What are the recommendations for testicular fixation after hydrocelectomy (surgical removal of a hydrocele) in patients with very large hydroceles?

Testicular Fixation After Hydrocelectomy in Very Large Hydroceles

Direct Recommendation

Testicular fixation is not routinely recommended after hydrocelectomy, even for very large hydroceles, as standard surgical techniques (Winkelmann's or Bergman's procedures) provide adequate testicular positioning without requiring additional fixation sutures. 1

Surgical Approach for Large Hydroceles

The primary concern with very large hydroceles is complete excision of the tunica vaginalis and prevention of recurrence, not testicular malposition:

• Winkelmann's procedure (61% of cases) and Bergman's procedure (33% of cases) are the gold standard surgical treatments for hydrocele, including large hydroceles. 1

• Complete resection of the tunica vaginalis covering sheets is recommended as a prophylactic measure against recurrence, regardless of hydrocele size. 1

• For giant hydroceles (>1000 mL), radical hydrocelectomy with excision of the sac remains the standard approach, with no mention of routine testicular fixation being necessary. 2

Technical Considerations for Large Hydroceles

When managing very large hydroceles, the surgical focus should be on:

• Pull-through techniques enable removal of large hydrocele sacs through small incisions (15 mm) with minimal dissection under direct vision of testicular structures. 3

• Mean operative time for hydrocelectomy ranges from 27-35 minutes, with patients resuming normal activity within 6 days on average. 3, 4

• Scrotoscopy can be used before and after hydrocelectomy to examine intrascrotal contents and ensure proper testicular positioning without requiring fixation sutures. 4

Complications to Avoid (Not Related to Fixation)

The documented complications of hydrocelectomy do not include testicular torsion or malposition requiring fixation:

• The most serious complication is iatrogenic injury to the vas deferens or epididymis, which can result in azoospermia—this occurred in 3 patients after hydrocele repair. 5

• Other complications include hematoma (requiring reoperation in 0.52% of cases due to testicular blood vessel compression), wound infection (1.02%), and persistent scrotal edema. 3, 1

• Testicular atrophy may be present preoperatively in giant hydroceles of long duration (15+ years), potentially warranting orchiectomy rather than hydrocelectomy. 2

When to Consider Testicular Evaluation

Rather than fixation, attention should focus on:

• Ultrasound examination is recommended for large hydroceles to evaluate testicular size and exclude underlying pathology before surgery. 6

• Testicular volumes <12 mL are considered atrophic and may indicate underlying pathology requiring different management considerations. 6

• In cases of marked testicular atrophy discovered intraoperatively, orchiectomy may be more appropriate than hydrocelectomy with attempted fixation. 2

Clinical Algorithm

For very large hydroceles, the surgical approach should be:

1. Preoperative ultrasound to assess testicular size and exclude masses 6
2. Standard Winkelmann's or Bergman's procedure with complete tunica vaginalis excision 1
3. Meticulous hemostasis to prevent hematoma and vascular compromise 1
4. Careful preservation of vas deferens and epididymis to prevent azoospermia 5
5. No routine testicular fixation required 3, 1

The absence of testicular fixation in all reviewed surgical series (192 patients) and surgical technique descriptions strongly indicates this is not a standard or necessary component of hydrocelectomy, regardless of hydrocele size.