Hydrocele Surgery by Dr.Sachin Kuber MS

Hydrocele Surgery Clinic

Hydrocele -www.hydrocele.in

Hydroceles are fluid collections within the tunica vaginalis of the scrotum or along the spermatic cord. These fluid collections may represent persistent developmental connections along the spermatic cord or an imbalance of fluid production versus absorption. Rarely, similar fluid collections can occur along the canal of Nuck in females.

The presence of fluid within the hemiscrotum imparts little clinical impact on the testis. However, determining the cause for the increased fluid, specifically any associated clinically significant pathology, remains the primary concern with regard to hydroceles. Once pathology that is more ominous has been excluded, persistence of the hydrocele or the association of discomfort may indicate the need for surgical intervention.

Etiology

The causes of hydroceles are legion. In children, most hydroceles are of the communicating type, in which patency of the processus vaginalis allows peritoneal fluid to flow into the scrotum, particularly during Valsalva. In the adult population, filariasis, a parasitic infection caused by Wuchereria bancrofti, accounts for most causes of hydroceles Following laparoscopic or transplant surgery in males, inadequate irrigation fluid aspiration may cause hydroceles in patients with a patent processus vaginalis or a small hernia. Careful aspiration of fluid at the end of laparoscopic procedures helps prevent this complication. In noncommunicating hydroceles, for both children and adults, the balance between fluid production within the tunica and the fluid absorption is altered.

Pathophysiology

The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and absorption. This imbalance can be divided further into exogenous fluid sources or intrinsic fluid production.

Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts.

Communicating hydroceles

With communicating hydroceles, simple Valsalva probably accounts for the classic variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat inexplicable. Those children with chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably warrant early surgical intervention.

Noncommunicating hydroceles

In noncommunicating hydroceles, the pathophysiology may occur as a result of increased fluid production or as a consequence of impaired absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increased fluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid production secondary to underlying inflammation. Although rare filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles.

Clinical

Hydroceles typically manifest as a soft nontender fullness within the hemiscrotum. The testis generally is palpable along the posterior aspect of the fluid collection. When the scrotum is investigated with a focused beam of light, the scrotum transilluminates, revealing a homogenous glow, without internal shadows.

The inability to clearly delineate or palpate the testicular structures; the presence of tenderness, fever, or any gastrointestinal symptoms (eg, vomiting, constipation, diarrhea), or the appearance of internal shadows on transillumination should raise the suggestion of a different diagnosis or some additional underlying pathology. A scrotal ultrasound is the next logical step.

Indications for intervention include the following:

* Inability to distinguish from an inguinal hernia

* Failure to resolve spontaneously after an appropriate interval of observation

* Inability to clearly examine testis

* Association of hydroceles with suggestive pathology (eg, torsion, tumor)

* Pain or discomfort

* Male infertility

* Patient desire

Imaging Studies* Ultrasound *

o As noted, sonography itself is rarely indicated for simple hydroceles.

o Furthermore, a reduced inguinal hernia may be missed on ultrasound images. However, ultrasound does provide excellent detail regarding the testicular parenchyma. Spermatoceles can be clearly distinguished from hydroceles on ultrasound images.

o If a testicular tumor is a diagnostic consideration, ultrasound is an excellent screening study.

TREATMENT

Asymptomatic adults with isolated noncommunicating hydroceles can be observed indefinitely or until they become symptomatic. However, if the diagnosis is in question or underlying pathology cannot be excluded, operative exploration is warranted.

Surgical therapy

Surgical therapy can be divided into 3 approaches.

1. The first is an inguinal approach with ligation of the processus vaginalis high within the internal inguinal ring and is the procedure of choice for pediatric hydroceles (typically, communicating). If a testicular tumor is identified on testicular ultrasound images, an inguinal approach with high control/ligation of the cord structures is mandated.
2. The second is the scrotal approach with excision or eversion and suturing of the tunica vaginalis and is recommended for chronic noncommunicating hydroceles. This approach should be avoided upon any suspicion for underlying malignancy.
3. The third, an additional adjunctive, if not definitive, procedure, is scrotal aspiration and sclerotherapy of the hemiscrotum using tetracycline or doxycycline solutions. Recurrence after sclerotherapy is common, as is significant pain and epididymal obstruction, making this treatment a last resort in poor surgical candidates with symptomatic hydroceles and in men in whom fertility is no longer an issue.

Intraoperative details

Intraoperative considerations during inguinal repair include meticulous attention to spermatic cord structures. A "no-touch" approach to the reactive testicular vessels and delicate vasa helps minimize complications. Excessive dissection around the testicular vessels may result in thrombophlebitis of the pampiniform plexus. The distal processus is spatulated widely to provide free drainage of scrotal fluid. The proximal processus is ligated above (deep to) the internal inguinal ring. Failure to identify a patent processus during inguinal exploration should prompt (1) a thorough reexamination of the cord structures and (2) partial or complete excision of the hydrocele or needle aspiration only of the hydrocele prior to closing.

During scrotal approaches, excision of redundant tunica vaginalis (with or without eversion) and suturing of the reflected tunica behind the epididymis results in a postoperative testis that is more easily and more reliably examined. Care must be taken to not injure the vas or epididymis during this procedure. A running hemostatic suture around the line of excision is helpful for assuring hemostasis. Plication of the sac (Lord procedure) is another technique useful for management of large hydroceles. Electrocautery fulguration of the edge of the excised tunica vaginalis promotes scarring and decreases recurrence while decreasing operative time.

Unexpected findings may be dealt with, as appropriate, either for the scrotal approach or by converting to an inguinal approach (eg, testicular tumors). If a testicular tumor is encountered, biopsy with frozen section and orchiectomy with resection of the spermatic cord up to the internal ring is warranted if tumor is confirmed. Placing a drain in the dependent portion of the scrotum is prudent for large hydroceles. A nonsuction drain such as a Penrose can be removed within the first 24-48 hours after surgery. If a drain is not used, expect a large hematoma and significant edema. Often, this enlargement is worse than the original problem, although it almost always transient.

Postoperative details

Children undergoing inguinal herniorrhaphies for repair of communicating hydroceles generally recuperate with minimal discomfort and exceedingly few restrictions. Tub baths are to be avoided for 5-7 days. The wounds of diaper-aged children are sealed with collodion, Dermabond, or occlusive dressing. No activity restrictions are required, and nonnarcotic analgesics are employed minimally.