Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group.

BACKGROUND: The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients. METHODS: Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure. RESULTS: The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*). CONCLUSIONS: Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes. TRIAL REGISTRATION: • Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

Unilateral Suprainguinal Ectopic Scrotum: Case Report and Literature Review.

Ectopic scrotum is an infrequent congenital scrotal anomaly. Different surgical methods of correcting ectopic scrotum have been used, but none have produced optimal cosmetic results for all types. We describe a case of left ectopic suprainguinal scrotum in a 14-month-old boy who had an undescended left testicle and a left-sided scrotal skin tag. Single-stage rotational flap scrotoplasty and unilateral orchiopexy were performed; however, we modified the surgical technique of scrotal rotation by excising the intervening longitudinal skin. Eight months after surgery, the repositioned scrotum had a better appearance, and the affected testicle was similar in size to the contralateral one. In comparison with other surgical methods, pedicle flap rotation of the ectopic scrotal skin with excision of the intervening longitudinal skin may produce a better cosmetic outcome.

Aesthetic Scrotoplasty: Systematic Review and a Proposed Treatment Algorithm for the Management of Bothersome Scrotum in Adults.

BACKGROUND: Increased scrotal laxity is a poorly defined entity often associated with discomfort while wearing loose clothes, walking, doing sports and during intercourse. In our experience, this condition is produced by an enlarged scrotal bag hanging more than 1-2 cm below the tip of the penis and can be associated with persistent penoscrotal webbing. Our objective was to perform a systematic literature review addressing the diversity of this entity and its surgical treatment, as well as propose a diagnostic and therapeutic approach. METHODS: A systematic search strategy was performed following PRISMA guidelines under the terms: Scrotum(Mesh), Plastic Surgery(Mesh), Reduction Surgery, Scrotoplasty, Ventral Phalloplasty, Scrotomegaly, Penoscrotal Web, Webbed Penis(Mesh), Scrotal Lifting, Scrotopexy and Scrotal Tuck. Articles referring to scrotum reduction or plasty in male genital rejuvenation context and ventral phalloplasty related to adult penoscrotal webbing correction were considered eligible for analysis. A management algorithm and surgical technique is proposed along with the results. RESULTS: A total of 1430 articles were found. After removing duplicates and applying inclusion and exclusion criteria, 11 articles were eligible for analysis. Most articles corresponded to case reports or surgical technique descriptions. Based on correcting excessive scrotal skin and/or penoscrotal webbing, we propose a vertical midline scrotal skin resection and a penoscrotal junction Z plasty, respectively. CONCLUSIONS: Aesthetic scrotoplasty and scrotal rejuvenation surgical techniques still remain as entities poorly addressed in the international literature. More reported experiences are needed in order to complement our proposed management algorithm and develop a nomenclature, diagnostic and treatment consensus. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 . Genital Surgery.

Synchronous Development of Hemiscrotal Tissue in the Orthotopic and Ectopic Locations in Association with other Urological Anomalies.

Ectopic scrotum is a rare form of congenital scrotal anomaly that is rarely encountered in pediatric surgical practice. Herein, we report an infant with a unilateral ectopic suprainguinal scrotum associated with undescended testis and multicystic dysplastic kidney. The case is reported in view of rarity of this anomaly in the general pediatric population.

Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics.

