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The challenge of surgical treatment for giant scrotal lymphoedema - the role of local flaps
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e187ee188
CORRESPONDENCE AND COMMUNICATION
The challenge of surgical treatment for giant scrotal lymphoedema - the role of local flaps Lymphoedema of the scrotum, regardless of its aetiology, occurs when there is a reduction of lymphatic flow with subsequent enlargement of the scrotum. The clinical course of this condition is characterised by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse and voiding in the standing position. Besides the physical difficulties that occur due to the giant scrotal lymphoedema, this condition interferes with the daily activities and physiological necessities of the patient which causes him to have significant functional, cosmetic, and psychological problems. Thus, it is important for the patient to undergo surgery for this condition as early as possible,1,2,3 thus leading to an improvement in his quality of life. Our objective is to report the case of a man with a voluminous scrotal lymphoedema that was not associated with either inguinal hernia or hydrocele, conditions that were originally thought to be the aetiology of the case. In August 2006, a 65-year-old male man arrived at our first-aid room with a massive increase of scrotal volume. The patient reported that his scrotum had been increasing in size for approximately 5 years. He denied having diabetes mellitus, high blood pressure, cardiac pathology or tuberculosis. There was no history of sexual contact, surgery, neoplasm, irradiation or travel either. On examination, the patient was found to have a massively enlarged scrotum extending below his knees (Figure 1). The scrotal skin was grey, thickened and wrinkled. No inguinal adenopathy was found. There was no accompanying swelling of the lower extremities. Laboratory evaluation, including complete blood count, renal tests and bleeding rates, was within normal limits for surgery. The ultrasonography of abdomen was suggestive of bilateral inguinal hernia, bulkier on the right. Scrotal exploration was performed to verify the first hypothesis of inguinal hernia and hydrocele, both of which were not found during the surgery. Therefore, a decision
was taken to proceed with the re-section of the mass. The reconstruction of the wound was achieved with the mobilisation of adjacent scrotal tissue flaps. The excised scrotal tissue was obtained in two parts. The main part measured 26 21, 5 11 cm, and weighed 3546 g. The other one, with irregular fragments, measured 12.5 9 4.5 cm, with a weight of 291.94 g. The total weight of the re-sected scrotum was 3837 g. Histopathological examination of the scrotal tissue showed serious oedema, dilated lymphatic vessels, nonspecific chronic inflammation with areas of epidermal thickening and a spread-out dermal fibrosis, findings that are compatible with lymphoedema.
Figure 1 Preoperative photograph of the patient in case. Note the massive scrotal lymphedema extending below his knees.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.01.092
e188
Correspondence and communication Even though this surgical site was subject to contamination because of the neighbouring structures, no infection, dehiscence or necrosis was observed, probably due to technical care and proper local hygiene.1 The follow-up time was 1 year. The patient was pleased with the aesthetic result and having normal sexual intercourse; no recurrences were observed. The procedure certainly improved his quality of life (Figure 2).
References 1. Modolin M, Mitre AI, da Silva JCF, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinician 2006;61: 289e94. 2. Milanovic ´ R, Stanec S, Stanec Z, et al. Lymphedema of the penis and scrotum: surgical treatment and reconstruction. Acta Med Croatica 2007;61:211e3. 3. Dandapat MC, Mohapatro SK, Patro SK, et al. Elephantiasis of the penis and scrotum. A review of 350 cases. Am J Surg. 1985; 149:686e90.
Figure 2
Postoperative photograph of the patient in case
Marcus Vinicius Ponte de Souza Filho Raphael de Almeida Gira ˜o Manoel Eliezer Toma ´s Filho Department of Surgery, Hospital Geral Waldemar Alcaˆntara, Brazil. Rua Dr. Pergentino Maia, 1559, Messejana, Fortaleza- CE.-60480-040, Brazil E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
The challenge of surgical treatment for giant scrotal lymphoedema - the role of local flaps Lymphoedema of the scrotum, regardless of its aetiology, occurs when there is a reduction of lymphatic flow with subsequent enlargement of the scrotum. The clinical course of this condition is characterised by extreme discomfort for patients, with limitation of local hygiene, ambulation, sexual intercourse and voiding in the standing position. Besides the physical difficulties that occur due to the giant scrotal lymphoedema, this condition interferes with the daily activities and physiological necessities of the patient which causes him to have significant functional, cosmetic, and psychological problems. Thus, it is important for the patient to undergo surgery for this condition as early as possible,1,2,3 thus leading to an improvement in his quality of life. Our objective is to report the case of a man with a voluminous scrotal lymphoedema that was not associated with either inguinal hernia or hydrocele, conditions that were originally thought to be the aetiology of the case. In August 2006, a 65-year-old male man arrived at our first-aid room with a massive increase of scrotal volume. The patient reported that his scrotum had been increasing in size for approximately 5 years. He denied having diabetes mellitus, high blood pressure, cardiac pathology or tuberculosis. There was no history of sexual contact, surgery, neoplasm, irradiation or travel either. On examination, the patient was found to have a massively enlarged scrotum extending below his knees (Figure 1). The scrotal skin was grey, thickened and wrinkled. No inguinal adenopathy was found. There was no accompanying swelling of the lower extremities. Laboratory evaluation, including complete blood count, renal tests and bleeding rates, was within normal limits for surgery. The ultrasonography of abdomen was suggestive of bilateral inguinal hernia, bulkier on the right. Scrotal exploration was performed to verify the first hypothesis of inguinal hernia and hydrocele, both of which were not found during the surgery. Therefore, a decision
was taken to proceed with the re-section of the mass. The reconstruction of the wound was achieved with the mobilisation of adjacent scrotal tissue flaps. The excised scrotal tissue was obtained in two parts. The main part measured 26 21, 5 11 cm, and weighed 3546 g. The other one, with irregular fragments, measured 12.5 9 4.5 cm, with a weight of 291.94 g. The total weight of the re-sected scrotum was 3837 g. Histopathological examination of the scrotal tissue showed serious oedema, dilated lymphatic vessels, nonspecific chronic inflammation with areas of epidermal thickening and a spread-out dermal fibrosis, findings that are compatible with lymphoedema.
Figure 1 Preoperative photograph of the patient in case. Note the massive scrotal lymphedema extending below his knees.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.01.092
e188
Correspondence and communication Even though this surgical site was subject to contamination because of the neighbouring structures, no infection, dehiscence or necrosis was observed, probably due to technical care and proper local hygiene.1 The follow-up time was 1 year. The patient was pleased with the aesthetic result and having normal sexual intercourse; no recurrences were observed. The procedure certainly improved his quality of life (Figure 2).
References 1. Modolin M, Mitre AI, da Silva JCF, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinician 2006;61: 289e94. 2. Milanovic ´ R, Stanec S, Stanec Z, et al. Lymphedema of the penis and scrotum: surgical treatment and reconstruction. Acta Med Croatica 2007;61:211e3. 3. Dandapat MC, Mohapatro SK, Patro SK, et al. Elephantiasis of the penis and scrotum. A review of 350 cases. Am J Surg. 1985; 149:686e90.
Figure 2
Postoperative photograph of the patient in case
Marcus Vinicius Ponte de Souza Filho Raphael de Almeida Gira ˜o Manoel Eliezer Toma ´s Filho Department of Surgery, Hospital Geral Waldemar Alcaˆntara, Brazil. Rua Dr. Pergentino Maia, 1559, Messejana, Fortaleza- CE.-60480-040, Brazil E-mail address: [email protected]