The Importance of Collaboration Between Mohs Surgeons and Urologists

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Complex reconstruction on the genitalia and perianal regions can be easier for both colleagues and patients when urologists and Mohs surgeons work together. Caleb Kovell, MD and Junqian Zhang, MD have collaborated in Philadelphia, Pennsylvania to reconstruct male genitalia to ensure cancer is removed and try to give patients their ideal outcomes. They presented case studies and pearls in the session “Mohs on the Genitalia and Perianal Region” at the 2023 American College of Mohs Surgery Meeting in Seattle Washington.

Kovell is a urologist at Penn Medicine and Zhang is an assistant professor at the University of Pennsylvania. Dermatology Times® caught up with them after their session to delve into the biggest takeaways.

Dermatology Times: Explain the value of collaboration when removing cancer and reconstructing genitalia.

Kovell: I think penile and a lot of the genital cancers are not always super well understood, and we tend to work in silos on them. What we found at our institution is that by combining our skill sets, which again, overlap in some ways, but we all bring something very different to the table. I think we've been able to have a really fruitful collaboration where we all get to do a lot of the stuff that we want to do, we build a bigger patient population base.And ultimately, I think, for these complex cases that are relatively rare tumors that we're able to give patients excellent oncologic outcomes, you know, equivalent to standard care, while optimizing penile length and penile tissue for later reconstruction, which gives them better quality of life in terms of urinary and sexual symptoms afterwards. I think it's a win-win for everybody.

Zhang: I think we sometimes take it for granted, but it'sprobably the most important thing and the most important take home message from our talk this morning is that having that collaboration is so important, and especially for these tougher cases, male genital cases, but also female genital cases, hand cases, what have you. I think there's benefit to having the Mohs surgeon that can control the margins when removing the cancer. There's also a lot of benefit to collaborating with our colleagues so that they can reconstruct, and basically optimize form and function for patients, whether that's the male genitalia, the female genitalia, the digit. Having this relationship only benefitsall of our parties, and in the end, it benefits the patient, because we'rebasically removing as little tissue as possible. At the same time, we'reoptimizing their overall functional outcome.

Dermatology Times: What should a Mohs surgeon keep in mind during genital procedures?

Kovell: Our team with Dr. Zhang and Dr. Miller talks a little about using Mohs, especially for penile lesions on the glands in the shaft, they talked about understanding the anatomy, and making sure that you're really familiar with this maybe less familiar anatomy of the male genitals to to be able to do this and do it well, and to make sure you're getting the right volume while maintaining the the tissue in the proper way. And then we talked a little about what's possible in terms of reconstructing these patients. So managing the urethra, you know, either in terms of rebuilding the urethra, mobilizing the urethra, or, you know, bailing out at times if you need, as well as tissue coverage for larger defects. So whenever it's not just the simple closure, using other tissues, substitutes, like grafts or flaps or different things to again, optimize, you penile function and, you know, coverage with these patients.

Zhang: So really, I think, from the Mohs perspective, we like to employ an anatomic approach to our dissections. And I think it's actually very helpful from tumor control perspective, and from taking your Mohs layers in a way that minimizes the amount of bleeding and potential complications. We we strongly believe in using the anatomic approach when taking tumors in these special sites, but also elsewhere in the body. But I think, again, if I had to have one take home point is that how important that collaborative effort is, and it can only really benefit everyone involved from the patient to our specialty to all our collaborators specialties.

Dermatology Times: Some cases studied had cancer for decades leading up to surgery. What is your approach to a delay in care?

Zhang: I think when there's a cancer in a more sensitive area, I think there's more likelihood for having a delay in care. And that's, I think it makes sense, right, if you have a spot in a sensitive area, it might be difficult for you to go to a physician to even have it looked at, let alone biopsied. And now you're asking a patient to go through a procedure where they're awake, they're not under general anesthesia. And they're, they've given you, you know, their trust, that you'll do a good job and remove this cancer with them awake. And so I think oftentimes, when patients come in, we tell them, “Thank you for coming in, so that we can help out when we're removing these cancers.” Just letting them know that, hey, you know, this, you have this cancer, don'tworry necessarily about how wide it is, we'regoing to take care of it. And it's just important that you've been plugged into care so that we can help out.

Dermatology Times: How does a patient’s desired outcomes, priorities, and lifestyle impact your approach?

Kovell: Every patient is a little different, right? When it comes to these things, different people are going to have different preferences. So one gentleman may be more interested in, you know, going full-bore and preserving as much penile tissue as possible. They may be young, they may be sexually active, they may want to stand up. Whereas you may have an older gentleman where that's not his priorities. He's much more interested in the idea of Cancer Control, or whatever it takes. He's not sexually active, he sits the key anyway. And so he says, "Listen, you know, whatever you need to do, just make sure you know, cancer care is number one. And you know, even if you have to take a bunch more tissue to do it doesn't bother me so much." So, delving into patient preferences is incredibly important in these cases, but also then understanding what you can do based on you know, what's available, what tissues available and the quality of the tissue available. We know that a lot of things in terms of vascular disease, the medications, they're on, different kinds of common cancers may affect what the possibilities are here. Understanding their history understanding what they do so that, again, you're setting them up for optimal outcomes because you're getting beyond the oncologic side of this, when you talk about reconstruction, now you're getting more into the quality of life stuff. So again, you want to set them up not only to do well, from cancer care, but also to ultimately do well, in terms of all of the quality of life things that come after in terms of cancer survivorship.

Zhang: I think really everything or as much as possible, right? Patients will have different levels of demand as to what they expect from the procedure and what they expect after the procedure. And that'swhat's nice about having a collaborative effort. Obviously, we're not the experts when it comes to, you know, penile form and function after surgery. Our colleagues in urology are. It's nice to have a consultation visit where when they come to the visit with the Mohs surgeon, we talk to them about the removal of the tumor, about how that day is going to be, about what to expect in the immediate postoperative period prior to them seeing the reconstructive urologist. We also have them see the urologist in consultation as well. And in those sessions, they can answer a lot of the questions about, you know, you'regonna not be able to have sexual activity for X amount of time after surgery, you can expect this type of bandage you can expect this type of if there's any change in urinary function, or sensation. Those are things that are they definitely have more experience compared to our specialty. It's nice to have the patient go to the expert in each of the fields.

Dermatology Times: What do you hope attendees take home from this session?

Kovell: I feel like this has been a incredibly fruitful collaboration, one that coming into my role as an attending urologist that I had no idea would even exist. So I think exploring that with your group, if it's something that you're interested in, you know, can hopefully allow this to disperse to a lot more institutions and ultimately, get the same benefits there that that we've been able to have it at Penn [Medicine].

Transcript edited for clarity.