CPT® Code 54135

1. Indications

The procedure described by CPT® Code 54135 is indicated for the management of malignant tumors or lesions located in the penis. The specific indications for performing a radical amputation of the penis in conjunction with a bilateral pelvic lymphadenectomy include:

• Malignant Tumors: Presence of cancerous lesions in the penile tissue that necessitate surgical removal to prevent further spread of malignancy.
• Positive Cloquet's Node: If Cloquet's node is found to be positive for malignancy during the procedure, indicating the potential spread of cancer to lymphatic tissues.
• Advanced Disease: Situations where the disease has progressed to a stage that requires extensive surgical intervention to ensure complete excision of cancerous tissues.

2. Procedure

The procedure for CPT® Code 54135 involves several critical steps that ensure the complete removal of the penis and associated lymphatic tissues. The steps are as follows:

• Step 1: The tumor or lesion in the penis is isolated using a sterile condom or glove, which is then sutured at the base to contain the area of interest.
• Step 2: An elliptical skin incision is made at the base of the penis, extending through the subcutaneous tissue to the pubis, allowing access to the underlying structures.
• Step 3: Blood vessels and lymphatic tissues are carefully ligated or fulgurated to minimize bleeding during the procedure.
• Step 4: The penile suspensory ligaments are identified and isolated to facilitate the amputation process.
• Step 5: The dorsal vein and penile arteries are clamped and ligated to ensure proper control of blood flow during the amputation.
• Step 6: The penis is positioned upward, and Buck's fascia is opened to allow for dissection of the urethra from the corpora cavernosa.
• Step 7: The urethra is divided at the distal bulbar region, ensuring adequate length remains for routing to the perineum.
• Step 8: The corpora cavernosa are dissected to the ischiopubic rami, where they are ligated and transected, completing the amputation of the penis.
• Step 9: Dissection continues around the urethra to the urogenital diaphragm, aiming for a straight course to the perineal urethrostomy site.
• Step 10: A wedge of skin and subcutaneous tissue is removed from the midline of the perineum, between the scrotum and the rectum.
• Step 11: A curved clamp is used to create a tunnel in the perineal subcutaneous tissue, allowing the urethra to be pulled through the perineal incision.
• Step 12: After spatulating the urethra dorsally, a V-shaped skin inlay is created and anastomosed to the lining of the urethra.
• Step 13: A catheter is inserted to maintain urethral patency post-surgery.
• Step 14: Penrose drains are placed on either side of the scrotum to facilitate drainage, and the wound is closed transversely to elevate the scrotum away from the perineal urethrostomy site.
• Step 15: If malignancy is detected in Cloquet's node, a bilateral pelvic lymphadenectomy is performed, which includes excision of external iliac, hypogastric, and obturator nodes.
• Step 16: The abdomen is incised without opening the peritoneum, allowing for exploration and excision of the pelvic lymph nodes.
• Step 17: The groin and abdominal incisions are closed in layers to complete the procedure.

3. Post-Procedure

Post-procedure care following the radical amputation of the penis and bilateral pelvic lymphadenectomy involves monitoring for complications such as bleeding, infection, and proper healing of the surgical sites. Patients may require pain management and should be advised on wound care to prevent infection. The placement of Penrose drains necessitates careful monitoring for drainage output and signs of infection. Follow-up appointments are essential to assess recovery and to ensure that there are no complications related to the urethrostomy. Additionally, patients may need counseling and support regarding the psychological and physical implications of the procedure, including changes in urinary function and sexual health.