Incidence and Management of Hydrocele Following Varicocele Surgery in Children

0022-5347/04/1713-1271/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 171, 1271–1273, March 2004 Printed in U.S.A.

DOI: 10.1097/01.ju.0000112928.91319.fe

INCIDENCE AND MANAGEMENT OF HYDROCELE FOLLOWING VARICOCELE SURGERY IN CHILDREN CIRO ESPOSITO,* JEAN STEPHANE VALLA, AZAD NAJMALDIN, FELIX SHIER, GIROLAMO MATTIOLI, ANTONIO SAVANELLI, MARCO CASTAGNETTI, GORDON MCKINLEY, HENRY STAYAERT, ALESSANDRO SETTIMI, VINCENZO JASONNI AND JEAN MICHAEL GUYS From the Pediatric Surgery Units, Magna Graecia University (CE), Catanzaro, University of Genova (GM, VJ), Genoa and “Federico II” University of Naples (AS, AS), Naples, Italy, Fondation Lanval (JSV, HS), Nice and La Timone Hospital (MC, JMG), Marseille, France, National Institutes of Health, Leeds (AN) and Edinburgh (GM), United Kingdom, and University of Jena (FS), Jena, Germany

ABSTRACT

Purpose: Hydrocele seems to be the most frequent complication in children who undergo surgery for varicocele and the issue of the optimal management of hydrocele remains controversial. In this retrospective study we evaluated the incidence and management of hydrocele following surgical treatment of varicocele in children treated at 8 European centers of pediatric surgery. Materials and Methods: In a 5-year period 278 children between 7 and 17 years old underwent surgical treatment for unilateral left varicocele, including 187 using video surgery and 91 via an open inguinal approach. Results: At an average followup of 24 months (range 12 to 60) 34 children (12.2%) had a left hydrocele. Of the 278 children 14 (5%) were lost to followup. The hydrocele appeared between 1 week and 44 months (median 2 months) after surgery. Concerning hydrocele management 16 of 34 children (47%) were treated with scrotal puncture while under local anesthesia, which led to hydrocele regression after a median of 3 punctures (range 1 to 5), 12 (35.3%) underwent clinical observation since the hydrocele reduced spontaneously within a median of 12 months after its appearance and 6 (17.7%) were treated with open surgery. In 4 cases the hydrocele disappeared and in 2 it recurred after surgery and was successfully treated with punctures. Conclusions: This study shows that the median incidence of hydrocele after varicocele surgery is about 12% but it seems higher after artery nonsparing vs sparing procedures (17.6% vs 4.3%). On the contrary, no difference was found when the procedure was performed using video surgery or with the open approach. Hydroceles generally develop a few months later but may also appear several years after the surgical repair of varicocele. Noninvasive procedures (scrotal punctures or clinical observation) seem to induce total hydrocele regression in more than 82% of cases. Children who undergo surgery for varicocele should undergo long-term followup to detect a possible hydrocele. In fact, the 5.4% of children lost to followup in our study may potentially have had a hydrocele. Surgery is not always successful for this condition, as shown in the 2 cases of recurrent hydrocele after surgical repair. KEY WORDS: hydrocele, varicocele, postoperative complications, testis

An analysis of the international literature showed that an artery nonsparing procedure (ANSP) remains one of the most recommended surgical procedure for treating children with varicocele because of the low recurrence rate, simple performance and lack of the risk of testicular atrophy.1–3 However, this procedure is based on partial or complete division of the testicular lymphatic vessels, which may lead to hydrocele formation in about 3% to 40% of the children treated.4 – 6 The management of hydrocele after varicocele surgery is extremely controversial.7, 8 In this study we established the incidence and management of hydrocele after surgical management of varicocele in children based on data from 8 European centers of pediatric surgery. PATIENTS AND METHODS

