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Debulking Scrotoplasty — Excision With Primary Closure

Debulking scrotoplasty removes disabling lymphedematous tissue and uses viable adjacent skin for tension-free scrotal coverage. It is appropriate when enough suitable tissue remains after adequate excision. Published evidence is mostly selected case series; it does not establish a universally lowest complication rate or a percentage-of-skin threshold for choosing primary closure.[1][2][3]

Terminology varies: some reports call a combined scrotal closure plus penile skin graft a modified Charles procedure. Describe the actual excision and coverage rather than assuming the operation name specifies which site was grafted.[4]

See Genital Lymphedema for diagnosis and Scrotal Reconstruction for coverage selection.

Selection and Preparation​

Consider surgery for persistent enlargement that impairs hygiene, walking, clothing, voiding or sexual activity, especially with bulky fibrotic tissue or troublesome skin changes despite appropriate conservative care. Etiology, clinical burden and tissue quality guide selection; BMI or a stage label alone does not select the operation.[5][6][7]

  • Map penile, scrotal, suprapubic and leg involvement, assess remaining healthy skin, and identify hydrocele or a buried penis requiring additional treatment. Evaluate new or rapidly changing swelling for another cause, including recurrent malignancy when relevant.[8]
  • Coordinate CDT, skin care and management of active infection. Preoperative decongestion may help tissue handling, but the 51-patient combined-care series does not prove every patient requires inpatient CDT or that it converts a graft requirement into primary closure.[2]
  • Discuss wound complications, repeat procedures, recurrent enlargement and possible penile grafting or alternative scrotal coverage. Plan positioning and perioperative care for body habitus and comorbidity.[6][9]
  • For suspected filariasis, assess active infection with appropriate expertise. Chronic elephantiasis alone is not an indication for repeated antifilarial courses, and antiparasitic treatment does not reliably reverse established late tissue damage.[10]

Operative Sequence​

  1. Expose and identify anatomy. Position to allow access to the scrotum, perineum and any planned donor site. Identify the urethra and penile shaft when concealed, and protect both testes, cords and vasa before removing bulky tissue. Catheter use depends on the planned reconstruction.[6][4]
  2. Design excision around disease and viable coverage. Mark abnormal tissue and usable adjacent skin. Remove the diseased skin/subcutaneous tissue that requires excision while preserving viable structures and suitable local tissue. A uniform instruction to strip every case to tunica vaginalis is inappropriate; planes depend on the distribution of disease.[5][4][11]
  3. Preserve vascular supply and support. Protect the pedicles of retained skin and minimize unnecessary undermining. Routine division of the scrotal septum or gubernaculum and superior relocation of the testes are not prerequisites for closure. Lu's reconstruction retained the septum and viable tissue; the septum also contains arterial connections. Any mobilization or fixation should address an actual reconstructive need while avoiding cord tension or torsion.[11][12]
  4. Address a documented hydrocele when indicated. Hydrocelectomy was performed in 22/51 men in Torio-Padron's series. This proportion is not a reason to perform routine tunica-vaginalis eversion in every patient.[2]
  5. Advance suitable adjacent skin. Create a comfortable, tension-free enclosure with careful hemostasis and dead-space management. Lateral/posterior tissue may be useful when healthy; neither its location nor its appearance guarantees normal lymphatic function. Drains are selected for the operation and output, and do not guarantee prevention of hematoma or seroma.[9][4][11]
  6. Treat penile involvement separately. Preserve suitable penile skin where feasible. When excision leaves an uncovered shaft, use the appropriate graft or flap. Scrotal primary closure can coexist with penile STSG; the two sites should not be combined into a single grafting endpoint.[13][14][4]
  7. Reassess before closure. Confirm skin perfusion, untwisted cords, adequate coverage and freedom from constriction. If primary closure compromises these goals, select graft or flap coverage for the actual wound. More than 50% skin involvement is not an automatic graft mandate, and healthy dartos is not intrinsically an unsuitable graft bed.[3][12][15]

