Introduction
Hydrocele is a common source of scrotal swelling in males. It is the collection of fluid around the testis. It can be congenital or acquired. Despite hydrocele being mostly painless, a patient seeks treatment due to the associated discomfort, aesthetic reasons, and disturbance in daily activities.
What Is Advanced Hydrocele Surgery?
Hydrocelectomy is the gold standard for hydrocele removal. However, some associated risks include infection, edema, bleeding, hydrocele recurrence, and long-standing swelling and pain. Also, in some patients, decreased fertility is reported.
Advances in hydrocele surgery have proven to be an asset to laparoscopic surgeons. Advanced hydrocele surgery, also called minimal hydrocelectomy, has been devised to overcome the disadvantages of standard surgical procedures.
Which Patients Are Included in Advanced Hydrocele Surgery?
The patients included in the surgery are:
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Associated Scrotal Symptoms - The patients in which the scrotal symptoms interfere with daily life, such as swelling, pain, and heaviness.
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Diagnosis of Testicular Hydrocele - Various laboratory investigations and imaging studies are employed to evaluate hydrocele before surgery. Other conditions such as trauma, hernia, tumor, or acute scrotum infection are excluded.
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Patient Consent - The patient’s agreement to undergo surgery is the most important. Moreover, patients having chronic heart and lung diseases, bleeding and clotting disorders, and acute systemic infections are excluded.
How Is Advanced Hydrocele Surgery Done?
Traditional surgical approaches for hydrocelectomy are Jaboulay’s (excision-eversion) and Lord’s procedures (plication). They are effective but linked with less patient satisfaction. Over the years, several minimally invasive methods have been invented to ensure maximum surgical success with minimal complications.
Minimal hydrocelectomy is usually a minor surgery. Surgeons can also safely perform the procedure on infants. Under general anesthesia, a small incision is made through the scrotum or groin area. Tissue dissected while approaching the testis. After the hydrocele sac is carefully removed, the testis is placed back. Suturing is done to approximate the wound. Recently, there has been an advancement regarding incision sizes. The examples are 1.18 inches, 0.78 inches, 0.59 inches, and 0.39 inches.
Different surgical methods are
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Minimal Access Hydrocelectomy - A 0.78 inch scrotal incision is made with electrocautery, and minimal excision of the tunica vaginalis (membrane covering the testis) is done. The surgery requires a shorter operating time of only 15 to 20 minutes. This results in better patient satisfaction and outcome.
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Pull-Out Technique - This technique is specifically used for large hydroceles. A 0.59 inch transverse scrotal incision is given. Then, the sac is bluntly dissected under a gentle pull, and the hydrocele is removed. The novel pull-out technique ensures faster recovery under minimal trauma to the patient.
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Scrotoscope-Assisted Minimal Hydrocelectomy - In this method, a rectoscope or cystoscope can be used as a scrotoscope. Blunt dissection is performed following a 0.39 inch scrotal incision, and the sac is evacuated of fluid. Next, a scrotoscope is used to evaluate the scrotal contents for abnormalities. Finally, the fluid is sent for infection assessment. A combination of minimal hydrocelectomy with a scrotoscope is a promising method. The scrotoscope can detect any misdiagnosed lesions by earlier examination. Hence, the technique is both diagnostic and therapeutic. Another technique called the ‘Su-Wang’ technique using a scrotoscope has been reported.
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Snip, Snitch, and Tug Repair - A 1.18 inch incision is made under the groin area. The hydrocele sac is delivered with gentle pressure on the scrotum. The advantage of this technique is that extensive dissection is not required. The authors believe it is easy and safe to perform and requires no specialized equipment. In addition, it is associated with lower complications. Further, it is claimed that scrotal swelling and discharge are less in this procedure.
Patients can resume normal daily activities two to three days after hydrocelectomy. If a drain is placed, it is usually removed after 48 hours. A follow-up is usually scheduled after a week, and sutures are removed. Besides, patients must avoid heavy workouts or exercises for some days. The operated area has to be kept clean to prevent infection. The surgeon should be contacted if heavy bleeding, fever, and sudden swelling appear. The scrotum typically regains its original size a few weeks after hydrocelectomy.
What Are the Advantages of Advanced Hydrocele Surgery?
Minimal hydrocelectomy carries many advantages. Some of them are an easy approach to the scrotal structures and tissues, minimal dissection, shorter hospital stay, pleasing cosmetic results, reduced risk of scrotal bleeding and hematoma (blood collection), and less post-operative pain or swelling. The prognosis of the surgery is favorable. The success rate is very high. If hydrocelectomy is done on an infant, it can prevent an inguinal hernia. It is a safe procedure with low side effects, in which most patients return home the same day. Moreover, it improves comfort in daily activities. It also boosts the patient’s confidence.
What Are the Complications Associated With Advanced Hydrocele Surgery?
Complications with advanced hydrocele surgery are:
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Scrotal edema.
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Swelling.
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Sinus formation.
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Postoperative pain.
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Infection.
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Scrotal scarring.
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Hardness.
However, the related incidence is low as compared to the conventional procedures.
What Are the Other Minimally Invasive Techniques for Hydrocele?
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Endoscopic Hydrocele Ablation - This technique was first described by Ho et al. Local anesthesia was used. The tunica vaginalis is removed with electrocautery or laser. Further, an endoscope was used to visualize the scrotal contents with less manipulation. There have been minimal complications reported. Hence, it is a very effective alternative to conventional surgery.
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Sclerotherapy - Injection of an agent into the hydrocele sac results in resolution. However, recurrence has been reported in many cases. Doxycycline is also used as an adjuvant. Aspiration of fluid can also be performed along with sclerotherapy. In this technique, hospital expenses and many complications are avoided.
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Silicone Catheter Drainage - Another minimally invasive technique is drainage with a silicone catheter. A 0.19 inch scrotal incision with a scalpel is given. A cannula is pushed through the sac, followed by the insertion of a perforated catheter. Drainage through the catheter is done before the removal of the cannula. The advantages are no dissection and manipulation of the scrotum. Also, the recurrence rate of hydrocele is low.
Conclusion
Advanced hydrocele surgery is a quick and efficient method for hydrocele removal. It overcomes the complications of traditional hydrocelectomy. However, close monitoring post-surgery is vital. It is especially true for parents whose infant has recently undergone hydrocelectomy. In addition, adequate counseling is necessary regarding the recurrence of the hydrocele.
