Hydrocele of the Canal of Nuck: A Review

[Hydrocele]

The hydrocele is overall a rare condition in urology. A differentiation between primary and secondary hydrocele is essential for further treatment. A primary hydrocele with a patent vaginal process tends to spontaneously regress in the first 2 years of life in newborns. If treatment is necessary, open as well as laparoscopic methods are available with good results. The treatment of scrotal pathologies, especially secondary hydrocele, often poses a challenge in the clinical practice. Despite the benign nature, supposedly simple surgical techniques and good chances of healing, postoperative complications are frequent. In comparison to open surgery, sclerotherapy provides a good alternative for the treatment of secondary hydrocele.

Laparoscopic Versus Open Surgical Management of Hydrocele of the Canal of Nuck: A Retrospective Analysis of 20 Cases

INTRODUCTION

 Hydrocele of the canal of Nuck is a condition that arises due to incomplete obliteration of the processus vaginalis or an abnormal outpouching from the round ligament during fetal development. It usually presents as a painless, rarely painful, groin swelling. The definitive diagnosis for this condition is magnetic resonance imaging. Various management options have been proposed for this condition, including open surgery, transabdominal preperitoneal approach, totally extraperitoneal approach, and a combination of laparoscopic and open surgery. The present study highlights the benefits of the transabdominal preperitoneal approach when compared with the open anterior approach and addresses the intraoperative challenges faced during laparoscopic surgery.

MATERIALS AND METHODS

 The study is a retrospective study inclusive of 20 patients who underwent surgery for the hydrocele of the canal of Nuck from June 2019 to December 2023. Case records of patients were studied for information such as demographic features, type of pathology, the surgery performed, intraoperative challenges encountered, operative time, duration of hospital stay, scores from the visual analog scale pain assessment chart at various intervals, and time taken to return to work. The variables were documented and statistically analyzed.

RESULTS

 The average age group of the study population was 27.8 ± 8.34 years. Of the 20 patients, 10 had undergone a transabdominal preperitoneal approach (Group A), and 10 had undergone an open anterior approach (Group B). Eleven out of 20 patients had an associated inguinal hernia, of which three were identified preoperatively and eight were identified incidentally during surgery. The mean operative time of Group A cases was 97.95 ± 7.54 minutes, while it was 66.3 ± 6.20 minutes for Group B cases. The Mann-Whitney U test showed a statistically significantly lesser operative time for Group B than for Group A (p-value < 0.001). The duration of hospital stays was comparable for the two groups with no significant difference (two days versus 3.8 ± 3.08 days, respectively). When the difference in the means of time taken to return to normal work was compared using the Mann-Whitney U test between Group A and B (6.1 ± 0.87 days and 11.2 ± 1.81 days, respectively), a statistically significant early return to normal work in the former group (p-value = 0.001) was revealed. Similarly, the Mann-Whitney U test when used to compare the median postoperative pain score of both groups at 12-24 hours, 48-72 hours, seven days, and three months showed a significantly lesser pain score among patients of Group A at all intervals (p-value < 0.001, p-value = 0.005, p-value = 0.005, p-value < 0.001, respectively). The incidence of intraoperative challenges, sero-hematoma, and surgical site infection were insignificant in comparison.

CONCLUSION

The transabdominal preperitoneal approach for the hydrocele of the canal of Nuck is ideal as it offers excellent intraoperative delineation of pathology and postoperative outcomes. Prophylactic placement of a mesh in all cases can help prevent a future occurrence of inguinal hernia in these cases.

A Review of Classification, Diagnosis, and Management of Hydrocele

This article summarizes and updates a number of issues related to hydrocele including anatomy, embryology, classification, etiology, clinical manifestations, imaging findings, and management. Hydrocele is an abnormal collection of serous fluid between the parietal and visceral layers arising from the mesothelial lining of the tunica vaginalis that surrounds the testis and spermatic cord directly. Hydroceles result from an imbalance of secretion and reabsorption of fluid from the tunica vaginalis. Hydroceles can be divided into two types as primary and secondary. The diagnosis should be based on medical history, clinical manifestations, and imaging studies. Understanding the causes and types of hydroceles is useful for accurately diagnosing and treatment strategy. Hydroceles can be managed by conservative treatment, fluid aspiration, or hydrocelectomy.

Totally laparoscopic surgery for a hydrocele of the canal of Nuck extending from the abdominal cavity to the subcutaneous space: a case report

BACKGROUND

Hydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established.

CASE PRESENTATION

A 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision.

CONCLUSIONS

Laparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

Hydrocele of the canal of Nuck: a rare differential diagnosis for an inguinal hernia

Hydrocele of the canal of Nuck is a rare condition which is commonly misdiagnosed as an inguinal hernia due to the unfamiliarity of clinicians with this pathology. There are three different types of hydrocele of the canal of Nuck, with type 1 being the most common, typically presenting as a unilocular cystic lesion with no communication with the peritoneal cavity. We present a case of a two-month-old female patient with an enlarging inguinal swelling raising the suspicion for an inguinal hernia or lymphadenopathy, with sonographic imaging revealing a fluid collection in the canal of Nuck, suggestive of a hydrocele. Diagnostic radiology plays a crucial role in the initial diagnosis of a canal of Nuck hydrocele, and ultrasound is considered the modality of choice for early diagnosis differentiating it from other causes of inguinal swelling.

Hydrocele and endometriosis of the canal of Nuck in two adults: a look at the imaging features

We present a report of two adult females who presented to the surgery clinic at different time frames in our hospital with a swelling in the inguinal region. The swelling was painful for one of our patients. The first patient was evaluated with a contrast-enhanced CT and an MRI, while the second patient underwent a ultrasonography and an MRI. Imaging revealed the structure to be cystic in nature and confirmed the diagnosis as a hydrocele of the canal of Nuck in both patients. Our second patient was also found to have concomitant endometriosis, with internal septations seen in the hydrocele. Aspiration revealed altered blood with haemosiderin deposition, which established a diagnosis of endometriosis of the canal of Nuck. The first patient underwent excision, while the second patient refused a surgical approach and opted for medical management for endometriosis.

A Case Report of Female Hydrocele of the Canal of Nuck (Type I): A Diagnostic Challenge and Surgical Solution

The canal of Nuck is an anomaly of the female inguinal canal that can lead to the development of hernias or hydroceles. It is a result of incomplete obliteration of a pouch of the parietal peritoneum that accompanies the round ligament throughout the inguinal canal. This is a case report of a 27-year-old female with hydrocele of the canal of Nuck which was initially misdiagnosed as a reducible right inguinal hernia. Physical examination and ultrasound revealed a right groin 64 × 15 × 36 mm cystic mass extending from the right inguinal region to the labia majora. Right inguinal exploration was performed with an oblique inguinal incision. A cystic lesion measuring 65 × 15 mm was carefully dissected from the round ligament and excised. Histopathological examination confirmed the diagnosis of hydrocele of the canal of Nuck. The patient is doing well after six months with no signs of recurrence on the operated side. The hydrocele of the canal of Nuck, though a rare condition, should always be considered in the differential diagnosis when evaluating inguinolabial swellings in female patients.