Guide to Hydrocelectomy - decision, preparation, expectations

First, why I'm posting this?

to help people considering this procedure

to advise on prep before/after surgery

Second, why me?

I had two, need a third surgery most likely. Operated by two different surgeons, both with 25+ yrs of experience.

In addition I talked to over a dozen urologists, foreign too, considering my case

Have 500+ hours educating myself on this topic (a bit possessive, I know) to understand broader anatomy, procedure types, and comm better with doctors.

I'm 39yo, 175lb(80kg) and was very physically active before all this, with zero health issues.. just had this painless but uncomfortable moderate (250ml) hydrocele I wanted gone. Had it very minor since teen ages but very slowly grew to small/medium avocado size over last 10yrs.

Third, why not me?

I'm not a doctor, so everything below is from my own experience, urologists and nurse discussions, and publications (mainly from PubMed). I may be minority experiencing complications and you could be fine, but more on those odds below.

Think really good

if you're really ready to cut into super sensitive part of you body full of nerves. Take it seriously, it's not like getting a tooth removed. It's NOT routine as it's advertised to be. Below are some risks I've got from papers, literature and doctors. Wish I was equipped with this knowledge before deciding on my surgery - hopefully it helps you make a more informed decision. if you have to do it due to pain or very large size, decision is much easier of course.

If you're going to do it

If it's not urgent, I strongly suggest finding a good gap in your life and a stable moment for several months out... If you just had a child or planning one, if you are starting a new job, or have important life events coming, etc... I strongly suggest postponing to a better moment if possible in case your surgery is not successful, as it can halt a lot in your life, causing complications, great or chronic pain, and other rabbit-hole issues like depression, anxiety, insomnia, etc.

Homework

Most important advice I can give you is to talk to several Urologists. Some (bad) will cut you open no matter what because you're asking for it, and they see it as easy to perform. Some (good) will advise you on how, when, even if you should do it, considering size, age, health, risks, etc. Don't buy the first doctor and story you get even if they are nice. If they take it lightly they are full of it and don't let them touch you. Good urologist will tell you risks and everything associated. Ask how many have they done or who is the best surgeon they would go to if it was them. It's important to find someone who is a good communicator if things go bad and is willing to go the extra mile later vs waving you off - a lot of them do!

Prep

Don't exercise few days prior, get a ton of sleep before surgery. Aim for fall or winter to have surgery if possible, easier to get much needed quality sleep and manage critical ice packs. Buy 4-6 ice packs, water filled soft ones, they shape the best. They freeze up slow and last only 2hrs or so. Buy a week worth of good anti inflammation snacks, cranberries, nuts, fruit, veggies, tumeric. Sleep a lot but get fresh ice packs even though the night! Avoid processed sugar and alcohol like plague. Your last few meals before and also few days after should be light, healthy, digestible. Soups and runny foods are your friend! Don't eat heavy like burgers and chips. This will avoid post op constipation, you'll have a harder time pooping first few days for sure and want to avoid any straining.

Surgery

Don't be nervous, since at this point you're already decided and committed. You get meds and IV, they roll you to the op room and gas you out. It's like an oil change. 30-60min and they're done. Op itself is the easy part and most people are not in too crazy pain waking up. (mine was both surgeries about 6-7/10, and in evening already 4-6/10). Heavy meds on first day/night help a lot. First day or three are most painful, but for most people not too crazy. If you have a drain put ask them how to manage it. Pay attention to doc/nurse instructions on what to do exactly, before they kick you out on street right away despite being high as a kite. You scrotum will be pretty swollen, bruised and even very hard. For some it can be as big or bigger than before op, depending on your HC size. If you have a drain, don't touch it to avoid infection.

Recovery

Extremely important - Ice with those ice packs 3-4 days without skipping, even at night while you sleep. Best if you can have a spouse/partner bring in every 3 hrs, if not prep in the portable cooler next to bed. Place not just on top, but few of them all around the sack. Inflammation is your enemy and can cause undesirable healing , adhesion and worse scarring. Pause icing often for 15min then ice again. Drink a lot of water for a week, half gallon min to heal faster, flush meds, poop easier as most people get constipated first day or two. Eating soups and soft foods helps a lot. Drink Ibuprofen as directed by docs/nurses (7days typically around the clock) even if you feel good! That inflammation will last longer than it seems outside. Swelling and hardening of the scrotal skin first few days is normal and should go down over next few weeks. If your swelling keeps growing after first day, that's not good. Could be another HC or less common hematoma. Bruising is normal, but developing black or red skin is not a good sign.

