Penectomy

ANATOMIC REVIEW

The penis is made up of 2 parts: the corpora cavernosa (CC) and the corpus spongiosum (CS). They are covered by skin called: “sheath”, on the body of the penis “foreskin”, at the level of the glans (removable skin covering it) The corpora cavernosa are the tissues which fill with blood during erection, thus allowing the rigidity necessary for sexual intercourse. They are surrounded by the albuginea, a strong and very elastic fibrous envelope. They form two expandable cylinders located side by side on the top of the penis. They are fixed under the pubis by a suspensory ligament, which holds them when they swell. The corpus spongiosum is unique. Its initial part is called the bulb, it is surrounded by the bulbospongiosus muscle and it surrounds the urethra (bulbar). The terminal part of the corpus spongiosum is the glans, which caps the distal end of the corpora cavernosa. Throughout its course, the corpus spongiosum contains the urethral canal which ends on the glans at the level of the urinary meatus through which urine exits. Penis cross section

PRINCIPLE OF THE INTERVENTION

Remove a malignant tumor or suspected of being malignant at the surgically healthy margin and sufficiently far from the tumor to limit the risk of recurrence. For this, your urologist may suggest removing part of the glans (tumorectomy), the entire glans (glandulectomy or glansectomy) or even the distal end of your penis, removing the glans and part of the body. of the penis (partial amputation) if necessary.

WHY THIS INTERVENTION?

The tests carried out by your doctor are in favor of a malignant tumor of the tip of the penis. The size of the tumor and its location make it possible to consider preserving the part of the penis which is not affected by the tumor. This operation is necessary to avoid local progression of the disease which would lead to urinary disorders (by obstruction of the urethral canal), painful manifestations, bleeding, the risk of superinfection and ultimately a regional evolution of the disease (involvement of the lymph nodes in the groin or pelvis). Depending on the case, an additional intervention on the groin lymph nodes may be offered to you.

ARE THERE OTHER POSSIBILITIES?

Other treatments may be considered to treat a penile tumor depending on its type, size and location: removal of the tumor only, laser treatment, external irradiation (brachytherapy). Your urologist has explained to you why surgical treatment by partial penectomy is suitable for your case. _ PREPARATION FOR THE INTERVENTION Any surgical intervention requires preparation which may vary depending on each individual. It is essential that you follow the recommendations given to you by your urologist and your anesthesiologist. If these recommendations are not followed, the intervention could be postponed. As with any surgical procedure, a pre-operative anesthesia consultation is necessary a few days before the operation. A urine analysis is requested to check for a urinary infection.

OPERATIVE TECHNIQUE

The procedure takes place under regional anesthesia or general anesthesia. It is frequently preceded by the administration of antibiotics due to frequent superinfection of the tumor. The surgical procedure consists of removing the part of the penis affected by the tumor. The remaining penis length will be sufficient to urinate in a standing position directing the stream. The urethral meatus (end of the penis where urine comes out) is restored by suturing the urethral canal to the skin of the remaining end of the penis. In some special cases, the glans can be retained but in general, it is necessary to remove it. A urinary catheter can be left in place for a few days to facilitate healing.

USUAL FOLLOW-UP

The pain associated with the procedure requires the administration of analgesic medications which are administered to you regularly if necessary. The urinary catheter is usually well tolerated, but it can sometimes cause discomfort, controlled by the administration of medication. The time of removal of the urinary catheter is defined by the surgeon depending on the healing. The duration of hospitalization is a few days and convalescence varies between 2 and 4 weeks. Follow-up after the operation has several objectives: monitoring the absence of tumor recurrence and evaluating the way you urinate as well as sexual function.

RETURN HOME

Partial penectomy of the penis is an excision procedure which transforms your body shape but also your way of urinating and your sexuality. This intervention,
as any surgical intervention requires respecting a post-operative period of rest and caution. You are advised to avoid significant effort and movement in the first weeks following the procedure. The prescriptions given to you include care for the skin scar(s) as well as the daily injection of an anticoagulant. Maintaining anticoagulant treatment is necessary after your hospitalization to prevent the risk of phlebitis. It may be advisable to wear compression stockings for at least 10 days after your procedure. A letter has been sent to your attending physician to keep him informed of your state of health. The incision is a gateway for infection. It is therefore necessary to ensure good local hygiene. Healing

This takes place over several days. Local home care may be prescribed. Baths are not recommended until complete healing has been achieved. Showers are, however, possible by protecting the operating area and drying it carefully by dabbing. The removal of the threads if they are not absorbable (then fall off on their own within a few weeks) will be carried out by a home nurse following the medical prescription. The duration of convalescence and the date you return to work or normal physical activity depend on your physical condition.

