Total Penile Amputation (Total Penectomy) with Perineal Urethrostomy

Indications and preoperative planning

• Confirm diagnosis histologically (biopsy, or excisional biopsy with frozen section at time of surgery if diagnosis isn't in doubt).
• Total penectomy is chosen when: (1) tumor size/location precludes an adequate surgical margin with a partial penectomy, or (2) preserving enough phallic length for standing voiding isn't achievable even with partial resection.
• Staging workup before surgery: careful bimanual palpation of inguinal nodes plus CT chest/abdomen/pelvis to assess for nodal or distant metastasis - this drives prognosis and the extent of concurrent lymphadenectomy.

Positioning and incision

• Exaggerated dorsolithotomy position (as for perineal prostatectomy), with careful leg padding to avoid peroneal nerve injury (risk of foot drop).
• The tumor/glans is isolated by covering it with a sewn-on surgical glove or a condom.
• An elliptical incision is made circumferentially around the penile base.

Operative technique

1. Dissect subcutaneous tissue dorsally with electrocautery; the corpora are planned to be transected near the pubic level.
2. Divide the suspensory ligament and ligate the superficial dorsal vessels.
3. Open Buck's fascia ventrally to expose the urethra. Sharply dissect the urethra off the corporal bodies (Metzenbaum scissors), preserving enough length to reach the perineum. Divide the urethra, tag the distal cut end dorsally (12 o'clock) with a stay suture, and continue mobilizing it proximally to the pubic ramus.
4. Dissect the corporal bodies back to their insertion on the pubic rami, divide them, and oversew each stump individually (running absorbable suture) for hemostasis.
5. Create a small (1-2 cm) elliptical or inverted-Y perineal incision. Pass a clamp from the perineal incision through the penectomy defect, retrieve the tagged urethral stay suture, and transpose the urethra into the perineum without twisting or grasping it directly (to protect its blood supply).
6. Trim excess urethra, spatulate it dorsally, and mature the neomeatus with interrupted fine absorbable sutures circumferentially to the perineal skin, keeping it tension-free. Place a Foley catheter (typically 18-20 Fr) through the new urethrostomy to confirm a smooth path into the bladder, then wrap the catheter site with petrolatum gauze.
7. Close the penectomy defect by approximating scrotal skin to suprapubic skin (vertical mattress, nonabsorbable monofilament suture given contamination risk), with deeper layers as needed to eliminate dead space.
8. Place a Penrose drain in the defect, brought out through the incision, and apply a bulky dressing with a supportive garment.

Postoperative care

• Inpatient admission with IV antibiotics; drain typically removed the next morning if output is minimal.
• Foley catheter stays in place 1-2 weeks until the urethrostomy is well healed; triple antibiotic ointment applied to the stoma until catheter removal.
• Oral antibiotics if preoperative infection or poor hygiene is a concern.

Complications

• Meatal/urethrostomy stenosis is the most common complication - managed with intermittent dilation if stream decreases.
• Bleeding, occasionally from an unexpected postoperative erection (rare); severe bleeding may need wound reopening and oversewing.
• Wound infection, more common in obese or diabetic patients - superficial infections treated with antibiotics, deeper infections may need incision, drainage, and healing by secondary intention.
• Urethral necrosis, mainly in the setting of postoperative infection or diabetes - requires debridement, with skin flap advancement later if stenosis develops.

Supporting outcomes data

Penis Anatomy

Gross structure - the three erectile bodies

• Paired corpora cavernosa - dorsally located, extending from the pubic rami (as separate crura proximally) to fuse in the midline and continue to the tip of the glans. They are the main erectile engines, filling with blood to produce rigidity.
• Corpus spongiosum - a single midline body lying ventrally, which invests and protects the anterior urethra. It expands distally to form the glans penis.

Tunica albuginea and supporting connective tissue

• The corpora cavernosa are each wrapped in a bilayered tunica albuginea (mostly type I/III collagen with interwoven elastic fibers): an outer longitudinal layer and an inner circular layer, with radiating intracavernous pillars/struts that support the erectile tissue and the septum between the two corpora. These struts are absent between the 5- and 7-o'clock positions, and the tunica is thinner ventrally (~0.8 mm) than dorsally (~2.2 mm) - the anatomic basis for the ventral "weak spot" implicated in penile fracture.
• Emissary veins draining the corpora run obliquely between the two tunica layers and are compressed during erection, which helps trap blood and sustain tumescence (the veno-occlusive mechanism).
• The corpus spongiosum has only a single-layer tunica (no outer layer or struts), keeping it a low-pressure system during erection, and its tunica does not extend into the glans.
• External support comes from the fundiform ligament (from Colles' fascia) and the suspensory ligament (from Buck's fascia), which anchor the penile base to the pubic symphysis.

Fascial layers (superficial to deep)

1. Skin
2. Dartos fascia - loose, areolar, carries the superficial (skin) blood supply
3. Buck's fascia - a tougher fascial envelope surrounding the corpora cavernosa and corpus spongiosum, relevant to the deep structures of the penis
4. Tunica albuginea (as above)

Urethra

Vascular supply

• Arterial: the deep structures are supplied by the common penile artery (a branch of the internal pudendal artery), which gives rise to the cavernosal, dorsal, and bulbourethral arteries. Genital skin is supplied separately by the perineal/scrotal branches of the internal pudendal artery and the superficial external pudendal vessels (femoral artery branches).
• Venous: drainage occurs through three systems - superficial, intermediate, and deep venous networks.

Innervation

• Pudendal nerve - somatic motor and sensory innervation (sensation, and control of the rhabdosphincter/bulbocavernosus reflex).
• Cavernosal nerves - autonomic (parasympathetic plus visceral afferent fibers), the nerves directly responsible for triggering and maintaining erection.

Regional/surgical anatomy

Clinically relevant variability