1.Hydrocele Tossif Ghodiwala Moscow 2014

2. Hydrocele A hydrocele is a collection of fluid within the processus vaginalis (PV) that produces swelling in the inguinal region or scrotum. 3. Relevant Anatomy The developmental anatomy of the inguinal canal is responsible for the genesis of pediatric communicating hydroceles. As the testis descends from the posterolateral genitourinary ridge at the beginning of the third trimester of fetal gestation, a saclike extension of peritoneum descends in concert with the testis. As descent progresses, the sac envelops the testis and epididymis. The result is a serosal-lined tubular communication between the abdomen and the tunica vaginalis of the scrotum. 4. The peritoneum-derived serosal communication is the processus vaginalis, and the serosa of the hemiscrotum becomes the tunica vaginalis. At term, or within the first 1-2 years of life, the processus vaginalis of the spermatic cord fuses, obliterating the communication between the abdomen and the scrotum. The processus fuses distally as far as the lower epididymal pole and anteriorly to the upper epididymal pole. Failure of complete fusion may result in communicating hydroceles, indirect inguinal hernias, and the bell-clapper deformity of abnormal testicular fixation in the scrotum. 5. Classification Primary hydrocelewhen there is no definitive cause / idiopathic. Secondary hydrocelediseases of testis 1. TB of epididymis 2. Epididymal orchitis 3. Syphilitic orchitis 4. Testicular tumours (seminoma5th decade of life and onwards, teratoma1st and 2nd decades of life, sertoli cell tumours, leydig cell tumours, lymphoma) 5. Orchitis arising by virus 6. Trauma 6. Difference between primary and secondary hydrocele: Primary Secondary Big and tense Small and loose, lax Testis cannot be felt Testis can be felt No definitive history Definitive history of the disease 7. Classification 8. Epidemiology Patent processus vaginalis are found in 80-90% of term male infants at birth. This frequency rate steadily decreases until age 2 years, when it appears to plateau at approximately 25-40%. Indeed, autopsy series of men have identified a frequency rate of 20% of the processus vaginalis remaining patent until late in life. However, clinically apparent scrotal hydroceles are evident in only 6% of term males beyond the newborn period. Certain conditions, such as breech presentation, gestational progestin use, and low birth weight, have been associated with an increased risk of hydroceles. 9. Etiology of Hydroceles Congenital Hydroceles With the descent of the testis, the parietal peritoneum forms the processus vaginalis and the cavity of the tunica vaginalis of the testis. The processus vaginalis normally obliterates till the fourth month of life. Congenital hydroceles occur mostly through lack of closure of the processus vaginalis (= communicating hydrocele). Acquired Hydroceles Usually, there is a balance between fluid production and outflow in the cavity of the tunica vaginalis. The following diseases disturb this balance: inflammation, tumors, testicular trauma, torsion of the testis or testicular appendages, defective lymphatic drainage (after surgery for varicoceles or inguinal hernias). 10. Pathophysiology The pathophysiology of hydroceles requires an imbalance of scrotal fluid production and absorption. This imbalance can be divided further into exogenous fluid sources or intrinsic fluid production. Alternatively, hydroceles can be divided into those that represent a persistent communication with the abdominal cavity and those that do not. Fluid excesses are from exogenous sources (the abdomen) in communicating hydroceles, whereas noncommunicating hydroceles develop increased scrotal fluid from abnormal intrinsic scrotal fluid shifts. 11. Communicating hydroceles With communicating hydroceles, simple Valsalva probably accounts for the classic variation in size during day-sleep cycles. Nonetheless, with the incidence of patent processus so great, why children with clinically apparent hydroceles are relatively few remains somewhat inexplicable. Chronically increased intra-abdominal pressure (eg, as in chronic lung disease) or increased abdominal fluid production (eg, children with ventriculoperitoneal shunts) probably warrants early surgical intervention. 12. Noncommunicating hydroceles In noncommunicating hydroceles, the pathophysiology may occur as a result of increased fluid production or as a consequence of impaired absorption. A sudden onset of scrotal hydrocele in older children has been noted after viral illnesses. In such cases, viral-mediated serositis may account for the net increased fluid production. Posttraumatic hydroceles likely occur secondary to increased serosal fluid production due to underlying inflammation. Although rare in the United States, filarial infestations are a classic cause of the decreased lymphatic fluid absorption resulting in hydroceles. 