Genital Lymphedema Research Articles

Penoscrotal elephantiasis after treatment of prostate cancer: A case report

Penoscrotal elephantiasis (EPS) is a terminal state of lymphoedema defined by a progressive histopathological state characterized by chronic inflammatory fibromatosis of the subdermal and dermal connective tissue caused by lymphatic and venous stasis. Its clinical appearance is typical of an increase, sometimes considerable, in the volume of the external genital organs, which can lead to an unaesthetic appearance, a sexual impact, and psychological distress. The etiology can be primary or secondary to a parasitic disease (filariasis) or intrinsic or extrinsic lymphatic obstruction. Genital lymphedema may affect after cancer treatment and prostate cancer ranks as the second most prevalent cancer in men, making it crucial to consider any complications that may occur following its treatment. We present a case of one patient, a 74-year-old man from Morocco, who underwent surgery two years ago for radical prostatectomy supplemented by radiotherapy and hormone therapy. The evolution was marked by an increase in scrotal size, with sexual and psychic prejudice. The Clinical examination revealed penoscrotal elephantiasis respecting the glans penis and both lower limbs. The diagnostic is clinical and etiological research requires specific complementary examinations, depending on the circumstances. Probably for this case, the penoscrotal elephantiasis was secondary to radical prostatectomy and/or post-radiotherapy.The patient was scheduled for surgical treatment involving en bloc resection of the elephantiasis scrotum, and immediate reconstruction after completely freeing the two testicles. The affected penile skin was also resected and replaced with a skin graft. The aesthetic and functional outcome was good with a follow-up of 7 months.

Chylous Reflux in Pediatric Primary Lymphedema of the Lower Limbs and Genitalia: A Retrospective Study of 167 Patients.

Background: Chylous reflux (CR) in primary lymphedema (PL) of the lower extremities is rare and requires particular diagnostic procedures. This study aimed to determine clinical and lymphoscintigraphic traits for efficient screening. Methods and Results: Pediatric patients with PL of lower extremities treated in our institution between January 2020 and December 2023 were reviewed. The medical history, lymphoscintigraphy, non-contrast MR lymphography, and direct lymphangiography were analyzed. Lymphoscintigraphic visual patterns were classified to detect CR. Patients with CR showed significantly higher proportions of childhood symptom onset (65.63% vs. 25.19%, p < 0.01), genital lymphedema (62.50% vs. 19.26%, p < 0.01), and proximal-to-distal swelling (31.25% vs. 8.89%, p < 0.01). Eight patients without skin lesions had milk discharge after acupuncture or skin breakdown. Pattern 4 shows diffused dermal backflow of the leg and an absence of superficial lymphatic drainage, or normal initial cephalad flow with subsequent reflux of tracer into the affected limb. CR showed significantly higher percentages of pattern 4 (87.50% vs. 12.59%, p < 0.01), normal/widened iliac lymphatics (78.13% vs. 11.11%, p < 0.01), and thigh/calf outlining (87.50% vs. 29.63%, p < 0.01). Genital swelling preceding limb swelling and genital radioactivity were more common in the CR group. Conclusions: CR tends to occur in childhood initially, begin centrally and progress distally, and involve genitals prior to lower extremities. Milk discharge after acupuncture or skin breakdown is important for screening CR without chylous vesicles. The patterns with typical "profiling of the leg" and normal or widened iliac lymphatic trunks strongly correlate with CR. Genital lymphedema with increased radioactivity indicates CR.

Case series of genital lymphaticovenous anastomosis for genital lymphatic vesicles

