A spermatocele is a paratesticular, sperm-containing cystic structure attached to the superior aspect of the epididymis. Spermatoceles are commonly asymptomatic, and conservative management is appropriate for the majority of patients. Discomfort because of large size is the primary indication for intervention.
Although surgical loupes are sufficient, the author prefers use of an operating microscope, which allows one to clearly identify structures adjacent to the spermatocele, aids in dissection of the spermatocele off of the epididymis (and away from the testicular blood supply), and allows isolation of the spermatocele neck for ligation and excision. The patient should be counseled regarding the following procedural risks: potential for epididymal obstruction and subsequent infertility, epididymal injury, scrotal edema, scrotal hematoma, spermatocele recurrence, chronic pain, testicular atrophy due to vascular injury, and infection.
Spermatocelectomy is most easily performed with the patient under general anesthesia to limit motion artifact while working under the operating microscope. The author prefers a median raphe incision carried down sharply to the level of the tunica vaginalis, although a transverse scrotal incision is an acceptable alternative.
Bluntly dissect the tunica vaginalis to deliver the testis within the tunic through the skin incision. Achieve hemostasis of the dissected dartos fibers with electrocautery. Open the tunica vaginalis to gain direct access to the testis, epididymis, and spermatocele ( Fig. 112.1 ).
After bringing the operating microscope into the field, a combination of sharp and blunt dissection is used to isolate the spermatocele off of the testis and epididymis. Fine-tipped Jacobson mosquito forceps may facilitate dissection when establishing a plane between the spermatocele and epididymis. Keeping the spermatocele intact allows for easier dissection and identification of tissue planes. Use of bipolar electrocautery helps to ensure hemostasis during dissection. After the fine neck of the spermatocele has been clearly identified and dissected free, ligate it on both the epididymal and specimen sides and divide ( Fig. 112.2 ).