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Reconstructive surgery of the scrotum: a systematic review

International Journal of Impotence Research volume 34, pages 359–368 (2022)Cite this article

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Abstract

The term scrotoplasty embraces several techniques which aim to restore a normal scrotal appearance and function. We provide here a quick reference tool to allow the urologist to select the appropriate surgical strategy among the several available options. A comprehensive research was carried out on MEDLINE/PubMed to identify relevant studies concerning this topic, including a range of key words, e.g., scrotoplasty, ventral phalloplasty, scrotal reconstruction, scrotomegaly, penoscrotal web, scrotal lifting, scrotal reduction, scrotectomy, scrotal lymphoedema. Scrotal skin defects may be related with Fournier’s gangrene, traumatic events, and surgery for genital cancers or peno-scrotal lymphoedema. The reconstructive management of these conditions is relatively reproducible in the hands of experienced urologists, if aware of the basics of scrotal surgery. Primary tension-free wound closure and local pedicled flaps typically allow optimal surgical outcomes for repairing most of these scrotal defects, with split-thickness skin grafts (STSGs) and/or distant flaps being required only when dealing with extensive skin losses. The demand for genitals’ aesthetic surgery among adults is on the increase recently. Although the scientific evidence regarding this topic is scarce, reduction scrotoplasty and peno-scrotal webbing correction techniques are easy, safe and effective solutions to improve genital cosmesis, being carried out in isolation or in combination with penile prosthesis implantation. More robust scientific evidence is needed to achieve a uniformed consensus regarding the optimal surgical management in this broad field, and surgical innovation should continue to refine current reconstructive techniques.

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Fig. 1
Fig. 2: Postoperative appearance in a case of Fournier’s gangrene with genito-perineal involvement, one month after surgical debridement.
Fig. 3: Various degrees of genital lymphedema.
Fig. 4: Buried penis due to penile lymphedema secondary to penile cancer treatment.
Fig. 5: Meshed split thickness skin graft being used to reconstruct the scrotum.
Fig. 6: Superomedial fasciocutaneous thigh flap.
Fig. 7: Ventral phalloplasty.

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References

  1. Lucas JW, Lester KM, Chen A, Simhan J. Scrotal reconstruction and testicular prosthetics. Transl Androl Urol. 2017;6:710–21.

    Article  Google Scholar 

  2. Garaffa G, Christopher N, Ralph DJ. The management of genital lymphoedema. BJU Int. 2008;102:480–4.

    Article  Google Scholar 

  3. Por Y-C, Tan B-K, Hong S-W, Chia S-J, Cheng CWS, Foo C-L, et al. Use of the scrotal remnant as a tissue-expanding musculocutaneous flap for scrotal reconstruction in Paget’s disease. Ann Plast Surg. 2003;51:155–60.

    Article  Google Scholar 

  4. Bryk DJ, Yamaguchi Y, Zhao LC. Tissue transfer techniques in reconstructive urology. Korean J Urol. 2015;56:478–86.

    Article  Google Scholar 

  5. Wang D, Zheng H, Deng F. Spermatogenesis after scrotal reconstruction. Br J Plast Surg 2003;56:484–8.

    Article  Google Scholar 

  6. Schifano N, Cakir OO, Castiglione F, Montorsi F, Garaffa G. Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review. Int J Impot Res. 2021. https://doi.org/10.1038/s41443-021-00444-5. Epub ahead of print.

  7. Thomas C, Navia A. Aesthetic Scrotoplasty: Systematic Review and a Proposed Treatment Algorithm for the Management of Bothersome Scrotum in Adults. Aesthetic Plast Surg. 2021;45:769–76. https://doi.org/10.1007/s00266-020-01998-3.

