Egypt, J. Plast. Reconstr. Surg., Vol. 43, No. 2, July: 345-350, 2019

Aesthetic Reconstruction of Peno-Scrotal Lymphedema:Refinements of Previous Technique

ABD EL-RAHMAN M. ABD EL-AAL, M.D.; MINA ESTAWROW, M.D. and IKRAM SAFE, M.D.

The Department of Plastic and Maxillofacal Surgery, Faculty of Medicine, Ain Shams University, Cairo

ABSTRACT

Background: Lymphedema is emotionally frustratingdisease due to its progressive course and no definite curativemethods of treatment, it was found that lymphedema resultsfrom local and/or systemic failure of the lymphatic transportsystem, and according to its cause and onset of lymphedemait is classified into primary and secondary lymphedema.Treatment methods of scrotal lymphedema and reconstructionwere limited in the literature to lymphangioplasty or directexcision of the involved tissue and local tissue reconstruction.The current study present patients with established scrotallymphedema and the way of surgical management in excisionand reconstruction.

Patients and Methods: Ten male patients were involvedin the study, their age was ranging between 25-60 years, threepatients were primary lymphedema, seven patients weresecondary lymphedema.

Results: Patients in the study were followed-up postoper-atively for a minimum 6-month period, it was found that aclear improvement of the aspect of the external genitalia andsubsequent improvement of ambulation, hygiene, and abilityto void in the standing position occurred for all patients.

Conclusion: The procedure is effective giving good resultswith no major complications were recorded, the techniquebased on anatomical background that is why recurrence wasnot recorded.

Key Word: Scrotal – Lymphedema – Penile – Inguinal lymphnodes.

INTRODUCTION

The lymphatic system is responsible for trans-ferring the interstitial fluid from different tissuesand parts of the human system and returns it aslymph, which is rich in proteins and fats, back intothe blood circulation [1]. Lymphatic channels inthe periphery play an essential role to enhance theimmune system as it transports leukocytes, regulatethe immune response as well as the processing ofboth self-antigens and foreign antigens [2], that iswhy lymphatic mal function has been shown topredispose to bacterial infections and malignancies[3,4].

345

Lymphedema can be defined as a progressivedebilitating condition which have local and/orsystemic failure of the lymphatic transport system,and it can be classified into primary and secondarylymphedema.

Primary lymphedema results from structurallyand functionally abnormal lymphatic channelscaused by obstruction, malformation, or hypoplasia.When primary lymphedema is present at birth orduring infancy, it is known as congenital Milroydisease; however, the presentation of symptomsmay occur later in life, such as in Meige disease(lymphedema praecox) (which manifests duringadolescence) or lymphedema tarda (which usuallybecomes apparent after the age of 30 years).

On the other side, secondary lymphedema iscaused by the destruction or obstruction of normallyformed lymphatic channels. Although the mostcommon cause of secondary lymphedema world-wide is filariasis, but secondary lymphedema canbe a consequence of cancer treatment [5].

Lower limb lymphedema in general is an emo-tionally incapacitating condition, especially scrotallymphedema and methods of reconstruction report-ed in the literature were limited to either lymphangi-oplasty or direct excision of the involved tissuewith local tissue reconstruction [6].

Authors in the current study present patientswith established scrotal lymphedema with theirway of surgical management in excision and re-construction.

PATIENTS AND METHODS

Current study is retrograde study which wasdone on patients with scrotal lymphedema presentedto the authors in Ain Shams University Hospitals.

Ten male patients were involved in the study,their age was ranging between 25-60 years, threepatients were primary lymphedema, seven patientswere secondary lymphedema with a history offilarial infestation early in their life, all patientswere severe grade of peno-scrotal lymphedemadetection of comorbid conditions as diabetes orhypertension was done as well as family historyof similar conditions.

