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Hemiscrotectomy With Contralateral Testicular Transposition for Scrotal Cancer
0022-5347/02/1684-1406/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 168, 1406 –1407, October 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000026387.51062.26
HEMISCROTECTOMY WITH CONTRALATERAL TESTICULAR TRANSPOSITION FOR SCROTAL CANCER ´N OCTAVIO ARANGO, OSCAR BIELSA, JOSE ANTONIO LORENTE, EDISON DE LEO AND ANTONI GELABERT MAS From the Department of Urology, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
ABSTRACT
Purpose: Wide excision of scrotal tumors results in serious defects to such an extent that in some cases the contents of the scrotum cannot be preserved. We describe a hemiscrotectomy technique with transposition of the testis to the contralateral hemiscrotum that facilitates closure of the surgical wound and allows preservation of the testis. Materials and Methods: Our procedure was used in 3 patients with scrotal neoplasia, including 2 with squamous cell carcinoma and 1 with extramammary Paget’s disease. After excision of the hemiscrotum affected by the tumor, which includes all layers of the scrotal wall, the testis is transposed into the contralateral hemiscrotum through a slit made in the medial scrotal septum. The defect is easily closed by apposing the surgical wound edges. Results: The 3 men were disease-free 8, 7 and 4 years after surgery, respectively. After intervention they remained pain-free. None had hydrocele or epididymitis secondary to placement of the 2 testes in the same hemiscrotum. Conclusions: In appropriate candidates this technique allows the scrotal defect to be easily reconstructed after tumor excision without any need for skin flaps or free skin grafts. The procedure makes it possible to preserve the scrotal content and perform more radical treatment since the scrotal wall is completely excised. KEY WORDS: scrotum; carcinoma, squamous cell; Paget’s disease, extramammary; transplantation
Neoplasia of the scrotum is currently one of the least common urological tumors in developed countries, although when they occur, they usually involve extensive areas of the scrotum that require wide excision and are difficult to reconstruct.1, 2 We present a surgical procedure that enables complete removal of the hemiscrotum affected by tumor, facilitates primary closure of the surgical wound in 1 step without using skin flaps or grafts and enables more radical therapy.
PATIENTS AND METHODS
Hemiscrotectomy, contralateral testicular transposition and bilateral inguinal lymphadenectomy were performed in 3 men with scrotum neoplasia. Two patients 75 and 78 years old had infiltrating squamous cell carcinoma extending 4 ⫻ 6 and 6 ⫻ 8 cm., respectively, on a lateral side of the scrotum. The remaining 56-year-old patient presented with extramammary Paget’s disease involving a 5 ⫻ 7 cm. area of the right hemiscrotum. After extensive evaluation no associated internal malignancy was detected. The surgical procedure involves wide resection of the affected hemiscrotum, including the full depth of the scrotal wall. The incision is made parallel to the medial raphe and then extended toward the scrotal root in spindle-like fashion (fig. 1, A). Intraoperatively frozen sections were obtained to confirm a disease-free resection margin. After hemiscrotectomy the ipsilateral testis remains completely free (fig. 1, B). An incision is made at the upper third of the medial scrotal septum and the free testis is introduced through the slit. Absorbable material is used to close the slit (fig. 1, C). An aspiration drainage tube is placed. Primary closure of the scrotal wound is done by apposing the edges with 2 suture planes (fig. 1, D). Accepted for publication May 17, 2002.
