Penectomy

Penectomy refers to the surgical removal of the penis - either all or a part of. It is usually done to treat penile cancer. The goal of penectomy is to remove the cancerous cells or tissues from the penis while keeping much of the healthy penis as it is. However, in a few cases, the scrotum and lymph nodes may also need to be removed. 

The type of penectomy depends on the location of the cancer on the penis. If the cancer is located on the foreskin, then a circumcision (removal of the foreskin) may be required; whereas if it is present on the head (glans) of the penis, then the head is removed or partial penectomy may be done. If the tumour is quite large, then total penectomy (removal of the entire penis) may be required.

A doctor may recommend this surgery when a person has penile cancer and shows the following signs and symptoms on the penis:

• Changes in skin colour or skin thickening
• Flat growths (bluish-brown in colour)
• Bleeding from the penis, including from under the foreskin
• Reddish velvety rash beneath the foreskin
• Small crusty bumps beneath the foreskin
• A sore or growth on the penis head or foreskin and at times on the shaft of the penis.
• A foul-smelling discharge
• Difficulty to draw back the foreskin (phimosis)
• Unusual swelling at the end of the penis
• Unexplained pain in the shaft or tip of the penis Read more: Pain in penis causes

Some rare symptoms of penile cancer include a lump in the groin, abdominal pain, weight loss, pain in the bones and feeling tired.

The following factors increase the risk of penile cancer in men:

• Smoking
• Infection with human papillomavirus or acquired immunodeficiency virus (AIDS)
• Age above 60 years
• Conditions like phimosis (tight foreskin) or smegma (collection of secretions under the foreskin)
• History of UV light treatment for psoriasis (a skin disorder)

Penectomy is also done as a part of gender reassignment surgery in male transsexuals, i.e., altering the gender of the individual from male to female.

Penectomy is done in individuals with penile cancers such as squamous cell carcinoma, adenocarcinoma, sarcoma and basal cell carcinoma. 

Contraindications for penectomy are as follows:

• Penectomy that involves the excision of tissue layers of the penis or excision of penile tissue with margins of normal tissue for cancers of the distal penis is contraindicated when the tumour is close to or involves the urethra or is of advanced stage.
• Partial penectomy is contraindicated when the penis that remains after surgery is not functional. In such cases, total penectomy should be done.

You may need to go through a few tests suggested by your doctor to find the cause of symptoms. Your doctor will perform a physical examination, take your medical history, and discuss your symptoms in detail. He/she will check your genitals for penile cancer symptoms and examine the lymph nodes in your groin to check if they are swollen. You may also require a biopsy and other tests mentioned below to determine the stage of the cancer (to know how much it has spread in the body).

• Biopsy: Biopsy (a small piece of tissue is taken from the affected area and sent for examination) can confirm the presence of penile cancer. It can be done as an incisional biopsy (part of the area is removed) or excisional biopsy (the whole affected area is removed) and is usually done in a hospital or outpatient surgical centre. Anaesthesia is used for the procedure to numb the part to be operated on (local anaesthesia) or to keep the person asleep during the procedure. Lymph node biopsy is also done to check if cancer has spread and to find out the stage of cancer, once diagnosed. It is usually done by fine-needle aspiration where a hollow needle is placed into the lymph node, and a syringe is used to aspirate some cells and drops of fluid). If the lymph nodes cannot be checked with the fine needle aspiration method, a surgical biopsy may be done to remove the lymph nodes for checking them.

The following imaging tests are done before the surgery:

• Computed tomography (CT) scan: A CT-scan helps to view the size of the tumour by using X-rays. It also helps in determining the spread of cancer to other body parts or lymph nodes.
• Magnetic resonance imaging (MRI): An MRI shows detailed pictures of soft tissues in the body using strong magnets and radio waves. The doctor may introduce a substance called prostaglandin into your penis to make it erect as MRI images are better when the penis is erect.
• Ultrasound: An ultrasound helps in finding enlarged lymph nodes in the groin by using sound waves to create images of internal organs.
• Chest X-ray: A chest X-ray helps to check the spread of cancer to the lungs.
• A positron emission tomography (PET) scan may also be done to check whether the cancer has spread.

The stages of cancer can also be described as early, intermediate or advanced disease:

• Early disease means the cancer has affected the foreskin or the surface of the head of penis.
• Intermediate indicates that cancer has spread below the surface of skin into the shaft of penis and may be found in one of the lymph nodes in the groin area. 
• Advance disease implies the cancer has spread to other parts of the body and lymph nodes.

The cancer is graded as low, intermediate and high grade where the grading describes how the cancer cells look under a microscope and how fast the cancer will develop.

The type of procedure to be performed depends on the location of the tumour and its grade and spread.

