V12-04: Resection & Reconstruction of Massive Lymphedema of the Male Genitalia
Massive lymphedema of the male genitalia arises from the disruption of lymphatic flow from numerous causes. We describe a standard approach to a difficult surgical resection and reconstruction and present a case series.
In the dorsal lithotomy position, priority is given to identification/protection of the penis and spermatic cords. The native penile skin is often unusable, requiring skin grafting. Careful dissection helps to isolate the spermatic cords and testicles. The LigaSure device provides rapid dissection and minimal blood loss by its ability to coagulate and cut large vessels. The posterior soft tissue is divided rapidly while preserving normal perineal skin for a neoscrotum. A new location for the penis is chosen on the midline of the anterior suprapubic skin-flap, through which the penis is transposed directly in line with the natural position of the penis, maximizing penile length. Orchiopexy is performed in the neoscrotum. When suitable, the resected scrotal tissue serves as a donor site for skin graft harvest. The dermatome is used to harvest a 0.016in-0.018in split-thickness sheet graft from an area free of skin breakdown, eliminating donor site morbidity. Fibrin sealant is sprayed onto the penis and the graft is quilted in place. A negative-pressure dressing is placed over the penile skin graft. Tongue depressor blades provide scaffolding for the dressing, keeping the penis at length when the vacuum is applied. After 5 days of bedrest, the dressing and catheter are removed.
Between 2014-2015, three men with massive lymphedema of the genitalia were treated. Patient 1 was super-morbidly obese, weighing >750 lbs. Patients 2 and 3 suffered from lymphedema related to previous complex inguinal hernia repairs. Scrotal specimens weighed 258 lbs, 90 lbs, and 48 lbs, respectively. Minor wound complications comprised small areas of skin graft loss and granulation tissue at the new penoscrotal junction and healed with application of silver nitrate.
We present a technique for resection and reconstruction of massive lymphedema of the male genitalia. The LigaSure minimizes operative time and blood loss. Transposition of the penis provides an anatomical reconstruction. Skin graft harvest from the excised specimen limits donor site morbidity. And application of a negative-pressure dressing aids in initial healing. We have successfully treated three patients with this technique at our institution.