Assessment of The Lymphatic System of the Genitalia Using Magnetic Resonance Lymphography Before and After Treatment of Male Genital Lymphedema

Abstract

Treatment for chronic male genital lymphedema (GL) is limited. No standard treatment or validated instrument to assess GL is available. The aim of this study was to explore whether magnetic resonance lymphography (MRL) could be used to assess GL, select proper treatment for patients, and monitor postoperative progress.This is a retrospective analysis of a prospectively acquired cohort of men with GL presenting for MRL over a 7-year period. Thirty-six of 47 eligible men were included. All men were offered preoperative and postoperative MRL and assigned a morphology and function classification. Men with mild, moderate, and severe nodal dysfunction underwent complex decongestive physiotherapy (CDP), lymphoveneous microsurgery, and surgical excision, respectively. The volume reductions in the genitalia of patients with mild and moderate nodal dysfunction were recorded and compared using Student t test.The abnormal superficial and deep lymphatic vessels in the lymphedematous genitalia were detected by MRL, and inguinal lymph node dysfunction was classified by MRL. Seven patients with mild dysfunction who underwent CDP showed a more significant mean volume reduction in the genitalia than did 9 patients with moderate dysfunction. Three patients with hyperplasia and moderate dysfunction who underwent microsurgical operations and 17 patients with hypoplasia and moderate or severe nodal dysfunction who underwent surgical excision had excellent cosmetic results with no lymphedema at the 3- to 5-year follow-up.MRL can be used to assess morphological and functional lymphatic abnormalities in GL, preoperatively select appropriate treatment, and postoperatively evaluate treatment outcomes.

FIGURE 1

A chart to report flow of participants through the study.

FIGURE 2

Lymphovenous microsurgery. (A) Under ×40 magnification, the targeted venule (black arrows) and deep lymphatic collector (white arrows) were identified using isosulfan blue dye and were prepared for anastomosis. (B) Lymphovenous terminolateral anastomoses were repaired using interrupted 9–0 polypropylene stitches (black arrow head).

FIGURE 3

Clinical photographs for surgical excision and scrotal reconstruction. (A) The incision design retaining the scrotal septum. (B) The affected scrotal skin and subcutaneous edematous tissues were excised maximally. (C) Circumcision combined with removal of the subcutaneous edema tissue. (D) The testes and spermatic cords were isolated and the tunicae vaginalis were inverted. (E) The inverted tunicae vaginalis was fixed with inferior scrotal tissue and separated by the scrotal septum. (F and G) The subcutaneous lymphatic tissue flaps were traced using vital blue, and the remaining adjacent skin was bridged to the contralateral tissue. (H) Immediate postoperative period showing normal scrotal appearance.

FIGURE 4

Morphological and functional characteristics of scrotal magnetic resonance lymphography (MRL). (A) Frontal 3D MRL image obtained from an 18-year-old man who had a 2-year history of scrotal swelling accompanied by left limb enlargement owing to primary lymphedema. Only 1 lymphatic vessel could be visualized on the right side of the scrotal wall (arrow), and dermal backflow, an area of progressive dispersion of the contrast media in the soft tissues, showed high signal intensity on left side of scrotal wall (star) and was classified as hypoplasia. (B) MRL image acquired from a 67-year-old man with secondary lymphedema and an 11-month history of a swollen scrotum and penis shows numerous tortuous lymphatic vessels with blurred outlines (arrows), which we classified as hyperplasia. (C) MRL image obtained from a 58-year-old man who had a 2-year history of scrotal swelling owing to secondary lymphedema. The deep lymphatic collector shows a thin linear outline with a high signal intensity along the spermatic cord (arrows). (D) Dynamic MRL obtained from a 37-year-old man with primary lymphedema who had a five-year history of scrotal swelling shows nodal enhancement of the bilateral inguinal lymph nodes in a series images. Peak enhancement could be found in the right inguinal lymph node at 12 minutes after contrast injection (black arrows), whereas no peak enhancement was found in the left inguinal lymph node within the acquisition time (black arrow heads), which we classified as moderate nodal dysfunction.

FIGURE 5

A 66-year-old man with 3-year secondary genital lymphedema underwent the lymphovenous anastomoses technique. (A) Clinical photograph of the scrotum taken before the operation showed evident scrotal and penis lymphedema and skin erythema. (B) Photo of the scrotum taken from the same patient at 6 months after the surgery. Note that the size of scrotum decreased significantly, and the normochromic excess cutaneous tissue disappeared after the edema resolved. (C) Magnetic resonance lymphography (MRL) obtained before microsurgery showed unrecognizable fine lymphatic vessels and dermal reflux (star). (D) Six month later, the patency of the lymphovenous anastomoses was confirmed by MRL and showed the passage of high-intensity signal contrast media from the venule through the anastomosis into the deep lymphatic vessel (arrows).

FIGURE 6

A 28-year-old man with a 13-year primary genital lymphedema underwent surgical excision and scrotal reconstruction. Clinical photographs of the scrotum taken before surgery (A), 3 years (B), and 5 years (C) after surgery showed evident size reduction of the scrotum and penis. (D) Magnetic resonance lymphography (MRL) obtained before surgery showed that the scrotal lymphatic drainage pathway could only be identified on the left side (arrows). The postoperative follow-up MRL at the third (E) and fifth years (F) showed the establishment of new scrotal lymphatic drainage pathways (arrow heads) and reopening of the lymphatic vessels (arrows). The dermal reflex area (star) decreased with postoperative time.