INTRODUCTION: Scrotoplasty has become a common practice during insertion of penile prosthesis, improving patient perception of penile length. Previous reports on scrotoplasty outcomes have only focused on the perceived benefits. The risk of wound complications after scrotoplasty is unknown. AIM: Identify wound complications and associated risk factors of scrotoplasty with insertion of penile prosthesis. METHODS: A retrospective review of a single-surgeon series (T.S.K.) of patients who underwent scrotoplasty with initial insertion of inflatable penile prosthesis (IPP) was performed from 2009-2014. Surgical outcomes and wound complications after scrotoplasty were examined, along with patient information, including basic demographics, medical comorbidities, and perioperative data. MAIN OUTCOME MEASURES: Studied outcomes included rate of wound complications after scrotoplasty and IPP insertion and identification of risk factors for wound dehiscence. RESULTS: Of the 103 scrotoplasties performed during the study period, a total of 15 had mild, moderate, or major wound dehiscence. Of these 15 cases, 9 had mild dehiscence and 5 cases had moderate dehiscence and required stitches to be placed in clinic to reinforce the closure. 1 patient had a major dehiscence requiring a return to the operating room for a washout, with exchange of IPP to malleable prosthesis. Multiple risk factors for wound dehiscence were found, including diabetes (odds ratio 6.1, CI 1.5, 25.0, P = .0129) and scrotoplasty technique (odds ratio 4.9, CI 1.2, 8.6, P = .003). Other examined variables, including patient age, Peyronie's disease, hypertension, intraoperative penile modeling, smoking, and device manufacturer, were not associated with wound dehiscence. CLINICAL IMPLICATIONS: Patients with diabetes and scrotoplasties performed via V-Y plasty are more likely to experience wound dehiscence. STRENGTHS & LIMITATIONS: Strengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include retrospective design, single institution series, and lack of long-term follow-up. CONCLUSION: Although scrotoplasty can improve patient satisfaction with IPP, scrotoplasty can lead to increased patient morbidity. Diabetic patients are at increased risk for wound complication after scrotoplasty. Gupta NK, Sulaver R, Welliver C, et al. Scrotoplasty at Time of Penile Implant is at High Risk for Dehiscence in Diabetics. J Sex Med 2019;16:602-608.

Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men.

INTRODUCTION: Testicular prosthesis implantation may be used for neoscrotal augmentation in transgender men. AIM: Assess the clinical outcomes and risk factors for postoperative complications of this procedure in transgender men. METHODS: All transgender men who underwent neoscrotal augmentation with testicular implants between January 1992 and December 2018 were retrospectively identified. A retrospective chart study was performed that recorded surgical characteristics and postoperative complications. Risk factors on complications were identified using uni- and multivariate analyses. MAIN OUTCOME MEASURE: Surgical outcomes included explantation due to infection, extrusion, discomfort, or leakage. RESULTS: We identified 206 patients, and the following prostheses were placed: Dow Corning (n = 22), Eurosilicone (n = 2), Nagor (n = 205), Polytech (n = 10), Promedon (n = 105) , Prometel (n = 22), Sebbin (n = 44), and unknown (n = 2). The mean clinical follow-up time was 11.5 ± 8.3 years. In 43 patients (20.8%), one or both prostheses were explanted due to infection, extrusion, discomfort, prosthesis leakage, or urethral problems. Currently, scrotoplasty according to Hoebeke is the most frequently performed technique. Our review found that for this technique explantation occurred in 6 of 52 patients (11.5%). A history of smoking was a risk factor for postoperative infections and prosthesis explantation. In earlier years, larger prostheses were immediately placed at scrotal reconstruction; however, a trend can be seen toward smaller and lighter testicular prostheses and delayed implantation. CLINICAL IMPLICATIONS: Patients wanting to undergo this procedure can be adequately informed on postoperative outcomes. STRENGTHS & LIMITATIONS: Strengths of this study include the number of patients, long clinical follow-up time, and completeness of data. Weaknesses of this study include its retrospective nature and the high variability of prostheses and surgical techniques used. CONCLUSION: Over the years, scrotoplasty techniques and testicular prostheses preferences have changed. Explantation rates have dropped over the last decade. Pigot GLS, Al-Tamimi M, Ronkes B, et al. Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men. J Sex Med 2019;16:1664-1671.

Technical nuances of the concealed penis repair.