You will discuss with your urologist the date of resuming your activities and the follow-up after the operation. A post-operative consultation is scheduled with your urologist to inform you of the result of the microscopic examination of the surgical specimen. Follow-up is planned to monitor the absence of recurrence of the cancer and manage possible adverse effects. Local pain If the pain persists despite the analgesic treatment prescribed to you, this may be a sign of a hematoma, an infection or another complication which requires medical advice. Signs of phlebitis and pulmonary embolism Pain in one leg, a feeling of heaviness or a reduction in tossing of the calf should suggest phlebitis.

It is therefore necessary to consult a doctor urgently. In order to avoid the occurrence of phlebitis, it is advisable to follow the recommendations given to you: regular and frequent contractions of the calves, movements of the feet, elevation of the legs and following your doctor’s prescription, wearing stockings. restraint. In the event of chest pain, side stitches, irritating cough or shortness of breath, it is necessary to consult urgently because these signs may indicate a pulmonary embolism. Contact your doctor or the nearest emergency department immediately.

Healing If the scar becomes red, hot or if there is an elevation of it, it is important to show this scar to your surgeon without urgency: it may be a hematoma or an abscess . Skin healing takes place over several days. During this period, a little bleeding may occur which can be stopped by compressing it with a compress or a clean cloth. The removal of the wires or staples is carried out by a nurse at home following the medical discharge prescription.

Disunion of the skin can sometimes occur. If this opening is superficial, you simply have to wait for it to close; the closing time can reach several weeks (especially in diabetic patients or those taking corticosteroids). Loosening of the suture and blackish appearance of the wound are complications requiring a consultation with your doctor and then your urologist. Indeed, a loose suture requires local care, a cardboardy, blackish and smelly healing can correspond to necrosis of the extremity also requiring local care or even surgical revision. A hematoma of the penis and or bursae It can cause a purple arch of all or part of the penis requiring a consultation with your doctor or your urologist after consulting the nurse, who provides the care.

Difficulty urinating The force of the jet may seem weak for the first few days. A worsening of these difficulties in urinating (abdominal thrust, dripping urination, etc.) may raise fears of urinary blockage (retention) and warrant rapid medical advice. After the procedure, difficulty urinating may be observed gradually, either in the form of a fine jet or in the form of a watering can head jet. It may reflect a narrowing of the urethral canal. You are then advised to contact your urologist again. Unexplained fever This fever may be due to an infection of the urinary tract or the surgical wound. It is necessary that you consult Contact your doctor or urologist if you repeatedly notice a temperature above 38.5°C or if you have chills or tremors.

RISKS AND COMPLICATIONS

In the majority of cases, the intervention offered to you takes place without complications. However, any surgical procedure carries a certain number of risks and complications described below. Some complications are linked to your general condition. Any surgical procedure requires anesthesia, whether locoregional or general, which carries risks. They will be explained to you during the pre-operative consultation with the anesthesiologist. Other complications directly related to the intervention are rare, but possible:

COMPLICATIONS COMMON TO ALL SURGERY ARE:

Local, generalized infection; Bleeding with possible hematoma and sometimes transfusion; Phlebitis and pulmonary embolism; Allergy.

THE COMPLICATIONS SPECIFIC TO THE INTERVENTION ARE IN ORDER OF FREQUENCY:

▪ Urinary infection: it is favored by catheterization and justifies the administration of antibiotics. Local infection: it requires treatment with antibiotics and sometimes surgical cleaning. Hemorrhage or hematoma: they may require further intervention to control the bleeding or evacuate the hematoma. Disunion of the suture: a new intervention or prolonged local care until complete healing is necessary. Narrowing of the urethral neo-meatus: scarring between the urinary canal and the skin of the perineum can lead to narrowing of the urethral canal. It then requires an intervention (widening or dilation), which can be followed by regular self-calibrations. Psychological impact: it is linked to the modification of the body image and may require specific treatment. These anatomical changes can be difficult to accept. Psychological support is often necessary, ask your urologist, he will direct you to a correspondent who can support you through this ordeal. Local recurrence: it justifies regular clinical monitoring.

POSTOPERATIVE FOLLOW-UP

You will be seen again in post-operative consultation to clarify the result of the analysis of the surgical specimen. The aim of postoperative follow-up is to monitor the absence of complications and to plan further treatment.

TOTAL PENECTOMY (TOTAL ABLATION OF THE PENIS)

Your urologist is at your disposal for any information. The intervention offered to you consists of removing your penis which is the site of a tumor.

