ICG-directed scrotal flap design for adult-acquired buried penis repair

Indocyanine green (ICG) lymphography is a validated tool used to map superficial lymphatic patterns. Patients with adult-acquired buried penis (AABP) secondary to penile engulfment by surrounding soft tissues often have abnormal lymphatic drainage of the genital region and experience high rates of postoperative lymphedema after surgical correction. To evaluate clinical utility of preoperative and intraoperative lymphography in surgical AABP repair, we performed a multicenter observational study of 15 patients presenting for surgical correction of AABP. Nine of these patients underwent preoperative nuclear lymphoscintigraphy, six of whom demonstrated stage one or greater lower extremity lymphedema. All patients underwent intraoperative lymphography via intradermal injection of ICG dye into the inferior abdominal fat pad, medial thighs, penile shaft, and scrotum. This revealed significant lymphatic congestion with dermal backflow in all patients, with variable patterns of genital and adjacent soft tissue involvement. In all patients, drainage of the posterior scrotum was completely or partially preserved. After injection and interpretation of lymphography, dissection and soft tissue removal were performed. The boundaries of the posterior scrotal flap were determined based on the preservation of observed linear scrotal lymphatics and exclusion of tissue displaying characteristics of lymphatic congestion. These findings reveal that lymphedema is highly prevalent in patients with AABP and should be addressed during the treatment. Drainage of the posterior scrotum toward the perineum is commonly preserved, validating the importance of preserving this tissue for scrotal reconstruction.