Circumcision is commonly performed but anatomic variants occur and can affect outcomes if not addressed properly. The combination of concealed penis and penoscrotal webbing is fairly common and presents across a spectrum of severity. If not repaired, this can result in a buried penis that can cause penile adhesions, wound healing concerns, and make the penis appear shorter secondary to a retracted position. We present our technique that is reproducible and highly successful in addressing both of these concerns. The paraphimotic band approach is performed more commonly and is able to reliably correct webbing and concealment without an incision at the penoscrotal junction. When more severe defect is present, a Y shaped incision is made at the penoscrotal junction to mobilize skin flaps to correct the deficit. In our cohort of 885 patients, 736 were corrected using the paraphimotic band technique while 149 underwent a complex scrotoplasty. None of the patients required a secondary surgery for complications.

Surgical management of acquired buried penis and scrotal lymphedema: A retrospective review.

Acquired buried penis is a condition that can have detrimental physical and psychological consequences for patients. Factors such as elevated BMI, chronic scrotal lymphedema, hidradenitis suppurativa, and chronic inflammation can lead to the condition. Surgical intervention is the treatment of choice for advanced disease. Following IRB approval, a retrospective chart review was performed for patients with a diagnosis of acquired buried penis who required surgical intervention. Details of patient history, surgical management including intraoperative and post-operative photography, and complications were reviewed. Seven patient cases were reviewed. The average age at time of surgery was 44 with a mean weight of 344 pounds and an average BMI of 48. Severe scrotal lymphedema and hidradenitis were common concurrent comorbidities. Concurrent scrotoplasty and infraumbilical panniculectomy were standard parts of the operations. Native glans skin was salvageable in all but one case. Penile shaft skin was reconstructed with skin grafts or adjacent tissue transfer. 88% of the cases had some element of wound dehiscence post-operatively. Surgical management of an acquired buried penis can be challenging. The patient demographic with the disease is frequently complicated by morbid obesity, concurrent lymphedema, or hidradenitis. Post-operative complications are expected. The surgical techniques presented can aid in simplifying the management of this challenging surgical population.

Giant scrotal lymphedema after paraffinoma injection: A case report.

Scrotal lymphedema is a rare condition characterized by blocked lymphatic drainage to the scrotum, resulting in physical and psychological discomfort for sufferers. Here, we present a case study of a 27-year-old male with giant scrotal lymphedema resulting from paraffinoma injection. The patient experienced scrotal enlargement since 2019, which engulfed the penis and was surrounded by edema. After confirming the absence of filariasis parasites, the patient underwent paraffinoma excision and scrotoplasty, resulting in a 13 kilograms scrotal specimen with no signs of malignancy. Giant scrotal lymphedema can be distressing, but surgical excision can improve the patient's quality of life.

Scrotal trichilemmal cysts: a case report.

Trichilemmal cyst (TC), commonly known as the pilar cyst of the scrotum wall, is an uncommon disease. It is a type of epidermoid cyst (EC) with a benign course, and malignant change is quite rare. This disease is unusual in the scrotum; therefore, multiple cysts in the scrotum are much more unusual. There have been reports of TCs in other parts of the body, but this is the first instance of scrotal TCs in Pakistan. Case presentation: We discuss the case of a 60-year-old male patient who presented to the clinic with a right-sided scrotal swelling, which was identified as a right-sided inguinal hernia on examination, and multiple small swellings on the scrotal skin identified as TCs. The patient had scrotoplasty after hernia surgery to remove the cysts and reconstruct the excised scrotum. Following scrotoplasty, the patient's discomfort was resolved, and cosmetic satisfaction was achieved. Clinical discussion: Excision is required if TCs become infected or for esthetic reasons. In the event of big cysts, full scrotal wall resection followed by scrotoplasty is necessary. The thigh fasciocutaneous flap is used to cover the denuded testes after scrotoplasty. The procedure's advantages include a good outcome, low morbidity, early discharge, and great esthetic outcomes. Conclusion: We present a literature review about multiple TCs in the scrotum and their surgical management. This case will guide surgeons and future researchers in dealing with similar cases in the future.

Combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum: A case report.

