Male Reproductive System Grossing

What are the three segments of the male urethra?

Prostatic

Membranous (bulbomembranous)

Penile (spongy)

How does the epithelium of the urethra change along its length?

Proximal urethra — Urothelium

Distal urethra — Stratified squamous epithelium (SSE)

What are the two segments of the female urethra?

Anterior (distal 1/3)

Posterior (proximal 2/3)

What are the periurethral glands in males and females?

Male — Littré glands

Female — Skene glands

Both can be sites of periurethral gland adenocarcinoma

What is the most common overall urethral carcinoma?

Urothelial carcinoma

• Commonly in the proximal urethra

  • Particularly in the:

    • Prostatic urethra

    • Bladder neck

What carcinoma is most common in the distal/penile urethra and female urethra?

Squamous cell carcinoma (SCC)

Where does urethral adenocarcinoma arise?

From the periurethral glands

• Littré glands in males

• Skene glands in females

What are other variants of tumor types of the male reproductive system?

Müllerian carcinoma

Neuroendocrine carcinoma

Sarcomatoid carcinoma

What types of urethral specimens may be received?

Biopsy/transurethral resection

Partial or total urethrectomy

Urethrectomy with radical cystectomy

Urethrectomy with radical cystoprostatectomy

Urethrectomy with penectomy

Anterior pelvic exenteration

What is the difference between partial and total penectomy?

Partial — Distal portion removed; shaft remains

Total— Entire penis removed

What should be documented when receiving a urethral specimen?

Nature of specimen received

• Fresh vs. Fixative; What type?

Specimen orientation

• Surgeon vs. anatomic landmarks vs. not orientated

Specimen integrity

• Intact vs. disrupted

Ink key

• Anatomic site of each ink color

NOTE: Also document uninvolved tissue/structures

What should be measured in a urethrectomy specimen?

Overall dimensions

• 3D, or length x diameter for a tubular segment

Measure every anatomic component present

• Bladder wall / bladder neck

• Prostate (lateral-lateral x apex-base x anterior-posterior), seminal vesicles, vasa deferentia

• Corpus spongiosum, corpus cavernosum, periurethral muscle

• Anterior vagina, rectum (female specimens)

What tumor characteristics should always be documented grossly?

Tumor site

Focality

Number of tumors

Size

Color/appearance

Configuration

Extent of invasion

What are possible gross appearances of urethral tumors?

Papillary

Polypoid

Verrucous

Ulcerated

Sessile

Pigmented

Solid/nodular

Flat

Infiltrative

What is important about taking gross photographs in urethral tumors?

They are:

• Quick

• Valuable

• Assist in gross descriptions

What is the general progression of male urethral tumor invasion?

Subepithelial connective tissue → prostatic stroma → periprostatic fat → corpus spongiosum/periurethral muscle → corpus cavernosum → adjacent structures such as bladder wall or rectum

What makes up a urethrectomy with radical cystectomy?

Bladder with ureters

What makes up a urethrectomy with radical cystoprostatectomy?

Bladder with ureters + prostate with vas deferens and seminal vesicles

What are the two options of a urethrectomy with penectomy specimen?

Partial penectomy (distal portion removed, shaft intact)

Total penectomy (entire penis removed)

What makes up a anterior pelvic exenteration?

Bladder

Urethra (+ rectum)

In women:

• Cervix

• Vagina

• Ovaries

• Regional LNs

What structures should be evaluated for invasion in female urethral tumors?

Subepithelial connective tissue → Periurethral muscle (fibromuscular/adipose tissue) → Interior anterior vagina → Adjacent structures

(Document extent for every structure present in the specimen, even if UNINVOLVED)

What urethral margins are assessed?

Proximal margin

Distal margin

Soft tissue margins

(all three inked separately)

What should be reported regarding tumor and margins?

The distance from tumor to the closest margin

• Each margin distinctly inked before sectioning

What is important to remember about lymph nodes in urethral specimens?

“No lymph nodes are identified” should still be documented

What should be recorded for identified lymph nodes?

Number examined

Number suspicious for tumor

Size

Site if known

Largest metastatic deposit

Macroscopic extranodal extension

What must be included in urethrectomy blocks/cassettes?

Proximal/distal margins

Tumor, especially deepest invasion

All uninvolved anatomic components

All identified lymph nodes

What are the major layers of the external penis from superficial to deep?

Skin → dartos fascia → Buck's fascia

What are the erectile bodies of the penis?

