Skip to main content

Debulking Scrotoplasty — Excision With Primary Closure for Genital Lymphedema

Excision with primary closure (debulking scrotoplasty) is the most commonly performed and lowest-complication excisional procedure for scrotal / penoscrotal lymphedema — accounting for 46.4% of all genital-lymphedema surgeries in the Guiotto SR with a total complication rate of only 10% vs 54.2% for flap reconstruction and 9% for microsurgical LVA.[1]

It is distinguished from the Modified Charles Procedure (which requires skin grafting) by achieving closure with the scrotum's inherent redundancy and elasticity. For the clinical condition see Giant Penoscrotal Lymphedema and Genital Lymphedema.

Indications​

  • Chronic scrotal lymphedema with irreversible fibroadipose deposition refractory to conservative therapy.[5]
  • MLL of the scrotum in morbid obesity (mean BMI ~54–60).[6][7]
  • Primary / congenital / idiopathic GL — up to 84% of European-series cases.[2]
  • Secondary GL — filariasis, post-oncologic, HS, chronic infection.[3][8][9]
  • Pediatric GL — surgical contouring in 44% of pediatric patients with sustained improvement at median 4.2 yr.[10]

Key determinant. Up to ~50% of the scrotum can be resected and closed primarily given native elasticity. When > 50% is diseased, alternative coverage is required.[8]

Preoperative — Integrated CDP​

Torio-Padron n = 51 — perioperative complex decongestive physiotherapy (CDP) is critical:[2]

  • Inpatient CDP before surgery reduces genital volume, facilitates excision, and preserves more tissue for primary closure (converting cases that would otherwise require grafting).
  • CDP continued postoperatively stabilizes the result.

Surgical Technique​

  1. Positioning. Supine lithotomy or frog-leg; urethral catheter.
  2. Incision and excision. All diseased skin and subcutaneous tissue down to the tunica vaginalis, preserving testes, spermatic cords, vas deferens. No orchiectomy needed even for massive specimens (up to 61 kg in Wisenbaugh).[2][6][11]
  3. Concomitant hydrocoelectomy in ~43% when present.[2]
  4. Closure-facilitating maneuvers:[8]
    • Division of the scrotal septum to allow bilateral mobilization.
    • Mobilization of dartos off the tunica vaginalis.
    • Division of the gubernaculum for testicular repositioning.
    • Orchidopexy at the penoscrotal junction — superior repositioning reduces scrotal-content volume.
  5. Flap design for closure:
    • Laterally based scrotal flaps ± mid-raphe Z-plasty for anatomic reconstruction.[7]
    • Posterior and lateral mobilized flaps advanced to create a neoscrotum; midline suture simulating the raphe.[11][12]
  6. Penile management:
    • Isolated scrotal disease → primary scrotal closure alone; no penile intervention.[3]
    • Penoscrotal disease → scrotal primary closure + penile STSG, or preserve healthy inner prepucial skin for distal shaft coverage.[11][12]
    • In Garaffa n = 90 — scrotal primary closure performed in 15; grafts required only for the penile shaft in 7.[3]
  7. Closed-suction drains to prevent seroma / hematoma.

When > 50% scrotal skin requires excision → meshed 2:1 STSG on the tunica vaginalis (orchidopexy first; 1–2 wk granulation before grafting). Dartos and tunica albuginea are inappropriate beds (poor take / fixed unnatural appearance). Thigh pouches are generally inferior because of unnatural appearance and impaired testicular self-examination.[8]

Outcomes​

VariableResultSeries
Complication rate10% overallGuiotto SR (n = 151)[1]
Revision surgery6% (3/51)Torio-Padron[2]
Hematoma4%Torio-Padron[2]
Wound dehiscence2%Torio-Padron[2]
QoL improvement1.3 → 7.7 / 10Wisenbaugh n = 11 MLL[6]
Would choose surgery again90% (19/21)Ogunbiyi[13]
Functional improvement100% improved voiding / ambulation / sexual functionSingh n = 48 filarial[11]
Recurrence (MLL / obesity)50%Machol n = 4[7]
Recurrence (filarial)~2% (1/48)Singh[11]
Recurrence (giant scrotal)9.1%Salako n = 11[14]
Pediatric sustained improvementMedian 4.2 yrSchook n = 6[10]

Complications​

Wound complications (hematoma 4–27%, SSI 18–25%, dehiscence 2–4%) are the dominant issue; recurrence varies dramatically by etiology — 50% in obesity-related MLL (persistent lymphatic obstruction), ~2% in filarial (antifilarial therapy addresses cause), ~9% in giant scrotal lymphedema of mixed etiology.[2][7][11][14]

