Skin graft reconstruction of chronic genital lymphedema

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Skin graft reconstruction of chronic genital lymphedema
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  ADULT UROLOGY ELSEVIER SKIN GRAFT RECONSTRUCTION OF CHRONIC GENITAL LYMPHEDEMA ALLEN F. MOREY, MAXWELL V. MENG, AND JACK W. McANINCH ABSTRACT Objectives. We present a simple, reliable method of scrotal and penile reconstruction yielding satisfactory cosmetic and functional results for patients with disabling chronic genital lymphedema. Methods. Nine patients were treated with wide excision of the affected genital skin and subsequent coverage of exposed areas with split-thickness skin grafts in a single-stage procedure. Results. All patients have had excellent cosmetic results without recurrence of genital lymphedema or com- promise of sexual function postoperatively. Conclusions. Single-stage reconstruction for idiopathic genital lymphedema by radical skin excision and split-thickness skin grafting provides gratifying functional and cosmetic results. UROLOGY 50: 423- 426, 1997. 0 1997, Elsevier Science Inc. All rights reserved. L mphedema arises from the abnormal reten- tion of lymphatic fluid in subcutaneous tissues as a result of lymphatic obstruction. Aberrant lym- phatic drainage may be idiopathic or secondary to parasitic infection, radiation, malignancy, or sur- gery. Regardless of cause, chronic lymphedema can be extremely debilitating and difficult to manage. Lymphedema of the male genitalia presents a particularly difficult management problem. Lym- phangioplasty, the establishment of new lym- phatic drainage patterns, is technically difficult and unreliable, and therefore is not often per- formed. l-4 A more common approach involves ex- cision of involved tissue lymphangiectomy), fol- lowed by reconstruction. Many surgeons use local tissue flaps in recon- struction of the scrotum.5-‘1 Dandapat et a1.,5 in a series of 350 patients, created a neoscrotum from craniodorsal scrotal flaps. Other surgeons have successfully used fasciocutaneous thigh flaps or thigh pouches to cover the testes.12’13 We have had excellent results with skin graft reconstruction of From the Department of Urology, University of Calijornia School of Medicine, San Francisco, and Urology Service, San Francisco General Hospital, San Francisco, California Reprint requests: Jack W. MC&inch, M.D., Department of Urology, U-575, University of Calijornia, San Francisco, CA 94143-0738 Submitted: February 13, 1997, accepted (with revisions): April 4, 1997 0 1997, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED chronic genital lymphedema and report our tech- nique. MATERIAL AND METHODS EVALUATION Between 1983 and 1997,9 patients with chronic lymphed- ema of the penis and scrotum were evaluated. Physical ex- amination revealed isolated genital disfigurement owing to extensive skin thickening. The testes were normal to palpa- tion, and the lower extremities were not involved with edema. One patient had previously undergone pelvic radiotherapy for localized prostate adenocarcinoma, but the others had no prior history of pelvic surgery, trauma, or malignancy. In all patients, the genital lymphedema was progressive and led to significant functional impairment. Conservative management with elevation and antibiotics was ineffective. In all patients, the abdomen, perineum, groin, and lower extremities were carefully examined; none had dermatologic manifestations of associated atopic or inflammatory conditions. Preoperative studies were negative for an infectious cause, including fila- riasis, syphilis, and tuberculosis. In some cases, abdominal and pelvic computed tomography (CT) was performed, re- vealing only genital edema. SURGICAL TECHNIQUE Surgery is performed with the patient in a low lithotomy position. A Foley catheter is placed intraoperatively. The gen- italia and both thighs are shaved and prepared (Fig. 1). Broad- spectrum antibiotic agents are administered preoperatively. A circumscribing incision is made around the scrotum, in- cluding the base of the penis, at a point where the skin appears grossly normal. The skin and subcuticular tissue are then ex- cised (Fig. 2), including the dartos fascia. Preserved are the external spermatic fascia, overlying the tunica vaginalis and testes, and the tunica dartos, supported by Buck’s fascia on the penile shaft. 