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Modified Bipedicle Scrotal Tunnel Flap (Murányi Technique)

The Murányi modified bipedicle scrotal tunnel flap is a single-stage penile skin reconstruction developed for paraffin-induced sclerosing lipogranuloma. Its defining innovation is a subcutaneous scrotal tunnel through which the denuded shaft is pulled, combined with an inverted-V ventral closure that converts the historical T-junction (a known necrosis site) into a longitudinal scar. In the largest single-institution series (n = 49), it achieved 90% patient-reported surgical success and 100% preservation of intercourse ability, with an overall complication rate of 26.5%.[1]

For the related single-stage flap relying on a central window rather than a tunnel, see Bipedicled Anterior Scrotal Flap (Fakin). For the graft alternative, see Penile Skin Grafting. For the full decision framework, see Penile Reconstruction.

Rationale​

Penile paraffinoma / sclerosing lipogranuloma requires complete excision of all infiltrated skin and subcutaneous tissue, often leaving a circumferential shaft defect.[1][2][3] The Murányi modification was designed to address limitations of prior techniques:[1]

Prior approachLimitation
Jeong 1996 bilateral scrotal flapsComplex flap design; T-style ventral-coronal anastomosis prone to necrosis[3][4]
Pribaz two-stage scrotal flapSecond operation, prolonged recovery[5]
STSG / FTSGSuboptimal when residual foreign material on the corpora prevents graft take[3]
Fakin bipedicled anterior scrotal flapRequires central window in the elevated flap + circumferential wrap[6]

Tunneling simplifies the dissection — the scrotal skin naturally envelops the shaft as the penis is pulled through, eliminating the need for window creation or complex bilateral flap rotation.[1]

Indications​

  • Paraffin-induced sclerosing lipogranuloma — the prototype indication (all 49 patients in the Murányi series)[1]
  • Requires intact, uninvolved scrotal skin — contraindicated if foreign material has infiltrated the scrotum
  • Circumferential penile shaft defect after radical excision
  • Conceptually extensible to other circumferential-loss etiologies (Fournier's, circumcision injury, oncologic excision), though the published evidence is paraffinoma only

Operative Technique​

1. Circumferential incisions and lipogranuloma excision​

  • Two circumferential incisions — subcoronal and at the penoscrotal junction
  • All lipogranuloma-involved skin + subcutaneous tissue between them excised to Buck's fascia; shaft fully denuded
  • Meticulous hemostasis

2. Horizontal scrotal incision​

  • Transverse anterior-scrotal incision 2–3 cm inferior to the penoscrotal junction
  • Length of incision matches the circumference needed to accommodate the shaft

3. Subcutaneous tunnel creation​

  • Tunnel dissected between the horizontal scrotal incision and the proximal penile circumferential incision
  • Plane is between scrotal skin / dartos and external spermatic fascia / tunica vaginalis
  • Tunnel must be wide enough to accommodate the shaft without compression
  • Both lateral pedicles preserved within the scrotal skin — bilateral external-pudendal / anterior-scrotal-artery blood supply maintained

4. Penile pull-through​

  • The denuded shaft is pulled through the tunnel from the penoscrotal junction, emerging through the horizontal scrotal incision
  • Scrotal skin naturally drapes circumferentially around the shaft

5. Subcoronal and dorsal suture lines​

  • Distal scrotal-skin edge sutured to the subcoronal skin circumferentially
  • Where the scrotal-skin edges meet on the dorsal shaft → longitudinal dorsal suture line
  • Interrupted absorbable sutures

6. Ventral inverted-V incision and longitudinal closure​

  • On the ventral side, where the shaft exits the scrotum, make an inverted-V incision in the scrotal skin
  • Inverted V serves two purposes:
    • Creates a penoscrotal angle — prevents scrotal-skin migration onto the ventral shaft (webbing)
    • Converts the horizontal scrotal incision into a vertical scar line
  • This step adapts the Shin inverted-V principle that eliminated the T-junction necrosis seen with traditional bilateral flaps[4]

7. Donor-site closure​

  • Remaining scrotal skin closed primarily
  • Testes covered by posterior + lateral scrotal skin