Objective: Genital lymphedema is a severe, disabling condition associated with a malfunction of the lymphatic system. Primary lymphedema of the scrotum is a variant of congenital dysplasia of lymphatic vessels. Secondary genital lymphedema is much more common and can be caused by parasitic invasion (filariasis) or damage to the lymphatic system during the treatment of cancer (radiation therapy, lymphadenectomy). Healthcare providers are frequently unable to detect and treat this illness successfully in ordinary clinical practice. This paper uses the case of a patient with stage 3 secondary lymphedema (unknown genesis) of both lower extremities and lymphedema of the scrotum, complicated by recurrent erysipelas, a history of lymphorrhoea, impaired skin trophic and multiple papillomatosis, to demonstrate the efficacy of a combination of conservative and surgical methods in the treatment of giant lymphedema of the scrotum. Methods: In the treatment, the combination of decongestant physical therapy (CDPT, CDT) according to M. Földi was used at pre-surgery and post-surgery stages, combined with a reconstructive operation, including the removal of the affected tissues of the urogenital region, phalloplasty, and scrotoplasty with rotational skin flaps. Results: A decrease in the circumference of the lowest extremities in the lower leg area by 68 cm on the right and by 69 cm on the left was achieved by conservative treatment. Due to the combination of conservative and surgical treatment, the patient's body weight decreased by 69.4 kg, and the scrotum decreased by 63 cm. Subsequently, the patient fully recovered his sexual function. Conclusion: A combination of complex decongestive physical therapy and surgery is necessary for patients with advanced genital edema. The isolated use of surgical or conservative treatment does not provide a sufficient improvement in the patient's quality of life. Modern plastic surgery technologies enable patients to achieve complete functional and cosmetic recovery, while proper selection and usage of compression hosiery help preserve and improve the outcomes acquired following treatment.

Ectopic scrotum and penoscrotal transposition: Case report and literature review.

Background: Ectopic scrotum (ES) is an extremely rare congenital scrotal malformation. Ectopic scrotum with VATER/VACTERL [vertebral defects (V), anal atresia or anorectal malformations (A), cardiac defects (C), tracheoesophageal fistula with or without esophageal atresia (TE), cardiac defects, renal malformations (R), and limb defects (L)] association is even rarer. There are no uniform guidelines for diagnosis and treatment. Clinical case: We described a 2-year-5-month-old boy who has ectopic scrotum and penoscrotal transposition and reviewed relevant literature in this report. We performed laparoscopy exploration, rotation flap scrotoplasty, and orchiopexy and achieved a great result during the postoperative follow-up. Conclusions: Combined with the previous literature, we made a summary to come up with a plan for the diagnosis and treatment of ectopic scrotum. Rotation flap scrotoplasty and orchiopexy are worthy of considering operative methods in treating ES. For penoscrotal transposition or VATER/VACTERL association, we can treat the diseases individually.

Comparing scrotoplasty complication rates in transgender and cisgender men: An ACS NSQIP study.

While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older (M trans = 38 years (SD:14), M cis = 53 years (SD: 15)) and had higher BMI than the transgender cohort (M trans = 26.9 (SD: 5.5), M cis = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health (p = 0.001), and were more likely to have hypertension (p = 0.001) and diabetes (p = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time (M trans = 303 min (SD: 155), M cis = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty (p = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender patients.

Bilateral T-shaped Scrotoplasty as an Ancillary Technique of Staged Anterior Urethroplasty: The End Justifies the Means.

Staged urethroplasty is performed to treat long-segment obliterating anterior urethral strictures. The technique is particularly challenging when the penobulbar junction is involved, as it requires the transection of the scrotum and the formation of lateral testicular fans. To date, there is no established surgical protocol for this ancillary technique in large volume scrotums with excess skin. We report a case of staged urethroplasty with the necessity of performing T-scrotoplasty due to bulky scrotum. After six months, the T-plasty was successfully resolved, and a new scrotum was formed from the two hemiscrota. In conclusion, scrotoplasty using a bilateral T-plasty is an excellent technique to overcome the necessity of splitting the scrotum by externalizing the urethra to allow for excellent buccal mucosal graft healing over a period of six months. The two separate testicular fans can be reapproximated along the raphe after re-tubularizing the urethra in the 2nd stage, shaping a new scrotum with satisfactory cosmetic results.

