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Guiotto et al. Plast Aesthet Res 2023;10:26 https://dx.doi.org/10.20517/2347-9264.2023.15 Page 3 of 14

Conservative therapy may produce satisfactory results, but these benefits are usually temporary without
[9]
maintenance and continued compression . In addition, compression bandaging and manual lymph
[10]
drainage are shown to be less effective in the case of GL due to anatomical limitations .
[7]
From a surgical perspective, the treatment options can be either reductive or functional . Reductive
intervention, on the one hand, involves radical excision of affected tissue (lymphangectomy), followed by
[11]
reconstruction of the genital area by local flaps or skin grafting .

Reductive surgery (also named debulking or ablative surgery in the text) aims to reduce pathologic adipose
and fibrotic tissue excess and to stop lymphoedema progression. Debulking or excision techniques can
involve partial or total resection of the skin and the subcutaneous tissue. Suction Assisted Lipectomy (SAL)
is commonly performed for initial soft tissue accumulation, especially in the pubic area, while in the case of
[12]
fibrosis, direct excision becomes necessary with more invasive procedures . These can improve patient
discomfort, hygiene, and quality of life .
[13]
On the other hand, functional surgery (mentioned as physiologic surgery or derivative surgery along the
text), such as lymphatic-venous anastomosis (LVA), multi lymphatic-venous anastomosis (MLVA) or
lymph nodes transfer/transplantation (VLNT), aim to re-establish or improve the lymphatic drainage and
require microsurgical expertise [13,14] .

Recent findings agree that physiologic treatments should be performed in the early stages of GL to preserve
lymph drainage and avoid the progression to fibrosis. Besides that, surgical debulking is recommended in
later stages, where lymphoedema has already progressed with significant fibrosis and adipose infiltration,
resulting in disruption of the remaining lymphatic pathways [12,15,16] .

Despite increased interest in GL treatment in recent years, no univocal consensus exists in its approach
from diagnosis to treatment choice and recurrency management. This study aims to define a therapeutic
algorithm based on the experience of three senior consultants, all with extensive experience in lymphatic
surgery and microsurgery.

Regarding the therapeutic strategy, here in the text, patients will be divided into two main categories as
follows: (1) debulking/ablative surgery only (Ablative surgery); (2) microsurgery (Microsurgery) OR a
combination of microsurgery and ablative surgery (Microsurgery + Ablative surgery).

MATERIAL AND METHODS
A tri-center (Lausanne, Switzerland; Bari and Genova, Italy) retrospective investigation, based on
prospectively maintained databases involving GL patients treated between January 2018 and January 2022,
was performed in this study.

Patients with genital (scrotal and/or penile) lymphoedema who underwent surgical treatments were
included in this study. Both primary and secondary aetiologies were considered, and eventual associated
lower limb lymphoedema was not an exclusion criterion.

Moreover, all patients without a complete follow-up (at least 12 months after the last procedure) were
excluded. Patient demographic data and comorbidities were gathered from medical and anaesthesiologic
charts. Operative technique details, pre- and postoperative symptoms (subjective and objective), clinical