0090-4295/97/ 17.00 PII SOO90-4295(97)00259-8 423  FIGURE 1. Preoperative view of massive genital lym- phedema. The penis has the tortuous “ram’s horn” ap- pearance typical in such patients. FIGURE 3. The spermatic cords are sewn together with interrupted 4-O chromic catgut sutures. FIG ;URE 2. The skin and subcutaneous tissue overlyir the ) penis and testes are first completely excised. Kl The spermatic cord structures are first identified high in the scrotum, isolated, and carefully preserved. Once freed from the cords and testes, the edematous scrotum is removed in its entirety. Dissection on the penis extends distally to the coronal sulcus. All subcutaneous tissue is separated and ex- cised down to Bucks fascia. Meticulous hemostasis is achieved with the electrocautery device. In harvesting the skin grafts, mineral oil is applied to the anterolateral thighs bilaterally and the Paget dermatome is used to procure a 0.015inch split-thickness graft. The donor sites are then covered with Biobrane. Before grafting is per- formed, the testes and spermatic cords are sutured together to prevent a bifid neoscrotum and then tacked to the peri- neum with interrupted 4-O chromic suture to provide addi- tional stability (Fig. 3). Scrotal grafts are meshed 1.5:l.O and secured with multiple interrupted 4-O chromic sutures to en- sure direct apposition to the spermatic cords and testes. The penis is covered with an unmeshed split-thickness skin graft 0.015 inch thick secured at the base and ventral raphe with interrupted 4-O chromic sutures (Fig. 4). Silk sutures of the same size are used along the coronal sulcus to tie over bol- sters. The grafts are covered with Xeroform gauze and a sec- ond layer of mineral oil-soaked cotton. Fluffs and bolsters secure the grafts to the penis and testes. A penile splint en- sures immobilization. POSTOPERATIVE CARE Postoperatively, the patient is maintained on bedrest for 5 days and antibiotic agents are continued for 7 days. The dress- ings are removed 5 days after surgery, after which the patient begins whirlpool therapy and the catheter is removed. Most 424 UROLOGY 50 (3), 1997  B FIGURE 4. A) The penis is completely covered with an unmeshed split-thickness skin graft, usually 0.015 inch thick. The graft is applied circumferential/y and sewn to itself in the ventral midline, thus creating a pseudoraphe. The graft is sewn distally directly to the coronal sulcus. B) The scrotum is covered with Q meshed graft of similar thickness. The folded graft is sewn to itself along the lateral borders, and several interrupted 4-O chromic sutures are placed randomly throughout the graft to ensure direct apposition to the underlying supporting tissues. patients are discharged as soon as the grafts are stabilized at about 7 days postoperatively. RESULTS All patients had excellent graft viability and re- quired no further surgery Fig. 5). Cosmesis was good, and sexual function was not compromised. In follow-up for 2 years, no patient had recurrence of genital lymphedema. COMMENT Genital lymphedema is a difficult problem for both patient and surgeon. Although we perform a thorough serologic and radiographic preoperative evaluation to exclude reversible causes, we find many cases to be idiopathic. Little information re- garding treatment is available in the world litera- ture, and medical management has generally proved ineffective. Several important factors must be emphasized regarding surgical reconstruction of genital lym- phedema. First, it is vital that all involved tissue be excised to prevent recurrence. The lymphatics UROLOGY 50 (3), 1997 lie in the dermis layer of the skin and in the un- derlying dartos fascia, and a surgical plane is easily created beneath this engorged