Hydrocele in the pediatric patient: inguinal or scrotal approach?

Diagnosis and management of a rare case of encysted hydrocele of spermatic cord: Case report and literature review

INTRODUCTION AND IMPORTANCE

A hydrocele is typically a non-cancerous condition that arises from the accumulation of fluid between the layers of the vaginal process. Diagnosis primarily involves a physical examination. In instances where the condition is mistaken for other pathological conditions, additional investigations may be undertaken. Surgical intervention is typically deferred until after the age of one year, unless the hydrocele is significantly large.

CASE PRESENTATION

A case was presented of a 4-year-old boy who was referred to the hospital with a suspected deep inguinal hernia. Upon examination, it was determined that the mass was actually an encysted hydrocele of spermatic cord. The patient underwent a minimally invasive surgery to remove the spermatocele, and the procedure was successful.

CLINICAL DISCUSSION

This emphasizes the importance of obtaining a detailed patient history and conducting a comprehensive physical examination, which often provide sufficient information to make a diagnosis. In many instances, these initial steps can spare patients from undergoing additional tests that may be invasive or pose unnecessary risks.

CONCLUSION

It is important to note that in cases of hydroceles, conservative treatment, such as observation, is the primary approach before the age of one year. Surgery is typically reserved for older children or those with large hydroceles.

Metachronous Contralateral Occurrence of Hydrocele After Unilateral Hydrocelectomy in Children Younger Than 8 Years

BACKGROUND

Hydrocele on the contralateral side after surgical repair is an uncommon condition compared to surgical site recurrence. Although there has been much research on metachronous contralateral inguinal hernia in children, metachronous contralateral hydrocele, which share a common pathology with inguinal hernias, has not yet been investigated. We have investigated the incidence and risk factors for metachronous contralateral occurrence of communicating and noncommunicating hydroceles in children younger than 8 years.

METHODS

From January 2017 to June 2020, 302 children younger than 8 who were diagnosed with unilateral hydroceles were treated in our hospital without surgical exploration of contralateral hydrocele. The disease was classified into communicating and noncommunicating hydroceles. We divided patients into two groups according to the presence of metachronous contralateral hydrocele and analyzed the differences between the two groups.

RESULTS

Among 302 patients, the mean age was 36.4 ± 20.9 months. Metachronous contralateral hydrocele occurred in 15 (4.9%) patients as communicating hydroceles. Comparison between the two groups showed statistically significant differences in type of hydrocele (P = 0.047) at first diagnosis.

CONCLUSION

Clinically evident risk of metachronous contralateral hydrocele after unilateral hydrocelectomy was 4.9%. Despite the relatively low incidence rate, the risk of metachronous contralateral occurrence should always be consulted with parents before surgical treatment of hydroceles.

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.

Laparoscopic hydrocelectomy with transabdominal preperitoneal hernioplasty or iliopubic tract repair for treatment of encysted spermatic cord hydrocele

BACKGROUND

An encysted spermatic cord hydrocele (ESCH) causes an inguinal swelling resembling an inguinal hernia (IH). An ESCH should be considered as a differential diagnosis of IH. Although laparoscopic operations have been performed to treat ESCHs in pediatric patients, such operations have not been reported in adults. This study was performed to evaluate the outcomes of laparoscopic hydrocelectomy for treatment of ESCHs in adults.

METHODS

The medical charts of 49 patients who underwent laparoscopic transabdominal hydrocelectomy for ESCHs from January 2015 to December 2020 at a single institution were retrospectively reviewed. The patients were divided into those with and without an IH. Laparoscopic hydrocelectomy was performed, and the internal inguinal ring was closed with iliopubic tract repair (IPTR) or transabdominal preperitoneal (TAPP) hernioplasty depending on the presence of an IH. The patients' age, ESCH location, postoperative complications, recurrence, and operating time were examined.

