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Ambulatory Penile and Inguino‐Scrotal Surgery

Ben Pullar

Background

Day‐case or ambulatory surgery is now the standard‐of‐care for the majority of penile and inguino‐scrotal procedures in modern urology. However, same‐day discharge cannot be reliably achieved unless consideration is given to achieving this from the outset. In general, the patient should be aware of the nature of the procedure and the intention that they will be discharged home the same day. This starts at the initial clinic consultation and will continue through effective pre‐assessment to the day of the procedure itself. Recovery and ward nursing staff are essential in delivering effective day case surgery with nurse‐led discharge now becoming routine, following a clear post‐operative plan from the operating surgeon.

Specific to surgical procedures, particular attention should be made to adequate post‐operative analgesia, catheter management (if applicable), and meticulous haemostasis to avoid unnecessary re‐admissions due to these preventable issues.

Individual Conditions and Procedures

Hydrocele

A hydrocele is an accumulation of fluid between the two layers (parietal and visceral) of the tunica vaginalis surrounding the testes. The diagnosis is made on clinical examination and it is important to differentiate a hydrocele from other causes of scrotal swelling. Examination will reveal a smooth, unilateral scrotal swelling with a palpable superior margin which trans illuminates. It is often difficult to palpate the underlying testes.

The differential diagnosis of a unilateral scrotal swelling includes varicocele, hernia, epididymal cyst, infection (orchiditis), or tumour.

Diagnosis is supported by ultrasound, which will both confirm the diagnosis and confirm that the underlying testes are normal.

Surgical management of a hydrocele is indicated if symptomatic. Small hydrocoeles or larger, asymptomatic hydroceles can be safely managed conservatively.

Hydrocele repair performed as a day case is well established. However, in older patients or men with a large hydrocele in which a drain is placed post operatively, an overnight admission may be warranted. Paediatric hydroceles are managed differently with a groin incision and ligation of a patent processes vaginalis. They are almost always performed as a day‐case procedure. There are three options for surgical management of an adult hydrocele. Definitive surgical repair is with either a Jaboulay or Lord’s technique. The Lord’s procedure is suitable for small and medium sized hydroceles. It involves plication of the hydrocele sac. Larger hydrocoeles may be managed with the Jaboulay procedure in which the hydrocele sac is excised. Both procedures can be complicated by recurrence or haematoma formation. A drain insertion may be used for larger hydroceles to prevent haematoma accumulation.

Hydrocele aspiration (with or without sclerotherapy) may be reserved for a patient deemed unfit to undergo any general anaesthesia (GA) procedure, but accepting the high recurrence rates associated with it and the risk of haematoma.

Varicocele

Varicocele is defined as a dilatation of the pampiniform plexus of veins in the spermatic cord. It is common and estimated to affect 15% of the general male population. It is seen much more commonly in men being investigated for both primary and secondary infertility.

Varicoceles develop from incompetent valves in the spermatic veins resulting in retrograde blood flow and engorgement of and subsequent dilatation of the veins in the pampiniform plexus. It is more common on the left side due the higher pressures within the left testicular vein owing to the acute angle at which it enters the left renal vein. (This is in contrast to the oblique angle at which the right‐side testicular vein enters the inferior vena cava (IVC), resulting in lower pressure on the right side).Most varicoceles are asymptomatic but if large may cause scrotal discomfort. They are commonly identified as part of the investigation of male subfertility. The link between varicoceles and infertility is thought to result from a loss of the countercurrent heat exchange mechanism that exists such that scrotal temperatures are lower than the rest of the body. The resulting rise in scrotal temperatures results in impaired spermatogenesis.

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