Historically, demolitive surgical approaches, such as total or partial penile amputation, were the most commonly used. Indeed, demolitive options were deemed to be necessary in order to respect a macroscopic surgical margin of at least 2 cm.3-4 If the oncological outcomes of these approaches demonstrated to be satisfactory, they significantly affected aesthetic outcomes, as well as sexual and urinary functions.5-12
Following these pieces of evidence, the development of organ sparing techniques took part over the last two decades. The basic principle underlying the development of a minimally invasive approach for the management of a localized or locally advanced PC was the newborn concept of a reduced safe surgical margin up to 5 mm. Recent pieces of evidence highlighted as the use of an organ sparing surgery (OSS) did not jeopardize oncological outcomes. Particularly, even if a higher local recurrence rate was recorded, it was easily managed by a salvage surgery without any negative impact on patients' overall survival.9-10,13-18
OSS progressively gained popularity among reconstructive urologists as it guarantees oncological safety, optimizing functional outcomes, and minimizing patients’ psychological impact.5,17-22
To date, among the OSS, glansectomy (GS) with split-thickness skin graft (STSG) represents a valuable option to manage localized or locally advanced PC,10,18 as it allows us:
- to achieve complete local oncological control, removing the entire glans within the malignant lesion
- to perform a frozen section examination focused on the distal urethral stump and on the corporal apex to have an intraoperative confirmation of a disease-free surgical margin
- to perform an effective reconstruction of the glans with the use of a STSG
- to minimize intra and postoperative complications
- to guarantee satisfactory functional and aesthetic outcomes3,10,12,20,23
Different surgical approaches can be considered to achieve the dissection of the glans during a GS. Despite that, the lack of actual evidence of a shared consensus on this topic. In our clinical practice, we carry out the dissection above Buck’s fascia in low-risk PC, whereas a dissection under Buck’s fascia is conducted in case of high-risk disease.
Dissecting Buck’s fascia may guarantee a wider surgical margin, jeopardizing the vascularity of the graft bed. Further clinical studies are warranted to assess any possible difference in terms of oncologic and function/aesthetic outcomes between these approaches.
Many grafts have been applied in glans reconstruction in the context of a GS for PC. Among them, skin grafts are more commonly used when compared to buccal or lingual mucosa grafts. A skin graft can be used as full or split-thickness according to the area to be covered. In penile reconstruction, a wide consensus among reconstructive genital surgeon can be found on the use of STSG, as it guarantees higher rates of graft take and it allows the detection of a local recurrence.
In reconstructive procedures, STSG is frequently meshed to increase the graft size as well as to favor the drainage of an underlying hematoma. However, the healing process of a meshed graft is based on a secondary intention healing of the defects, frequently leading to an anesthetic healing process. Focusing on glans reconstruction in the context of a GS, considering the small size of the area involved and the need for an aesthetic scarring, we do not recommend the use of a meshed STSG.24
Despite the availability of evidence supporting the safety of OSS in terms of oncological and surgical outcomes, functional data have been rarely inquired and they are willing to be investigated in detail in future series.
We strongly believe that the surgical treatment of PC should be reserved to referral centers where OSS is considered as the standard of care. Additionally, genitourinary reconstructive surgeons should manage the different OSS to obtain the best surgical and functional results according to any peculiar clinical condition.
Written by: Mirko Preto,1 Federica Peretti,1 Marco Falcone1,2
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino – Molinette Hospital, Turin, Italy
- Department of Neurourology, A.O.U. Città della Salute e della Scienza di Torino - Unità Spinale Unipolare, Turin, Italy
Read the Abstract