Hydrocele

Hydrocele testis is defined as an abnormal collection of serous fluid in the space between the parietal
and visceral layers of the tunica vaginalis, termed the cavum peritoneum scroti.1 Normal fluid volume
within the scrotum ranged about 2–3 ml between the tunical layers, however there is currently no
exact cut-off volume of which collection of serous fluid is considered hydrocele. Physical findings and
history evaluation remain crucial in diagnosis, and diagnosis may be confirmed by transillumination of
the hemi scrotum. For patients without a clear cause for hydrocele in their history, ultrasonography
provides a simple noninvasive imaging tool. ultrasonography eliminates the need for fluid aspiration,
which should be abandoned owing to its invasiveness, the potential hazard of tumor spillage in the
event of an occult testis lesion, and the inherent risk of infection.

There are few types of Hydrocele of testis, generally differentiated into congenital and acquired.
Congenital hydrocele happened because of loss of patency of processus vaginalis, which allows the
transfer of fluid between the peritoneal and tunical cavities. Congenital hydrocele usually resolves by
18–24 months.2 Adolescent and Adult hydroceles are generally acquired though both etiologies are
possible in adolescents, whereas a patent processus vaginalis that has remained silent until puberty
may occur or appear de novo. 3 The Etiology of acquired hydrocele may be seen in Figure 1.

Figure 1. Types of acquired hydrocele in adolescents3

Treatment of Hydrocele3

Basic principles in hydrocele treatment approaches covers around drainage of excessive fluid and
prevention of re-accumulation. Few methods are available ranging from the simplest to the most
complicated, as such, fluid is aspiration with a sterile syringe, sclerotherapy, or hydrocelectomy. The
later two approaches prevents fluid reaccumulation by elimination of space between parietal and
visceral layers of the tunica vaginalis; sclerotherapy by injecting inflammatory agent then subsequent
adhesion of layers of the tunica vaginalis; and surgical hydrocelectomy by removing tunica vaginalis
and allows drainage of fluid into inguinal lymph nodes. Active surveillance may act as a viable
treatment option where imbalance of production and reabsorption. This paper will focus upon the
surgical approach, which is hydrocelectomy.
Hydrocelectomy 3

Surgical hydrocelectomy act as the gold standard treatment for idiopathic hydrocele in adults. There
is still a controversy however, between between the two available approach is superior. The inguinal
approach which is favored to rule out the presence of a patent processus vaginalis or rather a scrotal
approach which is used for improved cosmesis, shortened operative time and elimination of the
possibility of ilioinguinal nerve damage during inguinal dissection.

There are three main methods of scrotal hydroceletomy: excision hydrocelectomy, the plication
technique, and internal drainage of the hydrocele. One RCT have made a clear comparison between
the three approaches performed by a single surgeon. Excision hydrocelectomy was found as the most
effective technique, though was the most morbid, with a 75% rate of postoperative scrotal edema.
Internal drainage was the least morbid procedure but also the least effective, with an 85% recurrence
rate. Plication hydrocelectomy was suggested to be superior as it offers the best cost-to-benefit
balance for adolescents/adult patients.

Excision hydrocelectomy 3

Performed by removing the tunica vaginalis leaving a 5–10 mm rim of tissue around the testicle. The
procedure is usually performed via a transverse scrotal incision. The intact vaginalis is delivered out of
the scrotum and opened. All fluid is removed and the tunica vaginalis is resected with scissors or
electrocautery. A modified technique, using a small (15 mm) transverse scrotal incision to identify and
grasp the tunica vaginalis parietalis was introduced. the sac is dissected bluntly under gentle traction
and delivered out of the incision. the fully mobilized tunica is excised at the base. this technique was
associated with a 95% cure rate with minimal associated morbidity.
1 2

3 4

Figure 2. Excisision Hydrocelectomy. 1 a-d) delivery of the vaginal sac. a | Surgical landmarks such as the spermatic cord and
scrotal midline are marked. b | A transverse scrotal incision is made. c,d | The vaginal sac is delivered through the incision;
2 a-d) fluid removal. a | The tunica vaginalis is marked for incision. b | Aspiration of fluid. c,d | The tunica vaginalis is opened
so the testis can be evaluated; 3 a-d) tunica vaginalis resection. Tissue is removed from the tunica vaginalis with a | scissors
or b | electrocautery. c | The edges of residual tunica vaginalis are aligned for the suture. d | The tunica vaginalis is sutured
with running 3/0 polyglycolic acid stitches; 4 a-d) closing up. a | Final check of the spermatic cord. b,c,d | Multiple layer
scrotal suture

Plication technique 4

Lord et al, devised the plication technique, which involves placing several evenly spaced plicating
sutures in the free surface of the sac. when tied, these stitches effectively obliterate the parietal tunica
vaginalis and provide hemostasis. There are putative advantages to the plication technique, including
speed and relative bloodlessness, owing to the fact it does not involve sac dissection.40,41

Figure 3. Plicating Technique. (1-9 from upper left to bottom right) 1) Allis’s forceps pick up all the incised tissues; 2) Allis’s
forceps evert the cut edge. All bleeding is thereby controlled; 3) The tunica vaginalis is incised and the hydrocele fluid is
removed; 4) The testis is delivered and the hydrocele turned inside out; 5) The first of 8-10 similar stitches; 6) The stitches
have all been tied. The tunica vaginalis is gathered up at the junction of testis and epididymis; 7) he testis has been
returned to the scrotum. The areolar tissue stretches to accommodate the testis; 8) Michele clips take over the control of
the bleeding points and maintain the eversion; 9) The clips are close together; any oozing is outwards on to the dressing

