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Vascularized Lymph Node Transfer (VLNT) into the Scrotum / Groin

Vascularized lymph node transfer moves lymph-node-bearing tissue with its blood supply to a recipient site where it may improve lymphatic drainage. For genital lymphedema it is a specialist option, sometimes combined with excision, rather than an established cure or a mandatory step for every advanced case. The small genital series do not prove superiority over excision alone, lymphaticovenous anastomosis or another donor/recipient site.[1][2]

See Genital Lymphedema for evaluation, Complex Decongestive Therapy for conservative care and LVA for bypass of usable collectors.

Selection​

Consider VLNT within a multidisciplinary plan when symptoms remain substantial despite appropriate conservative care, especially when mapped collectors are unsuitable for effective LVA. Assess fluid versus solid tissue enlargement, recurrent infections, genital and leg involvement, donor drainage, recipient vessels, prior surgery/radiation and the patient's goals. Active infection or new obstructive pathology requires treatment or investigation before elective transfer.[1][2]

  • Clinical stage alone is insufficient. Advanced-stage patients can retain usable collectors; a negative superficial ICG study does not prove that LVA is impossible. Conversely, transferring nodes does not remove bulky fibrosis or restore the contour of a buried penis without appropriate tissue reduction.[1][3]
  • A fixed six-month CDT prerequisite is not established for genital VLNT. Optimize care and document the residual problem; timing depends on symptoms, tissue condition and surgical readiness.[1]
  • MR findings are not a validated VLNT algorithm. Lu's genital MR-lymphography cohort used CDT, three microsurgical bypass procedures and excision; it did not establish a rule that nodal hypoplasia requires VLNT.[4]
  • Limb evidence requires qualification. The AAPS consensus supports selected lymphatic surgery for extremities but found no consensus that LVA or VLNT is more effective. Its grading does not establish genital-specific efficacy.[5]

Mechanism and expected benefit​

Proposed mechanisms include new lymphatic connections to the transferred tissue and lymph-to-venous drainage within the flap. A small human biopsy series supports increased lymphatic-vessel density after transfer; immune-cell and reconnection findings also come from animal experiments. These findings do not establish a predictable time to functional integration or prove immune restoration in genital patients. Clinical benefit must be measured separately from flap survival and imaging uptake.[3][6][7]

Donor sites and safety​

No donor is proven best for genital VLNT. Choose according to prior treatment, drainage mapping, available vessels, required tissue and donor-site risk. The number of nodes alone is not a validated selection rule.[1][2][3]

DonorAnatomical basis and practical tradeoff
Lateral thoracic / axillaryLateral thoracic vessels were used in Ehrl's five genital transfers. Preserve drainage from the arm; axillary harvest is not free of donor-lymphedema risk merely because a small series observed none.
Superficial inguinalCommonly based on superficial circumflex iliac vessels. Donor-leg drainage may enter superficial inguinal nodes, so physiologic mapping and limited harvest are important. Seroma and sensory symptoms remain possible.
Submental / submandibularFacial vessels were used in two reported scrotal cases. Neck dissection requires attention to local nerves and vessels; the small genital experience does not establish a preferred donor.
SupraclavicularUsually based on the transverse cervical vascular system. Node distribution and neck anatomy vary; cadaveric node counts do not determine clinical efficacy or eliminate donor morbidity.
Omental / gastroepiploicAvoids harvesting an extremity-draining nodal basin. It adds an abdominal donor operation, with intra-abdominal surgical risks.
Jejunal mesentericUses mesenteric node-bearing tissue and requires preservation of bowel perfusion. It avoids an extremity nodal basin but introduces abdominal and bowel-ischemia considerations.

The donor descriptions above are drawn from anatomical and operative studies, chiefly for limb lymphedema. Current genital experience is much smaller.[1][2][3][8][9][10][11][12][13]

Reverse lymphatic mapping​

The purpose of reverse mapping is to identify and preserve nodes draining the donor extremity while selecting tissue draining the intended trunk territory. ICG, radioisotope techniques and other tracers are used in center-specific protocols; each agent and route requires appropriate safety checks. Mapping can reduce risk, but it does not make donor-site lymphedema impossible.[1][8]

In one 39-patient groin-harvest study, ICG and gamma-probe localization agreed and no donor lymphedema was reported. Another study assessed 84 patients by SPECT/CT, of whom 56 underwent 58 groin flap transfers; no donor-leg lymphedema was reported during follow-up. These observational results support careful planning, not universal equivalence of mapping methods or a zero-risk consent statement.[14][15]

Recipient site and operative planning​

The groin is a regional nodal basin for superficial genital drainage. Direct scrotal inset places transferred tissue locally; it should not be called inherently “orthotopic” simply because it lies in the affected genital region. Choose the target using the distribution of disease, available drainage and vessel anatomy, and planned soft-tissue reconstruction.[2]