Special Considerations by Etiology​

  • MLL in obesity. Wisenbaugh n = 11 (mean BMI 60, mean resected 21 kg) — 10/11 closed primarily; QoL 1.3 → 7.7; most patients gained 5.2 kg postoperatively → must include a comprehensive weight-loss plan. 50% recurrence without addressing obesity; mean 2 operations per patient.[6][7]
  • Filarial. Complete multiple courses of antifilarial drugs before surgery. Singh n = 48 — lateral / posterior mobilized flaps; only 1 recurrence (in a patient with prior LND + RT for penile cancer).[11]
  • Post-oncologic. Frequently associated with LE lymphedema; higher recurrence; compression poorly adapted to genitalia, so surgery is the primary symptomatic option.[9]
  • Pediatric. Stepwise — expectant management for mild; excision without grafting for moderate; grafting only when other techniques fail (graft carries skin-contraction risk and does not prevent adjacent recurrence).[15]

Comparison With Other Approaches​

ApproachComplication rateRecurrenceBest for
Excision + primary closure~10%2–50% by etiologyModerate disease with sufficient residual healthy skin[1][2]
Excision + STSG (modified Charles)~10%~9%Severe / giant disease, insufficient skin for closure[1]
Excision + flap~54%VariableLarge defects with exposed structures[1]
Microsurgical LVA~9%LowEarly stage; functional restoration[1]
Combined excision + VLNT / SCIP-LFTLow0% in reported seriesEnd-stage; curative intent[17][18][19]

Advantages and Limitations​

Advantages. Lowest complication rate among excisional approaches; no donor-site morbidity; superior cosmesis (native scrotal skin with palpable testes); preserved thermoregulation; short OR time / hospitalization; reproducible without microsurgical expertise.[1][4][8][16]

Limitations. Does not restore lymphatic drainage — purely debulking, leaving patients vulnerable to recurrence (particularly in obesity-related MLL); limited by available healthy skin (< 50% excision); high recurrence in obesity without metabolic intervention. Emerging combined excision + SCIP-LFT or VLNT approaches offer 0% recurrence in early series.[6][7][17][18][19]

See Also​

References​

1. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A systematic review of outcomes after genital lymphedema surgery. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875

2. 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

3. Garaffa G, Christopher N, Ralph DJ. The management of genital lymphoedema. BJU Int. 2008;102(4):480–484. doi:10.1111/j.1464-410X.2008.07559.x

4. Schifano N, Castiglione F, Cakir OO, Montorsi F, Garaffa G. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res. 2022;34(4):359–368. doi:10.1038/s41443-021-00468-x

5. McDougal WS. Lymphedema of the external genitalia. J Urol. 2003;170(3):711–716. doi:10.1097/01.ju.0000067625.45000.9e

6. Wisenbaugh E, Moskowitz D, Gelman J. Reconstruction of massive localized lymphedema of the scrotum. Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063

7. Machol JA 4th, Langenstroer P, Sanger JR. Surgical reduction of scrotal MLL in obesity. J Plast Reconstr Aesthet Surg. 2014;67(12):1719–1725. doi:10.1016/j.bjps.2014.07.031

8. Hamad J, McCormick BJ, Sayed CJ, et al. Multidisciplinary update on genital hidradenitis suppurativa. JAMA Surg. 2020;155(10):970–977. doi:10.1001/jamasurg.2020.2611

9. Vignes S. Genital lymphedema after cancer treatment. Cancers (Basel). 2022;14(23):5809. doi:10.3390/cancers14235809

10. Schook CC, Kulungowski AM, Greene AK, Fishman SJ. Male genital lymphedema. J Pediatr Surg. 2014;49(11):1647–1651. doi:10.1016/j.jpedsurg.2014.05.031

11. Singh V, Sinha RJ, Sankhwar SN, Kumar V. Reconstructive surgery for penoscrotal filarial lymphedema. Urology. 2011;77(5):1228–1231. doi:10.1016/j.urology.2010.10.026

12. 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

13. Ogunbiyi SO, Modarai B, Smith A, Burnand KG. Quality of life after surgical reduction for severe primary lymphoedema of the limbs and genitalia. Br J Surg. 2009;96(11):1274–1279. doi:10.1002/bjs.6716

14. Salako AA, Olabanji JK, Oladele AO, et al. Surgical reconstruction of giant penoscrotal lymphedema in sub-Saharan Africa. Urology. 2018;112:181–185. doi:10.1016/j.urology.2016.09.064

15. Ross JH, Kay R, Yetman RJ, Angermeier K. Primary lymphedema of the genitalia in children and adolescents. J Urol. 1998;160(4):1485–1489.

16. Halperin TJ, Slavin SA, Olumi AF, Borud LJ. Surgical management of scrotal lymphedema using local flaps. Ann Plast Surg. 2007;59(1):67–72. doi:10.1097/01.sap.0000258448.17867.20

17. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema — what to do? J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586

18. 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

19. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis (3R SCIP-LFT). J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011