Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria

Comparison of the results of open repair and laparoscopic repair with the PIRS method in the treatment of hydrocele in children

PURPOSE

Hydrocele is a result of intraperitoneal fluid filling into the scrotum through the patent processus vaginalis (PPV). While the traditional approach of pediatric hydrocele has been open repair (OR) for years, laparoscopic repair (LR) of hydrocele has been accepted worldwide after the proven efficacy of laparoscopy. The purpose is to compare the outcomes of both techniques in a single center.

METHODS

We retrospectively analyzed the clinical data of all the patients who underwent hydrocele repair from August 2016 to November 2022. In our center, the standard approach was OR in hydrocele until the November of 2021. Starting from this date, LR has begun to be preferred, as the experience has increased and its success has been observed. In the LR group, single-port percutaneous internal ring suturing technique was performed.

RESULTS

The data of 113 patients (OR 58.4% (n = 66), LR 41.6% (n = 47)) were collected. In preoperative examination, 12.4% (n = 14) patients were diagnosed as communicating and 87.6% (n = 99) non-communicating hydrocele. Intraoperatively, 65.5% (n = 74) patients were communicating and 34.5% (n = 39) were non-communicating. Total recurrence rate was 7% (n = 8). The OR group experienced a recurrence rate of 10.6% (n = 7), while the LR group experienced 2.12% (n = 1).

CONCLUSION

Laparoscopy may reveal intrabdominal connection of hydrocele better than open approach. It provides a high quality view of both inguinal rings and has the advantages of minimally invasive surgery.

Encysted Hydrocele of Spermatic Cord in Adult: A Rare Case Report

Hydrocele represents a commonly encountered pathological condition characterized by the development of scrotal swelling. In contrast, spermatic cord hydrocele is a relatively rare condition that arises from the abnormal closure of the processus vaginalis. This condition entails the accumulation of fluid within the spermatic cord, and although hydrocele itself is a frequently observed ailment affecting roughly 100 out of 100,000 men, encysted hydrocele of the spermatic cord is a seldom-seen variant. Furthermore, it is noteworthy that spermatic cord hydrocele tends to be more prevalent in the pediatric population compared to adults. In our clinical practice, a patient presented with swelling localized to the right hemi-scrotum and was initially diagnosed as suffering from a chronic right-sided hydrocele of the tunica vaginalis. However, during the surgical intervention, the true nature of the condition became evident, as it was determined to be an encysted hydrocele of the cord. This case report chronicles the diagnostic journey surrounding hydrocele, highlighting the distinction in surgical management between encysted hydrocele and vaginal hydrocele of the testis.

Watchful waiting for communicating hydrocoele in infants

Background

One of the commonest pediatric surgeries is hydrocele. There are suggestions to wait for spontaneous resolution than to operate these cases without harmful adverse events. Herein, we evaluated the outcome of the watchfulness of these cases over 18 months.

Methods

The study included 93 infants with communicating hydrocele for the Pediatric Surgery Department, Faculty of Medicine (Assiut, Egypt). They were planned to be followed up for 18 months, and indications for intervention included hernia, increasing in size, being tense, and completion of 18 months of follow-up without improvement.

Results

The gestational age of the included patients was 38.5 ± 2.2 weeks and the age at the time of presentation was 50 (7, 495) days. Most cases were bilateral, reducible, and had an intermittent course. After 18 months of follow-up, 60.2% of the patients resolved spontaneously and 39.8% were surgically treated. Age at the time of presentation was higher among operated patients. Patients with reducibility criteria on clinical examination and lack of intermittent course had higher frequency among operated patients (89.2%).

Conclusions

It is safe to wait and not to operate on infants with hydrocele up to 18 months as long as there was no hernia. Higher age at presentation and reducibility on examination are indicators that favor the need for surgery.

Could increased expression of aquaporin-1 be an etiological cause in childhood noncommunicating hydroceles that do not regress spontaneously?

BACKGROUND

Aquaporins are membrane water channel proteins that are expressed in the epithelium and endothelium. Their primary function is to control the flow of water in the membranes of the cells.

OBJECTIVE

In this study, we investigated whether there is increased expression of aquaporin-1 in the tunica vaginalis of hydrocele patients in childhood that do not regress spontaneously an whether it has an effect on the etiology of hydrocele.

