CHASCIP — Combined Charles' Procedure and Bilateral Lymphatic SCIP Flap Transfer (Ciudad)
The CHASCIP technique (Pedro Ciudad et al., 2025) is a hybrid excisional-physiologic operation for ISL Stage III penoscrotal lymphedema that merges the radical debulking capacity of the Charles procedure with lymphatic restoration provided by bilateral pedicled lymphatic SCIP flaps, plus a hypogastric full-thickness skin graft (FTSG) for penile coverage. In the index series (n = 8, mean follow-up 34 months) CHASCIP achieved zero recurrence, GLS 6.6 → 0.6 (p < 0.001), and complete resolution of sexual dysfunction (87.5% → 0%, p < 0.001).[1]
For the broader condition see Genital Lymphedema and Giant Penoscrotal Lymphedema. For the related single-stage SCIP-LFT approach see 3R / SCIP-LFT (Yamamoto); for excision-only debulking see Modified Charles Procedure and Debulking Scrotoplasty; for free-flap LN transfer see VLNT; for the conservative anchor see Complex Decongestive Therapy.
Concept and Rationale
CHASCIP was designed to overcome the complementary limitations of its two parent operations:
- The Charles procedure alone (radical excision + STSG) provides volume reduction but no lymphatic restoration — leaving recurrence, lymphorrhea, and lifelong compression dependence.[2][3]
- The 3R / SCIP-LFT alone (Yamamoto) restores lymphatic transport, but a single SCIP skin paddle may be insufficient when both scrotum and penis are extensively involved.[4]
CHASCIP divides the reconstructive tasks: bilateral pedicled lymphatic SCIP flaps resurface the scrotum (the dominant site of lymphatic stasis and recurrence), providing both soft-tissue coverage and bilateral functional lymphatic drainage; an FTSG harvested from the hypogastric region covers the penile shaft — where elasticity and durability are needed but lymphatic reconstruction is not.[1]
Indications
- ISL Stage III genital lymphedema involving both scrotum and penis.[1]
- Secondary genital lymphedema (75% of the Ciudad series) — most commonly after pelvic lymphadenectomy or radiation for urologic / gynecologic malignancy.[1]
- Primary genital lymphedema (25% of the series).[1]
- Massive tissue burden requiring radical excision (mean resected weight 1,772.7 g).[1]
- Failure of CDT documented preoperatively.[1]
Preoperative Evaluation
- ICG lymphography of the groin to map functional lymphatic vessels and identify channels to incorporate into the SCIP flaps.[1]
- Lymphoscintigraphy to confirm staging and quantify baseline lymphatic transport.[1]
- Symptom-duration and prior-CDT response assessment.
- BMI documentation (mean 28.4 kg/m² in the series) — relevant for flap planning and perioperative risk.
Surgical Technique
CHASCIP is a single-stage operation with three sequential components.
Step 1 — Charles procedure (radical excision)
- Excision of all lymphedematous skin and subcutaneous tissue from scrotum and penis to the deep fascia (Buck's fascia on the penis; tunica vaginalis on the scrotum).[1]
- Testes, spermatic cords, and urethra are carefully preserved.
- Mean resected tissue 1,772.7 g (comparable to Yamamoto 3R's 1,511 g).[1][4]
Step 2 — Bilateral pedicled lymphatic SCIP flap transfer (scrotal reconstruction)
- Bilateral SCIP flaps are harvested — one from each groin — a key distinction from 3R, which is typically unilateral.[1][4]
- Each flap is raised on the SCIA and its accompanying vein, with deliberate inclusion of superficial inguinal lymph nodes and afferent lymphatic vessels — the LYST (Lymphatic System Transfer) principle.[5][6]
- Pivot point at the origin of the superficial SCIA branch; skin-paddle dimensions tailored to the scrotal defect.
- Both flaps are rotated into the scrotal defect and inset to resurface the scrotum, creating a neoscrotum with bilateral functional lymphatic drainage.
Step 3 — Hypogastric FTSG (penile reconstruction)
- A full-thickness skin graft is harvested from the hypogastric (suprapubic) region.
- The FTSG is wrapped circumferentially around the denuded penile shaft.
- FTSG (not STSG) is chosen for the penis to provide elasticity, durability, and cosmetic quality compatible with erectile function — a deliberate departure from the traditional all-STSG Charles approach.[1][7][8]
Step 4 — Donor-site closure
- Bilateral groin SCIP donor sites closed primarily.
- Hypogastric FTSG donor site closed primarily.