Orchiectomy is usually avoidable when the testis and its blood supply are viable. Wisenbaugh's 11 patients, including very large resections, required none; that experience is not a prohibition against orchiectomy when independently indicated.[6]

Interpreting the Outcome Literature​

Guiotto's review included 151 patients across 20 studies. Its 10% complication estimate combines primary closure and skin grafting; it is not a primary-closure-only rate. The flap and LVA groups differed in disease severity and selection, so their unadjusted percentages cannot rank the operations for the same patient.[1]

ReportRelevant findingImportant limit
Torio-Padron: 51 menCombined perioperative CDP/excision; adjacent-skin closure in all; three revisions (two hematomas, one dehiscence).Mixed penile/scrotal distributions; no comparator isolating CDP or closure.
Garaffa: 90 assessed, 34 operatedFifteen had scrotal excision with primary closure; seven required penile shaft grafts.The whole cohort was not a primary-closure series.
Wisenbaugh: 11 with scrotal MLLTen primary closures and one graft; mean follow-up 26 months; wound problems common; reported overall QoL improved from 1.3 to 7.7/10.Small retrospective cohort; questionnaire improvement is not an objective sexual-function or fertility endpoint.
Machol: four with obesity-associated MLLTwo recurrences; mean two operations per patient for complications or recurrence.Does not establish a 50% recurrence rate for all patients with obesity or prove a specific weight intervention prevents it.
Schook: 25 childrenEleven underwent contouring; six had postoperative follow-up, with sustained improvement at median 4.2 years.Follow-up outcome applies to those six, not all 25 children.

Sources: Torio-Padron,[2] Garaffa,[13] Wisenbaugh,[6] Machol,[9] and Schook.[16]

Singh's 48-patient filarial series reported improved standing voiding, ambulation and resumed sexual activity, with 12 local groin infections. The often-copied recurrence in a man previously treated with lymphadenectomy/radiotherapy for penile cancer belongs to Modolin's separate 17-patient series, not Singh's cohort. Modolin reported subjective outcomes and repeat operations in that patient; it did not use a validated sexual-function instrument.[14][4]

Follow-Up and Limits​

Monitor wound healing, collections, infection, dehiscence, recurrent swelling and any grafted area. Reassess urinary exposure, mobility, pain and the patient's own goals. Coordinate ongoing skin care and tolerated compression/support; excision does not ensure permanent resolution of the underlying lymphatic disorder.[8][7]

In obesity-associated MLL, offer continuing weight-management support: mass removal alone did not produce sustained weight loss in Wisenbaugh's series. For children, balance symptoms, growth, recurrence and the possible contraction of grafted skin; a five-child historical report is not a universal ordering rule for every reconstructive option.[6][17]

Adding LVA, VLNT or a lymphatic flap may be considered in specialist practice, but small uncontrolled reports of no recurrence do not prove superiority or cure. Ehrl's nine treated patients included five with additional VLNT and no recurrence across the entire cohort; those data cannot isolate the transfer's effect.[18][19][20] Native skin can provide useful contour and sensation, but comparative fertility and thermoregulation outcomes remain poorly established. Discuss those limits without promising preservation of fertility or claiming that all alternatives are inferior.[3][15]

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. 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

4. 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

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. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2023 consensus document. Lymphology. 2023;56:133–151. Full consensus.

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

9. 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

10. Centers for Disease Control and Prevention. Clinical treatment of lymphatic filariasis. June 13, 2024. Clinical guidance.

11. Lu Q, Jiang Z, Zhao Z, et al. Assessment of the lymphatic system of the genitalia using magnetic resonance lymphography before and after treatment of male genital lymphedema. Medicine. 2016;95:e3755. doi:10.1097/MD.0000000000003755.

12. Carrera A, Gil-Vernet A, Forcada P, et al. Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps. BJU Int. 2009;103:820–824. doi:10.1111/j.1464-410X.2008.08167.x.

13. 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

14. 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

15. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.

16. 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

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

18. 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

19. 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

20. 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