Examination was done for patient while stand-ing primarily then in supine position, evaluation

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involved the following size of scrotum and itsstages (all patients were as graded as 5th grade),lower limb edema (pitting or non-pitting), penisand penile skin with grading of buried penis inrelation to symphysis pubis (patients were gradedas 3rd and 4th), lymph nodes and lymph vesiclesas well as mons pubis area and its skin, and eval-uation of skin of the mons whether is stretched ornot as well as the length of suspensory ligamenteither increased or not. Patients were investigatedby routine hematological tests and urine analysis.

Photo (1): Diagram showing the grades and degrees of scrotalenlargement and buried penis.

(A) Scrotal enlargement stages 1-5 as described by Capuanoet al., [7]: (1) Smaller than tennis ball, (2) Larger thantennis ball but not reaching mid femur, (3) Reaching midfemur but above patella, (4) Reaching patella but abovetibial tuberosity, 5 below tibial tuberosity (dotted linestage reaching level of malleoli).

(B) Buried-penis grades 1-4: (1) Visible portion greater 2cm,(2) Visible portion less than 2cm, (3) Glans flush withskin, (4) Totally buried and irreducible.

Photo (2): Pre-operative photo for a patient while standing.

Photo (3): Diagrams of the original technique [8]: Showingdesign of the excision (Lt) & pattern of closure (Rt).

Surgical technique:

Primarily, as a routine, hair removal in thepubic, perineal and inguinal region were performedthen washing and cleaning of the whole scrotumand penis with betadine soap as well as the abdom-inal area and thighs down to the knees.

After that usual sterilization from the umbilicusdown to the knee including the penis and scrotum.

Prophylactic broad-spectrum intravenous anti-biotics were given. The original technique waspublished by the chief author 8 Photo (3) withaesthetic considerations in the current study, theprocedure started by marking of the mid-inguinalpoint then draw a lateral curved incision from it(the incisions were marked at the transition betweendiseased and normal).

The operation started by the lateral incisionsthrough which, the spermatic cord is identified anddelivered with associated dilated lymphatic trunksalongside the spermatic cord. These are separatedand excised completely, the cord is better identifiedin the inguinal region. After doing the procedureon both sides, the elephantoid skin is removed tillthe scrotal base then the posterolateral skin isthinned in order to remove any pathological tissue.The penile skin was shaved from the coronal sulcusto the base (no way to preserve the penile skin),

(A)

(B)

Egypt, J. Plast. Reconstr. Surg., July 2019 347

and according the extent of involvement of themons area, the incision may continue from the rootof the penis to continue the excision upward tomeet the incision in the lower abdominal crease ifthe skin of the mons is severely distended or justmake an opening in the mons in order to repositionthe penis to its place. Testis was examined forhydrocele and excised if present.

After complete hemostasis, closure startedposteriorly to obtain a scrotum with a size suitableto scrotal contents, closure was done in the midlinesimulating the scrotal raphe, the posterolateral skinwas lifted up with three-point suture to meet themidline of the abdominal flap.

Closure was done in tension free manner withexcision of excess skin, closure was done around

the penis, and a circular opening is done in thenormal site of the root of the penis. Closure wascompleted in 2 layers, subcutaneous layer of 2/0vicryl, skin closed with 2/0 silk sutures in a verticalmattress way.

The reconstructed scrotum was drained with 2drains inserted through 2 different stabs, which wasleft in place till the output became lower than 50ml.

Penis was covered with a split thickness skingraft harvested from the thigh with a tie-overdressing, the vertical suture better made in a zigzagfashion.

The patient remained with an indwelling urinarycatheter for the same period. The scrotum wascleansed daily and kept with a scrotal suspensor.

Photo (4): Intraoperative photo after surgical excision of thelymphedematous skin and dissection of the testes,shaft of the penis and spermatic cords.

Photo (5): Intraoperative photo showing the excised lymphe-dematous skin.

Photo (6): Intraoperative photo after surgical surgical closure. Photo (7): Intraoperative photo after application of STSG.

RESULTS

Patients in the study were followed-up post-operatively for a minimum 6-month period, it wasfound that a clear improvement of the aspect ofthe external genitalia and subsequent improvementof ambulation, hygiene, and ability to void in thestanding position occurred for all patients.