BackgroundThe management of lymphatic vesicles is challenging. This study aimed to clarify the lymphatic flow around the genitals and the effect of genital LVA on genital lymphatic vesicles. MethodsWe performed a retrospective study of 34 patients who underwent resection for lymphatic vesicle and LVA. In patients with genital lymphedema, two types of lymphatic inflow existed around the genital area; from the lower extremities (type 1) and from the buttocks (type 2). Lymphoscintigraphy was performed to detect type 1 lymphatics injecting isotope into the first interdigital area. ICG lymphography was performed to detect type 2 lymphatics injecting ICG into the ischial tuberosity. We performed resection of lymphatic vesicles and LVA in the legs and/or in the genitals. Postoperative recurrence rate of lymphatic vesicles and the frequency of cellulitis were evaluated. ResultsType 1 lymphatics were observed in 38.2% of the patients. In ICG lymphography, there was linear inflow to the genitals in 40.9% and DB inflow in 24.2%. In 10 patients (29.4%), both type 1 and 2 lymphatic vessels were observed. Genital LVA was performed in 31 patients and lower extremity LVA was performed in 15 patients. The average follow-up period was 332 days, and recurrence was observed in 8 (25.8%) of 31 patients who underwent total resection. The average number of cellulitis episodes decreased significantly from 2.8 times before surgery to 0.31 times after surgery (p<0.01). ConclusionLVA in the genital area and lower limbs was effective in preventing postoperative recurrence of lymphatic vesicles after resection.

MR Lymphangiography: Congenital Lymphatic Flow Disorders.

Congenital lymphatic flow disorders collectively refer to a heterogeneous group of diseases that manifest as chylothorax, chylous ascites, intestinal lymphangiectasia, protein-losing enteropathy, and peripheral extremity or genital lymphedema, all in the absence of identifiable injury to the lymphatic system. We have only recently begun to understand congenital lymphatic flow disorders through the ability to image lymph flow dynamically. Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) is a crucial technique for imaging lymphatic flow in pediatric patients with congenital lymphatic flow disorders. However, as lymphatic imaging is still a nascent discipline with many uncertainties regarding optimal imaging and treatment, effective patient management requires a comprehensive understanding of imaging techniques, disease pathophysiology, and multidisciplinary treatment approaches. Above all, a fundamental understanding of the physiological lymphatic flow of the central conducting lymphatics is essential for the correct interpretation of DCMRL images. This knowledge helps to avoid unnecessary examinations, erroneous diagnoses, and potentially harmful treatment approaches. This review provides an overview of the methods, advantages, and precautions for interpreting the DCMRL examination, a state-of-the-art lymphatic system imaging technique, and shares various case studies.

Complex decongestive therapy in hidradenitis suppurativa-related genital lymphoedema: a case report.

Genital lymphoedema is a rare but debilitating and disfiguring complication of longstanding hidradenitis suppurativa (HS). Despite the existence of medical and surgical methods that offer varying success rates in a limited number of cases, no data exist about the use of complex decongestive therapy (CDT) in HS-related genital lymphoedema. This case report describes the treatment and outcome of a 56-year-old male patient with severe scrotal lymphoedema due to underlying HS (Hurley stage 3). The patient was unresponsive to various topical and systemic antibiotics and biological agents, including adalimumab and certolizumab pegol. When the patient was assessed, ixekizumab treatment for his HS was planned. He had progressive oedema in the genital area for two years with difficulty in wearing trousers and having sexual intercourse, and painful urination. CDT was recommended for three days a week concurrently with ixekizumab treatment. The patient and his wife were also educated about self-drainage techniques and skincare maintenance. After six sessions of CDT over 14 days, the patient demonstrated a significant reduction in scrotal measurements. He achieved a better scrotal contour, the degree of the buried penis was decreased, and urination was easier and painless. The findings of this case report showed that CDT was an easily applicable, practical and promising method that offered a rapid treatment response for HS-related genital lymphoedema.

History of surgical treatment of lymphatic drainage at the Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital in Brno.

The Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital in Brno, and Faculty of Medicine of Masaryk University, Brno, has a long history of surgical treatment of lymphedema and elephantiasis, which started in 1970s. There were many types of surgeries described and performed at our department - starting with prof. Bařinka's radical operation of elephantiasis, then lower limb end-to-side lymphovenous anastomosis pulled through the wall to the great saphenous vein, and genital lymphedema reduction. We call this era "the first period" of surgical lymphedema treatment. "The second period" started in 2016 by using free flaps with lymph nodes or vascularized lymph nodes and using microsurgical techniques of end-to-end, end-to-side and side-to-end lymphovenous anastomoses to the subcutaneous veins of a small calibre, which then drain the lymph into the blood stream. "The third period" started 2 years ago after the visit of prof. Yang from Taiwan - we started to use the method of single stitch end-to-side anastomosis to big subcutaneous veins like the great saphenous vein or the cephalic vein.