RESULTS

The patients' mean age was 46.7 (20-77) years. All patients underwent laparoscopic hydrocelectomy without open conversion. ESCHs were more common on the right side (35/49, 71.4%) than on the left (14/49, 28.6%). The presenting symptom in all patients was inguinal swelling. The ESCH was located inside the inguinal canal in 47 patients and protruded to the abdominal cavity from the inguinal canal in 2 patients. After laparoscopic hydrocelectomy, 32 patients without an IH underwent IPTR and 17 patients with an IH underwent TAPP hernioplasty. The mean operating time was shorter in the IPTR than TAPP hernioplasty group. The postoperative complications and hospital stay were not different between the two groups. There were no recurrences in either group.

CONCLUSIONS

Laparoscopic hydrocelectomy with IPTR or TAPP hernioplasty is safe and feasible for treatment of ESCHs in adults.

Comparison of the Detection and Ligation of Patent Processus Vaginalis Between Laparoscopy-Assisted Transscrotal Orchiopexy and Single Scrotal Incision Orchiopexy

This study aimed to compare the detection and ligation of patent processus vaginalis (PPV) between laparoscopy-assisted transscrotal orchidopexy (LATO) and single scrotal incision orchiopexy (SSIO) for low palpable undescended testis (UDT). We performed a retrospective medical record review of transscrotal orchidopexies performed for low palpable UDT at our institution from 2017 to 2019; 33 and 39 boys underwent LATO and SSIO, respectively. Data collection included patient demographics, incidence of PPV, operative time, and clinical outcomes. All 95 testes were delivered into the scrotum. There was no significant difference between the two groups with respect to patients' age, side, and mean operative time. The incidence of PPV in the LATO group was significantly higher than that in the SSIO group (56.52 vs. 34.69%, P = 0.04). The incidence of contralateral PPV in the LATO group was 45%. One patient in the SSIO group underwent unilateral PV ligation and laparoscopic exploration revealed bilateral PPV owing to metachronous contralateral hydrocele. One patient in the LATO group demonstrated obliterated PV in the initial transscrotal procedure, but an ipsilateral PPV was found in the latter laparoscopic procedure. In conclusion, LATO has a higher detection rate and higher ligation of the PPV than SSIO, suggesting that, LATO may help reduce recurrent PPV-related issues. However, long-term follow-up results are needed to evaluate the advantages and disadvantages in a larger case series.

Laparoscopic Excision of Patent Processus Vaginalis for Pediatric Hydroceles

Background

The standard surgical practice for pediatric hydrocele is resection and ligation of the patent processus vaginalis (PPV). Non-ligation of PPV for pediatric hydrocele is another possibility that can be repaired laparoscopically.

Material & methods

A retrospective study was undertaken over 10 years (Jan 2011-Feb 2020), of a case series of boys with hydroceles that underwent laparoscopic PPV (Lap PPV) excision. Exclusion criteria were for parents who requested open surgery (10 cases) or an omental plug noted at the PPV site during laparoscopy (one case). Laparoscopic PPV excision was performed via a transperitoneal approach.

Results

There were 43 cases of Lap PP excision, including three recurrences after open surgery. There were no conversions, complications, or recurrences in any patients. The average operative time for unilateral cases was 21 mins (range 15-30 mins). Three concurrent contra-lateral hydroceles were noted and resected during the primary procedure. Time to regular activity was within one day. There was no visible scar or recurrence after Lap PPV at six months post-surgery review.

Conclusion

Lap PPV excision appears to be at least equivalent to the “open and ligation” approach. During laparoscopy, both internal rings are assessed for a PPV.

By avoiding an inguinal incision(s), a better cosmetic result is possible. It is conceivably safer than open surgery in recurrent cases.

Hydrocele in Pediatric Population

Hydrocele is a collection of fluid within the tunica vaginalis. Based upon the etiology and the pathophysiology, it is divided into, the primary and secondary. The primary hydrocele includes the neonatal or the congenital, the communicating and the non-communicating or the closed or the adult type. The secondary hydrocele can develop in the substrate of a pre-existing disease. After systematic and thorough systematic and thorough research of the relevant literature, we aim at describing all the aspects of this entity, with specific emphasis on the issues that remain unanswered from the scientific community.

