Total or Partial Penectomy Inguinal Lymph Node Dissection
Penectomy = an operation in which part of or all of the penis is removed
Lymph Node = small glands throughout the entire body that drain abnormal substances cancer cells or infection) from the organs with which they are associated.
Dissection = surgery to separate two areas of tissue
The most common reason to perform a penectomy is in an attempt to cure a patient of penile cancer. In this instance, you may have already had a biopsy (smaller procedure in which a part of the lesion is removed to be analyzed by a pathologist). A biopsy may be performed to confirm the diagnosis of cancer, and may also help to "locally stage" the tumor. The local stage of a cancer is a determination as to whether a cancer is superficial (just on the surface and not deeply invading) or has already invaded deeper tissue layers. It is this stage and the location of the tumor on the penis that will determine whether a partial or total penectomy should be performed. The most common type of cancer is called "squamous cell carcinoma," a skin cancer that only occurs in uncircumcised males. Penectomy for other types of cancer is far less common.
In instances of life-threatening infections involving the penis, part of or the entire penis may require amputation (removal).
Infections and cancers of the penis and scrotum (skin sac that covers the testicles) drain to lymph nodes that are located in the groin region. These are called "inguinal" nodes and are often palpable (able to be felt) when examining a patient. These lymph nodes then drain to deeper nodes in the body called "pelvic nodes". In certain, more advanced cases of penile cancer, it may be necessary to remove these lymph nodes on one or both sides of the inguinal region (groin area). If necessary, this operation is usually performed at a later date (for reasons that are beyond the scope of this educational paper) and serves one or two purposes.*The first reason is to better "stage" the cancer. The stage of a cancer (not to be confused with the local stage) is a measurement as to whether the cancer has begun to spread away from the organ in which the cancer originated (in this case the penis). *The second reason is that if some cancer cells have spread to the lymph nodes, then removing them may help to cure or control further spread of these cells.
If only part of the penis is removed, it is often still possible for a male to urinate through the urethra (tube through which one urinates) while standing. If the remaining portion of the penis is too short, it may be necessary for a male to sit while urinating. In cases where the entire penis is amputated (removed), the urethra is surgically relocated to the perineum (area behind the scrotal sac and in front of the anus). This is termed a "perineal urethrostomy," and once created, it is definitely necessary to sit in order to urinate.
If you have any significant medical problems, we may send you for an updated general physical and note of "medical clearance" from your primary physician. This precautionary and for your own protection.
It is definitely to your advantage not to strain to have a bowel movement in the week after the procedure. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
The duration of the operation is different for every patient, mostly reflecting a difference in whether partial or total penectomy is to be performed. The general range is less than two hours.
Your position on the table will be supine (flat on your back) or in the lithotomy position (on your back with your legs elevated in holsters called stirrups). A catheter is inserted into the urethra (tube through which you urinate) and into the bladder to help us identify the urethra during surgery. In a partial penectomy, the individual parts of the anatomy are all identified and divided at a point that leaves a planned width of normal tissue between the tumor and the remaining healthy tissue while attempting to spare as much penile length as possible. When we close the incision, we bring the new end of the urethra through an opening in the skin. In total penectomy, after the penis is removed, we bring the urethra to a new opening in the skin of the perineum. In either instance, the catheter may remain in place for 1-2 weeks (depending on the particular circumstances) to allow adequate time for the urethra to heal. Blood loss in either procedure is rarely enough to require a transfusion.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. Some patients may have this procedure done on an ambulatory basis and go home several hours after the procedure. As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a sensation that you need to urinate. This sensation typically disappears after a few days. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to prevent the formation of blood clots in your veins(deep venous thrombosis or DVT). There will be a gauze dressing wrapped around the penis or behind the scrotum. A typical hospital stay for this operation is one and rarely two nights.
Upon discharge, you may have no dressing (bandage) on your incision and your catheter will be attached to a small bag that straps to one of your legs. Occasionally, the catheter is removed just prior to discharge. The catheter is easily concealed under your clothing and nobody knows it is there. You will get instructions while in the hospital on how to empty the bag and even switch it to a larger bag for overnight use when you are sleeping.
You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic, a pain medication, and a stool softener so that you do not strain to have a bowel movement. Other medications are rarely necessary but depend on your particular needs.
It is normal to feel a bit tired for a few days after such an operation. We typically tell patients that they will be out of work for two weeks (anywhere from 3-4 weeks is possible) and that it may take longer before you truly feel like yourself.
Expectations of Outcome
As you may realize, all patients who have a total penectomy and most patients who have a partial penectomy will not be able to engage in sexual intercourse after this procedure.
Therefore, it is very normal for you to feel depressed after this procedure, more so than following other operations. It is important that you share your feelings with your family and closest friends, as they will be instrumental in helping you with this adjustment. Professional counseling can also be arranged upon request.
The pathology report should be available in a week, and at that time we will discuss the significance with you. Depending on the report, we may recommend the second procedure to remove the inguinal lymph nodes. In cases where the local stage is not as advanced, this decision will be based on whether your lymph nodes are enlarged.
If your inguinal lymph nodes were enlarged prior to the procedure, we will keep you on antibiotics for an extended time and re-examine the lymph nodes in six weeks. If the lymph nodes remain abnormally enlarged, we will usually recommend the procedure. At that time we will discuss whether the procedure is necessary on both sides, as well as the details of the surgery.
Recurrence of the cancer on the penis itself is uncommon.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with un foreseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, iti s important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Wound Infection: As with any incision, an infection can occur. This would present with redness, swelling, and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics and local wound care. In some instances, a small area of the superficial (upper layer) incision needs to be opened for adequate drainage. Infections are more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. If the infection enters the bloodstream, you may feel very ill. This is termed "sepsis."This type of infection often presents with any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. A septic patient may need a short hospitalization for intravenous antibiotics, fluids, and observation. Urinary Tract Infection or Urosepsis: It is possible for you to acquire a simple urinary tract infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This may not be readily apparent in the period that you have a catheter in place, as the catheter itself may cause these symptoms. The infection will usually resolve with a few days of antibiotics, and sepsis (infection in the bloodstream)is rare in this instance.
- *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office.
- Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
- Chronic Pain: While quite unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
- Death: The incidence of death during or shortly after the operation is less than 1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung) event.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.