BACKGROUND: Hydroceles are not uncommon, are often occult, and may be associated with an inguinal hernia. The rate of hydrocele perforation during elective vasectomy has not been reported in the medical literature. Our objective was to estimate the frequency and consequences of hydrocele perforation incidental to vasectomy.
METHODS: We retrospectively reviewed data from a series of patients undergoing vasectomy using the no-scalpel technique for the incidence of complications. A supplementary chart review was done to determine preoperative conditions, and telephone contacts were made if needed to assess later morbidity.
RESULTS: We noted 7 perforations in 150 vasectomies. Only one patient had a hydrocele documented preoperatively. Three had histories of inguinal hernia and herniorrhaphy. Five patients had evidence of minor swelling early on, but none had additional morbidity or long-term associated complications.
CONCLUSIONS: This small case series of vasectomies had a 4.7% incidence rate of perforated small or occult hydroceles. Physicians should be aware of this potentially alarming but apparently minor phenomenon that may accompany vasectomy.
Vasectomy is a common procedure in the United States with an estimated 500,000 performed annually for elective sterilization.1,2 Major reported complications are unusual (virtually no mortality is reported),3 but may include large hematomas, serious infections, primary surgical failure to close the vas, and late failure presumably due to vasal recanalization. Most complications are minor, including small hematomas, mild infection, minor bleeding, sperm granuloma, epididymitis, and orchitis.4
Perforation of a hydrocele that was not evident preoperatively is not rare, according to personal communication with experienced vasectomists. However, a MEDLINE search of the literature from 1959 to 1999 failed to find mention of this phenomenon.
We describe a series of patients who had hydroceles perforated acutely during a no-scalpel vasectomy. Clinical and telephone follow-up was used to track outcomes of this occurrence.
Methods
Study Population and Data
Patients were referred by a variety of community and academic practicing physicians, by institutional referral contacts, self-referred, or referred by physicians in our residency clinic practice. One hundred fifty consecutive patients who underwent no-scalpel vasectomy between March 1992 and September 1998 were concurrently listed in a computerized database. Patient identifiers, complications, and follow-up were among the data recorded.
Clinical Intervention
All patients had preoperative assessment, including genital examinations by one of the authors (J.S.), and gave informed consent. Local anesthesia of the scrotum and bilateral perivasal block were used in all cases, as was the no-scalpel method of Li to access each vas.5 The abdominal lumen of the vas was closed to approximately 1-centimeter depth with thermal cautery (through the first 29 cases), after which a bipolar electrical cautery source was used. A fascial interposition was created and closed using 4-0 chromic suture (through the first 20 cases, including hydrocele perforation case 1) after which medium-sized surgical clips were used. The single scrotal puncture was not sutured and was coated with triple antibiotic ointment covered with gauze, held in place with a supportive scrotal garment.
Outcomes
The occurrence of hydrocele perforation was identified by the spontaneous egress of clear, slightly amber-tinged fluid from the surgical wound during the procedure. In all cases this appeared to be less than 10 cc in volume, although there were no efforts to quantitatively assess the amount. The vasectomy procedure was completed in all cases. Information from the computerized database was confirmed and updated by chart review and additional telephone contacts with patients if necessary.
Results
Seven cases of hydrocele perforation (4.7%) occurred in this series of 150 vasectomy patients. All patients had at least one follow-up examination and either had no hydrocele-related symptoms or findings, or were asymptomatic at the time of subsequent telephone contact. The Table shows clinical features of the patients who had a hydrocele perforation. All 7 patients returned for a follow-up physical examination 3 to 19 days after the vasectomy. Follow-up telephone calls revealed no perceived problems in the 5 patients who were reachable by phone. None of the 7 patients had infections or complications other than those listed.
Discussion
A hydrocele is defined as an excess collection of fluid confined by the 2 layers of the processus vaginalis along the spermatic cord and most commonly surrounding the testis in adults.6 Hydroceles in adults are usually idiopathic or due to inflammation, torsion, or trauma.7 A true idiopathic hydrocele in an adult is benign and requires no treatment unless it causes pain, dysfunction, or is a cosmetic concern.6 In one series reported in a Medicare population, idiopathic hydroceles large enough to indicate treatment ranged in size from 125 to 630 cc.8 These were much larger than those in our series.