Patient: YSS Age: 32 years Race: Black. Personal history: No associated pathologies. HEA: Patient who presented with progressive enlargement of the external genital organs, lymph transudation and sexual impotence for the last two years.
Positive findings on physical examination at the time of admission:
External genitalia: marked oedema of the penis and scrotum with erythema and pain. Painless inguinal lymphadenopathy.

Complementary studies were performed to demonstrate possible aetiology: Complete blood count: normal figures. Serology: non-reactive. Mantoux test: Negative Total and fractionated proteins: Normal X-ray of the hip: No bone lesion. Abdominal U/S: Thickened right psoas of 48 mm Simple CT scan of the hypogastrium and pelvis: Aseptic necrosis of the femoral head with hypertrophy of the psoas at that level.
Various surgical procedures were performed: -Right retroperitoneal exploration. -Adenectomy of the right iliac and cava. -Needle lymphangioplasty. -Fasciotomy of the root of the penis.
At no time did this patient present any symptoms of chyluria or oedema of the lower limbs, nor was he found to have a varicocele or hydrocele.
Based on the clinical manifestations, as well as the findings and ruling out other possible causes of lymphoedema of the penis and scrotum in this patient, the following diagnosis was made:
-Primary local inflammatory lymphoedema of the penis and scrotum.
-Aseptic necosis of the femoral head.
The patient was then assessed by a multidisciplinary team comprising urologists, angiologists and plastic surgeons. It was decided to perform a lymphangiectomy.
Surgical anatomy
It is distorted by the condition, which prevents the normal evacuation of the lymph, due to the distortion and trapping of the lymphatic ducts as a result of the increased fibrous connective tissue and reduction of the elastic fibres, essential in these organs, fundamentally at the penile level. The skin and dermis; the dartos, a muscular tunic of smooth fibres (Sappey's peripenis muscle), which contributes with its contraction to compress the underlying venous ducts during erection; and the cellulose sheath rich in elastic fibres where the dilated lymphatic vessels and superficial veins, arteries and nerves are located, are found forming a block which is difficult to distinguish in layers and which must be excised in its entirety while respecting the thin penile fascia attached to the erectile, spongy and cavernous organs containing the urethra and dorsally the penile artery. In the pockets of the six sheaths that make up the lining of the testis: the scrotum, the muscular dartos, the cellulose, Cooper's fascia, the second muscular tunic called the erythroid, also form a block that must be removed in its entirety, leaving the vaginal layer covering the testis, the vascular-nerve bundle and the epididymis.