Varicocele indicated scrotoplasty with varicocelectomy: A case report.

A 72 -year- old male patient presented to the clinic complaining of mild dragging scrotal pain and hanging scrotum interfering with his daily activity. Clinical examination revealed grade three left varicocele, enlarged hanging scrotum for more than 15 cm from the scrotal neck. The scrotum was explored and left varicocelectomy was done then scrotoplasty. Fifteen months post-operatively patient has an excellent outcome.

Giant scrotal swelling in association with a congenital giant melanocytic nevus: A case report.

INTRODUCTION: Scrotal lymphedema is a rare condition, with significant psychological and functional disability. To date, association with giant congenital melanocytic nevus has not been reported. CASE REPORT: We report a case of a 15-year-old male with a giant congenital nevus associated with giant scrotal lymphedema. Surgical debulking with penoscrotoplasty achieved satisfactory functional and esthetic results. CONCLUSIONS: Early diagnosis and surgical intervention should be advocated for congenital causes of large scrotal swelling.

Surgical management of post-circumcision webbed penis in children.

OBJECTIVE: To report the outcomes of surgical correction of post-circumcision webbed penis using two previously described techniques: the Heineke-Mikulicz (HM) scrotoplasty and the multiple Z-plasty. PATIENTS AND METHODS: A prospective study of children with post-circumcision webbed penis was conducted. The patients were classified into two groups according to the degree of web and the remaining ventral penile skin as to whether adequate or short after circumcision. Group I was repaired by HM scrotoplasty and in Group II the multiple Z-plasty technique was used. RESULTS: This study included 86 patients of whom 71 maintained follow-up; 44 (62%) in Group I and 27 (38%) in Group II. The median (range) operative time was 45 (30-55) min in Group I and 75 (60-90) min in Group II. Wound infection occurred in two (4.5%) patients in Group I. In Group II postoperative mild self-limited penile oedema was present in three patients (11.1%). A self-limited scrotal haematoma developed in two (7.4%) patients. CONCLUSION: Correction of post-circumcision webbed penis in children can be done by one of two techniques: HM scrotoplasty in Grade 1 and multiple Z-plasty in Grade 2 and Grade 3, with favourable outcomes. ABBREVIATIONS: HM: Heineke-Mikulicz; IQR: interquartile range.

A Modified Scrotoplasty for Treating Severe Penoscrotal Webbing in Children.

To compare a novel modified W-incision scrotoplasty (MWS) operation method with the conventional V-Y scrotoplasty for treatment of severe penoscrotal webbing (PSW) in children a retrospective study was conducted on 26 children. Circumcision combined with modified scrotoplasty was used to repair the webbed penis and phimosis of children and another 32 patients undergoing V-Y scrotoplasty served as the control group. There was a statistically significant difference of angle improvements of penis and scrotum in a horizontal position (-66 ± 10; -57 ± 6, P < 0.001) and the parent satisfaction score (Five Likert Scale) (4.7 ± 0.56; 3.8 ± 0.47, P < 0.001) between the two groups. All 26 children who underwent MWS presented with no serious postoperative complications, and there was no significant difference in surgical complications compared to children treated with V-Y scrotoplasty.

Surgical management of giant scrotal lymphedema in morbidly obese patient with trisomy 21.

Huge scrotal lymphedema is a rare problem that affects the patient's lifestyle and leads to physical and emotional disability. It also carries potential challenges for the treating surgeon, especially if the patient is noncompliant or morbidly obese. A 21-year-old morbidly obese trisomy 21 man with huge scrotal lymphedema and buried penis that developed within 2 years presented for excision scrotoplasty with reconstruction of the penis using the original invaginated penile skin. Giant scrotal lymphedema with buried penis can be treated successfully by excision scrotoplasty with preservation of the invaginated healthy penile skin to reconstruct the penis.

Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male.

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.