FIG. 1. A, hemiscrotectomy incision limits. B, after removing whole scrotal wall ipsilateral testis remains completely free. C, testis transposition to contralateral hemiscrotum through slit made on medial septum. D, slit closure at medial septum and wound closure by apposing edges of suture planes. RESULTS
In 1 patient a tumor affected ipsilateral lymph node was identified after lymphadenectomy. The 3 men in our series 1406
HEMISCROTECTOMY WITH TESTICULAR TRANSPOSITION FOR SCROTAL CANCER
remained disease-free 8, 7 and 4 years after treatment, respectively. None has had pain, inflammation or hydrocele as a result of placing the 2 testes in the same hemiscrotum. Likewise, the esthetic result was good in all cases (fig. 2). DISCUSSION
The accepted treatment for malignant tumors that affect the scrotum involves resection of the primary lesion with a wide margin of tissue around the tumor.2⫺6 In a published series more than 80% of squamous cell carcinomas occurred on a lateral side of the scrotum, and so our technique may be used in most cases.5 Since problems due to a lack of space for the ipsilateral testis often arise after removal of the primary lesion, some groups choose to place the testis in the subcutaneous tissue of the thigh or femoral region, or even remove it, although it is not affected by tumor.1, 4, 6, 7 To close the extensive scrotal defects after radical excision and preserve the testis others use local thigh flaps and split-thickness skin grafts, or a mesh skin graft.8⫺11 Myocutaneous gracilis or adductor minimus myocutaneous flaps and heterologous fascia grafts have also been applied to reconstruct the scrotum.12⫺14 In appropriate candidates our technique allows preservation of the testis and facilitates primary closure of the surgical wound in 1 step. Although the testis transposed to the contralateral side initially remains above the ipsilateral testis, after 2 or 3 months the scrotum expands and the testis descends. Thus, the 2 testes remain at the same height and good cosmesis is achieved. Local recurrence is common after the excision of the pri-
FIG. 2. A, infiltrating squamous cell carcinoma involving wide area of right hemiscrotum. B, results 4 years after hemiscrotectomy with contralateral testicular transposition.
1407
mary lesion of squamous cell carcinoma with a relapse rate of 20% to 40%.1, 2, 11–15 Recurrence may depend on insufficient tumor resection. Thus, we consider that our technique makes it possible to perform more radical treatment from the oncological point of view since by removing the complete scrotal wall and tunica vaginalis in a wide area, negative resection margins can be achieved. CONCLUSIONS
Scrotal cancer is an uncommon but aggressive tumor that requires a wide excision of the primary lesion, the frequent use of free skin grafts and skin flaps for closing the surgical wound and preservation of the scrotal content. As we propose, with hemiscrotectomy and testicular transposition the scrotal defect after tumor removal is easily reconstructed, the testis is preserved and more radical treatment is attained since all layers of the scrotal wall were widely excised. Shirley Hooper assisted with manuscript review and translation. REFERENCES
1. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J Urol, 117: 741, 1977 2. Lowe, F. C.: Squamous-cell carcinoma of the scrotum. Urol Clin North Am, 19: 397, 1992 3. Dean, A.: Epithelioma of scrotum. J Urol, 60: 508, 1948 4. Kickham, C. J. E. and Dufresne, M.: An assessment of carcinoma of the scrotum. J Urol, 98: 108, 1967 5. Andrews, P. E., Farrow, G. M. and Osterling, J. E.: Squamous cell carcinoma of the scrotum: long-term followup of 14 patients. J Urol, 146: 1299, 1991 6. Hoch, W. H.: Adenocarcinoma of the scrotum (extramammary Paget’s disease): case report and review of the literature. J Urol, 132: 137, 1984 7. Lowe, F. C.: Squamous cell carcinoma of scrotum. Urology, 25: 63, 1985 8. Park, S, Grossfeld, G. D., McAninch, J. W. and Santucci, R.: Extramammary Paget’s disease of the penis and scrotum: excision, reconstruction and evaluation of occult malignancy. J Urol, 166: 2112, 2001 9. Wada, H. and Urabe, H.: Surgical treatment of genital Paget’s disease in men. Ann Plast Surg, 13: 199, 1984 10. Peters, K. M., Ordona, R. and Gonzalez, J. A.: Extramammary Paget’s disease requiring scrotectomy and scrotal reconstruction. Br J Urol, 77: 758, 1996 11. Lowe, F. C.: Squamous cell carcinoma of the scrotum. J Urol, 130: 423, 1983 12. Westfall, C. T. and Keller, H. B.: Scrotal reconstruction utilizing bilateral gracilis myocutaneous flaps. Plast Reconstr Surg, 68: 945, 1981 13. DiGeronimo, E. M.: Scrotal reconstruction utilizing a unilateral adductor minimus myocutaneous flap. Plast Reconstr Surg, 70: 749, 1982 14. El-Domeiri, A. A. and Paglia, M. A.: Carcinoma of the scrotum, radical excision and repair using ox fascia: case report. J Urol, 106: 575, 1971 15. Parys, B. T. and Hutton, J. L.: Fifteen-year experience of carcinoma of the scrotum. Br J Urol, 68: 414, 1991
Vol. 168, 1406 –1407, October 2002 Printed in U.S.A.
