Excision and reconstruction of a giant scrotal lymphedema without penile skin graft

S-H. Belbina, A. Lee, D. Shukla, Z. Zubair, G. Bales, M. Khalil

Introduction and objective:

Genital lymphedema is rare, and corresponds to 0.6% of all cases of lymphedema. Symptoms include pain, sexual dysfunction, limitations on mobility and urination, and infections. Treatment is based on the etiology of lymphedema, with surgical excision with possible flap or graft coverage as a last resort option.

This is a 43 year old male patient who presented with urinary tract infection and 1 year history of scrotal swelling. His exam was notable for massive diffuse nontender enlargement of the scrotum with thickened, firm, and indurated scrotal skin resembling the texture of an orange peel with a buried phallus. CT scan demonstrated marked edema and thickening of scrotal skin without rim enhancing fluid collection.

Methods:

The patient is positioned in dorsal lithotomy, prepped and draped in the usual sterile fashion. A sterile urethral foley is placed at the start of the case.

A 4 cm vertical incision is made at the groin lateral to the phallus on both sides to identify the spermatic cord and testicle. The entire scrotum was completely excised en bloc. The urethral catheter helped in identification of the penis which was then fully released with everted penile skin. After debulking of subcutaneous tissue and hemostasis was achieved, bilateral testes were pexied to each other and to underlying subcutaneous fibrofatty tissue to prevent future twisting.

Reconstruction was achieved by placing 2-0 absorbable sutures tacking the dartos layer of the proximal penile skin to the deep fibrofatty tissue lateral to bulbar urethra. Two JP drains were left in dependent portions of the scrotum. The wound was closed in multiple deep and superficial layers.

Results:

The foley and both drains were removed on POD2 and he was discharged home. On POD14, he had an area of dehiscence under the penis on the right side which was managed with oral antibiotics and local wound care with antiseptic washes and iodoform packing. On POD23, wound was healing well. The patient reported significant improvement in mobility and function.

Conclusions:

In extreme cases, giant scrotal lymphedema can be treated with surgical excision without the need for penile skin grafting with excellent cosmetic and functional outcomes.

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