The improvement of sexual performance couldnot be directly assessed, although some patientsstated that sexual intercourse became more effectiveas regards penetration and satisfaction for patientand partner.

Data regarding patients' ages, duration of thedisease, size of scrotum and follow-up period areshown in (Table 1).

Patients had a favorable outcome all throughtheir follow-up. There were no major complicationsrecorded, although this surgical site is subject tocontamination because of neighboring structuresdespite of that only 3 patients experienced littledehiscence in the vertical wound of the scrotum,but no surgical intervention was done and healedby 2ry intention, otherwise no infections or necrosiswas observed.

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condition will occur as well as damage of thepatient's quality of life and self-esteem [9].

Lymphedema of external genitalia either con-genital or acquired. Non-congenital cases usuallyresult from lymph node dissection, injury, or irra-diation [6].

Different studies reported that inguinal area isdrained by superficial and deep inguinal lymphchannels, superficial channels are responsible fordrainage of the scrotum and penile skin, diseasedskin of the penis must be removed and replacedby skin graft as well as skin of the scrotum andreplaced by flaps from nearby tissues, while thedeep channels drain testes and penile body, that iswhy obstruction of the superficial channels willresult in scrotal and penile lymphedema [10].

At present, it is generally agreed that the main-stay of therapy is surgical, as conservative measuresusually of little value. Diuretics, elevation, andscrotal support have a limited effect on the regres-sion of lymphedema except in mild cases andtreatment of lymphangitis [6].

Many surgical innovative techniques have beenevolved for scrotal and penile reconstruction. Theywere classified into physiologic and excisionalprocedures.

Physiologic operations were invented and de-signed to improve the lymph stasis condition byredirecting the static lymph fluid to the venousside. Huang et al., were the first surgeons whoapplied the concept of the lymphovenous shuntprocedure for the treatment of male genital lymph-edema, in which they performed anastomosis ofthe superficial lymphatic vessels to small veins inthe subcutaneous tissue [11].

Mukenge et al., [12] chose deep lymphatic ves-sels along the spermatic cord and anastomosedthem to the pampiniform venous plexus, whichalso runs beside the spermatic cord [11].

According to the lymphatic mapping of theinguinal region done by Sappy [13], there are twooptions for creating a lymphovenous shunt: Usingthe superficial lymphatic pathway or the deeplymphatic pathway, but the diameters of the super-ficial lymphatic vessels were smaller (0.2 to 0.5mm)compared with those of the deep lymphatic vessels(0.5 to 1mm); thus creating a lymphovenous shuntis technically more reliable using the deep lym-phatic vessel. Another advantage of selecting thedeep lymphatic vessels is that these vessels couldbe identified constantly beside the pampiniform

Table (1): Demographic data of the patients.

Age

25364233294050445660

Duration ofdisease (years)

4135410151012513

Patientno.

12345678910

Size ofscrotum

14 X 1020 X 1510 X 3014 X 1115 X 1030 X 1215 X 2513 X 2719 X 2415 X 10

–DehiscenceDehiscence

––

Dehiscence––––

Complications

DISCUSSION

Scrotal lymphedema is a condition leading tothe progressive enlargement of the scrotum andpenis causing significant discomfort for patients[9].

With the progression of the lymphedema patientambulation, sexual intercourse and voiding in thestanding position with proper hygiene of the peri-neal region become difficult and even in somesituations are impossible, as a sequalae for thatmalodor and recurrent episodes of skin infectionsas cellulitis and lymphangitis will be more frequent,that is why aggravation of the anatomopathological

Egypt, J. Plast. Reconstr. Surg., July 2019 349

veins [13], this technique has its limitations espe-cially in cases of peno-scrotal lymphedema aspatients usually need an effective rapid way oftreatment [14].

On the contrary side, in chronic lymphedemathere is a progressive fibrosis and obliteration ofthe collectors which is a characteristic feature ofthe disease, as well as the extent of skin resectiondetermine the strategy used in lymphedema treat-ment. In excisional procedures strategies, they areeither resection of the entire affected scrotal skinor minimization of the skin resection area forprimary closure, various methods have been studiedfor resurfacing the excised raw surface. Skin graft-ing, it may have the advantage of reducing therecurrence of lymphedema and cellulitis, but ther-mal regulation of the testes is disturbed, that iswhy they addressed the other way by using localflaps from a normal thigh flap or a remnant ofscrotal skin [13].