In a 5-year period 278 children underwent surgical treatment for unilateral left varicocele at 8 European units of

pediatric surgery. Patient age was between 7 and 17 years (median 12.5). Preoperative examination included scrotal examination and testicular volume determination in all cases, and scrotal ultrasound or color Doppler in 253 (91%). Varicocele was graded according to the Dubin and Amelaar classification8 as first to third degree in 5 (1.8%), 45 (16.2%) and 228 (82%) cases. Indications for surgery were always a third degree varicocele or, in cases of a first or second degree varicocele, pain or scrotal discomfort, or testicular asymmetry with hypotrophy of the affected side. Of the 278 children 187 (67.2%) were treated with video surgery. In particular, 150 of the 187 patients underwent laparoscopy and 37 underwent retroperitoneoscopy. In the video surgery group (VG) 53 of 187 patients (28.3%) underwent an artery sparing procedure (ASP) and 134 (71.7%) underwent ANSP. Of the 278 children 90 (32.8%) were treated with open surgery, including 73 using the inguinal or subinguinal approach with loupe magnification or blue venography and 18 using the high retroperitoneal approach. In open surgery group (OG) 61 of the 91 patients (67%) underwent ASP and 30 (33%) underwent ANSP. Overall in the VG and OG 164 of the 278 children (58.9%) were treated

Accepted for publication October 24, 2003. * Correspondence: Department of Experimental and Clinical Medicine, Pediatric Surgery Unit, “Magna Graecia” University of Catanzaro, Piazza degli Artisti 7/c, 80129 Naples, Italy (telephone: ⫹390961.706027; FAX: ⫹39-081-7463361; e-mail: [email protected]). 1271

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HYDROCELE AFTER VARICOCELE SURGERY TABLE 1. Hydrocele incidence according to surgical procedure ASP No.

VG: Laparoscopy Retroperitoneoscopy OG: Inguinal ⫹ venography Inguinal ⫹ loupe High retroperitoneal Totals

ANSP No. Hydrocele (%)

No. Hydrocele (%)

117 17

22 (18.8) 2 (11.7)

33 20

1 (3) 1 (5)

41 20 0

2 (4.8) 1 (5) 0 (0)

8 4 18

2 (25) 0 (0) 3 (16.6)

114

5 (4.3)

164

29 (17.6)

TABLE 2. Results of procedures used to treat hydrocele in our series Treatment

No. Children (%)

No. Success (%)

No. Failure (%)

Scrotal punctures Clinical observation Surgery

16 (47) 12 (35.3) 6 (17.7)

15 (93.7) 9 (75) 4 (66.6)

1 (6.3) 3 (25) 2 (33.4)

34

28

6

Totals

No.

with ANSP and 114 (41.1%) were treated with ASP. Results were analyzed statistically using the Mann-Whitney test.

TABLE 3. Aspirations necessary to resolve hydrocele in 15 of 16 children No. Aspirations 1 2 3 4 5

No. Recovered After Aspiration (%)* 1 (6.7) 3 (20) 7 (46.6) 3 (20) 1 (6.7)

Total 15 (100) * In 1 of 16 children hydrocele was present after first aspiration and this failure is included in the failure rate (table 2).

RESULTS

At an average followup of 24 months (range 12 to 60 months) 34 children (12.2%) had a left hydrocele and 14 (5%) were lost to followup. In 255 of the remaining 264 children (96.6%) the varicocele disappeared after surgery, whereas in 9 (3.4%) there was varicocele recurrence. The incidence of recurrence was higher after ASP than after ANSP (5.5% vs 2.1%). Hydrocele developed between 1 week and 44 months (median 2 months) after surgery. It was diagnosed clinically and confirmed by ultrasonography in all cases. Table 1 shows the relationship between hydrocele onset and the surgical procedure used to treat varicocele. In terms of hydrocele formation, there was no statistically significant difference between open surgery and laparoscopy/retroperitoneoscopy (p ⫽ 0.9163), whereas a statistically significant difference was evident between ANSP and ASP (p ⫽ 0.0478). As to treatment, 16 of 34 children (47%) underwent scrotal puncture under local anesthesia, which led to total regression after a median of 3 punctures (range 1 to 5) except in 1, who has currently received only the first puncture but in whom the hydrocele is smaller but still present. Of the 34 children 12 (35.3%) underwent simple clinical observation. In 9 children (75%) the hydrocele reduced spontaneously within a median of 12 months (range 4 to 20) after its appearance, while in the 3 in whom the hydrocele was still present after 18 months underwent scrotal punctures, which led to the disappearance of the hydrocele. Treatment for hydrocele is basically the surgeon choice. In general, our decision to aspirate the hydrocele is based on its size at ultrasonography. If it is larger than 20 to 30 ml, we prefer to puncture it but otherwise we perform clinical evaluation every 3 months. Six of 34 children (17.7%) were treated using open surgery. In 4 (6.6%) cases the hydrocele disappeared and in 2 it recurred after surgery and was treated successfully with punctures. Table 2 lists the results of the procedures used to treat hydrocele. DISCUSSION

