SECONDARY SCROTAL LYMPHEDEMA: A NOVEL MICROSURGICAL APPROACH SYLVAIN MUKENGE, M.D., 1 * CARLO PULITANO ` , M.D., 1 RENZO COLOMBO, M.D., 2 DANIELA NEGRINI, B.D., 3 and GIANFRANCO FERLA, M.D. 1 Secondary scrotal lymphedema is an infrequent complication of radical cystectomy assiociated with pelvic lymphadenectomy. We report a case of secondary lymphedema of male genitalia presenting more than 4 years after a radical cystectomy with extended pelvic lymphade- nectomy for adenocarcinoma of the bladder. Microsurgical lymphovenous anastomoses are usually performed using only the scrotal lym- phatics excluding the testicular lymphatics drainage. We have experimented a new microsurgical technique based on lymphovenous anas- tomosis between the collectors of the spermatic funiculus and the veins of the pampiniform plexus, allowing the testicular lymphatic drain- age. V V C 2007 Wiley-Liss, Inc. Microsurgery 27:655–656, 2007. Lymphedema of the scrotum, regardless of its etiology, is characterized by extreme discomfort for the patient, psychologically distressing, and difficult to treat. It may be idiopathic or secondary to parasitic infection, radia- tion, or surgery. Lymphangiectomy, the excision of involved tissue, remains the most common approach to the treatment of chronic scrotal lymphedema. However, this invasive approach is still associated with the risk of lymphedema recurrence. 1–3 During the last decade, the development of microsur- gical techniques has allowed a minimally invasive approach to the treatment of secondary lymphedema of inferior or superior extremities and more rarely of other body districts. 3 The present ‘‘case report’’ describes the application of a new microsurgical lymphovenous deriva- tion technique for the treatment of a case of scrotal lym- phedema associated to lymphedema of the lower limb secondary to radical cystectomy. CASE REPORT A 75-year-old man presented at our center with a 6- year history of a gradually enlarging scrotum and upper left limb. The patient had not been experiencing signifi- cant disability until 1 year prior when the lymphedema began to worsen. He had undergone a radical cysto-pros- tato-vesiculectomy with extended pelvi-iliac lymphade- nectomy (using as margins the external iliac vein and the posterolateral aspect of the obturator fossa) 10 years back for a bladder cancer. Pathologic examination revealed the involvement of prostate, seminal vesicules, and the lymph nodes (pT4a, G3, pN2). Postoperative course was unevent- ful, and the patient subsequently underwent adjuvant chemo- therapy and high energy radiotherapy. Ten years follow-up was negative for residual or recurrent disease. However, 4 years after the surgery the patient experienced a progressive swelling of the scrotum and upper left limb not responsive to rehabilitation treat- ment. The scrotum was painful, edematous, and the tes- ticulums were not palpable. A lymphoscintigraphy revealed no trunks or clinically relevant collaterals in left leg, and delayed and diminished flow in the right leg. Lymphoscintigraphy of the scrotum was not diagnostic. The diagnosis was secondary lymphedema of third degree of the left limb and fourth degree of the scrotum and penis with mild involvement of the right limb. A two- stage treatment was planed, a first operation consisted in a microsurgical lympho-venous derivation of the left lower limb, postponing to a subsequent operation the treatment of scrotal lymphedema. About 6 months later the successful treatment of left limb, the patient under- went a new microsurgical operation consisting in a direct anastomosis between the lymphatic collectors of the sper- matic funiculus (afferent to the external iliac chains) and the vessels tributary to the spermatic veins. Briefly, the microsurgical technique consisted in the subcutaneous injection of Blue dye to visualize lymphatic network, and a small left crural incision was used to identify the sper- matic funiculus and its elements. No dye was detected at the level of the spermatic funiculus neither in the subcu- taneous tissue. Using microscopical magnification (403) three main lymphatic collectors of the spermatic funiculus (diameter about 500 lm) were prepared and anastomized with three venous branches of the pampiniformis plexus. Three lympho-venous end to side anastomosis were real- ized using interrupted 9-0 polypropylene stitches. The same procedure was used for the right side with the iden- 1 Department of Surgery, Scientific Institute San Raffaele, Vita-Salute San Raf- faele University, Milan, Italy 2 Department of Urology, Scientific Institute San Raffaele, Vita-Salute San Raf- faele University, Milan, Italy 3 Department of Experimental and Clinical Biomedical Sciences, University of Insubria, Varese, Italy *Correspondence to: Sylvain Mukenge, M.D, Department of Surgery, Scien- tific Instistute H San Raffaele, Via Olgettina 60, 20132 Milan, Italy. E-mail: mukenge.mvunde@hsr.it Received 3 May 2007; Accepted 19 July 2007 Published online 10 October 2007 in Wiley InterScience (www.interscience.wiley. com). DOI 10.1002/micr.20426 V V C 2007 Wiley-Liss, Inc.