Aspiration and sclerotherapy versus hydrocoelectomy for treating hydrocoeles

Practice Variation in the Management of Adult Hydroceles: A Multinational Survey

Background

Although hydrocele is one of the most common urologic pathologies, it is seldom studied, and the major urologic associations have no guidelines for the management of adult hydroceles.

Objective

To characterize international practice variation in the treatment of adult hydroceles.

Design setting and participants

An international survey was conducted addressing the management of hydroceles among urologists in Belgium, Denmark, Finland, Iceland, Japan, and the Netherlands from September to December 2020. We invited a random sample of 170 urologists from each country (except Iceland).

Outcome measurements and statistical analysis

Urologists' treatment options, factors relevant for decision-making, expected patient satisfaction, and outcomes after aspiration versus surgery were assessed.

Results and limitations

Of the 864 urologists contacted, 437 (51%) participated. Of the respondents, 202 (53%) performed both hydrocelectomies and aspiration, 147 (39%) performed hydrocelectomies only, and 30 (8%) performed aspiration only. In Belgium (83%), the Netherlands (75%), and Denmark (55%), urologists primarily performed hydrocelectomies only, whereas in Finland (84%), Japan (61%), and Iceland (91%), urologists performed both hydrocelectomies and aspiration. Urologists favored hydrocelectomy for large hydroceles (78.8% vs 37.5% for small), younger patients (66.0% for patients <50 yr vs 41.2% for ≥70 yr), patients with few or no comorbidities (62.3% vs 23.1% with multiple comorbidities), and patients without antithrombotic agents (53.5% vs 36.5% with antithrombotic agents). Most urologists considered patient satisfaction to be highest after hydrocelectomy (53.8% vs 9.9% after aspiration) despite believing that hydrocelectomy is more likely to cause complications (hematoma 77.8% vs 8.8% after aspiration). Estimates varied between countries.

Conclusions

We found a large variation in the treatment of adult hydroceles within and between countries. Optimization of hydrocele management globally will require future studies.

Patient summary

Our international survey shows that treatment of adult hydrocele varies considerably within and between countries.

Aspiration and sclerotherapy versus hydrocelectomy for treating hydroceles: a systematic review and meta-analyses

BACKGROUND

In this meta-analysis, we aimed to compare the hydrocelectomy versus aspiration and sclerotherapy for treating primary hydrocele.

METHODS

We included randomized controlled trials (RCTs) and quasi-RCTs that compared aspiration and sclerotherapy with any type of sclerosants versus hydrocelectomy for primary hydrocele. Studies were identified via a systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ClinicalTrials.gov. Citation tracking of related articles was performed. Data extraction and quality assessment were performed independently by two authors. The primary and secondary outcome measures were compared and analyzed using the Review Manager 5.3.5 software.

RESULTS

Five small RCTs were included in the present study. These 5 RCTs included 335 patients with 342 hydroceles, randomized to aspiration and sclerotherapy (185 patients; 189 hydroceles) and surgery (150 patients; 153 hydroceles). There was no significant difference in clinical cure between sclerotherapy and hydrocelectomy (RR 0.45, 95% CI 0.18 to 1.10). Meta-analysis revealed a significant increase in recurrence in the sclerotherapy group compared with the surgical group (RR 9.43, 95% CI 1.82 to 48.77). There were no significant differences between the two groups in assessing fever, infection, and hematoma.

CONCLUSION

Aspiration and sclerotherapy is an efficient technique with a higher recurrent rate; therefore, we recommend aspiration and sclerotherapy for patients at high risk for surgery or avoiding surgery. In addition, included RCTs had low methodological quality, low sample size, and invalidated instruments for outcome assessment. Therefore, there is a great need for further methodologically rigorous RCTs with the registered protocol.

Office-based, Minimal-Incision Modified Fenestration Technique for Symptomatic Hydroceles Under Local Anesthesia

OBJECTIVE

To describe a minimal-incision modified fenestration technique (MIMFeT) for symptomatic hydroceles utilizing local anesthesia.

METHODS

A database was maintained for men undergoing in-office MIMFeT for symptomatic hydroceles between June 2015 and August 2018. Following local anesthesia, the hydrocele was sequentially everted through a small upper hemiscrotal incision, excised, and oversewn without delivering the testicle through the wound. Patient demographics and clinical outcomes were subsequently reviewed.

RESULTS

A total of 54 men (median age 67) underwent MIMFeT under local anesthesia for symptomatic hydrocele. Median estimated hydrocele size was 250 mL (IQR 150;500). Medical comorbidities included coronary artery disease (12%), hypertension (43%), diabetes (13%), and current antiplatelet or anticoagulant (44%) use. Six patients (11%) were deemed unsafe for monitored or general anesthesia. About 48 patients had follow-up data available (median 9 months; IQR 2-18). Mild recurrent scrotal swelling occurred in 4 patients (8%) and 9/48 (18%) experienced postoperative complications including hematoma (n = 2), prolonged pain (n = 3), wound infection (n = 2), and partial incisional separation (n = 2). No patient required repeat hydrocelectomy.

CONCLUSION

Our early results suggest that the MIMFeT for management of symptomatic hydroceles can be safely performed in the office setting under local anesthesia, including in those patients who are determined to be unsafe for monitored and general anesthesia.

Scrotal reconstruction and testicular prosthetics

Scrotal surgery encompasses a wide-variety of surgical techniques for an even wider variety of indications. In this manuscript, we review our indications, techniques, and pit-falls for various reconstructive scrotal surgeries as-well-as surgical tips for placement of testicular prostheses. Penoscrotal webbing (PSW) is an abnormal, often-problematic distal insertion of scrotal skin onto the ventral penile shaft. There are several effective and straightforward techniques used to revise this condition, which include simple scrotoplasty, single- or double-Z-plasty, or the VY-flap scrotoplasty. Reconstruction is also commonly indicated following scrotal skin loss caused by infection, trauma, lymphedema, hidradenitis, and cancer. Although initial management of these conditions often involves scrotal skin removal, repair of expansive scrotal skin loss can be technically difficult and can be accomplished by using one of several skin flaps or skin grafting. Split-thickness skin grafting of scrotal defects can be accomplished easily, and provides durable results.

Ectopic Hydrocele After Testicular Transposition

A 55-year-old man was treated for Fournier gangrene in 2004 with radical debridement and bilateral testicular transposition to the medial thighs. Eight years later, bilateral hydroceles formed. After conservative measures failed for treatment of the hydroceles, the condition was treated during desired testicular relocation, and creation of a neoscrotum. In the case presented, bilateral thigh hydroceles may have developed from lymphatic injury during testicular transposition. To our knowledge, this is the first case report of bilateral hydrocele testis in the medial thigh pouches following ectopic testicular transposition.