Definition:
It is a surgical technique that consists in removing the accumulation of excessive amount of fluid inside the tunica vaginalis via opening of the scrotum, which can be find in pediatric or adult age. In pediatric age it is associated with the persistence of the peritoneum-vaginal pervious ductus and the migration of peritoneal fluid into the tunica vaginalis. In this case the hydrocele very often resolves spontaneously in the first year of life. Otherwise the presence of a hernia sac can be suspected.
In the adult population, the hydrocele may occur due to an imbalance between the secretion of the tunica albuginea of the testis and the reabsorption of this fluid by the parietal layer of the tunica vaginalis. Moreover, in adulthood the hydrocele can be consequence of the presence of a tumor.
When an hydrocele is suspected it must be made a diagnostic scrotal ultrasound.
Indications:
The intervention is performed in pediatric age when the hydrocele has not resolved within the first or second year of life or when, in adulthood, causes problems to the patient such as heaviness, tightness or local discomfort or even aesthetic.
Description of the technique:
There are various techniques which can be made under local, spinal or general anesthesia:
1) Scrotal approach
The scrotal hydrocelectomy can be practiced in older patients, past the age where cancer is more common and where the scrotal ultrasound has revealed normal testicles. The scrotal hydrocelectomy can also be practiced safely when the ultrasound examination is normal in younger patients with a clear etiology for the hydrocele. In these circumstances a transverse incision in the scrotal folds and among the scrotal vessels or a median incision on the raphe generates a minimal bleeding and leaves a nearly invisible scar. After exposing the sac and, if the excision technique is intended to be used, having externalized it intact, the sac is cut open, frontally away from the testis, the epididymis, the vas deferens and the spermatic cord structures in an avascular area and hydrocele fluid samples may be withdrawn for culture and cytology in case of suspicion.
2) Inguinal approach
It is performed in children or in young patients with suspicion of scrotal heteroplasia. It is performed by making an incision of 3-4 cm at the level of the inguinal skin. This approach allows a better inspection of the inguinal canal.
After all the important structures within and adjacent to the hydrocele sac have been identified, the correction is performed with one of the techniques described below:
A) Excision techniques
The excision techniques are the safest with regard to the permanent disappearance of the hydrocele. Excision is practiced for longstanding hydroceles with thickened walls and multi-located hydroceles. If necessary, a drain is left that is brought out through the sloping part of the hemiscrotum and which is removed after 24 hours. The skin is closed with a resorbable suture material. A soft dressing is left in a jockstrap.
B) Plication technique
The plication interventions can be used for thin sacs, but are not suitable for multi-located hydroceles or for longstanding hydroceles with thickened walls. Plication leaves a big zone of residual tissue within the scrotum. Since the sac is not resected, the plication is quick and relatively bloodless. The testicle is exposed and the sac everted. It is not necessary to leave a drain.
C) Window technique
This is the fastest method of correction, but also burdened by the higher number of relapses. After exposing the sac, an “X”-shaped incision is performed on the sac itself and the four resulting flaps are folded and sutured to leave a window of at least 5 cm. It is not necessary to drain. The closure is as above.
D) Extradartoic pocket technique
This method is indicated for the sacs with thin wall. As for the technique of plication or of the window, the resection of the sac is not necessary and the bleeding is minimal. Once the testicle is externalized, the cut surface of the sac is coagulated or sutured by hemostasis and an extradartoic pocket is prepared just like an orchidopexy. The testicle is fixed into the pocket with nonabsorbable stitches and the skin is closed with absorbable stichtes.
E) Sclerotherapy
Sclerotherapy involves injecting tetracycline inside the sac or other irritants after emptying it, but this may cause an obstruction of the epididymis. On top of that, it is sometimes associated with considerable post-surgery pain and often a hydrocele recurrence follows. When that happens, the relapsed hydrocele is often more difficult to treat and multi-located.
Preparation of the surgery:
The patient must take preoperative tests, it shall be subjected to local trichotomy immediately before surgery and must remain fasting from the previous evening. The morning of the examination a broad spectrum antibiotics therapy should be initiated.
Duration of the surgery:
It varies depending on the technique used, but typically no longer than thirty, thirtyfive minutes.
Type and length of the stay:
Typically a day surgery.
Results:
They are generally excellent with the excision and eversion technique.
Advantages, disadvantages, side effects, complications:
Complications of hydrocelectomy interventions in children are pain, infection, and, more rarely, tying of the hernial sac.
In adults, the hematoma and pain are the most common complications. The use of a compressive dressing and the positioning of a drainage for 24 hours reduce the rate of these complications. If the hematoma enlarges a surgical re-operation is necessary. Relapsed hydrocele is rare in patients operated with a the technique of excision and eversion of the tunica vaginalis and it is more frequent in patients operated by other techniques.
Attention to be placed at hospital discharge:
At discharged, oral antibiotics therapy should be prescribed for 5 days, jockstrap and the dressing should be removed after 5-7 days. It is not necessary to remove the stitches that will self-hydrolyse spontaneously. It is advisable to avoid heavy work for 3-5 days.
What to do in case of complications after hospital discharge:
In all cases of fever or significant increase of the scrotal volume you must contact the reference hospital.
Controls:
A check is performed after 5 and 10 days.