DOI: 10.1097/01.ju.0000026387.51062.26
HEMISCROTECTOMY WITH CONTRALATERAL TESTICULAR TRANSPOSITION FOR SCROTAL CANCER ´N OCTAVIO ARANGO, OSCAR BIELSA, JOSE ANTONIO LORENTE, EDISON DE LEO AND ANTONI GELABERT MAS From the Department of Urology, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
ABSTRACT
Purpose: Wide excision of scrotal tumors results in serious defects to such an extent that in some cases the contents of the scrotum cannot be preserved. We describe a hemiscrotectomy technique with transposition of the testis to the contralateral hemiscrotum that facilitates closure of the surgical wound and allows preservation of the testis. Materials and Methods: Our procedure was used in 3 patients with scrotal neoplasia, including 2 with squamous cell carcinoma and 1 with extramammary Paget’s disease. After excision of the hemiscrotum affected by the tumor, which includes all layers of the scrotal wall, the testis is transposed into the contralateral hemiscrotum through a slit made in the medial scrotal septum. The defect is easily closed by apposing the surgical wound edges. Results: The 3 men were disease-free 8, 7 and 4 years after surgery, respectively. After intervention they remained pain-free. None had hydrocele or epididymitis secondary to placement of the 2 testes in the same hemiscrotum. Conclusions: In appropriate candidates this technique allows the scrotal defect to be easily reconstructed after tumor excision without any need for skin flaps or free skin grafts. The procedure makes it possible to preserve the scrotal content and perform more radical treatment since the scrotal wall is completely excised. KEY WORDS: scrotum; carcinoma, squamous cell; Paget’s disease, extramammary; transplantation
Neoplasia of the scrotum is currently one of the least common urological tumors in developed countries, although when they occur, they usually involve extensive areas of the scrotum that require wide excision and are difficult to reconstruct.1, 2 We present a surgical procedure that enables complete removal of the hemiscrotum affected by tumor, facilitates primary closure of the surgical wound in 1 step without using skin flaps or grafts and enables more radical therapy.
PATIENTS AND METHODS
Hemiscrotectomy, contralateral testicular transposition and bilateral inguinal lymphadenectomy were performed in 3 men with scrotum neoplasia. Two patients 75 and 78 years old had infiltrating squamous cell carcinoma extending 4 ⫻ 6 and 6 ⫻ 8 cm., respectively, on a lateral side of the scrotum. The remaining 56-year-old patient presented with extramammary Paget’s disease involving a 5 ⫻ 7 cm. area of the right hemiscrotum. After extensive evaluation no associated internal malignancy was detected. The surgical procedure involves wide resection of the affected hemiscrotum, including the full depth of the scrotal wall. The incision is made parallel to the medial raphe and then extended toward the scrotal root in spindle-like fashion (fig. 1, A). Intraoperatively frozen sections were obtained to confirm a disease-free resection margin. After hemiscrotectomy the ipsilateral testis remains completely free (fig. 1, B). An incision is made at the upper third of the medial scrotal septum and the free testis is introduced through the slit. Absorbable material is used to close the slit (fig. 1, C). An aspiration drainage tube is placed. Primary closure of the scrotal wound is done by apposing the edges with 2 suture planes (fig. 1, D). Accepted for publication May 17, 2002.