Adolescent de novo hydroceles - should they be dealt with by inguinal or scrotal approach?

AIM

The objective of this study was to investigate the optimal approach for the treatment of hydroceles in adolescents.

MATERIALS AND METHODS

A retrospective chart review of all adolescents (10-16 years old) diagnosed with a de-novo hydrocele in 2 tertiary care institutions over a 10 year period (2007-2016) was performed comparing the inguinal and trans-scrotal (Jaboulay) approaches.

RESULTS

Fifty-three boys with a mean age of 13.4 years (range 10-16 years) were diagnosed with hydrocele. The inguinal approach was used in 31 (59%) patients for treatment of their hydrocele. In 19 (61%) of these cases a patent processus vaginalis (PPV) ligation was performed. In the other 12 (39%) patients the PPV was closed or not found and a further repair of the hydrocele through the same inguinal incision was performed. A transcrotal Jaboulay procedure was performed in 22 (41%) of the patients. There was no difference in the complications rate between inguinal and trans-scrotal approaches (p = 0.71). Age of presentation less than 12 years was associated with the presence of a PPV (p < 0.05).

CONCLUSIONS

A trans-scrotal approach should be considered as first-line in adolescents when the history is not suggestive of a communicating hydrocele. Children less than 12 years of age are more likely to have a PPV and an inguinal approach may be more appropriate.

TYPE OF STUDY

Retrospective comparative study LEVEL OF EVIDENCE: Level II.

Hydrocelectomy via scrotal incision is a valuable alternative to the traditional inguinal approach for hydrocele treatment in boys

Purpose

Few studies have explored the treatment of isolated communicating hydroceles via scrotal incision. We prospectively evaluated the surgical outcomes of such treatment in boys with hydroceles compared with that using traditional, inguinal incision hydrocelectomy.

Materials and Methods

Of 347 boys aged 0–12 years who were diagnosed as hydrocele on ultrasonography, 173 boys were assigned to the scrotal incision hydrocelectomy group (group I, n=173) and 172 boys were assigned to the traditional inguinal incision hydrocelectomy group (group II, n=172), and finally 156 boys in group I and 156 boys in group II were included in this study. Surgical outcomes, including postoperative complications and hydrocele relapse rates, were compared between groups.

Results

The overall success rates were similar in both groups (group I, 96.8%; group II, 89.1%; p=0.740). The operation time and hospital stay were significantly shorter in group I (30.94±3.95 minutes and 3.94±0.30 days) than in group II (38.02±7.12 minutes and 4.24±0.99 days; p<0.001 and p=0.009, respectively). The postoperative complication rate was lower in group I than in group II (3.2% vs. 10.9%, p=0.740).

Conclusions

Scrotal incision hydrocelectomy in boys was associated with shorter operative time and hospital stay, and a lower postoperative complication rate, than was the inguinal incision approach. The scrotal incision technique might be an easy and effective alternative treatment when used to treat hydroceles in boys as well as inguinal incision approach.

Shear wave elastography evaluation of testes with non-communicating hydrocele in infants and toddlers: A preliminary study

INTRODUCTION

Shear wave elastography (SWE) is a new technology and non-invasive ultrasound device that can measure tissue rigidity and elasticity.

OBJECTIVE

This controlled prospective study aimed to demonstrate using SWE whether there was a difference between the elasticity of testes with non-communicating (NC) hydrocele in infants and toddlers and elasticity of controls' testes without hydrocele, and to reveal quantitative values of elasticity reflecting histological findings.

MATERIAL AND METHODS

Testes of 37 cases at an average age of 6.32 months and diagnosed with NC hydrocele between December 2016 and April 2017 were evaluated for hydrocele and testicular volumes, and testes elasticity through ultrasonography and SWE.