ANATOMIC REVIEW

The penis is made up of 2 parts: the corpora cavernosa (CC) and the corpus spongiosum (CS). They are covered by skin called: “sheath”, on the body of the penis “foreskin”, at the level of the glans (removable skin covering it) The corpora cavernosa are the tissues which fill with blood during erection, thus allowing the rigidity necessary for sexual intercourse. They are surrounded by the albuginea, a strong and very elastic fibrous envelope. They form two expandable cylinders located side by side on the top of the penis. They are fixed under the pubis by a suspensory ligament, which holds them when they swell. The body PATIENT INFORMATION SHEET | TOTAL PENECTOMY (TOTAL ABLATION OF THE PENIS) 2/8 spongy is unique. Its initial part is called the bulb, it is surrounded by the bulbospongiosus muscle and it surrounds the urethra (bulbar). The terminal part of the corpus spongiosum is the glans, which caps the distal end of the corpora cavernosa. Throughout its course, the corpus spongiosum contains the urethral canal which ends on the glans at the level of the urinary meatus through which urine exits. Cross section of the penis

WHY THIS INTERVENTION?

The tests that your doctor has performed on you are in favor of a malignant tumor of the tip of the penis. This operation is necessary to avoid local progression of the disease which would lead to urinary disorders (by obstruction of the urethral canal), painful manifestations, bleeding, the risk of superinfection and ultimately a regional evolution of the disease caused by involvement of the lymph nodes in the groin or pelvis. Following this operation, you may be offered additional surgery on the groin lymph nodes.

ARE THERE OTHER POSSIBILITIES?

There is no other treatment method than surgery to treat the tumor you have. The size and location of your tumor do not allow reasonable consideration of partial removal of the penis.

REPAIR DURING THE INTERVENTION

Any surgical intervention requires preparation which may vary depending on each individual. It is essential that you follow the recommendations that will be given to you by your e urologist and your anesthesiologist. If these recommendations are not followed, the intervention could be postponed. The procedure can be carried out under regional anesthesia or general anesthesia. As with any surgical procedure, a pre-operative anesthesia consultation is necessary a few days before the operation. A urine analysis is requested to check for a urinary infection. The procedure is frequently preceded by the administration of antibiotics due to frequent superinfection of the tumor. PATIENT INFORMATION SHEET | TOTAL PENECTOMY (TOTAL ABLATION OF THE PENAL) 3/8

OPERATIVE TECHNIQUE

The surgical procedure consists of removing the entire penis. The successful completion of the procedure requires several incisions (incision under the pubis and on the perineum). If the tumor affects the bursae, which is very rare, it is possible that removal of one or more testicles will be necessary (emasculation). In this case, healing can be facilitated by a plastic surgery procedure (filling the areas removed by taking skin and muscle from the thigh). The urethral canal will open on the perineum between the bursae and the anus to be able to urinate in a sitting position without soiling yourself. The intervention does not compromise urinary continence. The intervention ends with the installation of drains which limit the risk of collection in the operated area. To facilitate healing, a urinary catheter is left in place for a few days.

USUAL FOLLOW-UP

The pain associated with the procedure requires the administration of analgesic medications which are given to you if necessary. The urinary catheter is usually well tolerated, but it can sometimes cause discomfort which can be controlled by administering medication. The time for removal of the urinary catheter is defined by your surgeon based on healing. The duration of hospitalization is a few days and convalescence varies between 2 and 4 weeks. Follow-up after the operation has two objectives: Monitor the absence of tumor recurrence And evaluate the way you urinate. _ RETURN HOME Total amputation of the penis is an excision procedure which transforms your body image but also your way of urinating and your sexuality. This intervention, like any surgical intervention, requires a post-operative period of rest and caution. You are advised to avoid significant effort and movement in the first weeks following the procedure. The prescriptions given to you include care for the skin scar(s) as well as the daily injection of an anticoagulant. Maintaining anticoagulant treatment is necessary after your hospitalization to prevent the risk of phlebitis. It may be advisable to wear compression stockings for at least 10 days after your procedure. A letter has been sent to your attending physician to keep him informed of your state of health. The incision is a gateway for infection. It is therefore necessary to ensure good local hygiene. Healing takes place over several days. Local home care may be prescribed. Baths are not recommended until complete healing is achieved. Showers are, however, possible by protecting the operating area and drying it carefully by dabbing. The removal of wires or staples will be carried out by a nurse at home following medical prescription. The duration of convalescence and the date of return to work or normal physical activity depend on your physical condition. You will discuss with your urologist the date of resuming your activities and the follow-up after the operation. PATIENT INFORMATION SHEET | TOTAL PENECTOMY (TOTAL ABLATION OF THE PENIL) 4/8 A post-operative consultation is scheduled with your urologist in order to inform you of the result of the microscopic examination of the surgical specimen. Follow-up is planned to monitor the absence of recurrence of the cancer and manage possible adverse effects.