How It Differs From Other Scrotal-Flap Techniques​

FeatureMurányi tunnelFakin bipedicled[6]Jeong bilateral[3]Shin inverted-V[4]
Flap designTunnel pull-throughCentral window in flapTwo separate hemiscrotum flapsTwo hemiscrotum flaps
StagingSingleSingleSingleSingle
Dorsal suture lineLongitudinal dorsalCircumferential at base + coronalT-style at coronaDorsal only
Ventral closureInverted V → longitudinalCircumferentialT-style (necrosis-prone)Inverted V (end-to-end)
Tunnel creationYes (defining feature)NoNoNo
Series size49431734 (14 inverted-V)

Outcomes — Murányi Series (n = 49)​

Perioperative (2017–2020)[1]​

  • All paraffin-induced sclerosing lipogranuloma; all single-stage

Complications (Clavien-Dindo)​

  • Overall complication rate 26.5% (13 / 49)
  • Grade 1 (no intervention): 5 events
  • Grade 2: 0
  • Grade 3a (bedside / non-GA procedure): 8 events
  • Grade 3b (intervention under GA): 1 event
  • Grade 4–5: 0 (no life-threatening complications, no deaths)

Patient-Reported Outcomes (n = 30 questionnaire respondents)​

OutcomeResult
Surgical success90% (27 / 30)
Intercourse ability100%
Erectile dysfunction6.7% (2 / 30)
Pain / tension on erection10% (3 / 30)
Premature ejaculation3.3% (1 / 30)
Penile lymphedema3.3% (1 / 30)

Comparative Context​

OutcomeMurányi (n = 49)Fakin bipedicled (n = 43)Mendel bilateral (n = 22)
Overall complication26.5%~ 40% (combined minor)[6]~ 50% (early + late)[7]
Wound dehiscenceincluded in CD 3a19%31.8%
Erectile dysfunction6.7%0% reportedn/r
Pain / tension on erection10%n/rn/r
Intercourse ability100%100%n/r
Patient satisfaction90% success4.37 / 58 / 10 global

Single-stage vs two-stage data (Lumbiganon n = 42)[8]​

  • Postoperative fever — single-stage 56.5% vs two-stage 8.3% (RR 6.78, 95% CI 1.01–43.83)
  • Complication-free — single-stage 43.5% vs two-stage 83.3% (RR 0.53, 95% CI 0.31–0.89)
  • Hospital stay — single-stage 7.4 ± 3.2 d vs two-stage 10.9 ± 1.6 d

The Murányi tunnel complication rate (26.5%) sits between Lumbiganon's traditional single-stage (~ 56.5%) and two-stage (~ 16.7%), suggesting the tunnel + inverted-V modifications mitigate some of the historical single-stage complication burden.[1][8]

Advantages​

  1. Single-stage — avoids second operation and psychological burden of a buried penis
  2. Simplified flap design — no central window or complex bilateral rotation
  3. Eliminates the T-junction — inverted-V ventral closure avoids the necrosis-prone T-style anastomosis
  4. Preserved bilateral blood supply — both external-pudendal pedicles intact within the scrotal tunnel
  5. Natural skin draping — scrotal skin conforms to the shaft as it passes through the tunnel
  6. Suitable when residual foreign material on corpora — intrinsic flap blood supply tolerates a graft-hostile bed

Disadvantages and Limitations​

  • Requires intact scrotal skin — contraindicated if foreign material has infiltrated the scrotum
  • Pain / tension on erection (10%) — tunnel configuration may tether at the penoscrotal junction
  • Erectile dysfunction (6.7%) — higher than Fakin's 0%, possibly from tunnel constriction or nerve injury
  • High CD 3a rate — 16.3% required bedside intervention
  • Hair-bearing potential — variable
  • Testicular ascension / scrotal volume reduction — not specifically reported in Murányi but a known scrotal-flap complication[7]
  • Single-etiology evidence — all 49 patients were paraffinoma; applicability to other etiologies is extrapolated

Adjunctive Refinements​

Kim Y-V advancement for length preservation​

Y-V advancement at the dorsal penile base + partial suspensory ligament resection added to a bipedicled scrotal flap. n = 5 — prevented penile shortening with universal patient satisfaction.[9]