Delpech reported in his study in 1920, a suc-cessfully treated case of scrotal edema in whichexcision of lymphedematous tissue was followedby resurfacing of the penis and scrotum by localthigh flaps [6].

Sir Richard Henry Havelock Charles publisheda series of 140 consecutive patients which treatedsuccessfully of scrotal lymphedema. After that SirArchibald McIndoe in 1950, performed the treat-ment of leg lymphedema with radical excision andskin grafting and attributed his work to Sir Have-lock.

In 1985, Dandapat et al., [15] reported a caseof elephantiasis of the scrotum and penis, in whichexcision of elephantoid skin and subcutaneoustissue was done through a vertical incision andsuturing of the lateral scrotal neck skin in themidline for scrotal reconstruction.

Also, Martinez et al., displayed his work andhis plan of management for three patients withlymphedema of the scrotum treated by radicalexcision of all lymphedematous scrotal tissue andreconstruction using posterolaterally based scrotalflaps [16], our technique is different in the positionof the incisions as done in the junction betweennormal and pathologic skin with complete excisionof the whole pathological tissues.

Huang [11] has tried a microlymphaticovenousprocedure to treat elephantiasis of the scrotum andapplied it clinically with good results.

Apesos and Anigian [17] presented a case ofacquired genital elephantiasis in an elderly manafter radical cystectomy and pelvic irradiation fortransitional cell bladder cancer. Their plan ofmanagement involved the excision of the wholelymphedematous skin of the penis and scrotum,and reconstruction was done by the use of posteriorscrotal flaps, superiorly based flap from the pubicarea for testicular coverage, and split thicknessskin graft for penile coverage, this technique hasa disadvantage as they used a pathological tissuesso recurrence rate is higher than in our technique.

Konety with his team [18] presented a casereport of chronic hidradenitis of the perineum andscrotum with massive scrotal elephantiasis in whicha wide resection of the scrotal mass and perineumwas performed with reconstruction of the perineumand penis carried out using local skin flaps andsplit-thickness skin grafts.

Ndoye et al., [19] described his method scrotalreconstruction by anterior and posterior flap ofscrotum after excision of the lymphatedematousmass.

Tammer et al., [20] reported a surgical techniquefor treating scrotal lymphedema by resection andneoscrotal reconstruction using ventral peduncu-lated scrotal skin flaps in cases of congenitalhereditary of the Meige type.

All the previous studies are coincident withidea presented in the current study, as authorspreferred the use of surgical excisional of the wholelymphedematous skin but they did not specify thepoint of starting of the excision and some of themused pathological tissues in reconstruction.

Here we started the excision from the junctionwith normal residual skin and complete removalof the penile skin depending on the anatomicalbackground that all these structures are drained bysuperficial inguinal lymphatics and using localflaps from the remnant scrotal skin as this part isdrained by deep lymphatic channels with skingrafting of penile shaft to avoid recurrence oflymphedema in this area and putting in considera-tion the aesthetic point of view of the overall groinarea with reconstruction of the mons and lowerabdominal area by either resection of the skin ifseverely involved or using it to reposition the penisby opening through this skin area, resulting in anormally aesthetically pleasing peno-scrotal areaas well as mons pubis area.

The procedure took about 2-3 hours durationunder general anesthesia for ten patients who

involved in the study, all these patients experiencedunremarkable follow-up with very good improve-ment of their lives and very good psychologicalimprovement, they passed without major compli-cations, except for 3 patients who suffered fromlittle dehiscence in the vertical line. During thefollow up period there was no evidence of recur-rence in all patients.

Conclusion:In conclusion, the current technique scientifi-

cally based on anatomical knowledge so the rateof recurrence is low, also the technique is easy,reliable without major complications.

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