Lymphatic Mapping in the Repair of Adult-acquired Buried Penis: Proof of Concept

Summary: Adult-acquired buried penis (AABP) is an acquired clinical entity where a normal sized phallus is concealed by prepubic skin, fat, or subcutaneous tissue, often caused by obesity, lymphedema, or trauma. Surgical repair is the standard of care in management of AABP; however, up to 60% of patients have developed bothersome genital lymphedema postoperatively. Despite the rates of postoperative scrotal lymphedema, and lymphedema itself representing a risk for AABP, very little data exist on the role of lymphatic evaluation in this patient population. We present the previously unreported use of indocyanine green (ICG) for lymphatic mapping as an adjunct to buried penis repair. Using 0.1 mL 25 mg per mL of indocyanine green and SPY Portable Handled Imaging, lymph mapping is performed, identifying lymph channels that seem obstructed as possible targets for lymphovenous bypass. In addition, lymph mapping can be used as an adjunct to surgical resection so as to not disrupt the intact channels, reducing the risk of postoperative lymphedema. Through this article, we offer emerging clinical insight into the possible use of lymphovenous bypass, particularly in patients with AABP due to lymphedema or those who experience lymphedema as a complication of AABP repair.

Combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum: A case report.

Genital lymphedema is a severe, disabling condition associated with a malfunction of the lymphatic system. Primary lymphedema of the scrotum is a variant of congenital dysplasia of lymphatic vessels. Secondary genital lymphedema is much more common and can be caused by parasitic invasion (filariasis) or damage to the lymphatic system during the treatment of cancer (radiation therapy, lymphadenectomy). Healthcare providers are frequently unable to detect and treat this illness successfully in ordinary clinical practice. This paper uses the case of a patient with stage 3 secondary lymphedema (unknown genesis) of both lower extremities and lymphedema of the scrotum, complicated by recurrent erysipelas, a history of lymphorrhoea, impaired skin trophic and multiple papillomatosis, to demonstrate the efficacy of a combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum. In the treatment, the combination of decongestant physical therapy (CDPT, CDT) according to M. Földi was used at pre-surgery and post-surgery stages, combined with a reconstructive operation, including the removal of the affected tissues of the urogenital region, phalloplasty, and scrotoplasty with rotational skin flaps. A decrease in the circumference of the lowest extremities in the lower leg area by 68 cm on the right and by 69 cm on the left was achieved by conservative treatment. Due to the combination of conservative and surgical treatment, the patient's body weight decreased by 69.4 kg, and the scrotum decreased by 63 cm. Subsequently, the patient fully recovered his sexual function. A combination of complex decongestive physical therapy and surgery is necessary for patients with advanced genital edema. The isolated use of surgical or conservative treatment does not provide a sufficient improvement in the patient's quality of life. Modern plastic surgery technologies enable patients to achieve complete functional and cosmetic recovery, while proper selection and usage of compression hosiery help preserve and improve the outcomes acquired following treatment.

V11-02 PENILE-SCROTAL RECONSTRUCTION DUE TO MALE GENITAL LYMPHOEDEMA

You have accessJournal of UrologyCME1 Apr 2023V11-02 PENILE-SCROTAL RECONSTRUCTION DUE TO MALE GENITAL LYMPHOEDEMA Matthew Megson, Wai Gin Lee, and David Ralph Matthew MegsonMatthew Megson More articles by this author , Wai Gin LeeWai Gin Lee More articles by this author , and David RalphDavid Ralph More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This is a case of scrotal lymphoedema in a 36 year old gentleman who had had 3 years of recurrent infections. Due to the extent of the disease he required an excision of the lymphoedematous tissue and a scrotoplasty to reconstruct his scrotum from unaffected skin. METHODS: This is a video demonstrating the steps of the excision of the lymphoedematous tissue and subsequent reconstructive. Steps of the procedure start with marking of the lymphoedematous tissue. The surgeon the dissects down the isolate the cords and delivers the testes. The penile shaft can then be isolated and all lymphoedematous tissue excised. With the important structures now isolated, the scrotal lymphoedematous tissue can be removed. Care must be taken to keep the unaffected skin on the lateral aspects of the wounds, as these have a different lymphatic drainage and are therefore not involved in the pathology. This creates an ideal tissue for reconstruction as this allows primary closure of the neo-scrotum. The lymphoedematous tissue tends to be extremely vascular with large feeding vessels, therefore care much be taken with haemostasis. Due to the lymphoedematous tissue extending into the patients perineum he was then placed into lithotomy to allow better access to this area. Care was taken to avoid injury to the anus and rectum. Prior to the close of the neo-scrotum an Orchidopexy was performed to stop testicular retraction. The lateral skin was then closed to create a neo-scrotum over drains. RESULTS: The video shows a typical operation for male genital lymphoedema and the usual end results. The patient is happy with his final result. The histology showed an anogenital granulomatosis lymphoedema. CONCLUSIONS: A variety of treatment options for anogenital granulomatosis exist though if left to become severe then surgery is required before any of these medications would improve future outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Megson More articles by this author Wai Gin Lee More articles by this author David Ralph More articles by this author Expand All Advertisement PDF downloadLoading ...

Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer

To evaluate the functional efficacy of the superficial circumflex iliac artery perforator (SCIP) -lymphatic pedicled flap in the treatment of advanced male genital lymphedema. From February 2018 to January 2022, we treated 26 male patients with scrotal and penoscrotal advanced lymphedema using reconstructive lymphatic surgery. Isolated scrotal involvement was seen in 15 patients, and 11 patients had penoscrotal involvement. Excision of genital lymphedematous fibrotic tissue was followed by reconstruction utilizing the SCIP-lymphatic flap. Patient characteristics, intraoperative data, and postoperative results were evaluated. The mean patient age was 39 ± 4.6, and the mean follow-up time was 44.9 months. the SCIP-lymphatic flap was used to reconstruct partial (n=11) or total (n=15) scrotum and used to reconstruct total penile skin in 9 cases and partial in 2 cases. The flap survival rate was 100%. Cellulitis rates were dramatically reduced after reconstruction (P value <.001). The mean genital lymphedema score (GLS) after surgery was 0.05, which was significantly lower than the preoperative 1, 6.2 (P < .001). The median Glasgow Benefit Inventory (GBI) total score was +41, all 26 patients (100%) showed a degree of quality of life improvement. The pedicled SCIP lymphatic transfer approach in advanced male genital lymphedema can provide a durable complete functional lymphatic system that improves the appearance and genital lymphatic drainage. This leads to an improvement in quality of life as well as in sexual functions.

