Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection

Superficial circumflex iliac artery perforator propeller flap for penoscrotal extramammary Paget's disease

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare intra-epidermal adenocarcinoma, and reconstruction of the penoscrotal region remains a clinical challenge. The superficial circumflex iliac artery perforator (SCIP) flap has been successfully used as a free flap, while its application as a propeller flap in the reconstruction of penoscrotal EMPD defect is rarely reported. The objective was to evaluate the safety and efficacy of the SCIP propeller flap in the reconstruction of penoscrotal defects in EMPD.

METHODS

Between September 2010 and August 2022, consecutive patients diagnosed with penoscrotal EMPD were enrolled. All patients underwent penoscrotal EMPD excision and reconstruction with SCIP propeller flap combined with other flaps or skin grafts on individual defects. Demographic information, surgical parameters, postoperative complications, patient satisfaction, and recurrence rates were analyzed.

RESULTS

Twenty-four patients (mean age, 73 ± 8.8 years; mean BMI, 23.98 ± 3.62 kg/m2) with 33 SCIP propeller flaps (mean size 120.1 cm2; range, 24-208 cm2) were included, and the mean defect size was 67.4 cm2 (range, 12-255 cm2). The mean operative duration was 385.4 ± 146.8 min. Fifteen patients received autologous full-thickness skin grafts, and four received other flaps simultaneously. All flaps survived without total or partial loss, and all donor sites achieved primary closure, though local hematoma (one case) and limited skin graft necrosis (two cases) were observed. All patients experienced complete wound healing and maintained penoscrotal morphology and function without recurrent lesions over a mean follow-up of 59 months.

CONCLUSIONS

The SCIP propeller flap seems a safe and effective reconstructive method for penoscrotal EMPD.

LEVEL OF EVIDENCE

IV.

Posttraumatic Scrotal Reconstruction with a Pedicled "Extended" Superficial Circumflex Iliac Artery Perforator Flap: A Case Report

The superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has been used for scrotal reconstruction after Fournier's gangrene, skin cancer, or infections. However, there are few publications with regard to penoscrotal reconstruction after a traumatic injury with this flap. In this article, we propose a new SCIP flap variation, the "extended" or "direct" SCIP flap, to effectively reconstruct a wide scrotal defect after a traumatic injury. The "extended" SCIP flap is designed medial and cranial to the anterosuperior iliac spine (ASIS) using the superficial branch of the SCIA as the main pedicle.

Penoscrotal elephantiasis: A severe form of genital lymphedema

Penoscrotal lymphedema is a manifestation of disrupted lymphatic drainage, causing a significant increase in scrotal volume. impacting both aesthetics and quality of life. Elephantiasis, classified as stage III by the International Society of Lymphology, represents the advanced stage of scrotal lymphedema, often linked to parasitic diseases. The diagnosis is clinical, and the treatment involves mass excision. The lymphatic reconstruction is an innovative therapeutic approach that improves postoperative results and better quality of life. In this case report, we present the case of massive genital elephantiasis managed surgically, and we will focus on surgical techniques and reconstructive approaches.

Genital elephantiasis: Surgical treatment and reconstruction

Genital elephantiasis is a severe form of lymphedema of the groin. It is characterized by progressive enlargement and distortion of the genitals, presenting significant physical, psychological, and social challenges to the affected individuals. Although pharmacological treatment of filariasis is well-established in the medical field, the surgical management of genital elephantiasis can be varied and confusing. This review article provides an in-depth analysis of the etiology, classification, severity grading, and various effective surgical treatment and reconstructive modalities commonly employed by surgeons since the early twentieth century. We also discuss how a combination approach of ablation, soft tissue coverage, and lymphatic reconstruction is viable for treating genital elephantiasis. By examining the literature, we hope to provide insights into how surgery plays a role in the holistic management of genital elephantiasis.

A Comprehensive Approach to Posttraumatic Lymphedema Surgical Treatment

Background  Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema. Methods  A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year. Results  Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected. Conclusion  Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.

Pharmacoinformatics-based screening of active compounds from Vitex negundo against lymphatic filariasis by targeting asparaginyl-tRNA synthetase

CONTEXT

Lymphatic filariasis, generally called as elephantiasis, is a vector-borne infectious disease caused by the filarial nematodes, mainly Wuchereria bancrofti, Brugia malayi, and Brugia timori, which are transmitted through mosquitoes. The infection affects the normal flow of lymph leading to abnormal enlargement of body parts, severe pain, permanent disability, and social stigma. Due to the development of resistance as well as toxic effects, existing medicines for lymphatic filariasis are becoming ineffective in killing the adult worms. It is essential to search novel filaricidal drugs with new molecular targets. Asparaginyl-tRNA synthetase (PDB ID: 2XGT) belongs to the group of aminoacyl-tRNA synthetases that catalyze specific attachment of amino acids to their tRNA during protein biosynthesis. Plants and their extracts are well-known medicinal practice for the management of several parasitic infectious diseases including filarial infections.

METHODS

In this study, asparaginyl-tRNA synthetase of Brugia malayi was used as a target to perform virtual screening of plant phytoconstituents of Vitex negundo from IMPPAT database, which exhibits anti-filarial and anti-helminthic properties. A total of sixty-eight compounds from Vitex negundo were docked against asparaginyl-tRNA synthetase using Autodock module of PyRx tool. Among the 68 compounds screened, 3 compounds, negundoside, myricetin, and nishindaside, exhibited a higher binding affinity compared to standard drugs. The pharmacokinetic and physicochemical prediction, stability of ligand-receptor complexes via molecular dynamics simulation, and density functionality theory were done further for the top-scored ligands with receptor.

Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer

OBJECTIVE

To evaluate the functional efficacy of the superficial circumflex iliac artery perforator (SCIP) -lymphatic pedicled flap in the treatment of advanced male genital lymphedema.

METHODS

From February 2018 to January 2022, we treated 26 male patients with scrotal and penoscrotal advanced lymphedema using reconstructive lymphatic surgery. Isolated scrotal involvement was seen in 15 patients, and 11 patients had penoscrotal involvement. Excision of genital lymphedematous fibrotic tissue was followed by reconstruction utilizing the SCIP-lymphatic flap. Patient characteristics, intraoperative data, and postoperative results were evaluated.

RESULTS

The mean patient age was 39 ± 4.6, and the mean follow-up time was 44.9 months. the SCIP-lymphatic flap was used to reconstruct partial (n = 11) or total (n = 15) scrotum and used to reconstruct total penile skin in 9 cases and partial in 2 cases. The flap survival rate was 100%. Cellulitis rates were dramatically reduced after reconstruction (P value <.001). The mean genital lymphedema score (GLS) after surgery was 0.05, which was significantly lower than the preoperative 1, 6.2 (P < .001). The median Glasgow Benefit Inventory (GBI) total score was +41, all 26 patients (100%) showed a degree of quality of life improvement.

CONCLUSION

The pedicled SCIP lymphatic transfer approach in advanced male genital lymphedema can provide a durable complete functional lymphatic system that improves the appearance and genital lymphatic drainage. This leads to an improvement in quality of life as well as in sexual functions.

Genital Lymphedema after Cancer Treatment: A Narrative Review

Genital lymphedema may affect males and females after cancer treatment (gynecological, such as cervical, uterine or ovarian, melanoma, prostate, anus…). It is frequently associated with lower limb lymphedema, and is responsible for discomfort, cosmetic disfigurement and functional disturbances. Impacts on body image, sexual function and quality of life are major, and difficult to explore because cancer treatment itself and lymphedema are so closely interwoven. Local complications, e.g., papillomatosis, warty growth, lymph vesicles with embarrassing lymph oozing and cellulitis, may occur. Usual lymphedema therapies, like bandaging and elastic compression, are poorly adapted to these sites. Surgery, essentially based on cutaneous resection techniques, is the primary symptomatic treatment; it achieves good efficacy, in adults and children, with possible recurrence requiring reintervention.

Pedicled superficial circumflex iliac artery perforator flap for male genital reconstruction: A case series

BACKGROUND

Different issues may cause defects in the genital region, including urological, infective, oncological and genetic problems which often lead to significant defects. This is a very delicate region and a successful coverage requires a thin, pliable and reliable solution. In this setting the SCIP flap might be an outstanding procedure. Despite being a well-known solution in the groin region, its employment for genital reconstructions is still poorly described. For this reason, we gather our experience with this procedure showing the efficacy of the SCIP flap in this specific region.

PATIENTS AND METHODS

In the present case series we included 6 male patients who received a soft tissue defect reconstruction by means of pedicled SCIP flap over the last year. The average age was 53.6 years old (range 34-79 years). Among them, 5 patients received a surgical excision because of severe acne (2 cases), Fournier's gangrene (2 cases), or scrotal squamous cell carcinoma (1 case). In 1 case the cause of the missing volume was testicle agenesis and the reconstruction was performed for cosmetic purposes. Size of the defects ranged from 7 cm × 4 cm to 20 cm × 6 cm. Elliptical shaped flaps were designed either mono- or bilaterally according to the need. All the flaps were supplied by the superficial branch of the SCIA. The range of rotation varied between 150° and 180° in order to reach the affected area.

RESULTS

The flaps' dimension ranged from 8 cm × 4 cm to 20 cm × 6 cm. All the patients were successfully treated. In 1 case we encountered a small wound dehiscence, which was managed conservatively. The mean follow-up was 9.5 months (range 6-12 months). Good cosmetic result was achieved in all cases and no urinary or sexual dysfunctions were reported.

CONCLUSIONS

The pedicle SCIP flap represents a reliable solution for genital and inguinal defects reconstructions. Its versatility can be exploited throughout the region providing very good quality tissues that can be used for the most disparate situations.

Lymphatic Function of the Lower Limb after Groin Dissection for Vulvar Cancer and Reconstruction with Lymphatic SCIP Flap

Inguinofemoral lymphadenectomy, frequently performed for vulvar cancer, is burdened with substantial immediate and long-term morbidity. One of the most disabling treatment-related sequelae is lower limb lymphedema (LLL). The present study aims to describe the wound complications and the severity of LLL in patients who have undergone groin dissection for vulvar cancer and immediate inguinal reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap (L-SCIP). We retrospectively reviewed the data of patients who underwent bilateral groin dissection and unilateral inguinal reconstruction with the L-SCIP. The presence and severity of postoperative LLL during the follow-up period were assessed by lymphoscintigraphy and limbs' volume measurement. In addition, immediate complications at the level of the inguinal area were registered. The changes between preoperative and postoperative limb volumes were analyzed by Student's t test. p values < 0.05 were considered significant. Thirty-one patients were included. The mean variation of volume was 479 ± 330 cc3 in the side where groin reconstruction had been performed, and 683 ± 425 cc3 in the contralateral side, showing smaller variation in the treated side (p = 0.022). Lymphoscintigraphy confirmed the clinical findings. Based on our results, inguinal reconstruction with L-SCIP performed at the same time of groin dissection in patients treated for vulvar cancer can provide a significant protective effect on LLL.