What investigations are recommended for a patient undergoing hydrocele operation?

Preoperative Investigations for Hydrocele Surgery

Scrotal ultrasonography with Doppler is the essential preoperative investigation for hydrocele surgery, primarily to rule out testicular torsion and underlying testicular malignancy, particularly in adolescents and young adults. 1, 2

Mandatory Preoperative Imaging

• Scrotal ultrasound with Doppler assessment is the primary diagnostic tool that must be performed before hydrocele surgery 1, 2
• This imaging serves multiple critical purposes:
  • Rules out testicular torsion (a surgical emergency requiring intervention within 6-8 hours) with 96-100% sensitivity and 84-95% specificity 1
  • Differentiates hydrocele from inguinal hernia, which requires more urgent surgical intervention 1
  • Identifies "complex hydrocele" features that may indicate underlying testicular malignancy, particularly in adolescents and young adults 1, 3
  • Evaluates testicular blood flow and excludes epididymo-orchitis 1, 2

Age-Specific Considerations for Imaging

• In adolescents and young adults: Complex hydrocele on ultrasound warrants high suspicion for testicular malignancy, as this population has an 18-fold higher risk of testicular cancer with testicular microcalcifications 1
• In infants under 18-24 months: Ultrasound should still be performed to rule out inguinal hernia before proceeding with observation rather than surgery 1

Preoperative Laboratory Testing

Based on general preoperative guidelines for low-risk surgery, the following tests should be obtained:

• Complete blood count (CBC) if significant perioperative blood loss is anticipated, though hydrocele repair is classified as low bleeding risk (0-2% risk of bleeding >2 days) 4, 1
• Coagulation studies only if the patient has a history of bleeding disorders or is taking anticoagulants 4
• Electrolyte and creatinine testing if the patient has underlying chronic disease or takes medications predisposing to electrolyte abnormalities 4

Additional Preoperative Evaluation

• Tumor markers (AFP, β-hCG, LDH) should be obtained if ultrasound shows complex features suggesting possible testicular malignancy 1
• Fertility evaluation should be considered in men of reproductive age with bilateral hydroceles, as they can contribute to infertility through increased scrotal temperature and testicular dysfunction 1
• Physical examination with orchidometer is adequate for routine testicular volume assessment unless large hydrocele, thickened scrotal skin, or concern for underlying pathology exists 1

Critical Pitfalls to Avoid

• Never delay ultrasound evaluation in acute scrotal swelling, as testicular viability is compromised after 6-8 hours in torsion 1
• Do not confuse hydrocele with inguinal hernia, which requires more prompt surgical intervention 1
• Be highly suspicious of "complex hydrocele" on ultrasound in young men, as this may represent underlying testicular tumor rather than simple hydrocele 1, 3
• Do not rush to surgery in infants under 18-24 months unless there is concern for inguinal hernia or complications, as congenital hydroceles typically resolve spontaneously 1

Preoperative Optimization

• Routine preoperative testing (chest X-ray, ECG) is not required for healthy patients undergoing hydrocele surgery, as this is considered low-risk surgery 4
• Anticoagulation management: Consider stopping aspirin/NSAIDs preoperatively, though specific evidence for hydrocele surgery is limited 4