11. Discuss the treatment of scrotal lymphedema.
Answer:
Worldwide, most cases of scrotal lymphedema result from inflammation as a sequela of filarial infection, usually in tropical regions where the filariasis is endemic. In the U.S., the cause is usually surgery, irradiation, and/or cancer. The mainstay of therapy is surgical with medical therapy such as diuretics and scrotal elevation of little value except for very mild cases. Any underlying medical or infectious cause for the lymphedema, however, should be treated prior to attempting surgical therapy.
Surgical therapy can be categorized as either bypassing (lymphangioplasty) or excisional (lymphangiectomy). While numerous lymphangioplasty procedures have been conceived using autogenous material (skin bridges, omental transposition), prosthetic conduits (nonabsorbable suture threads), and microsurgical techniques (lymphaticovenous shunts), none have found to be consistently satisfactory in long-term results. It is generally agreed that excisional therapy, which was first described by Delpech in 1820, still provides the most expeditious and reproducible results.
Numerous variations of lymphangiectomy exist but they all have in common the excision of superficial lymphatics, subcutaneous tissue, and skin at the level of Buck’s fascia on the penis with dissection of the spermatic cord and testicles from the edematous scrotal mass. Scrotal reconstruction and coverage varies. If there is not enough scrotal skin left then split-thickness skin grafts and/or fasciocutaneous thigh flaps may be necessary.