    Article  PubMed  Google Scholar 

  8. Montasser E, Amin EM. Webbed penis: a new classification. J Indian Assoc Pediatr Surg. 2010;15:50–2.

    Article  Google Scholar 

  9. Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, et al. Methodological quality of case series studies: An introduction to the JBI critical appraisal tool. JBI Evid Synth. 2020;18:2127–33. https://doi.org/10.11124/JBISRIR-D-19-00099.

    Article  PubMed  Google Scholar 

  10. Akilov O, Pompeo A, Sehrt D, Bowlin P, Molina WR, Kim FJ. Early scrotal approximation after hemiscrotectomy in patients with Fournier’s gangrene prevents scrotal reconstruction with skin graft. Can Urol Assoc J = J l’Association des Urol du Can. 2013;7:E481–5.

    Article  Google Scholar 

  11. Voelzke BB, Hagedorn JC. Presentation and diagnosis of fournier Gangrene. Urology. 2018;114:8–13. Apr.

    Article  Google Scholar 

  12. Sorensen MD, Krieger JN, Rivara FP, Broghammer JA, Klein MB, Mack CD, et al. Fournier’s Gangrene: population based epidemiology and outcomes. J Urol [Internet]. 2009;181:2120–6. Available from https://doi.org/10.1016/j.juro.2009.01.034.

    Article  Google Scholar 

  13. NE Fournier’s gangrene: a review of 1726 cases. Br J Surg [Internet]. 2000 [cited 2021 Jul 7];87:718–28. Available from: https://pubmed.ncbi.nlm.nih.gov/10848848/

  14. Tan B-K, Rasheed MZ, Wu WTL. Scrotal reconstruction by testicular apposition and wrap-around skin grafting. J Plast Reconstr Aesthet Surg. 2011;64:944–8.

    Article  Google Scholar 

  15. Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstr Aesthetic Surg [Internet]. 2011;64:528–34. https://doi.org/10.1016/j.bjps.2010.07.018.

    Article  Google Scholar 

  16. Atik B, Tan O, Ceylan K, Etlik O, Demir C. Reconstruction of wide scrotal defect using superthin groin flap. Urology. 2006;68:419–22.

    Article  Google Scholar 

  17. McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am. 2013;40:323–34.

    Article  Google Scholar 

  18. Michielsen DPJ, Lafaire C. Management of genital burns: a review. Int J Urol J Jpn Urol Assoc. 2010;17:755–8.

    Google Scholar 

  19. Machol JA, Langenstroer P, Sanger JR. Surgical reduction of scrotal massive localized lymphedema (MLL) in obesity. J Plast Reconstr Aesthetic Surg [Internet]. 2014;67:1719–25. https://doi.org/10.1016/j.bjps.2014.07.031.

    Article  Google Scholar 

  20. AA O, DO B, DA G. Lymphoedema in urological cancer. Eur Urol [Internet]. 2004 [cited 2021 Jul 7];45:18–25. Available from: https://pubmed.ncbi.nlm.nih.gov/14667510/

  21. McDougal WS. Lymphedema of the external genitalia. J Urol. 2003;170:711–6.

    Article  Google Scholar 

  22. Modolin M, Mitre AI, Da Silva JCF, Cintra W, Quagliano AP, Arap S, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinics. 2006;61:289–94.

    Article  Google Scholar 

  23. Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY. Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis Publ Eur Soc Clin Microbiol. 2000;19:294–7.

    Article  CAS  Google Scholar 

  24. Alnajjar HM, Castiglione F, Ahmed K, Haider A, Nigam R, Muneer A. A novel ‘Batman’ scrotectomy technique for the management of scrotal lymphoedema following treatment for penile cancer. Transl Androl Urol. 2019;8:448–56. https://doi.org/10.21037/tau.2019.09.04.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Atta A, Saber El Basiouny M, Mostafa Abass S. Surgical treatment of scrotal lymphedema: modified surgical technique. Lymphology 2018;51:38–43.

    CAS  PubMed  Google Scholar 

  26. El-Mageed M. Evaluation of the anteromedial thigh fasciocutaneous flap for scrotal reconstruction. J Plast Reconstr Surg 2007;31:149–55.

