Primary Closure of the Scrotum
Primary closure or local advancement can preserve healthy native scrotal tissue and avoid a graft donor site. It is appropriate when the tissue is viable, infection is controlled and the closure is comfortable and without excessive tension. The commonly cited 50% skin-loss guide is not a validated cutoff; the amount and quality of remaining tissue matter more.[1]
See the reconstruction overview for alternatives when a closure would compromise coverage or perfusion.
Anatomy relevant to mobilization
Preserve the skin–dartos envelope and its vessels while distinguishing it from the deeper spermatic coverings and tunica vaginalis. Carrera's 15-cadaver microvascular study identified communicating lateral territories from the external pudendal system and a central territory supplied through perineal branches and the septum. Importantly, fine septal vessels can be injured by deep dissection. A rich vascular network is not permission for unlimited undermining or routine septal division.[2]
The gubernaculum should not be treated as an avascular tether. Gubernacular/cremasteric collateral vessels can contribute to testicular supply, especially after prior vessel-dividing orchiopexy. Ellis demonstrated these connections during second-stage Fowler–Stephens surgery; this pediatric observation establishes the anatomical concern, not an adult scrotoplasty outcome rate. Review previous testicular and inguinal operations before mobilization.[3]
Selection and timing
| Setting | Decision |
|---|---|
| Elective scrotal incision or limited defect | Layered closure after hemostasis when viable tissue approximates easily |
| Trauma | Evaluate the testis, cord and associated injuries; debride nonviable tissue and choose immediate or delayed skin closure according to contamination and viability |
| Fournier's gangrene | Urgent source control first; consider same-admission closure only once the patient and wound are suitable |
| Hidradenitis | Treat the underlying disease and close only if adequate healthy tissue remains after the indicated excision |
| Genital lymphedema | Tailored excision may permit native-skin closure; feasibility in selected series does not guarantee closure in all patients |
These decisions require a backup plan for graft or flap coverage rather than escalation to increasingly aggressive mobilization solely to avoid one.[4][1][5][6]
Operative principles
- Assess and preserve viable structures. In trauma, confirm the testicular repair before addressing the skin envelope. Suspected rupture or inconclusive ultrasound warrants exploration; tunica-albuginea closure and possible tunica-vaginalis tissue coverage are testicular repairs, distinct from scrotal skin closure.[4]
- Control bleeding and contamination. Do not bury an inadequately debrided infection, uncontrolled hematoma or necrotic tissue beneath a convenient skin closure.
- Mobilize only what is necessary. Preserve an adequate tissue layer around the vascular supply; tailor any local advancement to the defect. Septal division, gubernacular division and proximal cord mobilization are not standard prerequisites. Avoid cord twisting, compression or forced superior relocation of the testes.[2][3]
- Test the closure before committing. Assess perfusion, tension, room for the contents and the effect of expected swelling. If satisfactory closure is not possible, use delayed closure, grafting or a planned flap as appropriate.[1]
- Close the appropriate layers with minimal tissue trauma. Approximate viable dartos and skin using suitable absorbable material without constricting the blood supply. Tailor suture caliber, pattern, drainage and support to tissue quality and contamination. A drain does not replace hemostasis.[7][8]
Delayed closure and local advancement after Fournier's gangrene
Sandberg 2022 retrospectively evaluated 84 patients: 48 underwent primary closure and 36 healed by secondary intention. Management varied between reconstructive urology, general surgery/burns and conservative care, and wound extent differed among groups. Closed wounds had a reported 64% shorter convalescence after adjustment for anatomical extent. Secondary-procedure rates were 6.3% versus 11% (p = 0.67). This supports considering closure in suitable wounds; it does not prove a universal 64% treatment benefit, equivalence in complications, or that every large scrotal wound can be closed.[9]
Lauerman 2018 reported complete primary closure in 39.9% of 168 patients. Patients who received closure had less severe illness and were more likely to have perineum-limited disease. This is selection-dependent feasibility rather than a target closure rate for every service.[10]
Kumar 2023 described 16 selected patients receiving delayed primary closure. Median time to closure was 6.5 days and mean defect area was 119 cm². Eight required scrotal flaps alone; others required advancement from the thigh, lower abdomen or perineum. Four Clavien–Dindo III complications occurred: two partial flap necroses, one dehiscence and one bleeding episode. Thus, this was not simply suturing every large defect closed, and complications were not all minor. The cohort's median timing is not a requirement to close on day 6 or 7.[11]
Selected expansion and staging techniques
| Technique | What has been reported and its limits |
|---|---|
| Rapid intraoperative expansion | Kwon treated three patients with about 75% loss using bilateral residual scrotal/medial-thigh pockets and temporary 300-mL expanders, inflated over 20 minutes. All had satisfactory coverage at 12 months. This is a preliminary technique report, not a validated indication or safe universal inflation protocol.[12] |
| Tissue-expanded V-Y scrotoplasty | Rapp described staged expansion followed by advancement; it requires a separate expansion plan and subsequent operation.[13] |
| Expanded groin flap | Atik described three total-loss reconstructions using expansion over three weeks followed by a thin groin flap. This is regional flap transfer, not primary scrotal closure.[14] |
| Temporary thigh pouches | Okwudili's 12-patient series used delayed return of the testes over months. Normal reported testicular volume is not proof of normal fertility. Consider pain, cord safety, appearance and the patient's goals.[15] |
See Testicular Thigh Pouches for that separate operation. There is no obligatory progression through these maneuvers before offering a graft.