Lymph flows from the testicles and epididymis through the lymphatic trunks along the spermatic vessels.8, 9 There is no collateral drainage of testicular lymph into the inguinal nodes and it has been experimentally demonstrated that ligation of the lymphatic trunks results in lymphostasis with all of its concomitant pathophysiological consequences.9, 10 Hydrocele was thought to be a consequence of lymphatic

ligation during varicocelectomy due to the high protein content of hydrocele fluid.3 As for the surgical procedures used to treat children with varicocele, in the last few years ANSP has become the most widely adopted technique due to its extremely low rate of varicocele recurrence (less than 3%) compared with other procedures.3, 11, 12 However, ANSP is a lymphatic nonsparing procedure. For this reason it is associated with an important rate of hydrocele formation at long-term followup.12, 13 On the contrary, ASP seems to have a lower rate of hydrocele formation.14 The main interesting aspect of our study is that we collected experiences at 8 European centers of pediatric surgery, where the open approach and video surgery are performed as well as ANSP and ASP procedures. It is necessary to underline that this study focused only on the management of hydrocele after varicocelectomy. For this reason we only deal with hydrocele incidence and management, and not with the results of varicocele surgery. The median incidence of hydrocele after varicocele surgery in our series was about 12% but it was much higher for ANSP than with ASP (17.6% vs 4.3%). There seems to be no difference in hydrocele rate if the procedure is performed as open or video surgery, whereas it seems that the higher the level of ligation, the lower the incidence of hydrocele. However, the most important aspect of our study concerns the management of hydrocele. As a matter of fact, analysis of our data shows that more than 82% of the patients were not treated surgically. Since there seems to be a regeneration of lymphatic vessels several months after sectioning, nonsurgical procedures to treat hydrocele after varicocelectomy have shown an important development in the last few years.8, 15 Scrotal puncture using local anesthesia was the most widely adopted procedure in our series (47%), leading to hydrocele regression after a median of 3 punctures (range 1 to 5). The success rate in our series was 93.7%. Punctures were performed at 2 to 3-month intervals. An anesthetic lotion was applied to the scrotum before puncture and each procedure was followed by a 3-day antibiotic treatment. Another optional treatment is simple clinical observation of the hydrocele, which was done in 35.3% of the cases in our series. It seems that the hydrocele may undergo spontaneous regression within a median of 12 months after development. The success rate of clinical observation in our series was 75%. The persisting 25% of hydroceles were successfully treated

HYDROCELE AFTER VARICOCELE SURGERY

with scrotal punctures (table 3). In our series the surgical treatment of hydrocele seems to have had a marginal role. As a matter of fact, it was done in only 17.7% of cases with a failure rate of 33.4%. In cases of hydrocele after varicocelectomy parents generally prefer noninvasive procedures, such as simple clinical observation or scrotal puncture, rather than having their children undergo a second surgical procedure under general anesthesia. An interesting findings in our series is that hydrocele may occur even several months after varicocelectomy. This aspect should be clearly explained to parents when requesting informed consent. In addition, long-term followup is of fundamental importance for patients who undergo varicocelectomy with at least 1 examination 2 years after surgery to detect a possibly late occurring hydrocele.3, 16, 17 CONCLUSIONS

5.

6.

7.

8. 9. 10.

The median incidence of hydrocele after varicocele surgery in children is 12% but it is higher with ANSP than ASP (17.6% vs 4.3%). As to hydrocele management, noninvasive procedures (scrotal puncture or clinical observation) led to hydrocele regression in more than 82% of cases, even if these data must be supported by a randomized, prospective study. Moreover, long-term followup is necessary to detect hydroceles that occur months after surgery. As a matter of fact, the 5.4% of children lost to followup in our study may have had a hydrocele. Surgery is not always able to treat hydrocele successfully, as shown by the 33% hydrocele recurrence rate after surgical repair.

12.

REFERENCES

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