Open Hydrocelectomy for Scrotal Hydrocele

Abstract

Hydrocelectomy is a common and effective surgical procedure used to treat hydrocele, a condition in males defined as an accumulation of benign peritoneal fluid between the layers of the scrotum. The indications for hydrocelectomy include pain, poor cosmetic appearance, or negative impact on patient quality of life. Surgical treatment of hydroceles aims to treat symptoms as well as prevent complications of hydroceles left untreated, including chronic pain or testicular ischemia. A scrotal incision is the most common approach for surgical management of non-communicating hydroceles. The hydrocele sac is isolated, the fluid is drained, and the sac is excised and closed to prevent recurrence. In this video, we present a case of a patient with a left sided non-communicating hydrocele that was treated with hydrocelectomy. As part of the procedure, a surgical drain was left in place.

Keywords

Testicular hydrocele; scrotal hydrocele; hydrocelectomy.

Case Overview

Background

Hydrocelectomy is a common and effective surgical procedure used to treat hydrocele, a condition estimated to affect 1% of adult men worldwide.¹ Roughly 65% of men have limited hydroceles visualized incidentally on ultrasound imaging that usually do not require any treatment.² There are two types of hydrocele, communicating and non-communicating. A communicating hydrocele is one in which fluid may enter and exit the scrotum freely from the peritoneal cavity. In a non-communicating hydrocele, the fluid is trapped within the scrotum. The most common type of hydrocele in men is idiopathic non-communicating, which is thought to be due to an imbalance of peritoneal fluid production and resorption by the tunica vaginalis, the scrotal layer containing the hydrocele.³ The purpose of hydrocelectomy is to treat symptoms including pain, pressure, skin changes or cosmetic appearance, as well as prevent complications of untreated hydrocele, including testicular atrophy, infertility, rupture, or chronic testicular pain.^4,5 An alternative treatment option to hydrocelectomy is hydrocele aspiration. However, aspiration has a high risk of recurrence, almost always resulting in reaccumulation of fluid within weeks.⁴

Focused History of the Patient

The patient in this case is a 50-year-old male with a past medical history of myocardial infarction on baby aspirin who initially presented to the urology clinic as a referral two years ago for left-sided scrotal swelling. The patient had a scrotal ultrasound at that time that confirmed the swelling was a hydrocele. At the time, he elected to undergo observation, as the hydrocele was not causing discomfort and was fairly small. However, over two years the hydrocele continued to enlarge, causing discomfort, and he returned to the clinic to discuss surgical management. He denied any recent urinary tract infection, trauma to the area, or epididymitis.

He was scheduled for elective left-sided hydrocelectomy a few weeks later.

Physical Exam

The patient was afebrile and had a normal blood pressure and heart rate. On exam, he had bilaterally descended testicles and a circumcised phallus. His right hemiscrotum was without any palpable masses or hydrocele. The left hemiscrotum was significant for moderate hemiscrotal swelling which transilluminated. There was no obvious inguinal hernia on exam.

Imaging

Scrotal ultrasound from two years prior to hydrocelectomy showed a minimally complex left hydrocele with internal echoes.

Natural History

Idiopathic non-communicating hydroceles typically do not improve on their own without treatment. In this type of hydrocele, the tunica vaginalis is closed off from the peritoneum, and the peritoneal fluid remains trapped within the scrotum. This results in a slowly progressive increase in volume of these hydroceles over time. Patients who do not receive treatment for large non-communicating idiopathic hydroceles can eventually experience symptoms including pain, discomfort with tight-fitting clothing, and dissatisfaction with cosmetic appearance. Rarely, without treatment, these types of hydroceles can cause testicular atrophy, infertility, hydrocele rupture, pyocele, or infection.^4,5

Options for Treatment

There are several documented procedural treatments for idiopathic non-communicating hydrocele. These include aspiration/sclerotherapy and hydrocelectomy. There are multiple surgical techniques for hydrocelectomy, including surgical excision, Lord plication, or Jaboulay eversion. Each of these options has variable outcomes. Aspiration, as mentioned, has high risk for recurrence.⁶ Alternatively, hydrocelectomy has fantastic success rates and a very low rate of recurrence.⁶

Rationale for Treatment

The goal of surgical treatment of non-communicating idiopathic hydrocele is typically to relieve the burdensome symptoms. These include scrotal pain, discomfort with certain clothing, and dissatisfaction with cosmetic appearance. Furthermore, there are several rare complications from hydroceles left untreated including testicular atrophy, infertility, pyocele, or rupture.

