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Retroperitoneoscopically assisted repair of an abdominoscrotal hydrocele
Journal of Pediatric Urology (2007) 3, 66e69
CASE REPORT
Retroperitoneoscopically assisted repair of an abdominoscrotal hydrocele Maya Horst a, Ulrich Willi b, Rita Gobet a,* a b
Department of Urology, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland Department of Radiology, University Children’s Hospital, Zurich, Switzerland
Received 21 July 2005; accepted 1 February 2006 Available online 8 May 2006
KEYWORDS Abdominoscrotal hydrocele; Giant hydrocele; Retroperitoneoscopy
Abstract We present a 2-month-old boy with a primary obstructive megaureter and a giant abdominoscrotal hydrocele (ASH) on the left side. The ASH was initially misdiagnosed as a fornix rupture with infrarenal urinoma, but clinical and radiological examination led to the right diagnosis. Retroperitoneoscopically assisted mobilization combined with the inguinal approach allowed the successful resection of this large ASH. ª 2006 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Abdominoscrotal hydrocele (ASH) is a rare condition. Since the first description in 1834 only a few cases have been reported in children [1,2]. This case report demonstrates the diagnostic difficulties encountered in a patient with an associated urinary tract malformation, and our first experience with the retroperitoneoscopic therapeutic approach to a giant abdominoscrotal hydrocele.
Case report A 2-month-old boy with a prenatally diagnosed left hydroureteronephrosis was examined at our clinic. * Corresponding author. Tel.: þ41 44 266 71 11; fax: þ41 44 266 71 71. E-mail address: [email protected] (R. Gobet).
Physical examination showed a left scrotal hydrocele and was otherwise normal. Renal ultrasound confirmed moderate hydroureteronephrosis on the left and revealed significant fluid collection at the lower pole of the left kidney (Fig. 1). IVU/MAG3 and MRI were consistent with a primary obstructive megaureter (POMU); the normal ipsilateral renal function suggested a fornix rupture with infrarenal urinoma (Fig. 2). The boy underwent operative correction of the POMU and percutaneous drainage of the presumed urinoma. Three months postoperatively recurrent left retroperitoneal fluid collection was present on ultrasonography despite adequate drainage of the ureter intended to prevent further ‘fornix leakage’. Left scrotal hydrocele also recurred. Contrast injection into the hydrocele confirmed the now suspected diagnosis of an abdominoscrotal hydrocele radiographically (Fig. 3). Hydrocelectomy was performed using
1477-5131/$30 ª 2006 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2006.02.007
Figure 1 Ultrasound at 6 days shows moderate left hydronephrosis with inferiorly adjacent retroperitoneal fluid, thought to be a urinoma (A) from ipsilateral POMU (B, arrow), shown behind the bladder.
Figure 2 MAG3 scintigraphy (A) and magnetic resonance urography (B) suggest left POMU; MRI provides identical information to IVU (not shown) and demonstrates, in addition, retroperitoneal fluid inferior to left kidney.
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Figure 3 Contrast injection into left hydrocele shows progressive contrast expansion into left retroperitoneal space (A: antero-posterior view; B: lateral view).
a combined approach. We began with a conventional retroperitoneoscopic approach and were able to visualize the hydrocele sac at the lower pole of the kidney. It was then mobilized retroperitoneoscopically and completely removed through an inguinal incision. Clinical and sonographical follow up at 3, 12 and 24 months showed a normal retroperitoneum, no recurrency of hydrocele and a normal testis on the left side.