A video of penile-scrotal reconstruction due to male genital lymphoedema

A video of penile-scrotal reconstruction due to male genital lymphoedema

Patient With Genital Lymphedema, Pain, and Rash

A 47-year-old man presented to the emergency department (ED) with 3 days of worsening scrotal pain, genital edema, erythema and yellow penile discharge, after completing 2 weeks of doxycycline. He was in an open marriage with a male partner and denied new sexual partners. In the ED he was afebrile and normotensive without tachycardia. His physical exam revealed tender genital lymphedema without crepitus or fluctuance (Figure 1A, 1B). White blood cell count (WBC) was 8.8 × 109/L, Lactate 1.9 mmol/L, and Creatinine 1.22 mg/dL. CT scan revealed no subcutaneous air nor fluid collection. Physical exam evolved with the development of an umbilicated rash with pustules on hospital day #5 (Figure 1C). Tests for HIV, Hepatitis C, HSV-1, HSV-2, Neisseria gonorrhea and Chlamydia trachomatis were negative. His RPR and treponemal antibody were both positive. A)FilariasisB)Monkeypox + SyphilisC)Lymphogranuloma VenereumD)Molluscum Contagiosum + Secondary Syphilis What is the most likely diagnosis? B) Monkeypox + Syphilis In the 2022 United States Monkeypox (MPX) outbreak, infected individuals most often present with a prodrome of fever, lethargy, myalgia, and headache and with subsequent onset of a cutaneous lesions in 95% of cases, most frequently in the anogenital region (73%).1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Transmission occurs through direct and prolonged contact with skin lesions, fomites, and also large respiratory droplets.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Concomitant sexually transmitted infections (STI) have been seen in up to 29% of cases.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Furthermore, secondary bacterial infections involving MPX lesions have also been reported.2Ortiz-Martinez Y Rodriguez-Morales Alfonso J Franco-Paredes C Chastain DB Gharamti AA Vargas Barahona L Henao-Martinez AF Monkeypox - a description of the clinical progression of skin lesions: a case report from Colorado, USA.Ther Adv Infect Dis. 2022; 920499361221117726Google Scholar Primary infectious genital lymphedema is most commonly caused by Wuchereria bancrofti, causing Lymphatic Filariasis, which is rare in the U.S.3Pastor C Granick MS. Scrotal lymphedema.Eplasty. 2011; 11 (ic15)https://www.ncbi.nlm.nih.gov/pubmed/22184510Google Scholar Genital lymphedema may also be idiopathic or secondary to prior episodes of Streptococcus cellulitis.4Bjornsdottir S Gottfredsson M Thorisdottir AS et al.Risk Factors for Acute Cellulitis of the Lower Limb: A Prospective Case-Control Study.Clin Infect Dis. 2005; 41: 1416-1422https://doi.org/10.1086/497127Crossref PubMed Scopus (143) Google Scholar Additional considerations include secondary syphilis and Lymphogranuloma Venereum (LV), caused by Chlamydia trachomatis. Secondary syphilis presents with lymphadenopathy and systemic systems, but the presence of extensive perianal pain and proctitis is unusual and more suggestive of MPX.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar The patient described was diagnosed with syphilis by positive RPR and treponemal antibody tests, but this diagnosis alone did not explain his extensive pain. LV is usually characterized by proctitis, proctocolitis, and palpable inguinal and femoral lymph nodes.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar LV usually presents with a primary asymptomatic genital or anal lesion, but disseminated and persistent skin lesions have not been described and are more consistent with MPX. Patients presenting with acute scrotal pain and/or edema even without pathognomonic lesions, should prompt STI evaluation and early MPX precautions.7Gomez-Garberi M Sarrio-Sanz P Martinez-Cayuelas L et al.Genitourinary Lesions Due to Monkeypox.Eur Urol. 2022; 9 (Published online September)https://doi.org/10.1016/j.eururo.2022.08.034Abstract Full Text Full Text PDF Scopus (5) Google Scholar In the described case, the diagnosis was confirmed with DNA PCR testing of a swabbed genital lesion for Orthopoxvirus and Monkeypox Virus (West African Clade). On hospital day #6, the patient was started on Tecovirimat 600mg prescribed twice daily for two weeks. On hospital day #10, the scrotal lesions healed without areas of apparent necrosis, and scrotal edema subsided to baseline. 5Vives F García-Perdomo HA Ocampo-Flórez GM. Giant lymphedema of the penis and scrotum: a case report.Autops Case Rep. 2016; 6: 57-61https://doi.org/10.4322/acr.2016.026Crossref PubMed Google Scholar.

Surgical management of genital lymphoedema: experience and critical considerations from a tri-center study

Aim: Genital lymphoedema (GL) is a chronic and debilitating disease, which can severely affect the patient’s quality of life with significant socio-economic impact. Nowadays, no gold standard algorithm exists for GL from diagnosis to treatment. This study proposes our therapeutic flowchart based on the three senior consultants’ experience in lymphatic surgery. Methods: A retrospective investigation was conducted on a prospectively maintained database (2018-2022). Inclusion criteria involved all patients who underwent surgical procedures for treating GL in three plastic surgery departments (Lausanne, Bari, and Genova). Outcomes were assessed in terms of oedema reduction, stage regression, and functional reported outcomes. Results: 16 patients with GL were included: 50% underwent debulking surgery, 18.8% microsurgery, and 31.2% debulking + microsurgery. We recorded a significant regression of the GL stage: 62.5% shifted from stage II/III to postoperative stage I. Similarly, we found an infection recurrency resolution in 50%, a scrotal oedema reduction in 62.5%, and a scrotal oedema resolution in 37.5% of the patients treated. While almost half of the patients (53.3%) with associated penile oedema described persistent postoperative penile oedema, only two patients complained of persistent lymphorrhea. Conclusion: According to our clinical experience, preoperative and postoperative physical functional therapy is always recommended. For stages I and IIA, after the failure of the conservative treatment, lymph-venous shunts and lymph node transplantation surgery are proposed at the early time. When GL is already diagnosed at stages IIB and III, the debulking surgery, together with functional procedures, represents our first approach.