RESULTS

Of all cases, 15 had bilateral hydroceles, while 22 were diagnosed with unilateral hydrocele. Testes with NC hydrocele (n = 52) in infants and toddlers were compared with testes without hydrocele (n = 36) in controls. Median hydrocele volume of 52 testes with NC hydrocele was 5.0 cm³ (0.2-37). Median volume of testes with hydrocele was 0.6 cm³ (0.2-1.5) in the study group, and 0.5 cm³ (0.3-1) in controls (P = 0.577). Although median elastography values were measured as 1.67 m/s (1.29-2.59) and 10.0 kPa (2.1-23) in patients, those of controls were found to be 1.61 m/s (1.27-2.34) and 8.25 kPa (5.1-18.9) (P = 0.03, P = 0.005, respectively). While there was no between-group difference in testes volumes, a statistically significant difference was observed in SWE-derived quantitative data (Summary Table).

DISCUSSION

As a novel elastographic method, SWE is used to track shear waves passing through tissues by quantifying the elasticity of structures and nodules, such as liver fibrosis, and to improve the characterization of breast and thyroid nodules. Shear wave elastography was assessed to be a beneficial ultrasonography tool to predict the histologic features of undescended testicles, which might replace testicular biopsy in the modern management of undescended testes. This study also quantitatively measured whether there was a change in testicular tissues with NC hydrocele through SWE, and found that SWE values of testes with NC hydrocele were significantly higher compared with those of controls, despite the absence of a significant difference in testes volumes.

CONCLUSIONS

The present study confirmed that quantitative changes in testes elasticity can reliably be evaluated through SWE. Non-communicating hydrocele may be damaging to testicular tissues. More definitive results will be achieved with further comprehensive studies including larger patient populations. It is believed that the operation age of children with NC hydrocele can be re-evaluated in the future.

Tunica Vaginalis Thickening, Hemorrhagic Infiltration and Inflammatory Changes in 8 Children with Primary Hydrocele; Reactive Mesothelial Hyperplasia? A Prospective Clinical Study

The aim of this study is to describe an entity of primary hydrocele accompanied with fibrosis, thickening and hemorrhagic infiltration of parietal layer of tunica vaginalis (PLTV). During a 4-year period (2011-2014), 94 boys (2.5-14 years old) underwent primary hydrocele repair. Hydrocele was right sided in 55 (58.5 %), left sided in 26 (28.7%) and bilateral in 12 patients (13.8%). Eighty three out of 94 patients (88.30%) had communicating hydrocele and the rest eleven patients (11.7%) had non-communicating. Our case group consists of 8 patients (8.51%) based on operative findings consistent with PLTV induration, thickening and hemorrhagic infiltration. Preoperative ultrasonography did not reveal any pathology of the intrascrotal structures besides hydrocele. There weren't hyperechoic reflections or septa within the fluid. Evaluation of thickness of the PLTV was not feasible. Presence of lymph or exudate was excluded after fluid biochemical analysis. Tunica vaginalis histological examination confirmed thickening, hemorrhagic infiltration and inflammation, while there was absence of mesothelial cells. Immunochemistry for desmin was positive, excluding malignant mesothelioma. One patient underwent high ligation of the patent processus vaginalis and PLTV sheath fenestration, but one year later, he faced a recurrence. An elective second surgery was conducted via scrotal incision and Jaboulay operation was performed. The latter methodology was our treatment choice in other 7 out of 8 patients. During a 2-year postoperative follow-up, no other patient had any recurrence. We conclude that in primary hydrocele with macroscopic features indicative of tunica vaginalis inflammation, reversion of the tunica should be a part of operative strategy instead of sheath fenestration, in order to minimize the recurrence.

Effectiveness of Laparoscopy in the Treatment of Pediatric Hydrocele: A Systematic Review