FIG. 1. A, hemiscrotectomy incision limits. B, after removing whole scrotal wall ipsilateral testis remains completely free. C, testis transposition to contralateral hemiscrotum through slit made on medial septum. D, slit closure at medial septum and wound closure by apposing edges of suture planes. RESULTS
In 1 patient a tumor affected ipsilateral lymph node was identified after lymphadenectomy. The 3 men in our series 1406
HEMISCROTECTOMY WITH TESTICULAR TRANSPOSITION FOR SCROTAL CANCER
remained disease-free 8, 7 and 4 years after treatment, respectively. None has had pain, inflammation or hydrocele as a result of placing the 2 testes in the same hemiscrotum. Likewise, the esthetic result was good in all cases (fig. 2). DISCUSSION
The accepted treatment for malignant tumors that affect the scrotum involves resection of the primary lesion with a wide margin of tissue around the tumor.2⫺6 In a published series more than 80% of squamous cell carcinomas occurred on a lateral side of the scrotum, and so our technique may be used in most cases.5 Since problems due to a lack of space for the ipsilateral testis often arise after removal of the primary lesion, some groups choose to place the testis in the subcutaneous tissue of the thigh or femoral region, or even remove it, although it is not affected by tumor.1, 4, 6, 7 To close the extensive scrotal defects after radical excision and preserve the testis others use local thigh flaps and split-thickness skin grafts, or a mesh skin graft.8⫺11 Myocutaneous gracilis or adductor minimus myocutaneous flaps and heterologous fascia grafts have also been applied to reconstruct the scrotum.12⫺14 In appropriate candidates our technique allows preservation of the testis and facilitates primary closure of the surgical wound in 1 step. Although the testis transposed to the contralateral side initially remains above the ipsilateral testis, after 2 or 3 months the scrotum expands and the testis descends. Thus, the 2 testes remain at the same height and good cosmesis is achieved. Local recurrence is common after the excision of the pri-
FIG. 2. A, infiltrating squamous cell carcinoma involving wide area of right hemiscrotum. B, results 4 years after hemiscrotectomy with contralateral testicular transposition.
1407
mary lesion of squamous cell carcinoma with a relapse rate of 20% to 40%.1, 2, 11–15 Recurrence may depend on insufficient tumor resection. Thus, we consider that our technique makes it possible to perform more radical treatment from the oncological point of view since by removing the complete scrotal wall and tunica vaginalis in a wide area, negative resection margins can be achieved. CONCLUSIONS
Scrotal cancer is an uncommon but aggressive tumor that requires a wide excision of the primary lesion, the frequent use of free skin grafts and skin flaps for closing the surgical wound and preservation of the scrotal content. As we propose, with hemiscrotectomy and testicular transposition the scrotal defect after tumor removal is easily reconstructed, the testis is preserved and more radical treatment is attained since all layers of the scrotal wall were widely excised. Shirley Hooper assisted with manuscript review and translation. REFERENCES
1. Ray, B. and Whitmore, W. F., Jr.: Experience with carcinoma of the scrotum. J Urol, 117: 741, 1977 2. Lowe, F. C.: Squamous-cell carcinoma of the scrotum. Urol Clin North Am, 19: 397, 1992 3. Dean, A.: Epithelioma of scrotum. J Urol, 60: 508, 1948 4. Kickham, C. J. E. and Dufresne, M.: An assessment of carcinoma of the scrotum. J Urol, 98: 108, 1967 5. Andrews, P. E., Farrow, G. M. and Osterling, J. E.: Squamous cell carcinoma of the scrotum: long-term followup of 14 patients. J Urol, 146: 1299, 1991 6. Hoch, W. H.: Adenocarcinoma of the scrotum (extramammary Paget’s disease): case report and review of the literature. J Urol, 132: 137, 1984 7. Lowe, F. C.: Squamous cell carcinoma of scrotum. Urology, 25: 63, 1985 8. Park, S, Grossfeld, G. D., McAninch, J. W. and Santucci, R.: Extramammary Paget’s disease of the penis and scrotum: excision, reconstruction and evaluation of occult malignancy. J Urol, 166: 2112, 2001 9. Wada, H. and Urabe, H.: Surgical treatment of genital Paget’s disease in men. Ann Plast Surg, 13: 199, 1984 10. Peters, K. M., Ordona, R. and Gonzalez, J. A.: Extramammary Paget’s disease requiring scrotectomy and scrotal reconstruction. Br J Urol, 77: 758, 1996 11. Lowe, F. C.: Squamous cell carcinoma of the scrotum. J Urol, 130: 423, 1983 12. Westfall, C. T. and Keller, H. B.: Scrotal reconstruction utilizing bilateral gracilis myocutaneous flaps. Plast Reconstr Surg, 68: 945, 1981 13. DiGeronimo, E. M.: Scrotal reconstruction utilizing a unilateral adductor minimus myocutaneous flap. Plast Reconstr Surg, 70: 749, 1982 14. El-Domeiri, A. A. and Paglia, M. A.: Carcinoma of the scrotum, radical excision and repair using ox fascia: case report. J Urol, 106: 575, 1971 15. Parys, B. T. and Hutton, J. L.: Fifteen-year experience of carcinoma of the scrotum. Br J Urol, 68: 414, 1991