Two corpora cavernosa (dorsal)

• Surrounded by the tunica albuginea

One corpus spongiosum (ventral)

• Surrounds the urethra

What forms the glans?

The distal expansion of the corpus spongiosum

• Cone-shaped

Where is Buck's fascia located?

Subjacent to the skin and dartos fascia

Superficial to the tunica albuginea

What is the most common non-neoplastic penile specimen?

Circumcision—removal of the foreskin

What is the most common malignancy of the penis?

Squamous cell carcinoma

What is the difference between partial and total penectomy?

Partial — Distal penis removed; shaft remains

Total — Entire penis removed, generally for proximal/extensive disease

What are some penile speciemens?

Incisional bx

Excisional bx

Circumcision

Partial penectomy

Total penectomy

How is foreskin length classified during circumcision grossing?

Short — Orifice between corona and coronal sulcus

Medium — Orifice between meatus and glans corona

Long — Orifice beyond the glans meatus, completely covers the glans

What measurements are taken on a circumcision specimen?

Length × width × thickness, OR

Length × diameter if received as a cylindrical cuff

What surfaces should be identified on a circumcision specimen?

Mucosal/inner surface

Cutaneous/outer skin surface

How should circumcision margins be inked?

Ink the:

• Mucosal margin

• Cutaneous margins

in different colors

What structures should be identified in a penectomy?

Shaft

Glans

Two corpora cavernosa

Corpus spongiosum

How should sections be taken for circumcisions?

Serially section perpendicular to the margins

• Submit representative sections and all lesions

How should a penectomy specimen be measured?

Total specimen: length x diameter

Foreskin, if present: length x width x thickness

How should the foreskin be processed on a penectomy specimen?

Remove along the corona (if present)

Ink its resection margins on both sides

• Mucosal side

• Cutaneous side

What is the sectioning protocol for a penectomy?

1. Take a complete shave section of the proximal (amputation) margin

2. Bread-loaf the shaft with transverse sections

   1. Proximal to distal

3. Open the urethra with scissors on the ventral surface

4. Use the opened urethra as a guide to bisect the glans longitudinally

5. Section the glans additionally, parallel to the midline, as needed

6. Document tumor size and depth of invasion

Why should friable penile tumors be handled carefully?

To avoid tissue loss and seeding of the grossing field

What is the progression of tumor invasion through the glans?

Lamina propria → corpus spongiosum → tunica albuginea → corpus cavernosum

What is the progression of tumor invasion through the foreskin?

Lamina propria → dartos → dermis → epidermis

What is the progression of tumor invasion through the penile shaft/body?

Dermis → dartos → Buck's fascia → tunica albuginea → corpus cavernosum

What structures can penile cancer invade beyond the penis?

Regional skin such as the pubis/inguinal region

Adjacent structures including:

• Scrotum

• Prostate

• Pubic bone

What are the important penectomy margins?

Urethral margin

Periurethral tissues (lamina propria, corpus spongiosum, Buck’s fascia) margin

Corpus cavernosum margin

Skin margin

What are the important circumcision margins?

Coronal sulcus mucosal margin

Cutaneous margin

What should be reported for each penile margin?

Whether involved/uninvolved

Distance to the closest margin

What are the major lymph node groups relevant to penile cancer?

Sentinel nodes

Inguinal nodes

Pelvic/regional nodes

What is the general progression of penile lymphatic drainage?

Superficial inguinal → deep inguinal → pelvic nodes

What is this?

Penile SCC

What is the tunica albuginea?

A thick white fibrous capsule surrounding the testis

What is the tunica vaginalis?

A mesothelial-lined sac with visceral and parietal layers surrounding the tunica albuginea

Where is the epididymis located?

Posteriorly

• Continuity with the spermatic cord

What is the rete testis?

A network at the testicular hilum connecting seminiferous tubules to the epididymis

A common route of extratesticular spread

What are the two major prognostic groups of testicular germ cell tumors?

Seminoma

Non-seminomatous germ cell tumor (NSGCT)

What is the classic presentation of a testicular germ cell tumor?

Painless enlargement of the testis

What is the characteristic lymphatic route of testicular cancer spread?

Retroperitoneal lymph nodes

Para-aortic lymph nodes (characteristic)

What are common pattern of spread in testicular cancers?

Lymphatics

Hematogenous

What is the primary hematogenous metastatic site for testicular germ cell tumors

Lungs

Additional sites including:

• Liver

• Brain

• Bone

Which tumor marker is associated with choriocarcinoma?

