickness skin grafting after previous partial amputations for penile cancer – report of a case.

Background: Surgical strategy of buried penis depends on the etiology and quality of affected and surrounding tissues, as well as overall anatomy of the external genitalia.

Patients and methods: The authors describe the surgical principle of aquired buried penis reconstruction after previous partial amputations while using principles of split‑thickness skin grafting (STSG), prepubic lipectomy and scrotoplasty. A 65 yrs old patient after biopsy proven squamous cell carcinoma of the penis, had undergone a glansectomy with neo‑glans reconstruction using STSG. A second procedure with neo‑glans reconstruction and urethral flap reconfiguration was done, because of local recurrence. Shortly thereafter, due to a secondary infection of the penis shaft tissues, the patient developed a buried penis.

Results: The surgical goal should repair voiding/sexual functioning and psychological well being, which have been achieved during short term follow‑up.

Conclusion: STSG is a valid alternative for advanced cases in patients with already compromised scrotum.

Keywords:

Buried penis – penile cancer – partial penectomy – neo‑glans – split thickness skin graft

BACKGROUND

Buried penis covers wide spectrum of amonalies of different origins. Acquired buried penis (ABP) is a serious urologic condition with a detrimental impact on quality of life (QoL) and psychological well being. The disease is characterized by various degree of penis shaft entrapment, accompanied with impaired micturition, sexual dysfunctioning, as well as reduced hygiene of the impacted scrotal skin area and reccurent skin infections (1). The most common causes are secondary penoscrotal lymphodema, persistent infections, lichen sclerosus, surgical interventions such as circumcision, and organ sparing procedures for penile cancer (2).

The authors describe the surgical principle of aquired buried penis reconstruction after previous partial penectomy procedures for localised penile cancer.

CASE REPORT

A 67 yrs old, sexually active male patient was introduced to our department (in October 2019) with a suspicious well marginated erythematous lesion on the glans (5x5 mm). The lesion was refractory to the previous topical corticoid/antibiotic treatment. Verbal and written informed consent was obtained from the patient in order to proceed with all the diagnostic and therapeutic interventions, as well as a continuous photographic documentation for further academic purposes. The principles outlined in the Declaration of Helsinki have been followed.

The biopsy confirmed partially exulcerated moderately differentiated squamous cell carcimona (SCC) of the penis (p16 positive). Preoperative CT scan was negative and confirmed clinical‑N0 status. A total glansectomy with neo‑glans reconstruction from the corpora cavernosa and split‑thickness skin grafting (STSG) was performed (Fig. 1). Perioperatively we obtianed a negative resection margin from the glans as well as from the urethra. The final histopathology revealed a SCC with infiltration of the subepithelial tissues (pT1bNxL1V1R0, keratinizing type G2) and basaloid intraepithelial neoplasia (PeIN) of the urethra (p16 positive). The overall size of the specimen was 4x3x2.3 cm. In February 2020 we performed a new biopsy of the neo‑glans/ neo‑meatal region due to a newly formed erythematous lesion 2x4 mm (recurrence of SCC was confirmed) (Fig. 2 A, B). Further diagnostic steps using flexible cystoscopy showed otherwise normal urethra and the CT scan was negative. In the meantime the patient underwent two HPV vaccinations, the last one was planned for June 2020. Because of the covid pandemic the surgery was postponed 7 weeks thereafter (in April 2020). According to the patient’s wishes and careful examination of the penile/ scrotal anatomy, we decided to perfom another organ sparing procedure. A partial penectomy (29x27x10 mm/neo‑glans and; 8×5×3 mm/urethral tissue) with neo‑glans reconstruction and coverage of the corpora cavernosa with urethral flap was achieved (Fig. 2). The neo‑glans was reconstructed while using the same principles as described by Palminteri et al. previously (3) (Fig. 2F, G, H, I, J). In addition the technique of scrotoplasty followed the concept initially described by Miranda‑Sousa et al. (4, 5) (Fig. 2C) The pathology revealed HPV associated PeIN and focal finding of SCC pT1NxL0V1G2R0 in the neo‑glans region and PeIN in the urethra, however R0. 10 days later (3 days after the patient’s discharge from the hospital) after the definitive procedure the patient suffered from asuperficial penile shaft tissues infection. Despite local and targeted antibiotic treatment, the patient developed ABP (Fig. 2K, L).

DESCRIPTION OF TECHNIQUE

After initial careful examination of the impacted tissues, viability of the surrounding skin, circumferential extramarginal scar excision of the unhealthy skin around the penis shaft was initiated to get normal tissue at the wound margins. The penis was delivered after adequate release and multiple sharp excisions of postinflammatory subcutaneous tissues (Fig. 3A, B). In order to gain sufficient lenght, we decided to perform a suprapubic lipectomy and complete suspensory ligament division. The body mass index of out patient was 35, with the typical fat tissue deposit in the prepubic region. At this point, a testicular prosthesis (Polytech Health and Aesthetics/Germany 2x2.2 cm) was implanted in the prepubic space, to prevent adhesion of disconnected suspensory ligaments (Fig. 3C).