Objective: To conduct a systematic review of the published studies concerning laparoscopic pediatric hydrocele (PH) repair and summarize the surgical details and operative outcomes of this procedure. Materials and Methods: A PubMed search was performed for all studies concerning laparoscopic repair of hydrocele in children. The search strategy was as follows: (laparoscop* OR coelioscop* OR peritoneoscop* OR laparoendoscop* OR minilaparoscop*) AND hydrocele* AND (child* OR pediatric*). Inclusion criteria included (1) children with hydrocele as the study participant; (2) laparoscopic PH repair as the main surgical procedure; and (3) operation time and complications as the outcomes of interest. Reviews, studies with insufficient information or reporting the outcomes of abdominoscrotal hydrocele, and duplicate patient series were excluded. Results: Overall, 20 studies fulfilled the inclusion criteria of this review and 15 studies were included in the final analysis. These studies comprised at least 2920 patients undergoing laparoscopic repair for various PH subtypes, of which most were conducted in Asia. Most authors repaired PH laparoscopically through an extraperitoneal approach, while only a few studies applied a laparoscopic intraperitoneal method. The majority of the studies used nonabsorbable sutures to ligate hydrocele sac, while very few studies used absorbable materials. Hydrocele sac was resected or transected in only five studies, but left alone in the majority. Mean operation time was between 15.6 and 43.2 minutes for unilateral laparoscopic PH repair and between 16.9 and 53.2 minutes for bilateral surgery. Operative complications were not very common, with a highest recurrence/persistence incidence of 1.4%. Subgroup analysis showed that hydrocele subtype, surgical approach, suture material, and management of hydrocele sac did not significantly influence the operative complications. Conclusions: laparoscopic PH repair seems to be a safe and effective procedure. Given the limitations of this review, our conclusion needs to be confirmed by more well-designed studies.

A comparison between totally laparoscopic hydrocelectomy and scrotal incision hydrocelectomy with laparoscopic high ligation for pediatric cord hydrocele

BACKGROUND

The purpose of this study is to report clinical characteristics and to investigate the feasibility and safety of totally laparoscopic hydrocelectomy (TLH) compared to scrotal incision hydrocelectomy with laparoscopic high ligation (SIH) for pediatric cord hydrocele (CH).

METHODS

From September 2011 to February 2016, 148 patients underwent SIH, and 342 patients underwent TLH for CH. In the TLH group, a large hydrocele that could not pass through the internal ring was removed after percutaneous syringe aspiration. Age, laterality of hydrocele, inguinal comorbidities, operation time, surgical complications, and recurrences were evaluated.

RESULTS

All the patients had spermatic cord cysts and patent processus vaginalis in proximity to hydrocele (mixed type). The mean age of CH patients was 34.1 ± 22.1 months. CHs are more common on the right side (61.0%) than on the left (35.7%). Bilaterality occurred in 3.3%. Comorbidities such as hernia (8.6%) and cryptorchidism (1.2%) were observed. There were no complications except for two cases of wound hematoma in SIH group. There was one (0.7%) case of recurrence appeared in communicating hydrocele in SIH group. There were no significant differences in the age, laterality of hydrocele, inguinal comorbidities, operation time, complications, and recurrences between TLH and SIH groups. However, TLH for unilateral cord hydrocele had significantly shorter operation time compared to SIH. The mean operation time in TLH group was 15.6 ± 5.96 min and there was no conversion to open surgery.

CONCLUSIONS

TLH for pediatric CH is a feasible and safe procedure without additional incisions. Therefore, TLH can be one of the surgical options for pediatric CH especially in mixed type.

Classifying Hydroceles of the Pelvis and Groin: An Overview of Etiology, Secondary Complications, Evaluation, and Management

INTRODUCTION

A hydrocele is defined as the pathological buildup of serous fluid in the pelvis and groin due to various etiologies such as diseases or trauma. It has distinct clinical manifestations, particularly discomfort and psychosocial distress. Understanding the anatomy, embryology, and physiology associated with hydrocele formation is crucial to understand its onset and progression.

MATERIALS AND METHODS

A MEDLINE^® search was conducted using keywords for the relevant classification of hydrocele and its etiology, complications, sexual barriers, evaluation, and management.

RESULTS

Appropriately classifying the hydrocele as primary, secondary communicating, secondary noncommunicating, microbe-induced, inflammatory, iatrogenic, trauma-induced, tumor-induced, canal of Nuck, congenital, and giant is important for identifying the underlying etiology. Often this process is overlooked when the classification or etiology is too rare. A focused evaluation is important for this, so that timely management can be provided. We comprehensively review the classifications, etiology, and secondary complications of hydrocele. Pitfalls of current diagnostic techniques are explored along with recommended methods for accurate diagnosis and current treatment options.