    Google Scholar 

  27. Mopuri N, O’Connor EF, Iwuagwu FC. Scrotal reconstruction with modified pudendal thigh flaps. J Plast Reconstr Aesthet Surg 2016;69:278–83. Feb.

    Article  Google Scholar 

  28. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in perineoscrotal reconstruction. Plast Reconstructive Surg. 2002;109:610–6.

    Article  Google Scholar 

  29. Konofaos P, Hickerson WL. A technique for improving cosmesis after primary scrotum reconstruction with skin grafts. Ann Plast Surg. 2015;75:205–7.

    Article  CAS  Google Scholar 

  30. Maguiña P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier’s gangrene. Burns. 2003;29:857–62.

    Article  Google Scholar 

  31. Stokes TH, Follmar KE, Silverstein AD, Weizer AZ, Donatucci CF, Anderson EE, et al. Use of negative-pressure dressings and split-thickness skin grafts following penile shaft reduction and reduction scrotoplasty in the management of penoscrotal elephantiasis. Ann Plast Surg. 2006;56:649–53.

    Article  CAS  Google Scholar 

  32. Karian LS, Chung SY, Lee ES Reconstruction of Defects After Fournier Gangrene: A Systematic Review. Eplasty [Internet]. 2015;15:e18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26171090%0A; http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4447098.

  33. Parkash S, Gajendran V. Surgical reconstruction of the sequelae of penile and scrotal gangrene: a plea for simplicity. Br J Plast Surg. 1984;37:354–7.

    Article  CAS  Google Scholar 

  34. Kwon EO, Pareek G, Fracchia JA, Armenakas NA. Scrotal reconstruction using rapid intraoperative tissue expansion: a preliminary report. J Urol. 2008;179:207–9.

    Article  Google Scholar 

  35. Mello DF, Helene, Júnior A. Scrotal reconstruction with superomedial fasciocutaneous thigh flap. Rev Col Bras Cir. 2018;45:e1389.

    Article  Google Scholar 

  36. Khan Q, Knight RJW, Goodwin-Walters A. Scrotal reconstruction: a review and a proposed algorithm. Eur J Plast Surg. 2013;36:399–406.

    Article  Google Scholar 

  37. Karaçal N, Livaoglu M, Kutlu N, Arvas L. Scrotum reconstruction with neurovascular pedicled pudendal thigh flaps. Urology. 2007;70:170–2.

    Article  Google Scholar 

  38. Hsu H, Lin CM, Sun TB, Cheng LF, Chien SH. Unilateral gracilis myofasciocutaneous advancement flap for single stage reconstruction of scrotal and perineal defects. J Plast Reconstr Aesthetic Surg. 2007;60:1055–9.

    Article  Google Scholar 

  39. Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction. Ann Plast Surg 2011;67:526–30.

    Article  CAS  Google Scholar 

  40. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009;123:1710–8.

    Article  CAS  Google Scholar 

  41. Chen YB, Ding XF, Luo C, Yu SC, Yu YL, Chen BD, et al. A new plastic surgical technique for adult congenital webbed penis. J Zhejiang Univ Sci B. 2012;13:757–60. https://doi.org/10.1631/jzus.B1200117.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Herndon CDA, Casale AJ, Cain MP, Rink RC. Long-term outcome of the surgical treatment of concealed penis. J Urol. 2003;170:1695–7; discussion 1697.

    Article  Google Scholar 

  43. Maizels M, Meade P, Rosoklija I, Mitchell M, Liu D. Outcome of circumcision for newborns with penoscrotal web: oblique skin incision followed by penis shaft skin physical therapy shows success. J Pediatr Urol. 2019;15:404.e1–404.e8.

