Section: Urology Curriculum: Curriculum, page 5
Definition
- Pathological fluid collection within Tunica Vaginalis
Incidence
- Primary most often seen in young children and older men
- Secondary most often seen age 20-40 secondary to trauma, infection and neoplasm
Classification
- Primary
- In young – Patent Processus Vaginalis giving rise to communicating hydrocele
- In elderly – secretion from tunica vaginalis and defective absorption of secreted fluid
- Secondary
- due to abnormalities in underlying testis or epididymis (trauma, infection, neoplasm)
Clinical
- Swelling in scrotum
- Pain/discomfort
- Fluctuant swelling that transilluminates
- Able to get above
- Swelling often tense so testis is not palpable
- Do not affect fertility
Investigation
- USS (exclude underlying tumour)
Management
- Infants – do not repair until at least 2 years, most resolve
- If small – conservative
- If large/symptomatic
- Excision of tunica vaginalis or invagination
- Aspiration +/- sclerotherapy
- Jaboulay Repair of hydrocele – Sac excised leaving 2-3cm margin then everted and sutured behind cord
- Incision over the anterior aspect of hydrocele parallel to Median raphe made with back of blade between any visible vessels.
- Dissect through skin, Dartos, external spermatic fascia, Cremasteric fascia, internal spermatic fascia.
- Bluntly dissect in the plane between internal spermatic fascia and parietal layer of tunica vaginalis. Complete dissection using fingers and deliver the hydrocele intact from the scrotum.
- The hydrocele fluid is drained by a simple stab incision and collected in a bowl. A sample is sent for cytology, microscopy and culture.
- Place two artery forceps on the edges of sac and split the tunica vaginalis to expose the testis taking care not to damage testis or epididymis
- The parietal layer of the tunica vaginalis is trimmed as required everted and wrapped around the testis and sutured to itself around the back of testis and cord using 2/0 Vicryl or 3-0 monocryl
- Achieve perfect haemostasis of tunica, edges of scrotum.
- Return the testis to the sac created.
- Close the dartos layer using interrupted 2/0 Vicryl
- Close skin 3/0 monocryl
- Lord’s Procedure – Plication of the sac with sutures
- Suitable for medium-sized and thin-walled hydrocoeles
- If testis normal, scrotal approach
- If testicular mass, then inguinal approach