Discussion Giant ASH presents as a cystic lower retroperitoneal mass. It may, as in this case, reach the inferior pole of the ipsilateral kidney. Ultrasound is the primary imaging method to demonstrate the cystic mass [4], but the extension of a large ASH may be difficult to evaluate by ultrasound alone. The fact that our patient had a POMU led us to the initial misdiagnosis of a fornix rupture. After recurrence of retroperitoneal fluid collection and ipsilateral hydrocele the diagnosis of ASH was suspected and confirmed by a conventional radiographic contrast study. Schlup et al. [3] demonstrated that MRI can be helpful in showing the extension of the hydrocele and its typical hourglass shape non-invasively. In our patient,
however, MRI was only interpreted properly after the diagnosis had been suspected on clinical grounds. Total excision of the hydrocele is the treatment of choice in order to prevent recurrence [6]. In giant ASH, surgical management may be difficult; various approaches have been advocated in the literature, i.e. scrotal, inguinal, extended inguinal and midline incision [4e6]. We decided on the inguinal approach in combination with retroperitoneoscopic mobilization of the large hydrocele. A laparoscopic exploration provides excellent exposure of the anatomy, allowing full mobilization and excision by the inguinal incision.
Conclusions Giant ASH associated with ipsilateral POMU led to the erroneous initial diagnosis of urinoma, presumably due to urinary tract obstruction, in a 2-month-old boy. Correct diagnosis was made thanks to clinical observation. Successful retroperitoneoscopically assisted mobilization combined with the inguinal approach guaranteed complete and safe resection of this large ASH.
Retroperitoneoscopically assisted repair of an abdominoscrotal hydrocele
References [1] Dupytren G. Lecons orales de clinique chirurgicale [Orale lessons of surgical clinics]. Balliere 1834;4:705. [2] Wlochynski T, Wassermann J, Generowicz Z. Abdominoscrotal hydrocele in childhood. J Pediatr Surg 1993;28:248e50. [3] Schlup S, Hanquinet S, Dumont M, Je ´quier S, Bugmann P. MRI and MRA of a giant hydrocele in an infant. Pediatr Radiol 2002;32:885e7.
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[4] Saharia PC, Bronsther B, Abrams MW. Abdominoscrotal hydrocele. Case presentation and review of the literature. J Pediatr Surg 1979;6:713e4. [5] Ferro F, Spagnoli A, Lucchetti MC, Marchetti P. Abdominoscrotal hydrocele: a reliable surgical technique. Urology 2000;55:771e3. [6] Serels S, Kogan S. Bilateral giant abdominoscrotal hydroceles in childhood. Urology 1996;47:763e5.
CASE REPORT
Retroperitoneoscopically assisted repair of an abdominoscrotal hydrocele Maya Horst a, Ulrich Willi b, Rita Gobet a,* a b
Department of Urology, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich, Switzerland Department of Radiology, University Children’s Hospital, Zurich, Switzerland
Received 21 July 2005; accepted 1 February 2006 Available online 8 May 2006
KEYWORDS Abdominoscrotal hydrocele; Giant hydrocele; Retroperitoneoscopy
Abstract We present a 2-month-old boy with a primary obstructive megaureter and a giant abdominoscrotal hydrocele (ASH) on the left side. The ASH was initially misdiagnosed as a fornix rupture with infrarenal urinoma, but clinical and radiological examination led to the right diagnosis. Retroperitoneoscopically assisted mobilization combined with the inguinal approach allowed the successful resection of this large ASH. ª 2006 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Abdominoscrotal hydrocele (ASH) is a rare condition. Since the first description in 1834 only a few cases have been reported in children [1,2]. This case report demonstrates the diagnostic difficulties encountered in a patient with an associated urinary tract malformation, and our first experience with the retroperitoneoscopic therapeutic approach to a giant abdominoscrotal hydrocele.
Case report A 2-month-old boy with a prenatally diagnosed left hydroureteronephrosis was examined at our clinic. * Corresponding author. Tel.: þ41 44 266 71 11; fax: þ41 44 266 71 71. E-mail address: [email protected] (R. Gobet).