CONCLUSION

Due to the range of classifications and etiologies of hydrocele in the pelvis and groin, a deliberate differential diagnosis is essential to avoiding imminent life-threatening complications as well as providing the appropriate treatment.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

RETRACTED: A new technique for extraperitoneal repair of inguinal hernia

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief and authors, as portions of the clinical data used were inaccurate. Specifically, more than 500 cases of the total 1882 cases of hernia patients presented in the paper were actually hydrocele of tunica vaginalis, not hernia. The authors sincerely apologize for these errors.

Ten year experience of laparoscopic repair of pediatric hydrocele and the long-term follow-up results

PURPOSE

This study aims to assess the efficacy and safety of laparoscopic repair for pediatric hydroceles and its long-term follow-up results.

METHODS

We performed this procedure to 284 patients from 2002 to 2011 using our specially designed curved awl. The patent internal ring was enclosed and fixed under laparoscopy and fluid within the patent processus vaginalis was emptied by percutaneous needle aspiration.

RESULTS

The median operation time was 16minutes. Fifty-seven contralateral open internal rings were diagnosed during laparoscopic exploration and closed at the same time. During our 10-year follow-up only four kids had recurrence of moderate amount of fluid accumulation 1-3months after the surgery and 3 of them spontaneously resolved during the outpatient follow-ups. Only one of them was treated by percutaneous needle aspiration successfully. No abdominal viscera injury happened.

CONCLUSIONS

Laparoscopic hydrocele repair proved to be applicable and effective with satisfactory long-term results according to our experience.

Herniotomy in resource-scarce environment: Comparison of incisions and techniques

BACKGROUND

There are various methods for surgical treatment of hernia and hydrocele in children with variable cost-effectiveness, recovery and cosmetic outcomes. This study analyses our experience with mini-incision/invasive herniotomy in children in resource-limited centre.

MATERIALS AND METHODS

Seven hundred and eighty-four n = 784 patients underwent herniotomy via conventional and mini-invasive methods were assigned into Group A and Group B. Three hundred and seventy-six n = 376 (47.95%) in Group A while four hundred and eight n = 408 (52.04%) in Group B. Eight hundred and seventeen (817) herniotomy was performed. Demographic data, hernia/hydrocele sides, volume of surgical suture used, surgery duration, and complications analysed.

RESULTS

Right side hernia and/or hydrocele were 464 (59.18%). 287 (36.60%) had left sided while 33 (4.21%) had bilateral hernia and/or hydrocele. There were 14 bilateral hernia repair in Group A and 19 in Group B. The lengths of operation time for unilateral repair ranged from 14 to 54 min in Group A (median, 23 min) and 7-44 min in Group B (median, 15 min) with a mean surgical duration of 15.48 ± 4.16 min in Group B versus 23.41 ± 5.94 min in Group A (P < 0.001) while the range of the lengths of operation time for bilateral repair in Group A was 20-54 min (median, 36) and 12-30 min (median, 21) in Group B with a mean duration of 36.35 ± 9.89 min in Group A versus 20.42 ± 4.83 min in Group B P = 0.00563. 376 sachets of 45 cm suture material were used in Group A versus 137 in Group B. There were total of 87 (23.13%) complications in Group A versus 3 (1.47%) in Group B P = 0.000513. Superficial wound infection and abscess were 9 (2.36%) and 16 (4.25%) in Group A versus none (0) in Group B.

CONCLUSION

Mini-incision/invasive herniotomy in children and adolescents is fast, cost-effective with satisfactory cosmetic outcome and limited complications.

Primary new-onset hydroceles presenting in late childhood and pre-adolescent patients resemble the adult type hydrocele pathology

AIM

The aim of this study was to investigate the presence of a patent processus vaginalis (PPV) in children of late childhood and pre-adolescence presenting with new onset hydrocele.

