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

In our series, after the reductive intervention, we showed a clinical resolution or at least a reduction of the
pain and scrotal oedema in all the treated patients. Penile lymphoedema seemed to be more difficult to treat,
showing 75% oedema persistency.

In previous literature, patients receiving debulking surgery and flap reconstructions for GL generally had a
total complication rate of more than 50% [7,31,32] . Our study did not show such a complication rate with no
significant postoperative complications. Then, even cosmetically, ablative surgery applied in the advanced
stages of disease may be suboptimal in both donor and recipient sites with significant scarring and poor
wound healing [4,24,27,33] .

Microsurgical or ablative surgery + microsurgery
LVA and MLVA are microsurgical techniques in which a lymphatic channel is anastomosed to a small vein
(generally one-to-one in case of LVA, or multiple lymphatics into one vein in case of MLVA) to bypass an
[6]
area of reduced lymph flow and drain the lymphatic excess into the venous bloodstream . Mukenge et al.
previously reported successful treatment of advanced penile lymphoedema with anastomoses from
lymphatic vessels to the pampiniform plexus veins, which are located within the spermatic cord, adjacent to
[23]
the lymphatics .

LVA and MLVA improve the long-term outcome of lymphatic microsurgery, but the efficacy, in terms of
[34]
volume reduction and long-term stability, remains highly variable between surgical centres worldwide .
Moreover, recent reports demonstrated that the combination of reductive surgery (including less invasive
liposuction) and microsurgery improves volume reduction, reduces the need for continuous compressive
therapy and increases skin tone [35,36] . Similarly, excisional procedures, together with a VLNT, lead to limb
[12]
circumference reduction and decrease the infection rate .

Among our cases in this group, despite physiologic procedures do not remove fibrous tissue but lymph
component only, we observed a reduction (or resolution) of the GL (unfortunately, only a qualitative
interpretation can be extrapolated due to the lack of volume/lymphoedema quantification).

We can speculate, observing the TI, that cases treated with ablative surgery or a combination of ablative
surgery and microsurgical derivation presented a more advanced/extended GL (always TI > 15) [Figure 4].
On the contrary, the GL treated only with derivative surgery showed a preoperative TI always less than 15
(with an average TI reduction of 43% when comparing pre- and postoperative lymphoscintigraphies). As an
example, we reported the lymphoscintigraphic comparison pre- [Figure 5A] and post-operation at 12
months [Figure 5B] for the second patient of our series, who received only microsurgical treatment.

Besides that, no long-term complications (average follow-up longer than the previous group, 52.5 months)
were found. Finally, penile lymphoedema reduction/resolution was achieved more frequently with
physiologic or ablative + microsurgery than with only debulking surgery (75%).

To summarise, lymphatic-venous shunts can be indicated as the first choice in earlier stages (I or II) after
conservative treatment unsuccess. Patients in these early stages have much less fibrosis of lymphatic vessels,
limited skin, and subcutaneous anatomical changes. However, patients in the advanced lymphoedema stage
can also obtain moderate volume reductions, meaningful symptoms, and quality of life improvement with
functional surgery [6,30] .