Q. A 55-year-old patient previously treated with a partial penectomy and superficial modified bilateral inguinal lymphadenectomy presents with a large mass in the right groin fixed to the skin. What are the surgical treatment options?
A. A large mass in the groin presenting at follow-up after an inguinal lymphadenectomy will most likely represent metastatic disease. The prognosis is poor and the treatment is directed at palliation and improvement of the patient’s quality of life. If the performance status is good then a surgical resection combined with coverage of the defect with a flap is an option. As the defect is often large, coverage can be performed using a pedicled flap, e.g. vertical rectus abdominis (VRAM) or tensor fascia latae (TFL).
Q. He is brought in as an acute emergency as he is suffering from dehydration, feeling unsteady and confusion. Can you explain any metabolic reason for this to occur?
A. He is likely to have developed hypercalcaemia related to the bulk of the disease as opposed to metastatic bone disease. A series from Memorial Sloan Kettering reported that approximately 20% of patients with penile cancer develop hypercalcaemia possibly due to parathyroid hormone or parathyroid-like hormone secretion.
Q. A 67-year-old man has noticed a palpable lump in the mid-shaft of his penis which is getting progressively larger. The lump is not attached to the skin and he presents with urethral bleeding and discharge. How would you investigate this patient?
A. Having taken a full history and undertaken a general examination, I would also examine the inguinal areas to check for any palpable inguinal lymph nodes as well as the external urethral meatus. I would then organise an urgent cystoscopy and biopsy of the lesion. My suspicion would be a neoplasm of the urethra and There fore he requires CT staging of the chest, abdomen, pelvis and inguinal regions together with an MRI scan of the penis (ideally with an artificial erection).
Q. The cystoscopy shows an obvious tumour in the mid-urethra which is biopsied. What is the most common primary urethral tumour in males?
A. Squamous cell carcinoma accounts for 80% of the primary urethral tumours.
Q. Where in the urethra do these tumours most commonly arise?
A. Sixty per cent of these tumours are located in the bulbomembranous urethra with the majority (80%) being squamous cell carcinomas.
Q. What are the risk factors for a urethral tumour?
A. Risk factors include chronic stricture disease, inflammatory conditions, HPV infection and sexually transmitted diseases. Proximal lesions can also be adenocarcinomas or transitional carcinomas (TCCs). If it is TCC the same risk factors for bladder TCC apply.
Q. How would you manage this patient?
A. As these tumours are very rare, the management involves a multimodality approach. A tumour of the mid-shaft or anterior urethra with no synchronous tumour elsewhere can be managed by performing a wide local excision of the urethra together with the adjacent tunica albuginea and the anterior urethra. Urethral reconstruction is then performed either by bringing the urethra out as a perineal urethrostomy or if the length is adequate, a hypospadiac opening can be constructed. The inguinal lymph nodes are managed as for a penile cancer although the majority of patients will undergo a radical/superficial modified inguinal lymphadenectomy rather than a sentinel lymph node biopsy.
References
1. Muneer A et al. Molecular prognostic factors in penile cancer. World J Urol 2009; 27: 161-167.
2. Kayes O et al. The role of magnetic resonance imaging in the local staging of penile cancer. Eur Urol 2007; 51: 1313-1318.
3. Hadway P et al. Evaluation of dynamic lymphoscintigraphy and sentinel lymph-node biopsy for detecting occult metastases in patients with penile squamous cell carcinoma. BJU Int 2007; 100: 561-565.
4. Arya M et al. Malignant and premalignant lesions of the penis. BMJ 2013; 346: f 1149.
FURTHER READING
Arya M, Shergill IS, Silhi N, Grange P, Bott S (eds). Essential Urology in General Practice, London: Quay Books; 2009.
Muneer A, Horenblas S (eds). Textbook of Penile Cancer 2nd edn., London: Springer; 2016.
Wein AJ, Kavoussi LR, Partin AW et al. (eds). Campbell-Walsh Urology, 11th edn. Philadelphia, PA: Elsevier; 2016.