JU INSIGHT: A New Modified Bipedicle Scrotal Skin Flap Technique for the Reconstruction of Penile Skin in Patients with Paraffin-Induced Sclerosing Lipogranuloma of the Penis

By: Mihaly Muranyi, MD; Daniel Varga, MD; Zoltan Kiss, MD; Tibor Flasko, MD, PhD | Posted on: 01 Jul 2022

Murányi M, Varga D, Kiss Z et al: A new modified bipedicle scrotal skin flap technique for the reconstruction of penile skin in patients with paraffin-induced sclerosing lipogranuloma of the penis. J Urol 2022; 208: 171.

Study Need and Importance

Sclerosing lipogranuloma of the penis (SLP) caused by subcutaneous paraffin injection by nonmedical personnel as a procedure for penile girth enhancement is a serious problem in Southeast Asia and Eastern Europe. There is a consensus on mandatory complete excision of the lipogranuloma-affected tissue in these patients. However, the type of subsequent penile skin reconstruction technique is controversial. Herein, we introduce a new modified penile skin reconstruction procedure with a bipedicle scrotal skin flap to treat paraffin-induced SLP (see Figure).

What We Found

The new technique is an effective single-stage treatment option with a high success rate and good functional results. The overall complication rate was 26.5% in 49 patients. Only Clavien–Dindo grade 1 and 3 complications occurred during the postoperative period. According to the patient-reported questionnaire, surgery was successful in 90% of the patients. Erectile dysfunction, pain or tension during erection, premature ejaculation and penile lymphedema were observed in 2, 3, 1 and 1 patients, respectively. All patients reported the ability to have sexual intercourse.

“Advantages of the scrotal skin flap include easy accessibility, mobility, rich vascularity and similarity to penile skin in color, elasticity, and tactile and erogenous sensations. Being a 1-stage procedure, patients are spared from the biggest disadvantage of 2-stage surgery, ie the abnormal position of the penis between the 2 operations.”

Limitations

A single-center retrospective design and high dropout rate in followup visits (16.3%) and questionnaire responses (38.8%) are the limitations of our study.

“The new technique is an effective single-stage treatment option with a high success rate and good functional results.”

Figure. Schematic illustration of the surgery. A, the patient is prepped and draped in supine position. B, following penile skin removal, the exact position [b-(c/2)] and length (a/2) of the horizontal scrotal incision is based on circumference (a) and length (b) of the denuded part of the penile shaft and circumference of the proximal circumferential incision (c). C, after the penile shaft is pulled through the horizontal scrotal incision, subcoronal and dorsal longitudinal suture lines are made. D, an inverted V-shaped incision is made 1 cm proximal from the subcoronal suture line and b/2 distance lateral from the dorsal longitudinal suture line on both sides. E, the inverted V-shaped incision is closed in a longitudinal fashion.

Interpretation for Patient Care

“Erectile dysfunction, pain or tension during erection, premature ejaculation and penile lymphedema were observed in 2, 3, 1 and 1 patients, respectively.”

The modified penile skin reconstruction technique is an optimal treatment option for patients with SLP with intact scrotal skin. Advantages of the scrotal skin flap include easy accessibility, mobility, rich vascularity and similarity to penile skin in color, elasticity, and tactile and erogenous sensations. Being a 1-stage procedure, patients are spared from the biggest disadvantage of 2-stage surgery, ie the abnormal position of the penis between the 2 operations. The main drawbacks of scrotal skin flaps are their limited size and hairy skin. Patients with SLP extending to the scrotum may need other reconstructive techniques, such as a skin graft.