Penoscrotal Lymphedema Research Articles

Giant Penoscrotal Lymphedema-What to Do? Presentation of a Curative Treatment Algorithm.

While rare, penoscrotal lymphedema (PL) is accompanied with devastating effects on the quality of life of patients. Moreover, especially for patients with excessive (giant) PL, no standardized curative treatment has been defined. This article therefore retrospectively evaluates the authors' surgical treatment approach for giant PL, which includes resection alone or in combination with a free vascularized lymph node transfer (VLNT). A total of ten patients met the inclusion criteria. One patient dropped out of the study before therapy commenced. Eight of the nine remaining patients presented with end-stage (giant) PL. One patient presented with manifest pitting edema. All patients were treated with penoscrotal resection and reconstruction. Additionally, five patients received VLNT into the groin or scrotum. The extent of the lymphedema was specified with a treatment-oriented classification system. The median follow-up was 49.0 months. No patient showed a recurrence. Patients who received VLNT into the scrotum displayed a significantly improved lymphatic transport of the scrotum. Advanced PL should be treated in a standardized surgical fashion as suggested by our proposed algorithm. VLNT from the lateral thoracic region into the scrotum must be considered. If treated correctly, surgical intervention of end-stage PL leads to good results with a low recurrence rate.

Surgical treatment of penoscrotal lymphedema in a patient with Milroy's disease: case report

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Linfedema penoscrotal primario, una entidad clínica inusual: reporte de un caso

Caso clínico: Masculino de 52 años a quien se diagnostica linfedema penoscrotal primario tardío gigante, que fue tratado con linfangiectomía más reconstrucción de los genitales. En su seguimiento de un año, no ha habido recurrencia de la enfermedad y se logra conservar la función sexual.
 Relevancia: El linfedema penoscrotal gigante es una condición patológica de muy baja incidencia, pero con alto impacto en la morbilidad; Se desencadena por la acumulación de líquido rico en proteínas en el tejido celular subcutáneo, que genera deformidad, pérdida de la función sexual e infecciones por repetición.
 Implicaciones clínicas: Esta entidad clínica condiciona deterioro de la calidad de vida en los pacientes, ya que provoca malestar para la deambulación y sobre todo produce deterioro de la función sexual.
 Discusión y conclusión: El tratamiento quirúrgico de esta afección representa actualmente la mejor opción terapéutica, ya que previene la progresión de la enfermedad, la deformidad y preserva la función. La mejor de las técnicas es la linfangiectomía más la reconstrucción de los genitales, la cual se describe en el presente caso con evolución favorable.

MULTIPLE LYMPHATIC-VENOUS ANASTOMOSES (MLVA) FOR MICROSURGICAL DRAINAGE OF PRIMARY PENO-SCROTAL LYMPHEDEMA: A CASE REPORT

Single site Multiple Lymphatic-Venous Anastomoses (MLVA) provides optimal functional and cosmetic results with low complication rates in treatment of lower limb lymphedema. However, no evidence exists in literature concerning the use of this technique in treatment of peno-scrotal lymphedema. We report a case of a 44-year-old male patient who developed secondary peno-scrotal lymphedema with severe lymphorrhea, following a laser treatment for scrotal pustolosis, leading to recurrent infections and finally an established peno-scrotal lymphedema. Utilizing MLVA, a complete remission of scrotal lymphedema was achieved with significant volume reduction of the penile lymphedema. The post-operative course was uneventful with clear improvement in lymphatic flow demonstrable on lymphoscintigraphy (6 months) and no recurrence of scrotal lymphedema at 2 years follow-up. This article reports very promising results of a novel application of MLVA in the treatment of genital lymphedema and suggests that MLVA provides the possibility to shunt both superficial and deep lymphatics to improve the lymphatic drainage from the peno-scrotal area using a single surgical site.

Reconstructive surgery for penoscrotal filarial lymphedema: A decade of experience and follow-up with special emphasis on sexual function

Reconstructive surgery for penoscrotal filarial lymphedema: A decade of experience and follow-up with special emphasis on sexual function

Author Reply.

The comments of the editor truly reflect the findings of our study on the surgical treatment of giant penoscrotal lymphedema. All the 19 patients described in the study were to be treated by surgery. Eight patients, however, defaulted, possibly because of their belief in alternative traditional herbal medicine and or financial constraint, because health insurance schemes are yet to be fully established in our environment.

Pedicled Transfer of the Superficial Inguinal Lymph Node Flap for Lymphedema

Background Vascularized lymph node transfer is performed for select patients with lymphedema who remain refractory to nonsurgical therapies. Typically, this involves a microvascular free tissue transfer of donor lymph nodes to the affected area. We describe our experience with the transfer of a pedicled adipofascial flap containing the superficial inguinal lymph nodes for lower extremity lymphedema or penoscrotal lymphedema. Methods In eight patients, a unilateral pedicled superficial inguinal lymph node flap was harvested. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease. Blood supply was from either the superficial circumflex iliac vessels or the superficial inferior epigastric vessels. In certain patients, concurrent lymphaticovenular anastomosis was attempted as well. Results Four patients underwent pedicled superficial inguinal lymph node flap transfer for lower extremity lymphedema and for the other four patients the indication was penoscrotal lymphedema. Seven of the eight study patients reported improvements in their lymphedema symptoms. Postoperative complications included cellulitis in one patient and hematoma in another patient; neither patient required reoperation. Conclusion The pedicled superficial inguinal lymph node flap is a feasible and safe treatment option for either lower extremity lymphedema or genital lymphedema. This case series provides the basis for additional studies regarding the potential use of this vascularized lymph node flap in select patients.

