UROLOGICAL SURVEY
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
Technique for laparoscopic running urethrovesical anastomosis: the single knot method
Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV
Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium; and Department of Urology, University of California Irvine, Orange, California, USA
Urology 2003; 61: 699-702
OBJECTIVES: To describe a technique for facilitating the urethrovesical anastomosis at the time of laparoscopic radical prostatectomy.
METHODS: Two 6-in. polyglycolic acid sutures (one dyed, one white) are tied together at their tail ends and delivered into the operative field by way of a 12-mm port. A running suture is completed from the 6:30 to the 12:00-o'clock position and from the 5:30 to the 12:00-o'clock position, at the end of which a single intracorporeal tie is completed. The catheter is placed before completing the anterior row of sutures; the catheter is left in place for 5 to 7 days.
RESULTS: This anastomotic technique has been used in 122 laparoscopic radical prostatectomies and 8 robot-assisted laparoscopic radical prostatectomies. The average time for the anastomosis was 35 minutes (range 14 to 80). All anastomoses were watertight. No symptomatic postoperative urinary leaks have occurred, and no clinically evident clinical bladder neck contractures resulted.
CONCLUSIONS: We describe a simple, watertight, running laparoscopic suture technique for accomplishing the urethrovesical anastomosis during laparoscopic radical prostatectomy.
Editorial Comment
This really is a wonderful suturing technique, which I was fortunate enough to learn about directly from the authors while visiting the University of California Irvine. Although I have not found it useful for laparoscopic pyeloplasties (I use the Endostich device with a non-robotic laparoscopic technique), the 2 of us at our institution performing robotic-assisted laparoscopic radical prostatectomies have used it with great satisfaction for the urethrovesical anastomosis. The authors' current modification of the technique described in this article (accepted in December 2002) includes using a monofilament suture for one arm and a braided suture for the other. The braided suture is first placed for 2 throws (outside-in on bladder neck, then inside-out on the urethra) and then the monofilament suture is placed for 5 throws (first 2 as for the braided suture, then 3 more throws). At this point 20- 25% of the anastomosis is complete and the bladder is pulled down to the urethra with gentle traction. The monofilament slides easily. Traction on the monofilament suture by the assistant keeps the anastomosis opposed as a few more throws are placed with the braided suture. Friction from the braided suture now keeps the anastomosis together without additional assistance and the remainder can be completed rapidly. This technique markedly simplifies the laparoscopic urethrovesical anastomosis. Our experience to date (albeit with short follow-up) is similar to that of the authors with no "clinically evident post-operative urinary leak or symptomatic bladder neck contractures."
Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA
Publication Dates
-
Publication in this collection
26 Jan 2004 -
Date of issue
June 2003