SIGNS THAT MAY OCCUR AND WHAT TO DO ABOUT THEM

Local pain If the pain persists despite the analgesic treatment prescribed to you, this may be a sign of a hematoma, an infection or another complication that requires attention. medical advice. Signs of phlebitis and pulmonary embolism Pain in one leg, a feeling of heaviness or a reduction in tossing of the calf should suggest phlebitis. It is therefore necessary to consult a doctor urgently. In order to avoid the occurrence of phlebitis, it is advisable to follow the recommendations given to you: regular and frequent contractions of the calves, movements of the feet, elevation of the legs and following your doctor’s prescription, wearing support stockings. In the event of chest pain, side stitches, irritating cough or shortness of breath, it is necessary to consult urgently because these signs may indicate a pulmonary embolism. Contact your doctor or the nearest emergency department immediately.

Healing If the scar becomes red, hot or if there is an elevation of it, it is important to show this scar to your surgeon without urgency: it may be a hematoma or an abscess . Skin healing takes place over several days. During this period, a little bleeding may occur which can be stopped by compressing it with a compress or a clean cloth. The removal of the wires or staples is carried out by a nurse at home following the medical discharge prescription. Disunion of the skin can sometimes occur. If this opening is superficial, you simply have to wait for it to close; the closing time can reach several weeks (especially in diabetic patients or those taking corticosteroids). Loosening of the suture and blackish appearance of the wound These are complications requiring consultation with your doctor or urologist. Indeed, a loosening of the suture requires local care, cardboard and blackish healing can correspond to necrosis of the extremity also requiring local care. A hematoma of the penis It can cause a purple arch of all or part of the penis requiring a consultation with your doctor or your urologist after consulting the nurse, who provides the care. Difficulty urinating The force of the jet may seem weak for the first few days.

A worsening of these difficulties in urinating (abdominal thrust, dripping urination, etc.) may raise fears of urinary blockage (retention) and warrant rapid medical advice. A distance from the procedure, difficulty urinating may be observed gradually, either in the form of a fine jet or in the form of a watering can head jet. It may reflect a narrowing of the urethral canal. You are then advised to contact your urologist again. Unexplained fever This fever may be due to an infection of the urinary tract or the surgical wound. You should consult your doctor or urologist if you repeatedly notice a temperature above 38.5°C or if you have chills or tremors. PATIENT INFORMATION SHEET | TOTAL PENECTOMY (TOTAL ABLATION OF THE PENAL) 5/8

RISKS AND COMPLICATIONS

In the majority of cases, the procedure proposed to you takes place without complications. However, any surgical procedure carries a certain number of risks and complications described below. Some complications are linked to your general condition. Any surgical procedure requires anesthesia, whether locoregional or general, which carries risks.

They will be explained to you during the preoperative consultation with the anesthesiologist. Other complications directly related to the intervention are rare, but possible:

COMPLICATIONS COMMON TO ALL SURGERY ARE:

Local, generalized infection Bleeding with possible hematoma and sometimes transfusion Phlebitis and pulmonary embolism Allergy COMPLICATIONS SPECIFIC TO THE INTERVENTION ARE IN ORDER OF FREQUENCY: Urinary infection: it is favored by catheterization and justifies the administration of antibiotics. Local infection: it requires treatment with antibiotics and sometimes surgical cleaning. Hemorrhage or hematoma: they may require further intervention to control the bleeding or evacuate the hematoma. Disunion of the suture: a new intervention or prolonged local care until complete healing is necessary. Narrowing of the urethral neo-meatus: scarring between the urinary canal and the skin of the perineum can lead to narrowing of the urethral canal.

It then requires a widening or dilation procedure. Psychological impact: it is linked to the modification of the body image and may require specific treatment. These anatomical changes can be difficult to accept. Psychological support is often necessary, ask your urologist, he will direct you to a correspondent who can support you through this ordeal. Local recurrence: it justifies regular clinical monitoring.

POST-OPERATIVE FOLLOW-UP

You will be seen again in post-operative consultation to clarify the results of the analysis of the surgical specimen. The aim of postoperative follow-up is to monitor the absence of complications and to plan further treatment.