P-03-022 Surgical management of massive penoscrotal lymphedema underlying a giant smooth muscle hamartoma of the scrotum

P-03-022 Surgical management of massive penoscrotal lymphedema underlying a giant smooth muscle hamartoma of the scrotum

Treatment of male genital lymphedema: An integrated concept

Genital lymphedema is a debilitating condition. Currently, therapeutic concepts include conservative and surgical measures of genital volume reduction, but no therapy standards exist. The aim of this study was to analyze our experience with the treatment of male genital lymphedema and to describe our integrated concept, which combines perioperative complex decongestive physiotherapy (CDP) with surgical reduction. We conducted a retrospective study of 51 male patients who were treated in our clinic between 1998 and 2013, acquiring data on etiology, performed therapy, and complication rates. Forty-three (84%) of our patients suffered from primary and eight (16%) from secondary lymphedema. Two patients (4%) exhibited isolated penile affection and 22 (43%) isolated scrotal affection, while the majority (27 or 53%) exhibited penoscrotal lymphedema. All patients underwent inpatient CDP preceding and following surgery. Surgical therapy involved debulking the scrotum in 25 patients (49%), isolated penile reduction in two (4%), and penoscrotal reduction in 24 (47%). Hydrocoelectomy was performed in 22 (43%) patients. Following resection of the diseased tissue, the defects were closed primarily using adjacent healthy skin. There was no need for local flaps or skin grafts. Three patients suffered from complications requiring revision surgery: hematoma in two patients (4%) and wound dehiscence in one (2%). We measured the change in quality of life that was achieved by these procedures using the Glasgow Benefit Inventory questionnaire. The patients reported improvement in general functioning and physical health, whereas the social support score was largely unaffected by the procedure. Our results show that genital lymphedema patients can be reliably treated by combining conservative and surgical therapy. Prior conservative reduction of the genitals facilitates surgery and allows consistent results at a low complication rate, whereas surgical reduction serves to enhance and stabilize the results of conservative treatment.

Male genital lymphedema: clinical features and management in 25 pediatric patients

PurposeGenital lymphedema in the pediatric population is poorly understood. The purpose of this study was to determine the epidemiology, morbidity, and treatment outcomes for males with genital lymphedema. Materials and methodsMale patients with genital lymphedema evaluated at our vascular anomalies center between 1995 and 2011 were reviewed. Etiology, age-of-onset, location, morbidity, and treatment were analyzed. ResultsOf the 3889 patients with vascular anomalies, 25 (0.6%) had genital lymphedema: 92% (23/25) with primary and 24.0% (6/25) with familial/syndromic lymphedema. For primary disease, the mean age-of-onset was 4.5±6.3years with 60.9% (14/23) presenting in infancy, 13.0% (3/23) in childhood, and 26.1% (6/23) in adolescence. Combined penoscrotal lymphedema was identified in 72.0% (18/25) of patients; 19 children (76.0%) had concomitant lower extremity involvement. The most common complication was cellulitis (24.0%). Surgical contouring was performed in 44.0% (11/25) of patients. Patients with operative intervention and follow-up (n=6) had sustained improvement after a median of 4.2years (range: 0.3–11.0). ConclusionsLymphedema of the male genitalia is typically idiopathic. Most patients develop swelling in infancy but can present in adolescence and occasionally childhood. The penis and scrotum are usually both involved and concurrent lower-extremity swelling is common. Surgical debulking can improve symptoms and appearance.

Management of “Buried” Penis in Adulthood: An Overview

The condition of "buried" penis may arise from several factors. Although the pediatric form is a rare congenital disorder, it may become an acquired condition in adulthood, most commonly from obesity, radical circumcision, or penoscrotal lymphedema. As obesity has become a national epidemic, the incidence of this phenomenon will inevitably increase. The purpose of this article is to present current strategies in the management of this physically and psychologically debilitating condition. A literature review of the surgical management of buried penis was obtained mainly in the plastic surgery and urology literature (PubMed), from 1977 to 2007. Several risk factors were identified in adult patients with buried penis, including morbid obesity and diabetes mellitus. Multiple techniques for release and reconstruction are described, including primary closure, Z-plasty, and skin resurfacing, all of which may or may not include a lipectomy. Recent publications focus on resurfacing with split-thickness skin grafts and negative-pressure dressings. These techniques have been successful in terms of graft survival and long-term cosmetic result. Buried penis is an unusual, difficult-to-treat condition that presents a unique challenge to the plastic surgeon and the urologist. Predisposing factors such as morbid obesity and diabetes mellitus are becoming increasingly prevalent, which suggests a potential increase in the incidence of this condition. Although no specific approach may be applicable to all patients, a combination of various techniques may be applied. In complicated and severe cases, a split-thickness skin graft to the penile shaft, reduction scrotoplasty, suction-assisted lipectomy, and/or surgical lipectomy, such as panniculectomy, may be indicated. Therapy adapted to the individual patient can result in high rates of successful reconstruction with acceptable cosmetic results.

