Recurrence of Primary Hydrocele 1 Month after Hydrocelectomy in a 35-Year-Old Patient

Abstract

A hydrocele is a painless enlargement of the scrotum resulting from an irregular accumulation of serous fluid between the parietal and the visceral layers of the tunica vaginalis which surrounds the testis To treat hydrocele various modalities are used, the gold standard of which being open hydrocelectomy. Hydroceles can sometimes be recurrent. Rarely, in these cases, an underlying pathological condition such as hypoproteinemia, filarial infection, pelvic cavity malignancy, or a concurrent inguinal hernia is found during investigation. This paper describes a rare case of hydrocele recurrence immediately after open hydrocelectomy. The presence of intact tunical anatomy of the scrotum found during revision hydrocelectomy in our case raised questions concerning the extent of the previous excision and as such recurrence should be attributed to the uninverted remaining tunical sack.

Introduction

A hydrocele is a painless enlargement of the scrotum resulting from an irregular accumulation of serous fluid between the parietal and the visceral layers of the tunica vaginalis which surrounds the testis. It is estimated to affect 1% of all adult men and can be divided into primary (or idiopathic) and secondary hydrocele.[¹²] The etiology of primary hydrocele is considered to be an imbalance between secretion of fluid inside the tunica vaginalis of the testis and its absorption through lymphatic channels secondary hydrocele can result from trauma, infection, or even neoplasms (e.g. rhabdomyosarcoma, mesothelioma, adenocarcinoma, and neuroblastoma). The vast majority of hydroceles are primary and a particular etiology can rarely be identified.[²³] Although most hydroceles are of little clinical significance requiring conservative management, some cases of large hydroceles can cause esthetic problems or even become symptomatic causing awkwardness or pain during walking and will require treatment.[⁴⁵⁶] Transillumination of scrotum during the clinical examination can facilitate differential diagnosis of hydrocele from other causes of scrotal swelling. Nevertheless, the gold standard diagnostic modality is the scrotal ultrasound setting the diagnosis in the vast majority of cases. To treat hydrocele various modalities are used, the gold standard of which being open hydrocelectomy. Less invasive alternatives such as aspiration and/or sclerotherapy have also been proposed. The less invasive nature of these modalities, resulting in less complications and morbidity has attracted renewed interest.[⁷] Finally, hydroceles can sometimes be recurrent. Rarely, in these cases, underlying pathological conditions such as hypoproteinemia, filarial infection, or pelvic cavity malignancy are found during investigation. A concurrent inguinal hernia should also be excluded from the study.[³] In this paper, a case of hydrocele recurrence immediately after open hydrocelectomy will be described.

Case Report

A 35-year-old man presented to our department complaining for a painless enlargement of his right scrotum. The patient reports that he had been subjected to ipsilateral hydrocelectomy 2 months before for a large hydrocele present since 2 years back. Postoperatively, the patient reported an uneventful period with his scrotum regaining normal appearance within the first 2 weeks after surgery. Then, his scrotum started dilating again reaching the initial size of preoperative dilation within a month time after surgery. The clinical and ultrasonic evaluation revealed the presence of a big recurrent unilateral hydrocele with no other clinical pathology such as a concurrent inguinal hernia. The patient had no other comorbidities and underwent a hydrocelectomy revision with the excision of excessive tunica vaginalis and eversion behind the testis. Despite the previous surgery, the testicular tunics looked relative intact during surgery, calling into question the extent of the previous excision. The hydrocele's liquid was sent for bacterial culture, parasitological examination, malignant cytology, and acid-fast bacilli staining. The whole lesion was sent to a pathologist after its excision. No pathology or malignancy was found in both surgical specimen and hydrocele fluid. Three months after the revision of the hydrocelectomy, the patient remained asymptomatic with no evidence of recurrent hydrocele formation [Figure 1].

Figure 1: Revision of the hydrocelectomy performed in our department. (a) Preoperative appearance of recurrent hydrocele (b) operative picture before opening the visceral layer of tunica vaginalis (c) evacuated liquid (d) tunical sack after fluid evacuation (e) tunical excision using transillumination to avoid injury of scrotal contents (f) eversion of tunica vaginalis behind the testis

Discussion

Several different techniques have been described for the definite treatment of hydrocele including open surgery as well as less invasive options such as aspiration and sclerotherapy. Less invasive methods demonstrate less morbidity than surgery at the cost of a higher recurrence rate and less long-term patient's satisfaction. Concerning sclerotherapy, numerous chemical substances have been documented in the literature including tetracycline, sodium tetradecyl sulfate, polidocanol, fibrin glue, phenol, OK-432, ethanolamine oleate, antazoline, rifampicin, and talc. All these sclerosing agents cause adherence of the walls of the sac, limiting the production of fluid.[⁷]

Regarding the surgical treatment of hydrocele, the three most common corrective surgical techniques are the Jaboulay procedure (eversion of sac followed by sewing the edges together behind testicle), conventional hydrocelectomy (excision of sac with oversewing of edges), and Lord's procedure (drainage of hydrocele fluid with plication of the parietal layer of tunica vaginalis). The difference between the Lord's procedure with hydrocelectomy and the Jaboulay procedure is that minimal dissection between the layers of Dartos and tunica vaginalis takes place, avoiding the release of the hydrocele sac outside of the scrotum. Tsai et al. compared the recurrence rates and the postoperative complications between these three different techniques. They observed no difference in recurrence rates between them. However, Lord's repair was associated with the lowest overall rates of complications and of postoperative hematoma, establishing Lord's repair as an effective and safe choice in treating hydroceles.[⁸]

Recurrence of hydrocele after surgical correction such as in the case presented in this article is generally rare. Any recurrence of hydrocele after therapeutic interventions should raise suspicions for underlying medical conditions such as hypoproteinemia, filarial infection, pelvic cavity malignancy, or concurrent inguinal hernia. In our case, no underlying cause was found despite thorough investigation. The presence of intact tunical anatomy of the scrotum found during revision hydrocelectomy in our case raised questions concerning the extent of the previous excision and as such recurrence should be attributed to the uninverted remaining tunical sack.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.