Next stage of our reconstruction included penile fixation with so called „tacking sutures“ (Vicril 4.0) between the tunica albuginea of the penile shaft base and edges of subdermal dartos of abdominal skin to prevent retraction of the penis. This manoeuvre allows formation of the penoscrotal and penopubic angle. The urethral flap was inspected and left intact, the margins served as the neo‑sulcus border. The final step was aimed to correct the total penis shaft skin defect, which was substituted with STSG. The graft was typically harvested from the upper left lateral thigh using a pneumatic dermatome (at a thickness 0.4 mm, size of the graft was 9×7 cm). The skin graft was meshed at the ratio of 1:1.5 (Fig. 3D, E). The graft was sutured at the critical areas around the penis base, neo‑sulcus with a running Saphilquick 4.0 suture. Consequently, quilting sutures were used to enhance the overall adherence and optimal graft take. Saphilquick 4.0 interrupted sutures were placed between the graft and superficial part of the tunica albuginea to improve the stabilization. The graft was covered with 1 layer of nonadhering dressing (JENONET‑Paraffin gauze), followed by the „tie‑over dressing“ bolster placement. Penis shaft was wrapped within, and two bolsters were sutured together in order to maintain compression. (Fig. 3F). We routinely tend to leave the dressing for 5 days (Fig. 3K, L) in situ either for scrotal, penile shaft grafting or glans resurfacing cases.

The harvested area was managed with the application of Biatain silicone bolster (10×20 cm, Coloplast/ Austria) and the negative pressure V.A.C therapy (KCI Medical, Austria). The pressure was set to -50mmHg for 72 hours in the first phase (Fig. 3G, H). Thereafter the wound was evaluated for secretion, initial granulation, oedema, and degree of erythema around the margins (Fig. 3I). When the wound secretion was limited, we applied OpSite‑Post‑OP‑VISIBLE (10x20 cm, Smith & Nephew‑Austria) waterproof adhesive transparent dressing on the 4th postoperative day, which allowed us continuous inspection of the area. Two days later, we left the wound open. Topical administration of Vaseline mixted with Baneocin cream (Bacitracin/Neomycin) was recommended for the next 7–10 days for the harvested and grafting area. Strict bed rest was advised for 3 days. As a thromboprophylactic measure Enoxaparin‑Natrium (Sanofi‑Aventis‑Austria; 40 mg subcutaneously) was started the evening after the operation. Broad spectrum second generation cephalosporin (Cefuroxim 1.5 g) twice daily was administered for next 5 days. Urethral catheter CH 14 was left in situ for 10 days. The next abdominal CT scan was performed 3 and 6 months postoperatively with negative result. the patient was also advised to further check the neo‑glans as well as inguinal region.

DISCUSSION

Short term follow‑up (6 months) revealed, that we were able to achieve acceptable voiding as well as sexual functioning (self stimulation and oral intercourse). However due to the relative short penis, vaginal coitus was not satisfactory. During the first 4 weeks the patient was advised to perform clean intermittent catheterization (2× per week) with Ch12 catheter in order to prevent onset of meatal stenosis. The final cosmetic appearance was considered very adequate (Fig. 3M).

The missing penile shaft skin can be replaced either with local vascularised scrotal flaps or skin grafting. Skin grafts can be harvested and prepared as full thickness or meshed. Current literature does not provide enough evidence with regard to graft superiority. STSG is currently a well established surgical technique, with good survival rates (6, 7). To date, there is no universal treatment algorithm defined, one of the reasons is the heterogenous patient population and rarity of the disease (8, 9).

In our patient, we were sceptical about scrotal skin grafting, in order not to compromise the overall anatomy after previous scrotoplasty, Although the pedicled scrotal flaps has been widely established in pediatric and adult patient population with favourable outcomes (10, 11, 12). The relative disadvantage of the scrotal graft is the presence of hair follicles, which may require secondary multiple laser treatments.

CONCLUSION

Surgical strategy of buried penis depends on the etiology and quality of affected and surrounding tissues, as well as overall anatomy of the external genitalia. The definitive treatment and surgical goal should repair voiding/sexual functioning and overall psychological well being of these individuals. STSG is a valid alternative for advanced cases in patients with already compromised scrotum.

Došlo: 9. 11. 2020

Přijato: 4. 2. 2021

Kontaktní adresa:

Assoc. Prof. Peter Weibl, MD, PhD.

Department of Urology, Teaching Hospital – Landesklinikum Korneuburg, Wiener Ring 3–5, 2100 Korneuburg, Austria

e‑mail: pweibl@yahoo.com

Conflicts of interest: Authors have no conflicts of interest or any financial competing interests.

Financial support: None.

Contributions: Substantial contributions to the design of the work, or acquisition of the perioperative figures, analysis or interpretation of data for the work: P. Weibl, G. Ameli, J. Krauter.

Drafting of the manuscript and critical revision for important intellectual content: P. Weibl, W. Hübner.