Permanent internal drainage 5

Drainage of the accumulated fluid can be achieved by creating a small window in the hydrocele, which
involves minimal dissection and thus reduced bleeding. A cruciate incision is made in the tunica
vaginalis and the edges are folded back and sutured to themselves to create permanent drainage.
However, this window technique is associated with high recurrence rate (85%) owing to adhesion of
the tunica vaginalis causing closure of the window. To improve the effectiveness of internal drainage,
an alternative technique was developed involving insertion of a silicone catheter 15–20 cm in length,
which enables hydrocele fluid to flow from the parietal layer of the tunica vaginalis to the surrounding
scrotal tissue.
 Figure 5. Hydrocele treatment with silicone catheter (Arslan et al). (A) Entrance and progression of cannula
with obturator through scrotum to bottom of scrotum. (B) Progression of cannula in hydrocele sac. (C)
Progression of silicone catheter to incision point by way of the cannula. (D) Sutured subcutaneous silicone
catheter

New Minimally Access Hydrocelectomy 6

The new minimally access through excision of only a disk of the parietal tunica vaginalis about double
the size of the skin incision, with the aim of exposing the visceral tunica to the lymphatic-rich
subcutaneous tissues and scrotal skin, was introduced in 2011. A small scrotal incision, 2 cm long, was
performed, and an incision of the dartos muscles in the same line was completed using electrocautery.
The parietal tunica vaginalis was grasped, minimal blunt dissection was done with the aid of the index
finger, and a small hole was made for aspiration of hydrocele fluid (Fig. 6A). Next, a disk of tissue was
excised from the parietal tunica vaginalis about double that of the skin incision dimension using
electrocautery. The edge of the tunica vaginalis was sutured to the dartos and scrotal subcutaneous
tissue in an everted manner to expose the visceral tunica toward the underlying scrotal skin (Fig. 6B).
Closure with placement of a corrugated rubber drain and discharge was allowed the same day.

Figure 6. New Minimally Access Hydrocelectomy

Pediatric approach and Laparoscopic technique7

Unlike in adults and adolescents, sclerotherapy has no place in the definitive management of pediatric
hydroceles. Standard open surgical management has been the gold standard for the definitive
treatment of hydroceles. The safety and efficacy of laparoscopic repair for both an inguinal hernia and
a hydrocele in children are demonstrated to be similar to open procedures without any minor or major
complications. Several known advantages of the laparoscopic approach are that it is a less painful
approach for patients, patients return to their normal activity more rapidly, and it provides superior
cosmetic results. The approach of laparoscopic hydrocelectomy mostly is done in cases of pediatric
hydrocelectomy. Most of laparoscopic studies reported were in pediatric patients, concerning the
congenital type of the disease. Few laparoscopic approaches are mentioned below:

- Intra-peritoneal PPV excision with non-ligation

- Intra-peritoneal purse string closure pf PPV
- Extra-peritoneal purse string closure of PPV (2 or one trocar technique)

Lord’s procedure of hydrocelectomy for pediatric patients9

The technique requires at least eight small Allis forceps, a Wietlander retractor, and 4-0 synthetic
absorbable and 4-0 chromic catgut sutures on half-circle needles. In a supine position, the patient will
be anesthetized and prepped, while the operator will be standing on his right side (in right-handed
operators). Infiltrate the cord structures at the base of the scrotum with 1% lidocaine (optional). Grasp
the hydrocele in the left hand. Press it firmly against the scrotal skin to stretch the skin and dartos
muscle and to compress the scrotal vessels.
Make a 2-cm incision in the skin between the visible vessels and then through the dartos muscle down
to the surface of the tunica vaginalis. The initial incision includes the thin dartos layer. Fulgurate the
fine vessels as they are exposed. Pick up the full thickness of all the incised tissue layers on each side
with three or four small Allis forceps, each one catching the skin and the tissue immediately adjacent
to the tunica vaginalis. By keeping the tissues under tension with the left hand, the Allis forceps can
be placed to evert and compress the cut edge, thus controlling any bleeding and, most important,
preventing dissection among the easily irritated layers of the scrotum. With the knife handle, separate
the dartos layer from the tunica vaginalis to form a pouch large enough to hold the testis. Release the
grasp on the scrotum. Hold the suction tip nearby. Incise the tunica vaginalis and aspirate the fluid.
Expand the opening with scissors and squeeze the testis out. Inspect and palpate it.

Figure 7. Lord’s technique of placating technique for correction of hydrocele (taken from Hinman
atlas of pediatric urology)

Reference

1. Wallace, A. F. Aetiology of the idiopathic hydrocele. Br. J. Urol. 32, 79–96 (1969).
2. Christensen, T., Cartwright, P. C., Devries, C. & Snow, B. w. New onset of hydroceles in boys
over 1 year of age. Int. J. Urol. 13, 1425–1427 (2006).
3. Cimador M, Castagnetti M, Grazia ED. Management of hydrocele in adolescent patients.
Nature reviews. 7, 379–385 (2010)
4. Lord, P. H. A bloodless operation for the radical cure of idiopathic hydrocele. Br. J. Surg. 51,
914–916 (1964).
5. Arslan, M., Kilinç, M., Yilmaz, K. & Oztürk, A. A new approach in the management of the
hydrocele with a silicone catheter. Urology 63, 170–173 (2004).
6. Saber A. New Minimally Access Hydrocelectomy. UROLOGY 77: 487–490, 2011
7. Fourie N, Banieghba b. Pediatric Hydrocele: A Comprehensive Review. Clinics in surgery 2017.
5 (1448): 1-5
8. Hinman S, Bskin LS. Hinmans’ atlas of Pediatric Urologic Surgery 2nd Edition. Sounders. 2009