Hydrocelectomy, also known as hydrocele repair, is a surgical procedure performed to correct a hydrocele. A hydrocele is an accumulation of peritoneal fluid in a membrane called the tunica vaginalis, which covers the front and sides of the male testes. Hydroceles occur because of defective absorption of tissue fluid or irritation of the membrane leading to overproduction of fluid. In addition to filling the tunic vaginalis, the fluid may also fill a portion of the spermatic duct (epididymis) in the scrotum.
A hydrocelectomy is performed to correct a hydrocele and prevent its recurrence.
Hydroceles are found in male children or adult males (usually over 40). They have no known association with a man's ethnic background or lifestyle factors.
A hydrocele usually appears as a soft swelling in the membrane surrounding the testes. It is not usually painful and does not damage the testes. It typically occurs on one side only; only 7–10% occur on both sides of the scrotum. Inflammation is not usually present, although if the hydrocele occurs in conjunction with epididymitis (inflammation of the epididymis), the testes may be inflamed and painful. The main symptom of a hydrocele that occurs without epididymitis is scrotal swelling. As the hydrocele fills with fluid and grows, the scrotum itself gets larger. Some men may have pain or discomfort from the increased size of the scrotal mass. Hydroceles are usually congenital, found in a large percentage (80% or more) of male children and in 1% of adult males over 40.
The most common congenital hydrocele is caused by a failure of a portion of the testicular membrane (processus vaginalis, a membrane that descends with the testicles in the fetus) to close normally. This failure to close allows peritoneal (abdominal) fluid to flow into the scrotum. Although surgery is the usual treatment, it is not performed until the child is at least two years of age, giving the processus vaginalis sufficient time to close by itself. More than 80% of newborn boys are reported to have a patent (open) processus vaginalis, but it closes spontaneously in the majority of children before they are 12 months old. The processus is not expected to close spontaneously in children over 18 months.
In adults, hydroceles develop slowly, usually as a result either of a defect in the tunica vaginalis that causes overproduction of fluid, or as a result of blocked lymphatic flow that may be related to an obstruction in the spermatic cord. Hydroceles may also develop as a result of inflammation or infection of the epididymis; trauma to the scrotal area; or in association with cancerous tumors in the groin area. A hydrocele can occur at the same time as an inguinal hernia.
Hydroceles can be treated with aspiration or surgery. To aspirate the collected fluid, the doctor inserts a needle into the scrotum and directs it toward the hydrocele. Suction is applied to remove (aspirate) as much fluid as possible. While aspiration is usually successful, it is a temporary correction with a high potential for recurrence of the hydrocele. Aspiration may have longer-term success when certain medications are injected during the procedure (sclerotherapy). There is a higher risk of infection with aspiration than with surgery.
Generally, surgical repair of a hydrocele will eliminate the hydrocele and prevent recurrence. In adults, surgery is used to remove large or painful hydroceles. It is the preferred method of treatment for children over two years of age. It is also standard practice to remove hydroceles that reoccur after aspiration.
Patients are given general anesthesia for hydrocele repair surgery. A hydrocelectomy is typically performed on an outpatient basis with no special precautions required. The extent of the surgery depends on whether other problems are present. If the hydrocele is uncomplicated, the doctor makes an incision directly into the scrotum. After the canal between the abdominal cavity and the scrotum is repaired, the hydrocele sac is removed, fluid is removed from the scrotum, and the incision is closed with sutures. If there are complications, such as the presence of an inguinal hernia, an incision is made in the groin area. This approach allows the doctor to repair the hernia or other complicating factors at the same time as correcting the hydrocele. Some surgeons use a minimally invasive laparoscopic approach to repair a hydrocele. The operation is performed through a tiny incision using a lighted, camera-tipped, tube-like instrument (laparoscope) that allows the passage of instruments for the repair while displaying images of the procedure on a monitor in the operating room.
Diagnosis will begin with taking a careful history, including sexual history, recent injury, or illnesses, and observing signs and symptoms. Hydroceles can sometimes be diagnosed in the doctor's office by visual examination and palpation (touch). Hydroceles are distinguished from other testicular problems by transillumination (shining a light source through the hydrocele so that the tissue lights up) and ultrasound examinations of the area around the groin and scrotum.
The patient will be given standard pre-operative blood and urine tests at some time prior to surgery. Before the operation, the physician or nurse will explain the procedure, the type of anesthesia to be used, and, in some cases, the need for a temporary drain to be inserted. The drain will be placed during surgery to reduce the chances of post-operative infection and fluid accumulation.
Immediately following surgery, the patient will be taken to a recovery area and checked for any undue bleeding from the incision. Body temperature and blood pressure will be monitored. Patients will usually go home the same day for a brief recovery period at home. Follow-up appointments are usually scheduled for several weeks after surgery so that the doctor can check the incision for healing and to be sure there is no infection. The patient may notice swelling for several months after the procedure; however, prolonged swelling, fever, or redness in the incision area should be reported to the surgeon immediately.
Hydrocelectomy is considered a safe surgery, with only a 2% risk of infection or complications. Injury to spermatic vessels can occur, however, and affect the man's fertility. As with all surgical procedures, reactions to anesthesia, bleeding from the surgical incision, and internal bleeding can also occur.
Surgery usually corrects the hydrocele and the underlying defect completely; recurrence is rare. The long-term outlook is excellent. There may be swelling of the scrotum for up to a month. The adult patient is able to resume most activities within seven to 10 days, although heavy lifting and sexual activities may be delayed for up to six weeks. Children will be able to resume normal activities in four to seven days.
Morbidity and mortality rates
Chronic infection after surgical repair can increase morbidity. There are no instances reported of death following a hydrocele repair.
"Disorders of the Scrotum." Section 17, Chapter 219 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Sabiston, D. C., and H. K. Lyrly. Essentials of Surgery. Philadelphia, PA: W. B. Saunders Co., 1994.
Way, Lawrence W., MD. Current Surgical Diagnosis and Treatment, 10th ed. Stamford, CT: Appleton & Lange, 1994.
Chalasani, V., and H. H. Woo. "Why Not Use a Small Incision to Treat Large Hydroceles?" ANZ Journal of Surgery 72 (August 2002): 594-595.
Fearne, C. H., M. Abela, and D. Aquilina. "Scrotal Approach for Inguinal Hernia and Hydrocele Repair in Boys." European Journal of Pediatric Surgery 12 (April 2002): 116-117.
National Kidney and Urologic Diseases Information Clearinghouse. 31 Center Drive, MSC 2560, Building 31, Room
Dolan, James P., MD. Hydrocele Repair. <www.kernanhospital.com>.
Men's Health Topics. Hydrocele. <www.uro.com/hydrocele.htm>.
L. Lee Culvert
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A hydrocelectomy is performed in a hospital operating room or a one-day surgery center by a general surgeon or urologist.
QUESTIONS TO ASK THE DOCTOR
- Why is this surgery necessary?
- How will it improve my condition (my child's condition)?
- Is surgery the only option for correction of this problem?
- How many times have you performed this surgery? What are the usual results?
- How will I (my child) feel after the surgery?
- How soon can I (my child) resume normal activities?