Plastic & Reconstructive Surgery:
Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan (Otsuki, Yamada, Hasegawa, Kimata)
Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas (Suami)
Correspondence to Dr. Otsuki, Department of Plastic and Reconstructive Surgery, Okayama University, 2-5-1 Shikata, Okayama City, Okayama 700-8558, Japan firstname.lastname@example.org
Male genital lymphedema is a debilitating disease, and the patients suffer from not only physical discomfort but also psychological distress. There is currently no standard algorithm for the treatment of male genital lymphedema. Conservative treatments have been less common for scrotal lymphedema than for extremity lymphedema because a compression garment is difficult to apply. Surgical treatments for male genital lymphedema can be classified into two categories: ablative operations, which excise excess skin and soft tissue; and physiologic operations, which create new channels to increase the transport capacity of lymphatic fluid.
Various ablative techniques have been reported in accordance with the extent of skin resection (Fig. 1). Strategies are divided according to two concepts: resection of the entire affected scrotal skin or minimization of the skin resection area for primary closure. Various methods have also been reported for resurfacing the excised raw surface. Skin grafting may have the advantages of reducing the recurrence of lymphedema and cellulitis. However, it changes the thermal regulation of the testes, which is apt to interfere with testicular function. To address this issue, local flaps were harvested from a normal thigh flap or a remnant of scrotal skin.
The rationale for physiologic operations is to improve lymph stasis by redirecting the retained lymph fluid to the venous system at the peripheral region. Application of the lymphovenous shunt procedure for the treatment of male genital lymphedema was first reported by Huang et al., who chose to perform anastomosis of the superficial lymphatic vessels to small veins in the subcutaneous tissue.1 Mukenge et al. chose deep lymphatic vessels along the spermatic cord and anastomosed them to the pampiniform venous plexus, which also runs beside the spermatic cord.2
Anatomical lymphatic mapping of the male genital region is described in detail by Sappey3 and Mascagni4 (Fig. 2). Two different lymphatic pathways, the superficial and deep lymphatic routes, contribute to lymphatic drainage in the male genital region. According to these anatomical findings, there are two options for creating a lymphovenous shunt: using the superficial lymphatic pathway or the deep lymphatic pathway.
We performed both methods in three patients at different time points. In our experience, the diameters of the superficial lymphatic vessels were smaller (0.2 to 0.5 mm) compared with those of the deep lymphatic vessels (0.5 to 1 mm); therefore, creating a lymphovenous shunt was technically more reliable using the deep lymphatic vessel. Another advantage of selecting the deep lymphatic vessels is that these vessels could be identified constantly beside the pampiniform veins.
After the obstruction of lymphatic vessels, the structure of the lymphatic vessel is altered. These changes are more significant in the proximal region near the obstruction site than in the distal region.5 There is a possibility that lymphovenous bypass using the superficial lymphatic vessels may not improve symptoms because they degenerate in male genital lymphedema. Our preliminary experiences suggest that creating lymphovenous bypasses using the deep lymphatic vessel may be a more effective treatment for male genital lymphedema than selecting the superficial lymphatic vessels.
Yuki Otsuki, M.D.
Kiyoshi Yamada, M.D.
Kenjiro Hasegawa, M.D., Ph.D.
Yoshihiro Kimata, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan
Hiroo Suami, M.D., Ph.D.
Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas
The authors have no financial or professional relationships that might pose a competing interest.
The authors thank the Blocker History of Medicine Collections of the University of Texas Medical Branch for giving them an opportunity to see their valuable historical collections.
1. Huang GK, Hu RQ, Liu ZZ, Pan GP. Microlymphaticovenous anastomosis for treating scrotal elephantiasis. Microsurgery 1985;6:36–39.
2. Mukenge SM, Pulitanò C, Colombo R, Negrini D, Ferla G. Secondary scrotal lymphedema: A novel microsurgical approach. Microsurgery 2007;27:655–656.
3. Sappey MPC. Anatomie, Physiologie, Pathologie des vaisseaux lymphatiques. Paris: Adrien Delahaye; 1874.
4. Mascagni P. Vasorum Lymphaticorum Corporis Humani Historia et Ichnographia. Sienne: P. Carli; 1787.
5. Suami H, Pan WR, Taylor GI. Changes in the lymph structure of the upper limb after axillary dissection: Radiographic and anatomical study in a human cadaver. Plast Reconstr Surg. 2007;120:982–991.
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