Patients with adult-acquired buried penis and their surgical management: a single-center study

Adult-acquired buried penis (AABP) is a condition in which the suprapubic fat (the escutcheon) conceals the penis. The etiologies of AABP include obesity, pelvic lymphedema, lichen sclerosis, and scar contraction following a circumcision. If untreated, AABP can lead to hygiene-related infections, urinary and sexual disorders, and psychological issues, such as depression, diminished self-esteem, and poor quality of life. When weight reduction fails to resolve this condition, surgical correction can successfully manage the patient’s AABP. The goal of surgical repair is to extract the telescoped penis from the escutcheon. In our experience, this has been successful with a urologist/plastic surgeon team. Cases of surgical repair for AABP performed at a single medical center from 2012 to 2022 were retrospectively reviewed. Fourteen patients, whose age ranged from 40 to 74 years old, were identified, and their characteristics as well as the surgical techniques performed on them were reviewed. All patients were obese, their body mass index ranging from 32.1 to 62.4; eight patients were severely obese. Five patients had a history of adult circumcision, 5 had a prior diagnosis of lichen sclerosis, and 3 had genital lymphedema. The initial procedures were routine but with some variation. The surgical techniques included performing a panniculectomy and/or an escutcheonectomy, degloving the penis, removing nonfunctional fibrotic tissue, incising the suspensory ligament, and using a meshed split-thickness skin graft (STSG) for penile coverage. The most common complication was wound dehiscence. Two patients with complications required a return to the operating room; one patient returned for closure of an infected wound and the other for penile reconstruction and the placement of a new STSG for lymphedema. All patients eventually recovered, with no further complications reported.

Genital Lymphedema after Cancer Treatment: A Narrative Review.

Genital lymphedema may affect males and females after cancer treatment (gynecological, such as cervical, uterine or ovarian, melanoma, prostate, anus…). It is frequently associated with lower limb lymphedema, and is responsible for discomfort, cosmetic disfigurement and functional disturbances. Impacts on body image, sexual function and quality of life are major, and difficult to explore because cancer treatment itself and lymphedema are so closely interwoven. Local complications, e.g., papillomatosis, warty growth, lymph vesicles with embarrassing lymph oozing and cellulitis, may occur. Usual lymphedema therapies, like bandaging and elastic compression, are poorly adapted to these sites. Surgery, essentially based on cutaneous resection techniques, is the primary symptomatic treatment; it achieves good efficacy, in adults and children, with possible recurrence requiring reintervention.

The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review.

(1) Background: Secondary lymphedema is a chronic, progressive, and debilitating condition with an important impact on quality of life. Lymphedema is a frequently reported complication in oncological surgery but has not been systematically studied in the setting of prostate cancer. (2) Methods: Pubmed/MEDLINE and Embase were systematically searched to identify articles reporting on lower limb or genital lymphedema after primary treatment (surgery of radiation therapy) of the prostate and the pelvic lymph nodes in men with prostate cancer. Primary outcome was the prevalence of lower limb and genital lymphedema. (3) Results: Eighteen articles were eligible for qualitative synthesis. Risk of bias was high in all included studies, with only one study providing a prespecified definition of secondary lymphedema. Eleven studies report the prevalence of lower limb (0-14%) and genital (0-1%) lymphedema after radical prostatectomy with pelvic lymph node dissection (PLND) Seven studies report a low prevalence of lower limb (0-9%) and genital (0-8%) lymphedema after irradiation of the pelvic lymph nodes. However, in the patient subgroups that underwent pelvic irradiation after staging pelvic lymph node dissections, the prevalence of lower limb (18-29%) and genital (2-22%) lymphedema is substantially elevated. (4) Conclusion: Prostate cancer patients undergoing surgery or irradiation of the pelvic lymph nodes are at risk of developing secondary lymphedema in the lower limbs and the genital region. Patients receiving pelvic radiation after pelvic lymph node dissection have the highest prevalence of lymphedema. The lack of a uniform definition and standardized diagnostic criteria for lower limb and genital lymphedema hampers the accurate estimation of their true prevalence. Future clinicals trials are needed to specifically evaluate secondary lymphedema in patients undergoing prostate cancer treatments, to identify potential risk factors and to determine the impact on quality of life.

