Reconstruction for penile cancer
Reconstructive surgery helps restore the function and appearance of the penis. It may also be used to cover a defect in the skin if penile cancer has spread to the skin overlying lymph nodes. Reconstructive surgery may be planned shortly after surgery to remove the cancer or it may be done later. The risk of recurrence of penile cancer is highest within the first year after surgery. Therefore, men will often wait until they are told that they are disease-free before they have reconstructive surgery. A man with penile cancer may be offered the following reconstructive procedures:
- skin grafts and tissue flaps
- cutting the suspensory ligament
- fat removal
Reconstruction of the penis
Men who have had surgery that partially or completely removes the penis may be offered penile reconstruction. Surgeons use microsurgery (surgery that uses a microscope) techniques to reconstruct the penis. The goals of penile reconstruction are to:
- create a urethra so the man can pass urine normally
- enable the man to experience some feeling and sensation in the penis
- make the penis rigid enough for sexual intercourse
Skin grafts or tissue flaps may be used to reconstruct the penis after a partial or total penectomy. Skin grafts and tissue flaps used to reconstruct the penis may be taken from the leg, abdomen, forearm, scrotum or groin area.
Penile reconstruction often involves more than one operation. Sometimes as many as 6 operations are needed to get the desired results.
Reconstruction after partial penectomy
During a partial penectomy, the surgeon tries to leave enough of the shaft of the penis to allow the man to urinate standing up. If only the head of the penis (glans) is removed, the surgeon may use a skin graft to reconstruct it. After this operation, the penis looks like it is circumcised. The man can usually pass urine normally and have sexual intercourse with penetration.
Some men may also be eligible for other reconstruction techniques that try to preserve urination while standing up and that allow sexual intercourse with penetration.
- cutting the suspensory ligament
- This procedure involves surgically cutting the ligament that allows the penis to “stand” when a man has an erection.
- When this ligament is cut, the penis usually gains about 1 cm in length, which can help a man to urinate standing up and have sexual intercourse with penetration.
- fat removal
- Some men who have had a partial penectomy may also benefit from having fat above the penis (suprapubic fat) removed.
- When extra suprapubic fat is removed, it does not get in the way of the penis. This may help the man urinate standing up and allow sexual intercourse with penetration.
Cutting the suspensory ligament and removing suprapubic fat may both be offered to achieve the best possible results.
Reconstruction after total penectomy
It may be possible to reconstruct the penis after a total penectomy using skin and tissue from another part of the body. Various techniques may be used to create a penis.
- A flap of skin and muscle may be taken from the forearm, thigh, upper arm or abdomen to reconstruct the penis.
- A flap of skin, muscle and bone may be taken from the forearm or lower leg to reconstruct the penis.
- A flap of skin and tissue from the scrotum may be attached to the stump of the penis.
Sometimes it may be possible for a surgeon to reconnect nerves so a man has feeling in the reconstructed penis. The reconstructed penis may also be able to get an erection if the surgeon can reconnect blood vessels.
A penile implant (prosthesis) may be used to restore a man’s ability to have penetrative sexual intercourse. Unless a bone graft from the man’s body is implanted, skin graft techniques may not provide enough rigidity. Bone grafts are not ideal because the penis will always be erect. A semi-rigid or inflatable penile implant (prosthesis) may be preferred. Penile implant surgery is usually done 6–12 months after penile reconstruction surgery, once some sensation has returned to the skin of the reconstructed penis.
- semi-rigid implant
- The surgeon places 2 bendable rods in the penis.
- They are firm enough to allow sex, but leave the man with a permanent erection.
- inflatable implant
- An implant may be semi-inflatable or fully inflatable.
- The surgeon places 2 hollow rods (cylinders) in the shaft of the penis.
- A small balloon-like container (reservoir), which is filled with fluid, is placed in the lower abdomen. A small pump is implanted either at the head of the penis or in the scrotum.
- Squeezing the pump moves the fluid from the container to the rods in the penis and makes the penis hard.
- The rods are deflated after sex and the penis becomes soft again.
Other uses for skin grafts
Skin grafts may also be used when cancer in the lymph nodes of the groin has spread to the overlying skin. In this case, a skin graft is needed because a large area of skin is removed. Skin and muscle is often taken from the outer part of the thigh or abdomen.
Potential side effects
Side effects can occur with penile reconstructive surgery, but not everyone has them or experiences them in the same way. The side effects are similar for the different types of skin graft and tissue flap surgeries. Side effects of penile reconstructive surgery will depend mainly on the:
- type of surgery
- site of the donor tissue
- man’s overall health
- Men who are diabetic or obese may have more side effects.
- effect of other cancer treatments
It is strongly recommended that men stop smoking at least 3–4 weeks before having penile reconstructive surgery. Smoking affects blood flow to the skin and underlying tissues, which can lead to infection, delay healing and increase the risk of dead tissue in the skin graft or tissue flap (flap necrosis). Many surgeons will not offer reconstruction to men who do not quit smoking.
Side effects can happen any time during, immediately after, or a few days or weeks after penile reconstructive surgery. Most side effects go away after surgery. Late side effects can occur months or years after surgery. Some side effects may last a long time or be permanent. It is important to report side effects to the healthcare team.
Some potential side effects of penile reconstructive surgery include:
- infection and bleeding after surgery
- When the infection is associated with the implant, it may need to be removed and then reinserted after 6 months.
- scars on the reconstructed penis and areas of the body where a skin graft or tissue flap was taken from
- Scars will fade over time but may never completely go away.
- dead tissue (flap necrosis)
- Muscle, skin or fat tissue may not survive if there is a poor blood supply to the reconstructed area.
- Depending on how bad the circulation problem is, it may take a long time for the reconstructed area to heal or the reconstructed tissue may have to be removed.
- skin used in a reconstruction may have a different colour and texture than skin of the penis
- Some men may wish to have the head of the penis (glans) tattooed to improve the colouring.
- Tattooing is usually done 2–3 months after reconstruction, before sensation has returned to the penis. This makes the procedure less painful.
- fistula (abnormal opening) between the urethra and the skin of the reconstructed penis
- narrowing of the urethra
- urinary problems
- body image problems
- Some men may feel embarrassed about having a permanently erect penis. (This side effect depends of the type of implant or if a bone graft was used.)
- implant malfunction
The tube that carries urine from the bladder to the outside of the body.
In males, the urethra passes through the prostate and penis and carries semen as well as urine. In females, the urethra opens above the vaginal opening.