Function and follow-up
Native tissue can offer favorable contour and mobility, but it does not guarantee normal sensation, temperature regulation or fertility after severe infection, trauma or lymphedema. Demir's rat experiment cannot establish human superiority over grafting; human burn-graft heat-response studies are not measurements of fertility after scrotal reconstruction.[16][17][18]
Discuss reproductive goals and evaluate pain, mobility, sexual function and healing. Marked bleeding, threatened perfusion, infection, testicular compromise or major dehiscence may require intervention. Avoid interpreting a selected series of predominantly conservative wound treatment as a rule that all postoperative problems can be observed.[11][5]
Lymphedema and massive localized lymphedema need continuing disease-directed care. Torio-Padron's 51 patients underwent an integrated decongestive and surgical program; three complications required revision. Wisenbaugh's 11 patients reported improved quality of life despite common wound problems and postoperative weight gain. Neither study establishes a universal closure method or cure.[6][5]
See Also
References
1. Karian LS, Chung SY, Lee ES. Reconstruction of defects after Fournier gangrene: a systematic review. Eplasty. 2015;15:e18. Full text.
2. Carrera A, Gil-Vernet A, Forcada P, et al. "Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps." BJU Int. 2009;103(6):820–824. doi:10.1111/j.1464-410X.2008.08167.x
3. Ellis R, Lahiri R, Mahomed A. Mapping testicular blood supply in gubernaculum-sparing second-stage Fowler–Stephens procedure. Surg Endosc. 2014. doi:10.1007/s00464-014-3574-y.
4. European Association of Urology. Urological Trauma Guidelines. 2026. Testicular trauma: diagnosis, management and recommendations. Guideline.
5. Wisenbaugh E, Moskowitz D, Gelman J. "Reconstruction of massive localized lymphedema of the scrotum: results, complications, and quality of life improvements." Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063
6. Torio-Padron N, Stark GB, Földi E, Simunovic F. "Treatment of male genital lymphedema: an integrated concept." J Plast Reconstr Aesthet Surg. 2015;68(2):262–268. doi:10.1016/j.bjps.2014.10.003
7. Byrne M, Aly A. "The surgical suture." Aesthet Surg J. 2019;39(Suppl_2):S67–S72. doi:10.1093/asj/sjz036
8. Oesterling JE. "Scrotal surgery: a reliable method for the prevention of postoperative hematoma and edema." J Urol. 1990;143(6):1201–1202. doi:10.1016/s0022-5347(17)40224-2
9. Sandberg JM, Warner HL, Flynn KJ, et al. "Favorable outcomes with early component separation, primary closure of necrotizing soft tissue infections of the genitalia (Fournier's gangrene) debridement wound defects." Urology. 2022;166:250–256. doi:10.1016/j.urology.2022.03.042
10. Lauerman M, Kolesnik O, Park H, et al. Definitive wound closure techniques in Fournier's gangrene. Am Surg. 2018;84:86–92. doi:10.1177/000313481808400127.
11. Kumar SS, Sun HH, Tay K, et al. "Favorable safety outcomes of delayed primary closure of large Fournier's gangrene skin defects." Urology. 2023;180:270–277. doi:10.1016/j.urology.2023.07.028
12. Kwon EO, Pareek G, Fracchia JA, Armenakas NA. "Scrotal reconstruction using rapid intraoperative tissue expansion: a preliminary report." J Urol. 2008;179(1):207–209. doi:10.1016/j.juro.2007.08.129
13. Rapp DE, Cohn AB, Gottlieb LJ, Lyon MB, Bales GT. "Use of tissue expansion for scrotal sac reconstruction after scrotal skin loss." Urology. 2005;65(6):1216–1218. doi:10.1016/j.urology.2005.02.006
14. Atik B, Tan O, Ceylan K, Etlik O, Demir C. "Reconstruction of wide scrotal defect using superthin groin flap." Urology. 2006;68(2):419–422. doi:10.1016/j.urology.2006.04.003
15. Okwudili OA. "Temporary relocation of the testes in anteromedial thigh pouches facilitates delayed primary scrotal wound closure in Fournier gangrene with extensive loss of scrotal skin — experience with 12 cases." Ann Plast Surg. 2016;76(3):323–326. doi:10.1097/SAP.0000000000000505
16. Demir Y, Aktepe F, Kandal S, Sancaktar N, Turhan-Haktanir N. "The effect of scrotal reconstruction with skin flaps and skin grafts on testicular function." Ann Plast Surg. 2012;68(3):308–313. doi:10.1097/SAP.0b013e318214534f
17. Crandall CG, Davis SL. "Cutaneous vascular and sudomotor responses in human skin grafts." J Appl Physiol (1985). 2010;109(5):1524–1530. doi:10.1152/japplphysiol.00466.2010
18. Davis SL, Shibasaki M, Low DA, et al. "Sustained impairments in cutaneous vasodilation and sweating in grafted skin following long-term recovery." J Burn Care Res. 2009;30(4):675–685. doi:10.1097/BCR.0b013e3181abfd43