Apart from the biopsy and imaging tests, the following steps will also be taken before the surgery:

• You may undergo blood tests to check your overall health, an electrocardiogram (ECG) to check your heart health, lung function tests (breathing tests), and an echocardiogram (test of your heart using sound waves).
• You will need to sign a consent form to give your approval for the operation.
• You will be checked for any allergies, and the doctor will review the medicines you are taking. Inform the doctor if you take any blood-thinning medicines such as aspirin and warfarin.
• The surgeon will explain the operation to you, including its type, benefits and possible risks.
• A nurse will check your weight, blood pressure, pulse and temperature.
• A physiotherapist will teach you the breathing and leg exercises to perform after the operation for quicker and better recovery.
• Avoid eating about six hours before the surgery, but drinking water up to two hours before the surgery is alright.
• You may go to the hospital the evening before or the morning of the procedure.
• When you reach the hospital, a nurse may give you a drink rich in carbohydrates. It will give you energy and speed up the recovery.
• You will need to remove any jewellery, contact lenses, nail polish, makeup, and false teeth before going for the procedure.
• You may be given an injection or a tablet to relax an hour before you are taken to the operating room.

The general steps before the surgery include:

• You will be asked to change into a hospital gown after you are admitted to the hospital.
• A cannula (small tube) will be inserted into a vein in your arm to give you any fluids or medicines, including the general anaesthesia.
• A nurse may shave the skin above the operating area if required.
• A general anaesthetic will be given to you to put you in a deep sleep so that you won’t feel anything during the operation.
• Before you fall asleep, a tube may be inserted in the space around your spine. A pump will be attached to this tube in order to give pain medicines to control pain after the surgery.

A partial or total penectomy will be done depending on how much of the penis is affected. Other procedures that can be done along with this surgery include emasculation and lymph node removal. Emasculation is the removal of penis and testicles, often used to treat advanced cancers. Lymph node removal is applicable for deep tissue invasion of the cancer. Sometimes, a dye is injected near the cancerous tumour and the first lymph node with the dye is removed. It is called sentinel lymph node removal. A cut is made in the groin to remove inguinal lymph nodes.

Radiotherapy or chemotherapy may be given as needed after the surgery.

Penectomy is performed as below:

• Partial penectomy: It is the surgical removal of the end of the penis where the cancer is located. Here the surgeon removes the cancerous part and an extra margin of the penis to ensure that the entire cancer is removed. 
• Total penectomy: This approach is only used if cancer has spread deep into the penis or to the bottom of the penis. In this surgery, the surgeon will remove the shaft and root of the penis and, in rare cases, the scrotum and testes may also be removed. A perineal urethrostomy is done with total penectomy in which an opening into the urethra is made through the perineum - the area between the scrotum and the anus. A urinary catheter will be placed in order to drain the urine to allow healing of your wounds. You can maintain full bladder control as the muscle that keeps the bladder closed is deep inside the body and remains intact.

After the surgery:

• You will be shifted to the recovery area.
• You will be monitored until your condition stabilises, and then moved to the ward. 
• Painkillers will be given to make you comfortable.
• The dressing on the penis is usually removed a day after the surgery.
• The stitches used during the surgery are usually dissolvable and will disappear in two to three weeks.
• For partial penectomy, the catheter used to drain urine will be removed 48 hours after the surgery, and it will be ensured that you pass urine without any problems before going home.
• In case of total penectomy, the catheter will be removed seven to 10 days after the surgery. A drain will be placed near the wound which will be removed before you are discharged.
• You may eat and drink when you feel like it.
• You may require a hospital stay of two to three days.

You should take the following care after the surgery.

• Wound care

  • Avoid taking a shower after the surgery. A salt bath may be advised after two weeks.
  • Pat dry the operation site with a clean gauze (thin cloth) or towel.
  • Do not use any material that leaves fibres on the incision site. Instead, use a hairdryer on a cold setting to dry that area.
  • The stitches will self dissolve and may take four to six weeks to fully diffuse.
• Diet

  • You may add more fluids to your diet to manage constipation.

• Medicines

  • You will feel pain in the first week and will be given painkillers to help with it.
  • You will also be prescribed medicines to control infection or constipation.
• Take deep breaths and rest to help manage the pain.
• You may require at least four weeks of leave from work.
• In case of partial penectomy, avoid sexual activity for eight weeks after the surgery. If you have had a total penectomy, you will be unable to have sexual intercourse.
• You may need someone to help you with daily tasks until you feel better.
• Your doctor will inform you about activities that need to be restricted and when you can go back to your normal activities.

The benefits of this surgery are that it relieves pain and reduces the risk of further spread of the cancer.

You can join support groups for penile cancer to help you cope with the aftereffects of the surgery.

When to See the Doctor?

You should contact your doctor if you see any of the following symptoms after the surgery:

• Fever and chills, which could indicate an infection.
• Pain that cannot be controlled with medicines.
• Difficulty when urinating.
• Bleeding from the wound that persists.
• Redness, swelling or a foul-smelling discharge from the wound.

The potential risks and complications of penile surgery are:

• Infection
• Bleeding or swelling
• Chest infection
• Blood clots in the lower legs and lungs
• Urinary problems such as having to pass urine in a seated position
• Wound healing problems
• Narrowed urethra
• Change in self-image or depression
• Potential need for penile reconstruction surgery
• Potential inability to have sexual intercourse

You will have a follow-up appointment with your doctor six to eight weeks after your discharge. You may have to visit a nurse to get your wound checked around seven to 10 days after the surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.