If everything went ok you should not feel much pain after a few days, when resting at least. I felt great on my day 3 and 4, and started short walks.

Do not strain, lift or masturbate for at least a month. they say 2 weeks but don't risk living in agony of pain later and recurrence scenario. I even read that younger people usually get recurring HC more due to jumping back in sooner and harder. Scarring forms and peaks in following weeks, and fully heals after 6+, even 12+ months. Nerve regeneration is about inch per month.. so after few months you'll know what you ended up with because you can feel fine after surgery but two months later develop nerve pain if it regrows around scars. Some nerves can heal, some can permanently damage. Happened to me after being perfectly fine for 5 weeks.

Complications and Recurrences

It's important to understand that this procedure is NOT a definitive solution as some places or doctors say! They never remove entire sack lining that produces fluid, and inverting it doesn't always stop it from producing and acumulating. Per literature, about 20%(!) of the time things go bad - recurrence, hematoma, infection, are more common, but also, bad tissue adhesion, bad scarring, or nerve damage that could be permanent. Recurrence rate per literature is 6-10% but three urologists told me 10-15% realistically over longer period of time, and can come back a day after or months, years even, but typically much closer to surgery from what I've read. Recurrence can come in septations and loculations (compartmentalized HCs) making it a lot worse to manage moving forward and can be more symptomatic. Per few publications I found on PubMed, younger people have higher chances of recurrence, probably due to jumping back in activities and straining too soon. I had first recurrence 3 weeks after first surgery, second just one day after. Scarring and adhesions are like a box of chocolates - you never know what you're gonna get... you testicle and tissue might stick to scrotum, and not hang inside normally. all in all pretty terrible risk chances considering they label this as 'routine', 'gold standard', 'definitive'. But hey, you have about 75-80% chances to come out golden... if not, you might hate your life and yourself for doing this, like some of us. Few urologists told me they don't like doing HCmy because of these complication chances. Even if they do everything right, your tissue might be more sticky or keep producing fluid a lot and can fail easily, like me. I further developed non infectious Epidimitys due to fast recurrence and adhesions/inflammation, abdominal/groin pains, strong perineum pains after having fast and big recurrence, preventing me to sit or stand comfortably even today 4 months and counting. Unusual symptoms for most, but doubt any of this would happen to me with sclerotherapy. BTW, all urologist told me they often give this type of surgery to students and interns because how 'routine' it is... so know who is cutting you. Also, be prepared for possibility of being put aside and abandoned by doctors if you get a recurrence and some pain complications. A lot of them have hundreds of other patients, and if you are not easy to solve, they can just tell you to 'wait and see what happens', they stop being responsive and responsible. They performed the surgery as agreed and their job is often considered done. I've noticed this pattern among many of them in my case.

Alternatives

Aspiration drainage with needle is almost always pointless and carries infection risk. Fluid almost always comes back after few days to a month.

Sclerotherapy on the other hand looks very promising after reading many PubMed papers. Similar success rate as HCmy. And is minimally invasive. Downside it seems that it has slightly higher chance of infection via needle vs surgery and apparently makes Hydrocelectomy more difficult later if needed, but still possible, and can cause unfavorable scarring but so does surgery. Seems to hurt less, just few days, but short term pain is tiny cost considering your nuts are getting cut up in comparison. Seems like US doesn't practice this in hospitals/urology department. my doctor told me they phased this practice out for some reason while world marches on successfully. As someone who's nut looks like a warzone now with a lot of scarring pain, I highly regret not seeking sclerotherapy over HCmy first. There are a few offices I saw in US who offer that.

Biggest fear

is not surgery, it's "will it come back" and for some, things like infection, scarring and nerve damage risks. Don't worry about the outer scar, it will drastically disappear and blend after several months...or post op pain (unless they really damaged you somehow)...that stuff goes away fast and you quickly forget! living with complications, recurrences, additional operations that are a lot more complicated, more aggressive and uncertain, internal scarring and nerve pain, tissue adhesion.... that's the real nightmare and your life can stop - stopped for me after being physically very active and perfectly healthy before any of this.

Most people make it out fine

Don't take this as a scare post, my case is uncommon, numbers are still on your side, but they are certainly NOT great numbers to gamble with in my opinion! One of bigger studies that aligns with vast majority of them, and what some doctors told me:

https://pubmed.ncbi.nlm.nih.gov/36353068/

A lot of people came out perfectly satisfied and would disagree or find this post absurd, but don't just hope for blind luck, do your homework and see that risks are quite substantial.

Hope this informs you better before deciding - Good luck and wishing everyone happy & tiny balls.

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