What is the recommended treatment for a male patient with a hydrocele, considering hydrocelectomy as an option?

Hydrocelectomy: Treatment Recommendations

Primary Treatment Recommendation

Hydrocelectomy remains the definitive surgical treatment for symptomatic hydroceles, with traditional open techniques (Winkelmann or Bergman procedures) providing success rates of 89-97%, though aspiration with sclerotherapy using doxycycline offers an effective nonsurgical alternative with 84% success rates for simple, nonseptated hydroceles. 1, 2

Treatment Algorithm

Initial Assessment and Decision-Making

• Determine if the hydrocele is symptomatic (causing discomfort, size concerns, or functional impairment) versus asymptomatic, as asymptomatic hydroceles may not require intervention 3

• Evaluate for secondary causes using scrotoscopy or ultrasound to exclude testicular masses, epididymal pathology, or other intrascrotal lesions before proceeding with treatment 3

• Assess hydrocele characteristics on imaging: simple nonseptated hydroceles are candidates for aspiration/sclerotherapy, while complex or septated hydroceles require surgical excision 2

Treatment Options by Clinical Scenario

For Simple, Nonseptated Hydroceles in Adults

First-line option: Aspiration and sclerotherapy with doxycycline

• Achieves 84% success with single treatment, avoiding surgical complications and hospital costs 2
• Patients experience minimal pain (2-3 days of moderate discomfort in some cases) 2
• Failed cases can undergo repeat sclerotherapy or proceed to surgical hydrocelectomy 2
• Mean follow-up of 20.8 months demonstrates durability 2

Surgical hydrocelectomy if sclerotherapy fails or is contraindicated:

• Traditional open techniques (Winkelmann or Bergman) provide 89-97% success rates 1, 4
• Winkelmann procedure involves eversion of the tunica vaginalis 1
• Bergman procedure involves excision of the tunica vaginalis 1
• Always perform resection of the tunica vaginalis as prophylaxis against recurrence 1

For Complex or Septated Hydroceles

Surgical hydrocelectomy is required as these are not amenable to aspiration/sclerotherapy 2

Surgical Approach Selection

Minimal/Endoscopic Techniques (Preferred for Appropriate Candidates)

• Minimal hydrocelectomy with scrotoscopy through 2.0 cm scrotal incision provides excellent outcomes with mean operative time of 35.4 minutes and no major complications 3
• Allows visual inspection to exclude pathology before proceeding with excision 3
• Endoscopic hydrocele ablation using electrocautery or KTP:YAG laser through small incision results in minimal postoperative discomfort, with 6 of 10 patients requiring no analgesics and return to normal activity within 2 days 5
• Mean operative time comparable to open surgery (53 vs 46 minutes) but with significantly reduced postoperative pain 5

Traditional Open Techniques

• Inguinal approach remains standard but associated with longer operative time (38 minutes), longer hospital stay (4.24 days), and higher complication rates (10.9%) 4
• Scrotal approach in pediatric populations shows shorter operative time (30.94 minutes), shorter hospital stay (3.94 days), and lower complication rates (3.2%) with 96.8% success 4

Special Considerations and Caveats

Intraoperative Findings Requiring Modified Approach

• If thickening of hydrocele wall is identified on scrotoscopy, convert to open hydrocelectomy for complete excision 3
• If acute inflammation is present, defer definitive treatment until inflammation resolves 3

Complication Prevention

• Ensure meticulous hemostasis to prevent postoperative hematoma formation (reported in 0.52% of cases) 1
• Avoid compression of testicular blood vessels during closure, particularly with Winkelmann procedure (reoperation required in 0.52% of cases) 1
• Maintain sterile technique to prevent wound infection (1.02% incidence) 1

Postoperative Monitoring

• Traditional open surgery patients may experience scrotal pain requiring oral analgesics for up to 2 weeks 5
• Minimal/endoscopic approach patients typically resume normal activities within 2 days with minimal analgesic requirements 5, 3

Clinical Pitfalls to Avoid

• Do not perform hydrocelectomy without excluding secondary causes such as testicular tumors or epididymal pathology 3
• Do not use aspiration alone without sclerosant, as recurrence rates are unacceptably high 2
• Do not attempt sclerotherapy for septated or complex hydroceles, as success rates are poor 2
• Do not omit resection of tunica vaginalis in surgical cases, as this increases recurrence risk 1