STUDY DESIGN

Boys who were diagnosed with hydrocele and scheduled for surgery were included and formed the hydrocele group. Boys in the same age range who underwent surgery for inguinal hernia or undescended testicles were included as a control group. Aquaporin-1 expression was evaluated by immunohistochemical examination of capillaries in tissue samples taken from the tunica vaginalis during the operation. Aquaporin-1-positive vessels were counted by selecting 5 unrelated areas with the highest vascular density, and the average number of vessels was calculated for each case.

RESULTS

A total of 48 male patients were included in the study. Of these, 27 constituted the hydrocele group (mean age 3.51 ± 2.59 years), and 21 constituted the control group (inguinal hernia, n = 17; undescended testicle, n = 4) (mean age 3.95 ± 3.80 years). The mean ages of both groups were statistically similar (p = 0.32). The mean numbers of aquaporin-1-positive vessels at the capillaries in the tunica vaginalis of the patients were 20.74 ± 7.10 in hydrocele group and 17.23 ± 4.07 in the control group. The expression of aquaporin-1 in the hydrocele group was significantly higher (p = 0.037).

DISCUSSION

It was shown that aquaporin-1 expression was higher in adult cases with hydrocele. Also an increase in aquaporin-1 expression was detected in tunica vaginalis of children with hydrocele in our study.

CONCLUSION

It was thought that aquaporin-1 overexpression may play a role in non-communicating hydroceles in children.

The outcomes of conservative management and the natural history of asymptomatic hydroceles in children

PURPOSE

To elucidate the natural history of asymptomatic hydroceles (AHs) in children with conservative management and to discuss management strategies for AHs in children.

METHODS

We retrospectively reviewed 113 children with AHs who were followed without immediate surgery. Patients were divided into four groups according to age at presentation; group 1: ≤ 1 month, group 2: 1-12 months, group 3: 12-24 months, and group 4: > 24 months. Ages at spontaneous resolution or surgery were reviewed. To assess the effect of AH on the testis, testicular size before and after conservative management was compared in 11 cases.

RESULTS

In groups 1, 2, 3, and 4, spontaneous resolution occurred in 94.3%, 75.0%, 65.0%, and 33.3%, and the average time to resolution from presentation was 5, 5, 17, and 9 months, respectively. 41 patients underwent surgery at a mean age of 4.2 years. The testicular size did not differ significantly between before and after conservative management (14.4 vs. 14.5 mm, p = 0.483).

CONCLUSION

About one-third of children over 2 years of age achieve spontaneous resolution. Hydroceles with conservative management may not affect the testicular size. Thus, initial conservative management before surgery is recommend for AHs in children, even over 2 years of age.

Pediatric groin lesions: imaging findings

OBJECTIVES

The groin is a complex anatomic region that has traditionally been ignored by radiologists because most lesions can be diagnosed from clinical data and physical examination. Nevertheless, ultrasound examinations of the groin are increasingly being requested to confirm injury or to resolve diagnostic uncertainty. On the other hand, some conditions involving the groin are found only in pediatric patients. This article describes the key imaging findings in pediatric groin injuries, placing special emphasis on the ultrasound appearance.

CONCLUSIONS

Knowledge about conditions that can affect the groin in pediatric patients and the key imaging findings associated with them helps improve the diagnostic performance of ultrasound.

First trimester phthalate exposure and male newborn genital anomalies

BACKGROUND

Anti-androgenic phthalates are environmental chemicals that affect male genital development in rodents leading to genitourinary birth defects. We examined whether first trimester phthalate exposure may exert similar effects in humans leading to an increased incidence of newborn male genital anomalies in a multi-center cohort study.

METHODS

We recruited first trimester pregnant women within The Infant Development and the Environment Study (TIDES) from 2010 to 2012 from four study centers and limited analyses to all mother/male infant dyads who had complete urinary phthalate and birth exam data (N=371). We used multivariate logistic regression to determine the odds of having a genital anomaly in relation to phthalate exposure.

RESULTS

Hydrocele was the primary abnormality observed in the cohort (N=30) followed by undescended testes (N=5) and hypospadias (N=3). We observed a statistically significant 2.5 fold increased risk (95% CI 1.1, 5.9) of having any anomaly and 3.0 fold increased risk (95% CI 1.2, 7.6) of isolated hydrocele in relation to a one log unit increase in the sum of di-ethylhexyl phthalate (DEHP) metabolites.

CONCLUSIONS

First trimester urinary DEHP metabolite concentrations were associated with increased odds of any newborn genital anomaly, and this association was primarily driven by isolated hydrocele which made up the majority of anomalies in newborn males. The association with hydrocele has not been previously reported and suggests that it may be an endpoint affected by prenatal phthalate exposures in the first trimester of development. Future human studies should include hydrocele assessment in order to confirm findings.