Surgical treatment of peno-scrotal lymphedema in a patient with Hennekam syndrome

The management of genital lymphedema due to congenital agenesis of the lymphatic ducts is reported. The surgical procedure consisted of the total excision of the affected skin and subcutaneous tissue followed by scrotoplasty and split-thickness skin graft to resurface the penile shaft. The cosmetic and functional results were excellent.

Lymphedema of the external genitalia: Experience of the Conakry University Hospital

Objective: This study was carried out to evaluate the management of lymphedema of the external genitalia at the department of general surgery, National Hospital Ignace Deen, Conakry, Republic of Guinea. Patients and Methods: In a retrospective study covering a period of 10 years, the files of all patients treated for genital lymphedema at the Ignace Deen Hospital were reviewed. The patient group consisted of 4 male patients and one female patient with a mean age of 46 years (range: 30 – 71 years). The four male patients had penoscrotal lymphedema with concealment of the penis, while in the only female patient the right labium major and the buttock were affected. No microfilaria could be detected in any of the cases. All patients were subjected to resection of the lymphedematous tissue and reconstructive surgery. Results: In three patients convalescence took 21 days and the postoperative period was uneventful. The two remaining patients developed scrotal suppuration and recovered after 60 days. After two years of follow-up, good cosmetic and functional results could be reported in four patients. Conclusion: Surgery consisting of total excision of the lymphedematous tissue followed by reconstructive surgery remains the only effective method of treatment. It usually yields good cosmetic and functional results and minimizes the recurrence rate. African Journal of Urology Vol. 12 (4) 2006: pp.209-213

SURGICAL TREATMENT OF LYMPHEDEMA OF THE PENIS AND SCROTUM

Lymphedema of the penis and scrotum, regardless of its etiology, is determined by reduced lymphatic flow with subsequent enlargement of the penis and scrotum. The clinical course of this condition is characterized by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse, and voiding in the standing position. The purpose of the present study is to present the experience and results of the treatment of lymphedema of the penis and scrotum by removing affected tissues and correcting the penoscrotal region. Seventeen patients with lymphedema of the penis and scrotum were treated with a modified Charles procedure, which consists of the excision of the affected skin followed by scrotoplasty and midline suture simulating the scrotal raphe. The penis is covered with a split-thickness skin graft by means of a zigzag suture on its ventral surface. Regression of symptoms and improvement of previous clinical conditions were verified in the follow-up which ranged from 6 months to 6 years. One patient who had undergone lymphadenectomy with radiation therapy due to penile cancer had recurrent scrotum lymphedema. The modified Charles procedure for the treatment of penoscrotal lymphedema is easily reproducible and allows better local hygiene, easier ambulation, voiding in the standing position, resuming sexual intercourse, and finally, better cosmetic results in the affected area with remarkable improvement in quality of life.

Tratamiento quirúrgico de linfedema peneano secundario a hidrosadenitis supurativa

Penoscrotal lymphedema is a rare disease in the developed countries, although it is relatively frequent in tropical countries. The most common cause is filariasis, although in our practice usually is associate to neoplasic and inflammatory processes, surgery, radiotherapy, hidroelectrolitic disbalances and idiopathic.We present a 22 years old patient with penoscrotal lymphedema due to hidradenitis suppurativa. After unsuccessful medical treatment, was performed a total excision of the penile skin and subcutaneous tissue to Buck’s fascia. Split thickness skin grafts were used to cover the defect. Even medical management of penoscrotal lymphedema is not effective for most patients, surgery is a safe and effective procedure that gives excellent functional and cosmetic results.

Scrotal Elephantiasis Associated with Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic relapsing infection of the apocrine sweat glands. Its association with penoscrotal lymphedema is not well recognized. A case of massive scrotal elephantiasis associated with chronic hidradenitis of the perineum and scrotum is described. A wide resection of the scrotal mass and perineum was performed, with reconstruction of the perineum and penis carried out using local skin flaps and split-thickness skin grafts. This one-stage treatment yielded an excellent cosmetic and functional outcome.

Total scrotal reconstruction with vertical rectus abdominis musculocutaneous (VRAM) flap in the treatment of penoscrotal lymphedema

A 37-year-old man with scrotal and penile lymphedema was treated by total excision of the scrotal and penile skin and subcutaneous tissue. Split thickness skin grafts were used to cover the penis and the pubic area. An inferiorly based left rectus abdominis muscle with a 12 x 16 cm skin island from the epigastric region was used to reconstruct the scrotum. The VRAM flap is a simple, reliable flap and it provides sufficient coverage of the exposed testicles after total excision of diseased scrotal skin. It also gives a satisfactory esthetic result. The VRAM flap may be another source for reconstruction of the total scrotum.