Management of Large Septated Extratesticular Cystic Lesion of the Left Scrotal Sac
Surgical intervention is the recommended treatment for this large septated extratesticular cystic lesion causing constant pain, with complete excision being the optimal approach to provide symptom relief and prevent recurrence.
Clinical Assessment
The patient presents with:
- 36-year-old male
- Large septated extratesticular cystic lesion (4.9 x 8.7 cm) in left scrotal sac
- Constant pain, especially when walking
- History of previous drainage in 2008
- Ultrasound findings consistent with a complicated hydrocele
Diagnostic Evaluation
The ultrasound findings show:
- Normal bilateral testes with normal blood flow
- Right testicle: 5.2 x 3.1 x 4.1 cm with spermatoceles in epididymis
- Left testicle: 5.4 x 2.4 x 3.5 cm with normal epididymis
- Large septated cystic lesion in left scrotal sac (4.9 x 8.7 cm)
- Impression: Complicated hydrocele
Treatment Algorithm
First-line Treatment
- Complete surgical excision of the cystic lesion is recommended due to:
- Large size (4.9 x 8.7 cm)
- Septated nature
- Constant pain affecting quality of life
- History of recurrence after previous drainage
Surgical Approach Options
Complete excision via scrotal approach
- Indicated for symptomatic extratesticular cystic masses
- Allows for definitive treatment and pathological diagnosis
- Preferred for complex or septated lesions
Partial cystectomy (if complete excision risks damage to vital structures)
- May be considered if the cyst is adherent to spermatic cord structures
- Higher risk of recurrence compared to complete excision
Non-surgical Options (generally not recommended for this case)
- Simple aspiration/drainage: Not recommended due to high recurrence rate and history of previous drainage failure
- Sclerotherapy: Limited efficacy for complex, septated lesions
Rationale for Surgical Management
The American College of Radiology guidelines support surgical intervention for symptomatic scrotal masses, especially when they cause pain and affect quality of life 1. While the ACR guidelines don't specifically address complicated hydroceles, they emphasize the importance of definitive treatment for symptomatic extratesticular lesions.
Surgical excision is particularly important in this case because:
- The patient has constant pain affecting his mobility and quality of life
- The lesion is large (4.9 x 8.7 cm) and septated, suggesting complexity
- Previous drainage (2008) was unsuccessful in providing long-term relief
- Complete excision allows for definitive pathological diagnosis to rule out rare malignancy
Post-treatment Follow-up
- Clinical examination at 2 weeks for wound healing
- Follow-up ultrasound at 3 months to ensure complete resolution
- Additional follow-up as needed based on pathology results
Important Considerations and Caveats
- Pathological examination: All excised tissue should undergo histopathological examination to confirm diagnosis and rule out rare malignancy
- Surgical risks: Inform patient about potential complications including bleeding, infection, damage to testicular vessels or vas deferens, and recurrence
- Differential diagnosis: While likely a complicated hydrocele, other possibilities include lymphangioma, spermatocele, or other cystic lesions 2, 3
- Recurrence risk: Even with complete excision, complex cystic lesions can recur, requiring long-term follow-up
The evidence strongly supports surgical intervention for symptomatic extratesticular cystic lesions, particularly when they are large, complex, and causing pain that affects quality of life. Simple drainage procedures have high recurrence rates, as evidenced by this patient's history of previous drainage with subsequent recurrence.