CHASCIP vs Yamamoto 3R vs Traditional Charles
| Feature | Traditional Charles | Yamamoto 3R | Ciudad CHASCIP |
|---|---|---|---|
| Excisional component | Radical excision + STSG cover | Radical excision of fibrotic tissue | Charles procedure (excision to deep fascia) |
| Scrotal reconstruction | STSG | Pedicled SCIP-LFT (unilateral) | Bilateral pedicled lymphatic SCIP flaps |
| Penile reconstruction | STSG | SCIP pure-skin-perforator flap (when needed) | FTSG (hypogastric donor) |
| Lymphatic restoration | None | Yes (LYST — unilateral) | Yes (LYST — bilateral) |
| SCIP flaps used | n/a | 1 (+ optional 2nd for penis) | 2 (bilateral) |
| Skin graft used | Yes (STSG) | No | Yes (FTSG, penis only) |
| Microsurgery required | No | No | No (pedicled) |
| Mean resected tissue | Variable | 1,511 g | 1,772.7 g |
| Mean operative time | Variable | Not reported | 160 min |
Why bilateral SCIP
Using two SCIP flaps (one per groin) provides:
- Greater surface area for scrotal coverage in giant disease where one flap is insufficient.
- Bilateral lymphatic drainage — nodes and vessels from both groins contribute to neoscrotal lymphatic function, potentially yielding more robust restoration than a unilateral flap.
- Symmetric reconstruction — anatomically symmetric scrotum.
Outcomes — Ciudad CHASCIP Series (n = 8)
| Parameter | Result |
|---|---|
| Patients | 8 (all ISL III penoscrotal lymphedema) |
| Etiology | Secondary 75%, Primary 25% |
| Mean age | 43 y |
| Mean BMI | 28.4 kg/m² |
| Mean follow-up | 34 months |
| Mean resected tissue | 1,772.7 g |
| Mean estimated blood loss | 200.6 mL |
| Mean surgical time | 160 min |
| Complications | 25% (2/8 — 1 seroma + dehiscence, 1 partial graft loss) |
| Recurrence | 0% |
| GLS (pre → post) | 6.6 → 0.6 (p < 0.001) |
| Sexual dysfunction | 87.5% → 0% (p < 0.001) |
Comparison Across SCIP-Based Genital-Lymphedema Series
| Parameter | Yamamoto 3R (n = 7) | Abdelfattah SCIP-LFT (n = 26) | Ciudad CHASCIP (n = 8) |
|---|---|---|---|
| Mean follow-up | 22.7 mo | 44.9 mo | 34 mo |
| Mean resected tissue | 1,511 g | Not reported | 1,772.7 g |
| Flap survival | 100% | 100% | No flap loss reported |
| Complications | 0% | Not detailed | 25% (minor) |
| Recurrence | 0% | Not reported | 0% |
| GLS (pre → post) | 6.7 → 0.3 | 6.2 → 0.05 | 6.6 → 0.6 |
| Sexual function | Improved | Improved | 87.5% → 0% dysfunction (p < 0.001) |
| Postop compression | Not required | Not reported | Not reported |
| Penile coverage | SCIP pure-skin-perforator | SCIP-lymphatic flap | FTSG |
| SCIP flaps | Unilateral | Unilateral | Bilateral |
Advantages
| Advantage | Detail |
|---|---|
| Hybrid design | Charles excision delivers volume reduction; SCIP-LFT delivers lymphatic restoration where it matters most (scrotum)[1] |
| Bilateral lymphatic restoration | Two SCIP flaps double the lymphatic tissue transferred vs unilateral approaches[1] |
| Efficient operative time | 160 min mean despite excision of nearly 1.8 kg of tissue[1] |
| Low blood loss | 200.6 mL mean — favorable vs traditional Charles, which may require ICU-level fluid management[1][2] |
| Sexual-function restoration | 87.5% → 0% dysfunction (p < 0.001) — the most substantial reported in any genital-LE series[1] |
| No microsurgery | Pedicled SCIP harvest avoids microvascular anastomosis[1] |
Limitations and Considerations
- 25% complication rate (seroma / dehiscence, partial penile graft loss) is higher than the Yamamoto 3R series (0%) but well below the 54.2% historically reported for excision + flap reconstruction.[1][4][9]
- Partial penile graft loss is intrinsic to the Charles-style FTSG component — the penile graft lacks the vascularized pedicle the SCIP flaps confer on the scrotum.[1]
- Small sample size (n = 8) limits generalizability, though results align with the broader SCIP-LFT literature.[1]
- Postoperative GLS of 0.6 is marginally higher than 3R (0.3) and Abdelfattah (0.05) — possibly reflecting the larger excised tissue volume (more severe baseline disease).[1][4][10]
- No data on postoperative compression requirement — unlike the Yamamoto 3R series, which explicitly documented none was needed.[1][4]
- Bilateral groin harvest theoretically increases donor-site morbidity risk, though no donor complications were reported.[1]
CHASCIP Within the Genital-Lymphedema Surgical Algorithm
| Disease severity | Recommended approach | Rationale |
|---|---|---|