Treatment of contralateral hydrocele in neonatal testicular torsion: Is less more?

OBJECTIVE

Treatment of neonatal testicular torsion has two objectives: salvage of the involved testicle (which is rarely achieved) and preservation of the contralateral gonad. The second goal universally involves contralateral testicular scrotal fixation to prevent the future occurrence of contralateral torsion. However, there is controversy with regards to management of a synchronous contralateral hydrocele. It has been our policy not to address the contralateral hydrocele through an inguinal incision to minimize potential injury to the spermatic cord. Our objective in this study was to determine whether the decision to manage a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal approach is safe and effective.

PATIENTS AND METHOD

We reviewed all cases of neonatal testicular torsion occurring at our institution between the years 1999 and 2006. Age at presentation, physical examination, ultrasonographic and intraoperative findings were recorded. Patients were followed after initial surgical intervention to determine the likelihood of developing a subsequent hydrocele or hernia.

RESULTS

Thirty-seven patients were identified as presenting with neonatal torsion. Age of presentation averaged 3.5 days (range 1-14 days). Left-sided pathology was seen more commonly than the right, with a 25:12 distribution. All torsed testicles were nonviable. Twenty-two patients were noted to have a contralateral hydrocele at presentation. All hydroceles were opened through a scrotal approach at the time of contralateral scrotal fixation. No patient underwent an inguinal exploration to examine for a patent process vaginalis. None of the patients who presented with a hydrocele have developed a clinical hydrocele or hernia after an average 7.5 years (range 4.3-11.2) follow-up.

CONCLUSION

We have demonstrated that approaching a contralateral hydrocele in cases of neonatal testicular torsion solely through a scrotal incision is safe and effective. Inguinal exploration was not performed in our study and our long-term results demonstrate that such an approach would have brought no additional benefit. In avoiding an inguinal approach we did not subject our patients to unnecessary risk of testicular or vasal injury. Contralateral hydrocele is commonly seen in cases of neonatal testicular torsion. In our experience this is a condition of minimal clinical significance and does not warrant formal inguinal exploration for treatment. This conservative management strategy minimizes the potential of contralateral spermatic cord injury in the neonate. The aims of the study were met.

Pediatric Urology for the General Surgeon

Pediatric urology spans the neonatal period through the transition into early adulthood. There are a variety of common pediatric urologic conditions that overlap significantly with pediatric surgery. This article reviews the pertinent pathophysiology of a few key disease processes, including the pediatric inguinal hernia and/or hydrocele, cryptorchidism, and circumcision. General surgeons may find themselves in the position of managing these problems primarily, particularly in rural areas that may lack pediatric subspecialization. An understanding of the fundamentals can guide appropriate initial management. Additional focus is devoted to the management of genitourinary trauma to guide the general surgeon in more acute, emergent settings.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Males' Awareness of Benign Testicular Disorders: An Integrative Review

Disorders that affect the testes can range from painless and benign to debilitating and life threatening. Despite the availability of literature on the etiology, diagnosis, and treatment of benign testicular disorders (BTD), very little is known about men's awareness of these conditions. The aim of this review was to extract and analyze evidence from studies that explored males' awareness of BTD. Four e-databases (CINAHL, MEDLINE, PsychINFO, and PubMed) were thoroughly searched and four articles met the review inclusion criteria. The quality of the included studies was appraised and data were extracted and cross-checked using a standardized data extraction table. It was determined that participants lacked education about testicular self-examination and scrotal signs and symptoms which contributed to their lack of awareness of BTD. Help seeking in the event of scrotal abnormalities was suboptimal which is alarming given the acuteness of some BTD such as testicular torsion. Individuals who are at risk for health disparities were underrepresented in the reviewed literature. Findings from this review highlight the need to address barriers to BTD knowledge and help seeking. This could be achieved through making use of past interventions that succeeded in increasing men's awareness of testicular cancer such as university campaigns and mass media. From a practical standpoint, clinicians must be encouraged to educate young men about BTD. This could be attained through tailoring creative educational interventions that are sensitive to the needs of individuals who are at risk for health disparities.

Modified single-port minilaparoscopic extraperitoneal repair for pediatric hydrocele: a single-center experience with 279 surgeries

PURPOSE

The purpose of the study is to introduce our experience of a modified single-port minilaparoscopic technique for the treatment of pediatric hydrocele.