MATERIAL AND METHODS

All males with hydrocele presenting at our department from January 2011 to January 2013 were followed. Patients with secondary hydroceles were excluded. Demographic data, medical history, clinical symptoms and signs relative to their pathology and U/S findings were recorded. According to their indications, patients were either operated or followed up. Patients surgically treated, consisted our study group.

RESULTS

Sixty patients were identified. Thirteen were followed until resolution of their hydrocele. Forty-seven patients were surgically treated. Twenty-seven had right sided hydrocele (57.44%), 13 had left sided hydrocele (27.66%) whereas in 7 patients the hydroceles were bilateral (14.9%). All patients were operated by an inguinal approach. In all 9 patients (19.14%) presenting with new-onset hydrocele at the age >10 years (range: 10-15 years), intraoperative exploration did not reveal a PPV. All patients were followed at least for 6 months post-operatively.

CONCLUSION

Early evidence shows that primary new onset hydroceles presenting in late childhood and pre-adolescence seem to be non-communicating and resemble the adult type hydrocele pathology.

Laparoscopic treatment of pediatric hydrocele and the evaluation of the internal inguinal ring

BACKGROUND

There are few reports of the laparoscopic findings of the internal inguinal ring (IIR) in patients with hydrocele. The purpose of this study was to assess the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) for hydrocele in comparison with that of open repair (OR) and compare the findings of the IIR between cases of hydrocele and inguinal hernia (IH).

MATERIALS AND METHODS

We analyzed 69 consecutive patients with hydrocele who underwent surgery at our institution between April 2009 and February 2014. The patients were divided into two groups (LPEC and OR) according to the procedure. Age, length of operation/anesthesia, and complications were compared. Concerning the findings of the IIR, we classified the features into three categories, as follows: Type 1, flat; Type 2, narrow patent processus vaginalis (PPV) with a peritoneal veil; and Type 3, widely opened PPV. We then compared these findings between the cases of hydrocele and IH treated with LPEC during the study period.

RESULTS

Among a total of 69 patients, 40 underwent LPEC, and 29 underwent OR. There were no significant differences in the length of operation/anesthesia and complications. No recurrences were observed in either group. The findings of the IIR were mostly classified as Type 2 (59.1%) among the cases of hydrocele and Type 3 (92%) among the cases of IH.

CONCLUSIONS

LPEC is a safe and effective procedure for treating hydrocele. The findings of the IIR differ between cases of hydrocele and IH.

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.

Comparison of the inguinal and scrotal approaches for the treatment of communicating hydrocele in children

The inguinal approach is used for the treatment of hydrocele in the pediatric population. Although studies on scrotal orchiopexy have mentioned hernia or hydrocele repair through the same scrotal incision as a part of an orchiopexy procedure, there are a few studies reporting the treatment of isolated communicating hydrocele through a scrotal incision. We retrospectively evaluated and compared the outcomes of inguinal and scrotal approaches for the treatment of communicating hydrocele in boys. The classical inguinal and scrotal approaches to the treatment of communicating hydrocele were performed on 46 and 30 testicular units (in 43 boys and 27 boys, respectively). The patients' charts were reviewed to assess the operative times as well as the immediate and long-term complications during follow-up periods. The patients' ages ranged from 1 year to 8 years (3.6 ± 2.0 years) in the inguinal group and from 1 year to 10 years (mean 4.6 ± 2.8 years) in the scrotal group. Operative time was significantly lower in the scrotal group (p < 0.0001). The early minor complication rate did not differ between the two groups. Furthermore, there were no major complications noted. None of the patients had hydrocele recurrence after a mean follow-up of 6 months. The advantages of the scrotal approach for the treatment of communicating hydrocele are as follows: it is well tolerated, simple, and cosmetically appealing, and it has a short operative time in comparison with the standard inguinal approach. The scrotal incision technique is an effective alternative in communicating hydrocele treatment.

Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: a novel technique

BACKGROUND

The development of laparoscopic processus vaginalis repair has provided an alternative approach to the management of inguinal hernia and hydroceles in children. Here we describe our new technique for laparoscopic extraperitoneal ligation of processus vaginalis with subumbilical single-port using a modified Kirschner pin.