  1. Plan donor and recipient together. Evaluate prior incisions, radiation, infection, lymphatic pathways and vascular suitability. Use imaging when it will resolve a planning question rather than copying one series' imaging regimen for every patient.
  2. Preserve donor drainage and perfusion. Use the selected mapping strategy and protect extremity-draining structures. Avoid excessive nodal or surrounding-tissue dissection.
  3. Prepare a viable recipient bed. Tailor scar release and tissue excision to the actual pathology, retaining healthy skin and protecting genital structures. Plan coverage and dead-space management alongside the transfer.
  4. Perform and verify the vascular connections. A free transfer needs arterial and venous anastomoses; a pedicled transfer retains its vascular connection. Avoid pedicle compression, twisting or tension and establish a monitoring plan.
  5. Coordinate postoperative monitoring and rehabilitation. Follow the flap, wounds and donor site; restart compression and other therapies according to the repair and team protocol. Improvement may evolve over months, and ongoing conservative care may still be needed.

These are planning principles, not a donor-specific harvest manual. Detailed dissection and flap-monitoring decisions require the relevant technique and local microsurgical expertise.[1][2][8][10][12]

Ehrl used superficial circumflex iliac recipient vessels for three groin transfers and superficial external pudendal vessels for two scrotal transfers. Phan's two neck-node transfers used deep inferior epigastric perforator vessels in the groin. These are reported options, not interchangeable mandatory recipients.[2][10]

What the genital reports actually show​

ReportProcedure and follow-upInterpretation
Ehrl 2023Nine patients had excision/reconstruction: four without VLNT, three with groin VLNT and two with scrotal VLNT. No recurrence was observed across all nine at median 49 months. The two scrotal-transfer patients had only 18 and 16 months of follow-up, with improved postoperative scintigraphy.Imaging in two patients is hypothesis-generating. The 49-month median and absence of recurrence cannot be attributed specifically to scrotal transfer; there was no randomized comparison.
Phan 2020Two free submental/submandibular transfers to the groin; scrotal dimensions improved at nine and six months.Feasibility report, without a comparative or durable-cure estimate.
Abdelfattah 2020One patient had bilateral pedicled superficial inguinal tissue transfer, to the scrotal root and proximal thigh, plus lower-limb LVA; reported improvement at nine months.A combined procedure in one patient cannot identify the effect of each component.
SCIP lymphatic flap reportsAbdelfattah reported 26 men undergoing excision plus pedicled SCIP lymphatic reconstruction, with 100% flap survival and improved symptom scores at mean 44.9 months. Yamamoto reported seven men with excision plus SCIP lymphatic flap reconstruction, with no observed genital recurrence at mean 22.7 months.Pedicled tissue/lymphatic reconstruction differs from an isolated free-node transfer. Flap survival is not freedom from all complications, and these cohorts cannot prove added benefit over excision alone.

The genital literature supports discussing these options in selected patients with explicit uncertainty. It does not establish a universal “curative algorithm,” permanent freedom from compression, preserved fertility or superiority of one flap.[2][10][16][17][18]

The Ehrl treatment-oriented classification describes anatomical involvement—scrotum alone, scrotum plus penis, and combined involvement with buried penis. It is separate from ISL extremity staging and does not mean stage I is pitting/CDT only or that stage III requires VLNT.[2]

Evidence from limb lymphedema​

A 2019 Cochrane review found only one 36-participant trial of VLNT for established stage II breast-cancer-related arm lymphedema, with very-low-certainty evidence. It did not evaluate genital VLNT. The newer 2025 Hahn review included 52 studies of LVA and/or VLNT across 1,920 extremities, mostly nonrandomized, with very high heterogeneity. Its pooled changes in excess circumference or volume are not whole-genital-volume reduction rates or reliable head-to-head estimates.[3][19]

The 2025 Jungbauer review associated both operations with fewer long-term cellulitis episodes in limb cohorts; its reported VLNT size estimates were circumference, not volume. A 2026 recipient-site review could pool only distal-inset data because other sites were too heterogeneous; this cannot establish that distal placement is superior to groin or scrotal placement for genital disease.[20][21]

Follow-up and counseling​

Monitor flap viability and wound healing early, including donor-site swelling, seroma and sensory problems. Long-term review should record genital and leg measurements separately, lymphorrhea, cellulitis, compression use, functional limitations and patient-reported benefit. Assess recurrence for residual disease, new obstruction or other causes before assuming flap failure.[1][2]

Discuss the possibility of flap thrombosis or loss, donor injury, persistent edema, recurrence and further procedures. Abdominal donor options have different risks from groin or axillary harvest. A technically surviving flap or positive lymphoscintigram does not guarantee sufficient symptom improvement, and a report of zero observed complications does not establish zero risk.[1][2][9][12][13]

See Also​

References​

1. Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2023 Consensus Document. Lymphology. 2023;56:133–151. Full consensus.

2. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema — what to do? J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586

3. Hahn BA, Kleeven A, Richir MC, et al. Objectifying Clinical Outcomes After Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer in the Treatment of Extremity Lymphedema: A Systematic Review and Meta-Analysis. Microsurgery. 2025;45(3):e70050. doi:10.1002/micr.70050

4. Lu Q, Jiang Z, Zhao Z, et al. Assessment of The Lymphatic System of the Genitalia Using Magnetic Resonance Lymphography Before and After Treatment of Male Genital Lymphedema. Medicine (Baltimore). 2016;95(21):e3755. doi:10.1097/MD.0000000000003755

5. Chang DW, Dayan J, Greene AK, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg. 2021;147(4):975-993. doi:10.1097/PRS.0000000000007783

6. Maruccia M, Giudice G, Ciudad P, et al. Lymph-node transfer and neolymphangiogenesis: from theory to evidence. Plast Reconstr Surg. 2023;152(5):904e–912e. doi:10.1097/PRS.0000000000010434

7. Aschen SZ, Farias-Eisner G, Cuzzone DA, et al. Lymph node transplantation results in spontaneous lymphatic reconnection and restoration of lymphatic flow. Plast Reconstr Surg. 2014;133(2):301-310. doi:10.1097/01.prs.0000436840.69752.7e

8. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135(1):277-285. doi:10.1097/PRS.0000000000000822

9. Liu HL, Pang SY, Lee CC. Donor limb assessment after vascularized groin lymph node transfer for the treatment of breast cancer-related lymphedema: Clinical and lymphoscintigraphy findings. J Plast Reconstr Aesthet Surg. 2019;72(2):216-224. doi:10.1016/j.bjps.2018.10.013

10. Phan R, Seifman MA, Dhillon R, et al. Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases. Microsurgery. 2020;40(7):808-813. doi:10.1002/micr.30651

11. Oonjitti T, Piyaman P, Apichonbancha S, et al. Anatomic insights into the vascularized supraclavicular lymph node flap and a novel design for enhanced lymphedema surgery. Sci Rep. 2025;15(1):28811. doi:10.1038/s41598-025-11090-y

12. Coriddi M, Wee C, Meyerson J, et al. Vascularized Jejunal Mesenteric Lymph Node Transfer: A Novel Surgical Treatment for Extremity Lymphedema. J Am Coll Surg. 2017;225(5):650-657. doi:10.1016/j.jamcollsurg.2017.08.001

13. Schaverien MV, Hofstetter WL, Hall MS, et al. Jejunal Mesenteric Vascularized Lymph Node Transplantation for Lymphedema: Outcomes and Technical Modifications. Plast Reconstr Surg. 2022;149(4):700e-710e. doi:10.1097/PRS.0000000000008960

14. Pons G, Abdelfattah U, Sarria J, et al. Reverse Lymph Node Mapping Using Indocyanine Green Lymphography: A Step Forward in Minimizing Donor-Site Morbidity in Vascularized Lymph Node Transfer. Plast Reconstr Surg. 2021;147(2):207e-212e. doi:10.1097/PRS.0000000000007585

15. Broyles JM, Smith JM, Wong FC, et al. Single-Photon Emission Computed Tomographic Reverse Lymphatic Mapping for Groin Vascularized Lymph Node Transplant Planning. Plast Reconstr Surg. 2022;150(4):869e-879e. doi:10.1097/PRS.0000000000009557

16. Abdelfattah U, Elbanoby T, Ayad W, et al. Treatment of secondary scrotal and lower extremity lymphedema using combined pedicled lymph node transfer and lymphaticovenous anastomosis: A case report. Microsurgery. 2020;40(8):901-905. doi:10.1002/micr.30656

17. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of Advanced Male Genital Lymphedema With a Complete Functional Lymphatic System Pedicled Transfer. Urology. 2023;175:190-195. doi:10.1016/j.urology.2023.02.006

18. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg. 2022;75(2):870-880. doi:10.1016/j.bjps.2021.08.011

19. Markkula SP, Leung N, Allen VB, et al. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Cochrane Database Syst Rev. 2019;2:CD011433. doi:10.1002/14651858.CD011433.pub2

20. Nicholas Jungbauer W, Solomon S, Verhey EM, et al. Lymphovenous Anastomosis and Vascularized Lymph Node Transfer Reduce Long-term Cellulitis Events in Patients With Secondary Lymphedema: A Systematic Review and Meta-analysis. Ann Plast Surg. 2025;95(5):522-530. doi:10.1097/SAP.0000000000004508

21. Ramadan MR, Angelin P, Atmodiwirjo P. Recipient site selection in vascularized lymph node transfer for secondary lymphedema: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2026;114:160-171. doi:10.1016/j.bjps.2026.01.005