METHODS

Between June 2008 and May 2012, 279 boys (115 communicating hydrocele and 164 "non-communicating" hydrocele, diagnosis based on preoperative physical examination and scrotal ultrasound) underwent the modified single-port minilaparoscopic repair in our institution. During surgery, a 3-mm laparoscope was inserted into the abdomen through a mini-umbilical incision. The hydrocele sac orifice was closed by an extraperitoneal purse-string suture placed around the internal ring with an ordinary taper needle and an endoclose needle.

RESULTS

Of all the 279 patients, 16 (5.7 %) were found to have a potential patent processus vaginalis (PPV) on the contralateral side. Of the 164 boys diagnosed with "non-communicating" hydrocele preoperatively, 5 (3.0 %) had no PPV identified in laparoscope and the other 159 (97.0 %) had PPV actually. A total of 274 single-port minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral and bilateral operations, respectively. Postoperative complications were noted in 4 cases, 2 (0.7 %) patients with scrotal edema, 1 (0.4 %) patient experienced an umbilical hernia, and 1 (0.4 %) patient with suture site abscess. During a median follow-up period of 9 months (range 6-24 months), postoperative hydrocele recurrence was seen in 2 patients (0.7 %).

CONCLUSIONS

This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles.

The discovery of lymphatic stomata and its ultrastructure in mouse tunica vaginalis

BACKGROUND/PURPOSE

The communicating hydrocele is caused by the failure of the processus vaginalis closure. After the patent processus vaginalis is closed, the hydrocele can subside spontaneously, but the mechanism responsible for the drainage of hydrocele has not been expounded. Former studies showed that lymphatic stomata between the mesothelial cells lining the peritoneum and pleura were responsible for the drainage of ascites and pleural effusion. Although the tunica vaginalis is also lined by mesothelial cells, the existence of lymphatic stomata in it has never been reported. Therefore, we investigated the presence and ultrastructure of lymphatic stomata in mouse tunica vaginalis.

METHODS

We studied the ultrastructure of mouse tunica vaginalis by scanning and transmission electron microscopy. The submesothelial connective tissue with foramina were investigated after the mesothelial cells were digested by NaOH solution. Typan blue was used as a tracer to show the absorptive function of lymphatic stomata.

RESULTS

The lymphatic stomata were found between the mesothelial cells. The trypan blue was directly absorbed by the lymphatic stomata. Milky spots which possessed immune function were observed, and the lymphatic stomata were found within the milky spots.

CONCLUSION

Our study is the first to report the presence and ultrastructure of lymphatic stomata in mouse tunica vaginalis. They might be related to the lymphatic drainage in the tunica vaginalis cavity.

Assessment and management of inguinal hernia in infants

Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral groin, use of laparoscopy, and anesthetic approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled trials to determine best practices for the management of inguinal hernias in infants.

Inguinal and genital anomalies

Problems of the groin and genitalia are a common presenting complaint in both pediatrician's offices and emergency departments. The authors endeavor to provide a comprehensive review of the most common inguinal and genital anomalies encountered by the pediatrician, with a special focus on examination and management.

Surgery for hydrocele in children-an avoidable excess?

BACKGROUND

There is little consensus over the optimal timing of ligation of a patent processus vaginalis (PPV) in boys with hydrocele. We hypothesized that a proportion of procedures may be unnecessary because they are performed at an age before which the PPV may be expected to close spontaneously. Such excess may expose the child to unnecessary surgery and have significant cost implications.

METHODS

A systematic literature review relating to timing of PPV ligation and a population-based study to define number of PPV ligations performed annually in England and age at surgery were conducted.

RESULTS

Most hydroceles resolve before 2 years of age, but their natural history beyond this age is poorly documented. Current guidelines recommend PPV ligation at 2 years of age. An average of 2878 operations for hydrocele is performed per year in children in England. Commonest age at repair is 2 years. There are no randomized controlled trials comparing PPV ligation with an observational nonoperative approach.

CONCLUSIONS

The natural history of hydrocele is poorly documented beyond the age of 2 years. There is no good evidence to support current practice. Delaying surgery may reduce the number of procedures necessary without increasing morbidity. A prospective study to investigate this is warranted.

Common scrotal and testicular problems

Scrotal and testicular problems range from the benign and painless to the malignant and debilitating. The primary care physician should be able to triage these problems and know when to give reassurance and when to initiate a targeted workup that may lead to specialist intervention. This article focuses on scrotal pain and palpable abnormalities. Scrotal pain includes well-defined acute causes such as torsion and infection and the less well-defined chronic orchialgia. Palpable abnormalities covered here include cryptorchidism, hydrocele, spermatocele, varicocele, and testicular cancer.