Hydrocelectomy Complication Rates in the United States

Introduction

A hydrocele is a benign collection of fluid between the parietal and visceral layers of the tunica vaginalis and can range in size from barely palpable to a bulging collection of 1 liter of fluid or more.¹ Hydrocelectomy, the gold standard of hydrocele treatment, has multiple variations all of which include incision of the tunica vaginalis and either eversion or excision of the tunica vaginalis to prevent further accumulation of fluid.² Although hydrocelectomy is the most definitive treatment for hydroceles, it is associated with complications.² Several studies have reported hydrocelectomy complication rates ranging from 16% to 27%, but were limited in sample size and assessment of risk factors.^3–7 Accurate data on the complication rate is critical for preoperative counselling of patients.

Given the common nature of hydroceles, it is essential for urologic practices to be versed on rates of adverse events associated with surgical repair. Therefore, the purpose of our study is to quantify the rate of hydrocelectomy complications in the United States and explore associated risk factors.

Methods

This study reviewed data queried data from the US Collaborative Network on TriNetX to analyze complication rates associated with hydrocelectomy surgeries. We identified 27,418 individuals who underwent hydrocelectomy in the United States between 2004 and 2024 using diagnosis and procedural codes (Appendix 1). Exclusions were for age<18 years, testicular neoplasm, and orchiectomy. The primary outcome was rate of any emergency department (ED) visit, complication, readmission, or reoperation within 90 days of hydrocelectomy. Statistical analysis used summary statistics, t-tests, and chi-squared tests. This study was conducted in accordance with the Declaration of Helsinki. This retrospective study is exempt from informed consent. The data reviewed is a secondary analysis of existing data, does not involve intervention or interaction with human subjects, and is de-identified per the de-identification standard defined in Section §164.514(a) of the HIPAA Privacy Rule. The process by which the data is de-identified is attested to through a formal determination by a qualified expert as defined in Section §164.514(b)(1) of the HIPAA Privacy Rule. This formal determination by a qualified expert refreshed on December 2020.

Results

Our analysis included 27,418 patients with a mean age of 51 years (SD ± 20) (Table 1). The overall complication rate was 13.2% within 90 days of surgery. The ED visit rate was 6.7%, complication rate was 5.6%, hospital admission rate was 2.6%, and reoperation rate was 2.6%. Within 7 days of surgery, 1.3% of patients had complications and 1.9% had an ED visit, while at 14 days the rates increased to 2.9% and 3.3%, respectively.

Table 1 Hydrocelectomy Cohort Characteristics

Of complications, 25% were hematoma, 13% were infection, and 63% were inflammation related or unspecified procedural complications. The median ED visit was day 14 (IQR 6–41) and the median reoperation was at day 21 (IQR 9–38). Patients had a 9.2% rate of overall complications in the first month after surgery, after which the risk rapidly decreased (Figure 1).

Figure 1 Rates of adverse events.

The complications group had higher proportions of older patients (mean of 55 vs 51 years old; p < 0.001) and African-American patients (15.8% vs 9.8%; p < 0.001). The complications group had higher proportions of patients diagnosed with obesity (29% vs 18%; p < 0.001), hypertensive disease (58% vs 40%; p < 0.001), diabetes mellitus (23% vs 14%; p < 0.001), coagulation defects (9% vs 3.5%; p < 0.001), and nicotine dependence (20% vs 14%; p < 0.001).

Discussion

In this large cohort study, we found that hydrocelectomy was associated with a 13% complication rate, including 7% rate of ED visits and 3% rate of reoperation within 90 days of surgery. Complications were documented in 6% of patients and were mainly composed of unspecified disorders of the skin and genital inflammation, while hematoma occurrence was listed for 25% of these patients (1.5% of overall cohort).

Other studies have reported similar complication rates ranging from 16% to 27%, but all have smaller cohorts.^3–7 A Swedish study retrospectively examined 9,174 cases of surgically managed hydroceles which found a 17.5% rate of surgical complications within 30 days of the operation.³ A similar retrospective analysis was performed in Finland with a cohort of 866 patients who underwent hydrocelectomy which reported a 90-day complication rate of 16% and a 25% rate of unplanned emergency room visits.⁴

In addition to complication rates, our study identified risk factors associated with higher proportions of complications. These include greater patient age, Black or African American race, obesity, hypertensive disease, diabetes mellitus, coagulation defects, and nicotine dependence. These associations may be discussed with patients regarding surgical optimization, risk of complications and expectations for healing. These comorbidities may be associated with poor wound healing while the race association could be due to residual confounding, access-to-care differences or coding limitations rather than a direct biological effect.

Our study was limited by its retrospective nature and reliance on electronic medical records. Certain details could not be verified, such as the reasons for ED visits and readmissions, and, as such, were only temporally associated with the procedure. Using the TriNetX database we were unable to accurately assess the details of the surgical care, such as operative technique, antibiotic use, drain use, hydrocele size, operative technique, drain use, antibiotic prophylaxis, surgeon experience and follow-up care. We also note that there is significant overlap between individuals who have complications reported (eg, first admitted to hospital via emergency department and then proceed to operating room). Given these limitations, large retrospective datasets can be useful for identifying postoperative return visits and patient-level risk patterns, and these findings help guide follow-up planning after common surgical procedures.⁸

Conclusion

The rate of complications after hydrocelectomy in the United States is 13%, with 9% occurring in the first 30 days. There was a 2.8% risk of surgical intervention within 90 days. We recommend patient optimization prior to surgery and close follow-up in the first month to evaluate for developing complications, particularly for patients with obesity, hypertension, diabetes, nicotine dependence, or coagulation defects, although even with these interventions the complication rate may be similar. Future research should focus on prospective patient optimization practices prior to hydrocelectomy.