Genital lymphoedema and its hidden impact: a treatment guide.

Genital lymphoedema is recognised as a rare consequence of cancer surgery or its treatment, which also occurs with primary lymphoedema. Over recent years, there has been an increased understanding of the condition; however, good assessment, early recognition and effective management are crucial to prevent the progression and improve the lives of those with this condition. Treatment needs to be individualised and the psychosocial and emotional aspects of the condition need to be carefully considered to ensure that the patient can achieve successful outcomes with realistic expectations.

Case report: surgical management of massive scrotal lymphedema in a bariatric patient

A morbidly obese male patient was referred to our department for joint-venture excision surgery of a massive genital lymphedema that had increased 10-fold in volume over a 3-year period. The patient underwent two-stage excision and reconstruction surgery including orchiectomy and was discharged with no major complications and reported improved outcome and urogenital function after surgery at 6-month follow-up. Genital lymphedema is a rare and surgically challenging disease that is related to obesity and causes functional and psychosocial impairment. The planning, performance and postoperative care of surgery on bariatric patients requires tailored surgical treatment and the involvement of several different medical professions and specialties. Surgical debulking can bring about satisfactory outcomes and profound improvements in quality of life.

Control of the extracellular matrix by hypoxic lymphatic endothelial cells: Impact on the progression of lymphedema?

Initial lymphatic vessels do not have a continuous basement membrane. Therefore, the ability of lymphatic endothelial cells (LECs) to produce extracellular matrix (ECM) has received little attention. Untreated lymphedema is a chronic disease that progresses to massive fibrosclerosis in advanced stages. Expansion of the intercellular space and fibrosclerosis cause hypoxia, which also affects the LECs. We studied the expression of genes in human LECs in vitro by RNA sequencing, analyzed the effects of hypoxia (1% O2 ) vs. normoxia (21% O2 ), and focused on ECM genes. LECs express fibrillin-1 and many typical components of a basement membrane such as type IV, VIII, and XVIII collagen, laminin β1, β2, and α4, perlecan, and fibronectin. Under hypoxia, we found significant upregulation of expression of genes controlling hydroxylation of procollagen (PLOD2, P4HA1), and also cross-linking, bundling, and stabilization of collagen fibrils and fibers. Also striking was the highly significant downregulation of elastin expression, whereas fibulin-5, which controls the assembly of tropoelastin monomers, was upregulated under hypoxia. In the dermis from genital lymphedema, we observed significant PLOD2 expression in initial lymphatics. Overall, hypoxia results in the picture of a dysregulated ECM production of LECs, which might be partly responsible for the progression of fibrosclerosis in lymphedema.

Genital Lymphedema and How to Deal with It: Pearls and Pitfalls from over 38 Years of Experience with Unusual Lymphatic System Impairment.

Background and Objectives: Conservative treatment represents an essential pillar of lymphedema management, along with debulking and physiologic surgeries. Despite the consistent number of treatment options, there is currently no agreement on their indications and possible combinations. When dealing with unusual lymphedema presentation as in the genitalia (Genital Lymphedema—GL), treatment choice becomes even more difficult. The authors aimed to present their targeted algorithm of single and combined treatment modalities for rare GL in order to face this paucity of information. Materials and Methods: Data were collected from a prospectively maintained database since January 1983, and cases of GL that were managed in the authors’ department were selected. Only patients that were treated in the authors’ institution and presented a minimum follow-up of 3 months were admitted to the current study. Results: From January 1983 to July 2021, 19 patients with GL were recruited. All the patients were male, and their ages ranged from 21 to 73 years old (average: 52). Ten cases (52.6%) presented with ISL (International Society of Lymphology) stage I, five (26.3%) were stage II and four (21.1%) were stage III. GL was managed with conservative treatment (12 cases), LVA (LymphaticoVenous Anastomosis) (3) or surgical excision (4). In a mean follow-up of 7.5 years (range: 3 months—11 years), no major complications occurred, and all cases reached improvements in functional and quality of life terms. Conclusions: Contrary to the predominant thought of the necessity to avoid surgery in unusual lymphedema presentations such as GL, they can be managed using targeted multimodal approaches or by adapting well-known procedures in unusual ways to achieve control of disease progression and improve patients’ quality of life.