Urological surgery includes operating on the scrotum and testes.
The typical operations include a cure of hydrocele.
Hydrocele is a fluid accumulation around the testis, within a sac known as the tunica vaginalis. It is imperative that this is distinguished from a communicating open inguinal canal, which is fluid collection or hydrocele, in the context of an indirect inguinal hernia. Hydrocele surgery via the scrotum, in the context of an indirect inguinal hernia, will not solve the problem. Sometimes if it is clinically in apparent that the patient does or does not have an inguinal hernia, this patient may require a groin ultrasound prior to proceeding with hydrocele scrotal surgery.
As long as the tunica vaginalis hydrocele sac is at least part excised with preservation of the vas and spermatic cord structures, the hydrocele is unlikely to recur. After hydrocele surgery, recurrence rates are quoted around 10%.
Non-communicating primary hydroceles occur due to infection or inflammation, or epididymal cysts, or testicular malignancy.
In each case of hydrocele surgery, ultrasound of the testis must exclude testicular cancer, as in that scenario, the operation would need to be performed via the inguinal approach.
Varicocele is a condition where there are incompetent venous valves within the testicular/internal spermatic venous system, allowing reflux of venous blood down into the veins of the spermatic cord and accumulation of venous blood around the testicles can be felt as a “bag of worms”, by the patient. There is a dragging or dull sensation related to this scrotal venous swelling, noticed by the patient at the end of the day or after long periods of standing upright.
The approaches to solving this problem including interventional radiologic embolisation with coils or gel foam to prevent further venous reflux, which is said to have the least risk of testicular arterial or inadvertent vasal injury. This however does require radiation exposure due to X-rays performed during the procedure by the radiologist, and also exposure to intravenous iodinated contrast and therefore the patient must not have an iodine or shellfish allergy.
Urologists can attend to varicocele by an open inguinal or laparoscopic surgical approach, where these veins are sequentially tied off, whilst taking care not to injure the vas or testicular arterial vessels.
If varicocele appears at an early age in adolescence or before this, and is bilateral and large, the increased heat transmitted to the testis can impair sperm quality and production and may be a possible long term cause of infertility.
Epididymal cysts are typically benign cysts of the epididymis, which is a structure found on top of the testis, that allows transit of sperm from the testis through the epididymal tubules and into the vas tube. The convoluted nature of the epididymis lends itself to cyst formation and when these cysts are quite large, (> 4-5cm) and uncomfortable, they can be surgically excised through a simple scrotal operation.
It is best not to excise epididymal cysts in younger men who are yet to have children, as at times epididymal surgery can lead to infertility. This is because sperm transit can be affected through the epididymis as a result, but is not often the case.
Chronic epididymal pain related to epididymal obstruction or previous surgery or chronic epididymal cysts, can be treated in a man who has had his children and completed his family, by way of complete epididymectomy, which is a simple day procedure.
A testicular prosthesis can be placed after a testis is removed for malignancy by the inguinal surgical approach. This is a simple matter of opening the scrotum and placing and suture fixing a testicular prosthesis within the hemiscrotum, such that side is no longer an empty sac.
Occasionally through the Emergency Departments of various hospitals, teenagers present with a ruptured testicle after cricket ball injury to the scrotum, or some other form of trauma, whereby the tunica albuginea is ruptured, and as a result, the seminiferous tubules spill out into the scrotum. This requires an emergency suture repair to salvage the rest of the testis, and that patient is followed up with serial ultrasound imaging to assess final volume and vascularity done through the rooms.