Scrotal elephantiasis is a rare form of lymphedema of the scrotum. Its pathophysiology is diverse and often not clear, as there are only a few diagnostic tools available. Primary therapy consists, as usual for lymphedema, of conservative measures. However, due to anatomical and physiological findings, conservative therapy options are not always applicable. Although the only possible therapy in severe cases is the surgical resection, there is a lack in the literature regarding a standardized surgical approach. Surgical treatment of massive scrotal elephantiasis was performed in two patients according to a standardized strategy. After computed tomography and planning the operation, the penis and testicles were first exposed. Then, the reduction of the scrotum was performed, by holding the lateral flaps to the contralateral side and setting the cutoff line to the center. The cranial flap was decreased as in a modified abdominoplasty. After surgical treatment following the standardized approach, both patients showed functionally and esthetically positive results. Scrotal elephantiasis has a huge impact on life quality of the affected patients. With the described combination of intense conservative therapy and a standardized surgical procedure, these challenging patients can be helped.