METHODS

A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision. A Kirschner pin with a hole in one flat terminal was inserted at the point of the internal inguinal ring. The processus vaginalis was closed extracorporeally by a non-absorbable suture, which was introduced into the abdomen through the Kirschner pin performing dissection within the extraperitoneal space in a series of movements. When a contralateral patent processus vaginalis is present, laparoscopic-assisted extracorporeal ligation is performed during the same operation.

RESULTS

Between September 2010 and September 2012, 211 children (130 cases of inguinal hernia and 81 cases of hydrocele) underwent processus vaginalis repair using this novel technique. A contralateral patent processus vaginalis was present and thus simultaneously closed in 20 patients with unilateral inguinal hernias and 12 patients with unilateral hydroceles. The mean operative time was 18 min (8-35 min). The mean follow-up period is 12 months (range 5-24 months), and no recurrence and complications has been observed to date.

CONCLUSIONS

This article describes a unique technique of extracorporeal circuit ligation of processus vaginalis using a minimally invasive technique as afforded by a reused modified Kirschner pin. Single-port laparoscopic processus vaginalis repair using this instrument is feasible and seems to be safe.

Omental incarceration may cause hydrocele and this hydrocele confused simple or scrotal hydrocele

BACKGROUND

The recommended approach to hydrocele repair in children is inguinal. Recently, a transscrotal approach has been recommended for hydroceles in children. This report describes our experience with hydrocele with omentum incarceration.

METHODS

This retrospective study reviewed the records of ten children who underwent inguinal hydrocele repair with omentum incarceration in our clinic.

RESULTS

The mean age of the patients was 4.5 years (range 1.5-16). Hydroceles were located on the right side in all patients. Scrotal erythema, inguinal pain, signs of intestinal obstruction and hernia sac were not determined. Hydrocele repairs were made by inguinal approach in all patients. The procesus vaginalis was rougher than normal and noted as the hernia sac. Thus, the hernia sacs were opened and omental incarceration was defined in all cases. Omentum protruded into the abdomen in all cases. A high ligation was performed and the distal parts of the sacs were fenestrated.

CONCLUSIONS

In the light of our experience, a scrotal approach to hydrocele repair in children would be difficult in cases of incarceration with hernia. Omental incarceration may cause hydrocele, and this hydrocele can be confused with normal hydrocele. Therefore, we would continue to recommend an inguinal approach for childhood hydroceles.

Pediatric inguinal hernia and hydrocele: an evidence-based review in the era of minimal access surgery

Pediatric inguinal hernia and hydrocele share a common etiology as well as management. The era of minimal access surgery is challenging the conventional surgical management for pediatric inguinal hernia in particular. This review article aims to highlight the nature of diagnosis and treatment for both hernia and hydrocele and examines both the traditional and contemporary treatment strategies from an evidence-based perspective.

Management of hydrocele in adolescent patients

Hydrocele is defined as an abnormal collection of serous fluid in the potential space between the parietal and visceral layers of the tunica vaginalis. In the majority of affected adolescents, hydrocele is acquired and is idiopathic in origin. The pathogenesis of idiopathic hydrocele is thought to be an imbalance in the normal process of fluid production and reabsorption. The diagnosis is usually clinical. Taking a thorough history is essential to rule out any fluctuation in size, which is an indication of a patent processus vaginalis. Scrotal ultrasonography is mandatory in nonpalpable testicles to rule out a subtending testicular solid mass requiring inguinal exploration. Otherwise, open hydrocelectomy via a scrotal incision is the standard treatment of idiopathic hydroceles. The second most common cause of hydrocele in adolescents is varicocelectomy. The risk of hydrocele formation is higher with non-artery-sparing procedures or those performed without microsurgical aid, and in surgery requiring cord dissection. If hydrocele occurs after varicocelectomy, initial management should include observation with or without hydrocele aspiration. Large persistent hydroceles are best served by open hydrocelectomy.