β-hCG

• Can also be elevated in some seminomas because of syncytiotrophoblasts

Which tumor marker is associated with yolk sac tumor?

AFP (alpha-fetoprotein)

What does LDH indicate in testicular germ cell tumors?

It is less specific than AFP or hCG

Correlates with:

• Tumor burden

• Stage

• Treatment response

When should testicular tumor markers be obtained/trended?

Before and after orchiectomy to assess treatment response

What is the primary operation for a suspected testicular mass?

Radical orchiectomy

• Through an inguinal approach

Is biopsy performed for a suspected testicular tumor?

No — Biopsy is performed only for infertility evaluation and never for a suspected tumor

When are lymphadenectomy specimens received?

Received for staging/post-chemotherapy resection

• Retroperitoneal LN dissections

What should always be documented for an orchiectomy?

Laterality

• Right, left, or not specified

When should the testis be weighed?

Before fixation

What dimensions are taken in an orchiectomy?

Testis: 3 dimensions

Epididymis: 3 dimensions

Spermatic cord: length × diameter

Why should the surgeon not bisect the testis before it reaches pathology?

It can obscure tunical invasion

It can compromise tissue needed for flow cytometry/karyotyping

If possible, when should testis specimens be grossed?

Fresh!

• Prevents poor fixation

  • If delayed, fix in 10% buffered formalin

What is the overview for measurement and triage of testis specimens?

Weigh (prior to fixation)

Record dimensions

Asses integrity

Gross fresh whenever possible

How should the testis be sectioned after inking?

Bisect sagittally from the anterior aspect

What is the critical first step involving the spermatic cord?

Shave the spermatic cord margin before anything else

• Then continue transverse sections along the cord first

What structure must be confirmed in the spermatic cord margin?

The vas deferens

• A thin, firm, white tube and may retract

How should testis specimens be inked?

Ink per institutional protocol

• Could be:

  • Tunica AND spermatic cord, OR

  • Tunica only where adhesions are found

What structures should be evaluated for testicular tumor extension?

Testis

Rete testis

Hilar soft tissue

Epididymis

Tunica albuginea/vaginalis

Spermatic cord

Scrotum

(Note any fluid within the TA sac)

What is the primary margin of interest in an orchiectomy?

The spermatic cord margin

What additional testicular margins may be evaluated?

Parietal tunica vaginalis margin

Scrotal skin margin

How should uninvolved structures be stated for testicular specimens?

Testis

• Unremarkable, presence/absence of fine tubules, soft, fibrotic, hemorrhagic, infarcted, ischemic, ruptured

Epididymis

• Unremarkable or describe abnormality

Tunica albuginea

• Unremarkable or describe abnormality

Where are the major retroperitoneal lymph nodes relevant to testicular cancer?

Interaortocaval

Para-aortic

Paracaval

Preaortic

Precaval

Retroaortic

Retrocaval

What can post-chemotherapy retroperitoneal lymph nodes look like grossly?

They may be hemorrhagic, cystic, or necrotic

What is this?

Testis — Sebaceous cyst

What is this?

Testis — Atrophic

What is this?

Testis — Torsion

What is this?

Testis — Seminoma

What is this?

Testis — Embryonal carcinoma

What is this?

Testis — Embryonal carcinoma w/ teratoma

What is this?

Testis — Teratoma

What are the indications for prostate needle core biopsy?

Elevated PSA or a palpable/imaging-identified nodule

What is the purpose of a TURP?

To relieve obstruction from benign prostatic hyperplasia (BPH)

• Carcinoma can be an incidental finding

What is the purpose of radical prostatectomy?

Definitive treatment for clinically localized adenocarcinoma

What is the purpose of a suprapubic prostatectomy/enucleation (simple or subtotal)?

To remove a large gland causing obstructive symptoms; benign disease

What measurements should be taken on a radical prostatectomy?

Overall prostate dimensions and weight

Right/left prostate gland — medial-lateral (R-L) x anterior-posterior x superior-inferior

Right/left vas deferens length × diameter

Right/left seminal vesicles in 3D

Extraprostatic soft tissue and its location

What landmarks must be identified before inking the prostate?

Apex

Base

Anterior

Posterior

Right

Left

How is each side (R/L) of the prostate divided in the 12-zone system?

Each side has six zones:

• Anterior base

• Anterior mid

• Anterior apex

• Posterior base

• Posterior mid

• Posterior apex