ENDOUROLOGY & LAPAROSCOPY

Aspiration and sclerotherapy versus hydrocelectomy for treatment of hydroceles
Beiko DT, Kim D, Morales A
Department of Urology, Queen’s University, Kingston, Ontario, Canada
Urology 2003; 61: 708-12

• Objectives: To compare aspiration and sclerotherapy using sodium tetradecylsulfate (STDS) with open hydrocelectomy in the treatment of hydroceles with regard to safety, efficacy, and cost-effectiveness.
• Methods: Patients with symptomatic hydroceles were prospectively enrolled in an aspiration and sclerotherapy protocol between October 1998 and June 2000. Patients in this group underwent percutaneous aspiration followed by sclerotherapy with an STDS-based solution. This group was compared with a group of patients chosen consecutively who underwent hydrocelectomy between December 1996 and August 1999. Primary outcome measures included patient satisfaction and procedural success. Secondary outcome measures included complications and comparative costs.
• Results: A total of 27 patients with 28 hydroceles were enrolled in the aspiration and sclerotherapy protocol and compared with 24 patients with 25 hydroceles in the hydrocelectomy group. Mean follow-up for the aspiration and sclerotherapy group and hydrocelectomy group was 8.9 and 16.4 months, respectively. Patient satisfaction was 75% for aspiration and sclerotherapy and 88% for hydrocelectomy. The overall success rate for aspiration and sclerotherapy was 76% compared with 84% for hydrocelectomy. The complication rate was only 8% in the aspiration and sclerotherapy group, but 40% in the hydrocelectomy group. Comparative costs per procedure demonstrated that hydrocelectomy was almost ninefold more expensive than aspiration and sclerotherapy.
• Conclusions: In the treatment of hydroceles, aspiration and sclerotherapy with STDS represents a minimally invasive approach that is simple, inexpensive, and safe but less effective than hydrocelectomy. Aspiration and sclerotherapy is a viable first-line therapeutic option in the management of hydroceles.
  
• Editorial Comment
  My experience with regards to surgical hydrocelectomy is similar to that reported by the authors. The complication rate is high and the limitation of patient activity for the first few weeks after the procedure can be significant. The same comments are echoed by my colleagues at the frequent presentation of hydrocele complications during our monthly Mortality and Morbidity Conference. Sclerosis would seem to be an attractive option. Beiko and associates used 4 ml of 3% STDS, 6 ml 2% lidocaine, and 140 ml of 5% dextrose in 0.45% normal saline (final concentration of 0.08% STDS), replacing 25% of the aspirated hydrocele volume. This is similar to the regimen used in another recent study (1). After draining the hydrocele completely, the sclerosing solution is left in place. Antibiotics but no analgesics are provided. In the discussion section of their article, Beiko and associates stated that they now advocate use of a smaller volume of a more concentrated STDS solution. Unfortunately, specifications for their new regimen were not provided. Even with the reported regimen, however, the authors achieved complete or more than 50% reduction of hydrocele volume in 13 of 25 patients (52%), and overall success (includes patient satisfied with outcome but with less than 50% volume reduction) in 19 of 25 (79%). Of these 19, only 4 required a second sclerosis session to achieve the desired outcome. I have used dehydrated alcohol mixed with lidocaine, replacing 10% of the hydrocele volume, with good success in a few patients but that regimen requires a local anesthetic infiltration of the spermatic cord and the patient has pain for about 48 hours. The STDS regimen appears to be easier on the patient. This option should be considered an excellent alternative to the surprisingly morbid “minor surgery” called hydrocelectomy.

Reference
1. Fracchia JA, Armenakas NA, Kohan AD: Cost-effective hydrocele ablation. J Urol. 1998; 159: 864-7.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA