Recurrent Perineal Urethral Squamous Cell Carcinoma Multidisciplinary Approach

Perineal recurrence of urethral squamous cell carcinoma (SCC) after radical penectomy is a rare and technically demanding entity, and non-surgical modalities such as radiotherapy or systemic chemotherapy may not achieve optimal local control in this setting, necessitating aggressive surgical resection combined with complex reconstructive techniques. We report the multidisciplinary management of an extensive perineal recurrence in a 56-year-old male with a history of primary urethral SCC (pT2 pN0 G2, first diagnosed in 2013) treated by radical penectomy and bilateral inguinal lymphadenectomy, who presented in April 2021 with perineal tumor recurrence. After an endoscopic and diagnostic evaluation, a perineal resection was performed, resulting in rpT4 G2 with positive surgical margins cranially toward the bladder and ventrally toward the symphysis. Complete tumor resection was deemed unachievable in that conventional way. After further consultation, the patient underwent robot-assisted radical Cystoprostatovesicourethrectomy with en bloc perineal tumor excision, bilateral pelvic and salvage inguinal lymphadenectomy with ICG-guided lymphangiography, prophylactic appendectomy, urinary and stool diversion via ileal conduit and colostomy. Histopathology confirmed R0 resection. Three weeks after the initial ablative surgery, the resulting large perineal defect, extending from the symphysis anteriorly to the rectum posteriorly, was closed with a left pedicled gracilis muscle flap. The 5-year follow-up was oncologically and functionally uneventful (last CT 03/2026). This case underscores the importance of interdisciplinary management involving urology, visceral surgery, reconstructive surgery, and radiology. It also highlights the benefits of integrating minimally invasive robotic techniques.