13. Symptoms Although each child may experience symptoms differently, the most common symptom is a fluid mass that is usually smooth and not tender in the scrotum. In the case of a communicating hydrocele, the mass fluctuates in size, getting smaller at night while lying flat,and increasing in size during more active periods. 14. Diagnosis Physical examination Ultrasound 15. Differential Diagnoses Abdominal Trauma Cryptorchidism Testicular Torsion Varicocele in Adolescents 16. Surgery 17. Unlike hernias in infants, many newborn hydroceles resolve because of spontaneous closure of the PPV early after birth. The residual noncommunicating hydrocele does not wax and wane in volume, and no silk glove sign is present. The fluid in the hydrocele is usually reabsorbed before the infant reaches age 1 year. Because of these facts, observation is often appropriate for hydroceles in infants. 18. The following factors indicate hydrocele repair: Failure to resolve by age 2 years Continued discomfort Enlargement or waxing and waning in volume Unsightly appearance Secondary infection (very rare) 19. Specific conditions or demographics and timing of surgery In full-term infants with no history of incarceration, schedule surgery as soon as possible on an outpatient basis. For preterm neonatal intensive care unit (NICU) infants weighing 1800-2000 g, schedule surgery before hospital discharge. For formerly premature infants younger than 60 weeks postconceptual age, schedule surgery as soon as possible with 24-hour postoperative monitoring for apnea and other anesthesia- related complications. 20. SURGERIES: LORDS PLICATION EVACUATION AND EVERSION SUBTOTAL EXCISION JABOULEYS OPERATION SHARMA and JHAWERS TECHNIQUE 21. IF SAC IS SMALL THIN AND CONTAINS CLEAR FLUID ->LORDS PLICATION SAC IS MADE TO FORM FIBROUS TISSUE OR EVACUATION & EVERSION IF SAC IS THICK IN LARGE HYDROCELE SUBTOTAL EXCISION JABOULEYS OPERATION SHARMA & JHAWER TECHNIQUE 22. Drainage The fluid can be drained easily with a needle and syringe. However, following this procedure, it is common for the sac of the hydrocele to refill with fluid within a few months. Draining every now and then may be suitable though, if you are not fit for surgery or if you do not want an operation. 23. Surgery for Hydroceles of the Cord Treatment of hydroceles of the cord starts with an inguinal incision for exposure of the spermatic cord. After excision of the hydrocele of the cord, the processus vaginalis is ligated at the internal inguinal ring. 24. Surgery for Communicating Hydroceles Treatment of communicating hydroceles starts with an inguinal incision for exposure of the testis. The processus vaginalis is isolated from the spermatic cord, divided and ligated at the internal inguinal ring. The distal sac is resected as far as possible, the end of the sac can be left open. The contralateral exploration is not a standard therapy, but is sometimes performed. The probability for an open contralateral processus vaginalis in unilateral communicating hydrocele is 50%, but only about 1522% become clinically significant. 25. Surgery for Hydroceles of the Testis After scrotal incision for exposure of the scrotal hydrocele, two surgical techniques are available. The recurrence rate should be below 5% with either technique, Lord's technique has probably the lowest complication rate: Hydrocelectomy with excision of the hydrocele sac: Winkelmann's technique or Jaboulay's technique Hydrocelectomy with plication of the hydrocele sac: Lord's technique 26. Operation Winkelmann. This surgical intervention is one of the leaflets own shell eggs dissect the anterior surface, turn inside out and stitch the back of the testicle. At the same time accumulation of fluid no longer occurs. Operation Bergman. Part own inner layer shell eggs are removed, the remaining part of ligated. Postoperatively appointed antimicrobials and for some time wearing a jockstrap. Operation Lord. When this operation is performed dissection egg shells, release of dropsical fluid and a so-called corrugation of the tunica vaginalis testis around. It goes from the surrounding tissue egg is not released and the wound did not dislocate. This reduces trauma to adjacent tissues and blood vessels supplying the testicle. 27. Follow-up At least one postoperative follow-up visit is recommended. For small infants, chronic recurring hydroceles, or patients with unsuspected intraoperative findings, more protracted follow-up evaluations may be warranted biweekly, monthly, or every 2-3 months to ensure complete recovery and normal testicular size and architecture. 28. Outcome and Prognosis Inguinal repairs of communicating hydroceles are exceedingly successful, with a less than 1% recurrence rate. If a unilateral approach is completed, the small but recognized risk for a metachronous hydrocele or inguinal hernia developing remains, but the rate is likely less than 10%. Likewise, recurrence after tunica excision is also uncommon. 29. COMPLICATIONS OF HYDROCELE: 1. INFECTION 2. PYOCELE,HEMATOCELE 3. INFERTILITY 4. ATROPHY OF TESTIS 5. HERNIATION OF HYDROCELE SAC (rare) 6. RUPTURE (rare)