Surgical management of penoscrotal lymphedema

INTRODUCTION Genital elephantiasis is a debilitating condition that can have profound effects on both physical and emotional well-being. This condition arises from a reduction in lymphatic flow, resulting in significant swelling of the penis and scrotum.[1] The resulting swelling can cause considerable discomfort, making it difficult to maintain local hygiene and mobility, and can progressively impact sexual and urinary function. The aim of the surgical procedure was to address the patient’s discomfort and mobility issues caused by the weight and swelling of the penis and scrotum. The patient, a 38-year-old male, had been experiencing a gradual swelling of his penis and scrotum for 4 years. Although he had been able to manage the swelling using antibiotics and anti-filarial medications, the weight of his genitals had begun to significantly restrict his mobility. He also developed recurring scrotal skin infections, causing concern for potential complications and long-term effects on his quality of life. Despite his initial apprehension, the patient opted for surgery. Examination showed enlarged, firm, and hyperpigmented skin on the penis and scrotum, with palpable but not significantly enlarged inguinal nodes [Figure 1].Figure 1: (a and b) Genital lymphedemaVarious tests, including urine, blood, and biochemical analysis, as well as magnetic resonance imaging, showed no significant abnormalities. Lymphoscintigraphy, which could have provided further insight, was not possible due to the ongoing scrotal infection. A blood test for filariasis came back negative. The surgical procedure began by attempting to catheterize the penis, but the glans penis was not visible. To locate the urethral opening, the edematous preputial skin was opened. A catheter was inserted through the opening, serving as a guide to palpate the corpus spongiosum. Incisions were made on the distal penis, extending to Buck’s fascia and the root of the penis. The edematous penile skin, weighing 500 g, was then removed circumferentially [Figure 2].Figure 2: (a) Visualization of urethral opening after making prepuce incision. (b) After removal of penial oedematous skinThe spermatic cord structures were traced from the external inguinal ring openings to the base of the scrotum. The dissection was performed above the tunica vaginalis on both testes. The right side had a hydrocele, which required eversion of the sac. The entire edematous scrotal skin was excised, preserving the unaffected lateral skin. The excised scrotal skin weighed 1500 g [Figure 3]. To prevent torsion, both testes were anchored with multiple sutures to their respective beds, and the lateral scrotal skin was used to cover them. A thick split skin graft from the thigh was used to cover the penis, followed by the application of a negative pressure dressing to the penis skin grafts. After 1 week, the negative pressure dressing was removed, and regular dressing was continued. Although there was a 2 cm gap in the junction between the penis skin graft and sutured scrotal skin, it healed through secondary intention within 2 weeks [Figure 4]. The patient had a 6-month follow-up with no reported complications.Figure 3: (a) Opening of the hydrocele sac. (b) Negative pressure dressing over the penisFigure 4: (a) Immediately after negative pressure removal. (b) After 6 monthsGiant scrotal edema can be caused by filariasis, radiation, neoplasms, and granulomatous diseases. Genital lymphedema can cause disfigurement, urinary issues, impotence, and recurrent cellulitis. Emotional well-being is also impacted.[2] Early diagnosis and intervention are crucial to manage genital lymphedema and prevent irreversible skin changes.[3] Conservative measures such as compression, scrotal elevation, and antibiotics are initially used, but as fibrosis sets in, the skin becomes coarse and tough.[4] Lymphostasis leads to fluid accumulation, collagen production, and inflammation, resulting in edema, fibrosis, and thickening of the skin. Surgical intervention involves removing the diseased lymphatic network above Buck’s fascia, including affected skin and subcutaneous tissue around the penis and scrotum. Reconstruction may involve split skin grafts and flaps as done in this patient.[5] Limitation of the study is the short follow-up period. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.