Physical examination showed a left scrotal hydrocele and was otherwise normal. Renal ultrasound confirmed moderate hydroureteronephrosis on the left and revealed significant fluid collection at the lower pole of the left kidney (Fig. 1). IVU/MAG3 and MRI were consistent with a primary obstructive megaureter (POMU); the normal ipsilateral renal function suggested a fornix rupture with infrarenal urinoma (Fig. 2). The boy underwent operative correction of the POMU and percutaneous drainage of the presumed urinoma. Three months postoperatively recurrent left retroperitoneal fluid collection was present on ultrasonography despite adequate drainage of the ureter intended to prevent further ‘fornix leakage’. Left scrotal hydrocele also recurred. Contrast injection into the hydrocele confirmed the now suspected diagnosis of an abdominoscrotal hydrocele radiographically (Fig. 3). Hydrocelectomy was performed using
1477-5131/$30 ª 2006 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2006.02.007
Figure 1 Ultrasound at 6 days shows moderate left hydronephrosis with inferiorly adjacent retroperitoneal fluid, thought to be a urinoma (A) from ipsilateral POMU (B, arrow), shown behind the bladder.
Figure 2 MAG3 scintigraphy (A) and magnetic resonance urography (B) suggest left POMU; MRI provides identical information to IVU (not shown) and demonstrates, in addition, retroperitoneal fluid inferior to left kidney.
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Figure 3 Contrast injection into left hydrocele shows progressive contrast expansion into left retroperitoneal space (A: antero-posterior view; B: lateral view).
a combined approach. We began with a conventional retroperitoneoscopic approach and were able to visualize the hydrocele sac at the lower pole of the kidney. It was then mobilized retroperitoneoscopically and completely removed through an inguinal incision. Clinical and sonographical follow up at 3, 12 and 24 months showed a normal retroperitoneum, no recurrency of hydrocele and a normal testis on the left side.
Discussion Giant ASH presents as a cystic lower retroperitoneal mass. It may, as in this case, reach the inferior pole of the ipsilateral kidney. Ultrasound is the primary imaging method to demonstrate the cystic mass [4], but the extension of a large ASH may be difficult to evaluate by ultrasound alone. The fact that our patient had a POMU led us to the initial misdiagnosis of a fornix rupture. After recurrence of retroperitoneal fluid collection and ipsilateral hydrocele the diagnosis of ASH was suspected and confirmed by a conventional radiographic contrast study. Schlup et al. [3] demonstrated that MRI can be helpful in showing the extension of the hydrocele and its typical hourglass shape non-invasively. In our patient,
however, MRI was only interpreted properly after the diagnosis had been suspected on clinical grounds. Total excision of the hydrocele is the treatment of choice in order to prevent recurrence [6]. In giant ASH, surgical management may be difficult; various approaches have been advocated in the literature, i.e. scrotal, inguinal, extended inguinal and midline incision [4e6]. We decided on the inguinal approach in combination with retroperitoneoscopic mobilization of the large hydrocele. A laparoscopic exploration provides excellent exposure of the anatomy, allowing full mobilization and excision by the inguinal incision.
Conclusions Giant ASH associated with ipsilateral POMU led to the erroneous initial diagnosis of urinoma, presumably due to urinary tract obstruction, in a 2-month-old boy. Correct diagnosis was made thanks to clinical observation. Successful retroperitoneoscopically assisted mobilization combined with the inguinal approach guaranteed complete and safe resection of this large ASH.
Retroperitoneoscopically assisted repair of an abdominoscrotal hydrocele
References [1] Dupytren G. Lecons orales de clinique chirurgicale [Orale lessons of surgical clinics]. Balliere 1834;4:705. [2] Wlochynski T, Wassermann J, Generowicz Z. Abdominoscrotal hydrocele in childhood. J Pediatr Surg 1993;28:248e50. [3] Schlup S, Hanquinet S, Dumont M, Je ´quier S, Bugmann P. MRI and MRA of a giant hydrocele in an infant. Pediatr Radiol 2002;32:885e7.
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[4] Saharia PC, Bronsther B, Abrams MW. Abdominoscrotal hydrocele. Case presentation and review of the literature. J Pediatr Surg 1979;6:713e4. [5] Ferro F, Spagnoli A, Lucchetti MC, Marchetti P. Abdominoscrotal hydrocele: a reliable surgical technique. Urology 2000;55:771e3. [6] Serels S, Kogan S. Bilateral giant abdominoscrotal hydroceles in childhood. Urology 1996;47:763e5.