Shin inverted-V anastomosis​

Direct comparison (n = 34) of T-style vs inverted-V ventral closure — 100% flap survival with no ventral skin necrosis in the inverted-V group. The Murányi technique incorporates this principle in step 6.[4]

Kang single-stage NPWT + dermal substitute + STSG​

For paraffinoma patients who lack adequate scrotal skin or prefer a graft pathway — NPWT + Matriderm Flex + STSG single-stage. n = 11, 90.9% near-complete take, satisfaction 37 / 45.[10]

Patient Selection — When Murányi Wins​

Choose Murányi tunnelChoose two-stage scrotal flapChoose Fakin bipedicled
Circumferential paraffinoma defect with intact scrotal skinContaminated / actively infected bedSurgeon comfort with central-window technique
Single-stage preferredConcern about flap viability (prior scrotal surgery, RT)Residual material doesn't dictate flap-vs-graft choice
Residual foreign material on corporaPatient can tolerate two operationsSingle-stage with similar reliability
Surgeon experienced with tunnel dissectionLower complication rate prioritized

Key Takeaways​

  • The subcutaneous tunnel and inverted-V ventral closure are the two defining innovations
  • Single-stage, simpler dissection than Fakin or Jeong bilateral approaches
  • 100% intercourse preservation; ED 6.7%, pain on erection 10% — counsel patients explicitly
  • Half of the complications are CD 3a (bedside) — expect a meaningful rate of wound issues even with the modifications
  • Currently the largest published single-institution single-stage paraffinoma series

See Also​

References​

1. Murányi M, Varga D, Kiss Z, Flaskó T. "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(1):171–178. doi:10.1097/JU.0000000000002480

2. Napolitano L, Marino C, Di Giovanni A, et al. "Two-Stage Penile Reconstruction After Paraffin Injection: A Case Report and a Systematic Review of the Literature." J Clin Med. 2023;12(7):2604. doi:10.3390/jcm12072604

3. Jeong JH, Shin HJ, Woo SH, Seul JH. "A New Repair Technique for Penile Paraffinoma: Bilateral Scrotal Flaps." Ann Plast Surg. 1996;37(4):386–93. doi:10.1097/00000637-199610000-00007

4. Shin YS, Zhao C, Park JK. "New Reconstructive Surgery for Penile Paraffinoma to Prevent Necrosis of Ventral Penile Skin." Urology. 2013;81(2):437–41. doi:10.1016/j.urology.2012.10.017

5. McLaughlin MM, Abbassi B, Pribaz JJ. "Bipedicled Scrotal Flap for Penile Resurfacing." Plast Reconstr Surg. 2024;153(4):935–942. doi:10.1097/PRS.0000000000010811

6. Fakin R, Zimmermann S, Jindarak S, et al. "Reconstruction of Penile Shaft Defects Following Silicone Injection by Bipedicled Anterior Scrotal Flap." J Urol. 2017;197(4):1166–1170. doi:10.1016/j.juro.2016.11.093

7. Mendel L, Neuville P, Allepot K, et al. "Bilateral Pedicled Scrotal Flaps as an Alternative to Skin Graft in Penile Shaft Defects Repair." Urology. 2023;176:206–212. doi:10.1016/j.urology.2023.03.025

8. Lumbiganon S, Pachirat K, Sirithanaphol W, et al. "Surgical Treatment of Penile Foreign Body Granuloma: Penile Shaft Reconstruction With Single- Versus Two-Stage Scrotal Flap Techniques." Int J Urol. 2023;30(8):681–687. doi:10.1111/iju.15209

9. Kim SW, Yoon BI, Ha US, et al. "Treatment of Paraffin-Induced Lipogranuloma of the Penis by Bipedicled Scrotal Flap With Y-V Incision." Ann Plast Surg. 2014;73(6):692–5. doi:10.1097/SAP.0b013e31828637d3

10. Kang D, Hong SE, Kim YH. "Single-Stage Penile Resurfacing for Foreign Body Granuloma: A Simplified Negative Pressure Wound Therapy-Assisted Protocol With Dermal Substitute." Urology. 2026. doi:10.1016/j.urology.2026.04.013