Discussion

Hydroceles are a common, burdensome urologic condition affecting many males in the United States annually. While most hydroceles do not require surgical management, those that are non-communicating, idiopathic, and large, can cause symptoms including pain, discomfort with certain clothing, and distressing cosmetic appearance. Hydrocelectomy is a cost effective and safe surgical treatment option with a low rate of recurrence for men with symptomatic idiopathic non-communicating hydroceles. For this type of hydrocele, a scrotal approach is most common and effective.

Several techniques for hydrocelectomy exist. The most common excision approach is the Jaboulay technique.⁴ In this approach, a scrotal incision is made, the hydrocele sac is peeled away from the surrounding scrotal layers, the hydrocele sac is exposed, incised, and drained, and finally, the hydrocele sac is excised. Some of the hydrocele sac adjacent to the testicle is left behind, everted, and oversewn to provide hemostasis, prevent recurrence, and reduce bulkiness of the affected testicle. This was the technique used in this case. 

The patient in this case had a history of non-ST elevation myocardial infarction and a large non-communicating idiopathic left-sided hydrocele. He was brought electively to the operating room under general anesthesia for left hydrocelectomy through a single scrotal incision. He remained on low-dose aspirin throughout the perioperative period. Intraoperatively, we documented drainage of 450 mL of clear yellow serous fluid from his hydrocele. There were no surgical complications in this case. A surgical drain was placed intraoperatively and was removed on postoperative day one. The patient was discharged home on the same day as the surgery with a short course of narcotic medication, which the patient did confirm using.

Because the scrotum is elastic, it is crucial to obtain adequate hemostasis prior to incision closure during hydrocelectomy to prevent hematoma formation. In addition to hematoma, surgical site infection represents the most common postoperative complication post-hydrocelectomy.⁷ At the end of the procedure, the decision must be made whether or not to leave a temporary surgical drain. While surgical drains may reduce risk of fluid accumulation and hematoma formation, they also have been shown to pose risk for infection in one study of general, orthopedic trauma, and vascular surgery patients.⁸ The decision amongst urologists to leave drains post-hydrocelectomy appears skewed based on varying data, as a recent study showed that routine drain placement after hydrocelectomy does not reduce risk of hematoma formation nor increase rate of surgical site infection.9 In our case, a surgical drain was placed to help drain additional inflammatory fluid or any potential postoperative venous oozing.

In this case, a surgical Penrose drain was placed exiting the dependent portion of the scrotum. We made a small, new incision away from the primary surgical site. The drain was not secured to the skin, but instead was loosely attached to gauze fluffs via a durable permanent suture. The patient removed the drain himself on postoperative day one by pulling on the gauze fluffs until the entirety of the drain was removed. The drain incision was left to heal via secondary intention, allowing for additional drainage of postoperative fluid in the subsequent postoperative days. Leaving the drain free from skin attachment prevents the need for patients to return to clinic for drain removal, but may increase risk for early accidental drain removal. Nonetheless, this was a unique technique that does not appear described in the literature.

The patient in this case was seen in follow-up 4 weeks postoperatively. He reported improvement in left-sided scrotal pain that he experienced preoperatively. There were no postoperative complications and his left-sided hydrocele had resolved with minimal residual scrotal edema and induration.

Equipment

• Electrocautery device x 1
• Yankauer suction x 1
• Adson forceps x 2
• 15 blade scalpel x 1
• 3-0 chromic suture x 3
• 0 PDS suture x 1
• 1/4-inch Penrose drain
• Gauze fluffs
• Mesh briefs

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given his informed consent to be filmed and is aware that information and images will be published online.