    Article  CAS  Google Scholar 

  44. Hakky TS, Wilson SK, Salem EA, Parker J, Carrion R, Mulcahy JJ, et al. Correction of congenital penoscrotal webbing in children: a retrospective review of three surgical techniques. J Sex Med [Internet] 2016;36:161.e1–161.e5. https://doi.org/10.1016/j.aju.2013.04.003.

    Article  Google Scholar 

  45. McLeod DJ, Alpert SA. Double-V scrotoplasty for repair of congenital penoscrotal webbing: a hidden scar technique. J Pediatr Urol. 2014;10:810–4.

    Article  Google Scholar 

  46. Negm MA, Nagla SA. Surgical management of post-circumcision webbed penis in children. Arab J Urol. 2020;18:101–5.

    Article  Google Scholar 

  47. Alter GJ. Correction of penoscrotal web. J Sex Med. 2007;4:844–7.

    Article  Google Scholar 

  48. Li Y, Zhu X, Feng D, Gong J, Sun G, Zhang X, et al. A modified scrotoplasty for treating severe penoscrotal webbing in children. Front Pediatr. 2020;8:551.

    Article  Google Scholar 

  49. Lorenzo AJ, Sowerby RJ, Kanaroglou N. Preliminary report on a new surgical technique for the management of bothersome scrotomegaly in selected adolescent males. J Pediatr Urol. 2015;11:295–8.

    Article  Google Scholar 

  50. Chierigo F, Capogrosso P, Dehò F, Pozzi E, Schifano N, Belladelli F, et al. Long-Term Follow-Up After Penile Prosthesis Implantation-Survival and Quality of Life Outcomes. J Sex Med. 2019;16:1827–33. https://doi.org/10.1016/j.jsxm.2019.08.001.

    Article  PubMed  Google Scholar 

  51. Miranda-Sousa A, Keating M, Moreira S, Baker M, Carrion R. Concomitant ventral phalloplasty during penile implant surgery: a novel procedure that optimizes patient satisfaction and their perception of phallic length after penile implant surgery. J Sex Med. 2007;4:1494–9.

    Article  Google Scholar 

  52. Gupta NK, Sulaver R, Welliver C, Kottwitz M, Frederick L, Dynda D, et al. Scrotoplasty at time of penile implant is at high risk for dehiscence in diabetics. J Sex Med. 2019;16:602–8.

    Article  Google Scholar 

  53. Caso J, Keating M, Miranda-Sousa A, Carrion R. Ventral phalloplasty. Asian J Androl. 2008;10:155–7. Jan.

    Article  Google Scholar 

  54. Garaffa G, Sansalone S, Ralph DJ. Augmentation procedures for the penis. In: Atlas of male genitourethral surgery. Chichester, West Sussex: John Wiley & Sons; 2013. p. 92–102. https://doi.org/10.1002/9781118651292.ch8.

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Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Università Vita-Salute San Raffaele, Milan, Italy

    Nicolò Schifano & Francesco Montorsi

  2. Division of Experimental Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy

    Nicolò Schifano & Francesco Montorsi

  3. Institute of Andrology, Department of Urology, University College London Hospitals NHS Trust, London, UK

    Fabio Castiglione & Onur Omer Cakir

  4. Division of Surgery and Interventional Science, UCL, London, UK

    Fabio Castiglione & Onur Omer Cakir

  5. Andrologia Internazionale, Rome, Italy

    Giulio Garaffa

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Contributions

Conception of the work: NS and GG; Data Collection: NS and OC; Data analysis and interpretation: NS, OC and FC; Drafting the article: NS and OC; Critical revision of the article: FC, FM and GG; Final approval of the version to be published: NS, OC, FC, FM and GG.

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Correspondence to Giulio Garaffa.

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Schifano, N., Castiglione, F., Cakir, O.O. et al. Reconstructive surgery of the scrotum: a systematic review. Int J Impot Res 34, 359–368 (2022). https://doi.org/10.1038/s41443-021-00468-x

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