Abstract

Introduction: Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction byeither local flaps or skin grafts. Reconstructive procedures aim to restorelymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL.

Methods: A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or “surgical treatment”), evaluating outcomes, and complications after surgical treatment of GL.

Results: Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%.Lymphovenousshunt(LVA)procedures(14.5%)hadatotalcomplicationrate of 9%.

Conclusions: This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures

Main findings

• Treatment of GL is extremely challenging with no perfect solution. Surgical approaches are considered in combination with maximal conservative therapy (decongestive physiotherapy and exercises, manual lymph drainage, compression garments and treatment of the underlying condition).
• Surgical options can be either palliative or functional. Palliative surgery mainly involves radical excision of affected tissue (lymphangectomy), followed by reconstruction of the genital area by local flaps or skin grafting.
• Functional treatments aim to reestablish or improve lymphatic flow. Developments in microsurgery have made lymphaticovenous anastomosis (LVA) an alternative surgical method for lymphedema treatment, which preserves the lymphatic drainage by shunting the lymph into the main venous bloodstream.
• Lymphaticovenous shunts can be either from the residual superficial or the deep lymphatic systems, although the deep lymphatics are of greater caliber and generally less affected by the degeneration process associated with chronic lymphedema and so may give better results.
• Genital lymphedema is a debilitating disease causing both physical discomfort and psychological distress. Conservative management is more difficult than for extremity lymphedema owing to the difficulties using compression garments. These can, however, be broadly classified into either ablative or physiologic procedures. Ablative procedures aim to remove excess skin and soft tissue and close the residual defect. The newer physiological procedures available aim to restore lymphatic drainage and mostly rely upon microsurgical techniques. The use of microsurgical procedures for GL has been mainly developed in the last few decades, but despite the promising early outcomes, further studies are required before their more widespread application.
• Two different surgical modalities are currently available for GL: debulking followed by direct closure or reconstruction and functional restoration of lymphatic pathways. This review found much higher complication rates in patients treated with debulking and flap reconstructions, although these were generally patients with advanced stage disease. Patients reconstructed with direct closure or skin grafts.