tissue. Although some surgeons have reported good results with posterior scrotal flaps, the possibility of recurrence remains a concern when local genital tissue is used. Split-thickness skin grafts minimize the chance of recurrent lymphedema because they contain lit- tle reticular dermis, and native lymphatic channels are therefore negligible.14 They have also proved effective for lower limb lymphedema.15 In per- forming more than 50 skin grafts among patients with posttraumatic or postinfectious genital skin loss at San Francisco General Hospital, we have found split-thickness grafts to be easily harvested and highly successfu1.16’17 In our experience, unmeshed skin grafts to the penis have yielded the best functional and cos- metic results. Contraction is minimal with thick split-thickness grafts 0.014 to 0.016 inch) and, in contrast to full-thickness grafts, they are hairless and highly reliable. Most patients are able to have erections sufficient for intercourse postopera- 425  FIGURE 5. One week after skin graft reconstruction of massive chronic genital lymphedema. tively, and erections are encouraged after hospital discharge because they act as a natural tissue ex- pander. We prefer meshed scrotal grafts because they are more pliable and more closely resemble natural scrotal rugae. Maximal graft contraction can be ex- pected at about 3 months. Subsequently, the de- pendent position of the testes encourages gradual graft expansion, which results in a loose, natural, pendulous neoscrotum. CONCLUSIONS Most cases of severe chronic genital lymphed- ema we have treated are idiopathic. We advocate excision of affected skin and subcutaneous tissue and single-stage genital reconstruction with split- thickness skin grafts. Our graft technique is based on our experience in reconstruction for genital skin loss after necrotizing infection, burns, and trauma. With this simple and reliable method, we have achieved substantial cosmetic and functional improvement in these patients. REFERENCES 1. Gillies MH, and Fraser FR: Treatment of lymphedema by plastic operation. Br Med J 96: 96, 1935. 2. Goldsmith HS, and De Los Santos R: Omental trans- position in primary lymphedema. Surg Gynecol Obstet 125: 607-610, 1967. 3. McDonald DF, and Huggins C: Surgical treatment of elephantiasis. J Urol 63: 187, 1950. 4. Nielubowicz J, Olsewski W, and Sokolowski J: Surgical lymphovenous shunts. J Cardiovasc Surg 9: 262, 1968. 5. Dandapat MC, Mohapatro SK, and Patro SK: Elephan- tiasis of the penis and scrotum. A review of 350 cases. Am J Surg 149: 686-690, 1985. 6. McKay HA, Meehan WL, Jackson AC, and LeBlanc GA: Surgical treatment of male genital lymphedema. Urology 9: 284-287, 1977. 7. Holman CM Jr, Arnold PG, Jurkiewicz MJ, and Walton KN: Reconstruction of male external genitalia with elephan- tiasis. Urology 10: 576-578, 1977. 8. Feins NR: A new surgical technique for lymphedema of the penis and scrotum. J Pediatr Surg 15: 787-789, 1980. 9. Yormuk E, Sevin K, Emiroglu M, and Tiirker M: A new surgical approach in genital lymphedema. Plast Reconstr Surg 86: 1194-1197,199o. 10. Apesos J, and Anigian G: Reconstruction of penile and scrotal lymphedema. Ann Plast Surg 27: 570-573, 1991. 11. Steinberg J, Kin ED, and McVary KT: A surgical ap- proach to penoscrotal lymphedema. J Urol 156: 1770, 1996. 12. McDougal WS: Scrotal reconstruction using thigh ped- icle flaps. J Urol 129: 757-759, 1983. 13. McAninch JW: Management of genital skin loss. Urol Clin North Am 16: 387-397, 1989. 14. Malloy TR, Wein AJ, and Gross P: Scrotal and penile lymphedema: surgical considerations and management. J Urol 130: 263-265, 1983. 15. Wolfe JH: The management of lymphedema, in Ruth- erford RB (Ed): Vascular Surgery. Philadelphia, WB Saunders, 1995. 16. Armenakas NA, and McAninch JW: Genital recon- struction after major skin loss, in McAninch JW (Ed): Trau- matic and Reconstructive Urology. Philadelphia, WB Saunders, 1996, p 699. 17. Gomez RG: Genital skin loss. Probl Urol8: 290, 1994. 426 UROLOGY 50 (31, 1997
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