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Surgical Induction of Endolymphatic Hydrops by Obliteration of the Endolymphatic Duct
Published on: January 22, 2010
A mechanism for chronic filarial hydrocele with implications for its surgical repair
Joaquim Norões1, Gerusa Dreyer
1Departamento de Cirurgia, Centro de Ciências da Saúde, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil. noroes@uol.com.br
Insights
Complete hydrocele sac excision significantly reduces recurrence in bancroftian filariasis patients. This surgical approach also helps preserve testicular integrity by addressing leaking lymphatic vessels, crucial for endemic areas.
Area of Science:
- Tropical Medicine
- Surgical Urology
- Parasitology
Background:
- Chronic hydrocele is a primary manifestation of bancroftian filariasis, prevalent in 80 countries.
- Bancroftian filariasis significantly impacts populations in endemic regions, necessitating effective management strategies.
- Understanding intrascrotal pathologies associated with hydrocele is vital for patient outcomes.
Purpose of the Study:
- To evaluate intrascrotal lymphangiectasia in filarial hydrocele patients.
- To assess the gross appearance and consistency of testes in affected individuals.
- To determine the efficacy of complete hydrocele sac excision in preventing recurrence.
Main Methods:
- A prospective study comparing hydrocelectomy with complete sac excision (Group-1) versus sac-sparing techniques (Comparison Group).
- Recurrence rates, testicular abnormalities, and presence of dilated lymphatic vessels were analyzed.
- Follow-up periods ranged from 5.3 to 12 years for Group-1 and 5 to 6.9 years for Group-2.
Main Results:
- Complete sac excision (Group-1) resulted in a significantly lower recurrence rate (0.3%) compared to sac-sparing surgery (19.3%).
- No recurrence was observed in patients re-operated with complete excision (Group-2).
- Testicular abnormalities were noted in 18% of Group-1 and 35.7% of Group-2 patients, with dilated lymphatics present in 30.9% and 46.3% respectively.
Conclusions:
- Ruptured lymphatic vessels contribute significantly to chronic filarial hydrocele fluid and testicular damage.
- Complete excision of the hydrocele sac is recommended to prevent recurrence.
- Suturing or excising identified leaking lymphatic vessels is crucial for preserving testicular integrity.
Background:
Chronic hydrocele is the most common manifestation of bancroftian filariasis, an endemic disease in 80 countries. In a prospective study, we evaluated the occurrence of intrascrotal lymphangiectasia, gross appearance/consistency of the testis, and the efficacy of complete excision of hydrocele sac in patients living in a bancroftian filariasis endemic area who underwent hydrocelectomy at the Center for Teaching, Research and Tertiary Referral for Bancroftian Filariasis (NEPAF).
Methodology/Principal Findings:
A total of 968 patients with uni- or bilateral filarial hydrocele (Group-1) and a Comparison Group (CG) of 218 patients from the same area who already had undergone hydrocele-sac-sparing hydrocelectomy elsewhere were enrolled at NEPAF. Twenty-eight patients from the Comparison Group with hydrocele recurrence were re-operated on at NEPAF and constitute Group-2. In Group-1 a total of 1,128 hydrocelectomies were performed (mean patient age of 30.3 yr and mean follow-up of 8.6 yr [range 5.3-12]). The hydrocele recurrence rates in Group-1 and in the Comparison Group (mean age of 31.5 yr) were 0.3%, and 19.3%, respectively (p<0,001). There was no hydrocele recurrence in Group-2 (mean patient age of 25.1 yr and mean follow-up of 6 yr [range 5-6.9]). Per surgically leaking or leak-prone dilated lymphatic vessels were seen in the inner or outer surface of the hydrocele sac wall or in surrounding tissue, particularly in the retrotesticular area, in 30.9% and in 46.3% of patients in Group-1 and Group-2, respectively (p = 0.081). The testicles were abnormal in shape, volume, and consistency in 203/1,128 (18%) and 10/28 (35.7%) of patients from Group-1 and Group-2, respectively (p = 0,025).
Conclusions/Significance:
Lymph fluid from ruptured dilated lymphatic vessels is an important component of chronic filarial hydrocele fluid that threatens the integrity of the testis in an adult population living in bancroftian filariasis endemic areas. To avoid hydrocele recurrence the authors advise complete excision of hydrocele sac and when identified, leaking or leak-prone dilated lymphatic vessels should be sutured or excised.
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