| ISL Stage I (pitting) | CDT alone | Reversible — no surgical indication |
| ISL Stage II (moderate, functional lymphatics) | LVA ± CDT | Physiologic restoration sufficient |
| ISL Stage II–III (moderate-severe, no LVA targets) | Excision + primary closure ± VLNT | Debulking with optional lymphatic restoration |
| ISL Stage III (giant, scrotum-predominant) | Yamamoto 3R (SCIP-LFT) | Unilateral SCIP sufficient for scrotal coverage |
| ISL Stage III (giant, penoscrotal) | CHASCIP or Yamamoto 3R | Bilateral SCIP for scrotum + FTSG for penis — or 3R + SCIP pure-skin flap |
| ISL Stage III with prior groin surgery | Excision + free VLNT (lateral thoracic / omental) | SCIP pedicle may be compromised |
CHASCIP occupies a specific niche for ISL Stage III penoscrotal disease where both scrotum and penis require reconstruction — an alternative to Yamamoto 3R when bilateral lymphatic restoration is desired or when the tissue defect exceeds the surface area a single SCIP flap can cover.[1][4]
Key Takeaways
- CHASCIP is the first named technique to formally combine the Charles procedure with bilateral lymphatic SCIP flap transfer — a standardized hybrid excisional-physiologic approach for ISL Stage III penoscrotal lymphedema.[1]
- Zero recurrence at 34 months and complete resolution of sexual dysfunction (87.5% → 0%, p < 0.001) in the index series.[1]
- Bilateral SCIP flaps double the transferred lymphatic tissue and are placed where lymphatic restoration is most critical — the scrotum.[1]
- The hypogastric FTSG for penile coverage provides thin, extensible skin while reserving SCIP flaps for the lymphatic-critical scrotum.[1]
- 160-min operative time and 200.6 mL blood loss are efficient given the ~1.8 kg excision burden.[1]
- The 25% minor-complication rate compares favorably with the 54.2% historical rate for excision + flap reconstruction.[1][9]
- The technique is pedicled — no microsurgical anastomosis required.[1]
- Secondary post-cancer-treatment lymphedema (75% of the series) is the dominant indication — making CHASCIP directly relevant to urologic-oncology patients.[1]
References
1. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. Surgical management of genital lymphedema using the combined Charles' procedure and lymphatic superficial circumflex iliac artery perforator flap transfer (CHASCIP). Microsurgery. 2025;45(5):e70075. doi:10.1002/micr.70075
2. Hassan K, Chang DW. The Charles procedure as part of the modern armamentarium against lymphedema. Ann Plast Surg. 2020;85(6):e37–e43. doi:10.1097/SAP.0000000000002263
3. McDougal WS. Lymphedema of the external genitalia. J Urol. 2003;170(3):711–716. doi:10.1097/01.ju.0000067625.45000.9e
4. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011
5. Xu KY, Finkelstein ER, Wu S, Tadisina K, Mella-Catinchi J. Lymphatic system transfer (LYST) with pedicled SCIP for patients with lymphedema and concomitant chronic venous disease. Plast Reconstr Surg. 2026. doi:10.1097/PRS.0000000000012927
6. Yoshimatsu H, Cho MJ, Karakawa R, et al. The role of lymphatic system transfer (LYST) for treatment of lymphedema: a long-term outcome study of SCIP flap incorporating the lymph nodes and the afferent lymphatic vessels. J Plast Reconstr Aesthet Surg. 2025;101:15–22. doi:10.1016/j.bjps.2024.11.052
7. Modolin M, Mitre AI, da Silva JC, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinics (Sao Paulo). 2006;61(4):289–294. doi:10.1590/s1807-59322006000400003
8. Morey AF, Meng MV, McAninch JW. Skin graft reconstruction of chronic genital lymphedema. Urology. 1997;50(3):423–426. doi:10.1016/S0090-4295(97)00259-8
9. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A systematic review of outcomes after genital lymphedema surgery: microsurgical reconstruction versus excisional procedures. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875
10. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of advanced male genital lymphedema with a complete functional lymphatic system pedicled transfer. Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006
11. Torio-Padron N, Stark GB, Földi E, Simunovic F. Treatment of male genital lymphedema: an integrated concept. J Plast Reconstr Aesthet Surg. 2015;68(2):262–268. doi:10.1016/j.bjps.2014.10.003
12. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema — what to do? Presentation of a curative treatment algorithm. J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586