Spermatocelectomy and Partial Epididymectomy for a Large Multilocular Spermatocele and Epididymal Head Cyst

Spermatocelectomy is a surgical procedure used to treat spermatoceles, which are cystic structures that arise from the epididymis that contain spermatozoa and proteinaceous fluid. In cases of symptomatic spermatoceles, such as in the setting of pain or discomfort, spermatocelectomy may be offered. The general approach to a spermatocelectomy is via a scrotal incision to deliver the testis. The spermatocele is then dissected from the epididymis and divided to complete the procedure. In cases of large and broad-based spermatoceles where complete dissection of the spermatocele off the epididymis is not possible, an epididymectomy can be carried out for complete removal. The tunica vaginalis, dartos fascia, and scrotal skin are reapproximated in separate layers. In this video, we present a patient electing to undergo spermatocelectomy secondary to pain and discomfort.

Spermatocele; spermatocelectomy; partial epididymectomy; epididymal cyst.

A spermatocele is a type of cyst arising from the efferent ductules of the head of the epididymis that contains spermatozoa and proteinaceous fluid.¹ It is generally benign, painless, and fluctuant. They are commonly asymptomatic. In symptomatic cases, such as in the setting of pain and discomfort from enlargement, surgical intervention can be considered.² Surgical interventions can include spermatocelectomy, percutaneous aspiration, and sclerotherapy.³ However, the most common standard treatment for a symptomatic spermatocele is surgical excision (spermatocelectomy). Percutaneous aspiration with sclerotherapy is usually reserved for poor surgical candidates, or those who prefer non-surgical management. The procedure in the film details the removal of a spermatocele for a patient who was symptomatic with pain and discomfort secondary to his cysts.

The patient presented in this case is a 78-year-old male with a past medical history of metabolic dysfunction-associated steatotic liver disease, hypertension, lumbosacral spondylosis, gastrointestinal reflux disease, ulcerative colitis, and erectile dysfunction who began noticing post-coital left-sided scrotal discomfort a month prior to presenting for further evaluation. He has a past surgical history significant for cholecystectomy, total proctocolectomy and ileostomy creation, knee arthroscopy, and clavicle surgery. He underwent a scrotal ultrasound which showed multiple fluid-filled structures above the left testicle with the largest cyst measuring about 7 cm. The patient was counseled on his options which included continued observation, but he ultimately decided to proceed with surgery due to his symptoms.

On physical exam, the patient was in no acute distress. He was well-nourished, afebrile, non-tachycardic, and normotensive. He had a circumcised phallus and a right testicle that was descended and palpable. He had moderate left hemiscrotal swelling superior to the left testicle. The left testicle was palpable at the inferior aspect of the scrotum. No obvious inguinal hernias were noted bilaterally.

A scrotal ultrasound completed preoperatively showed normal testes that were symmetric in echogenicity and size. Additionally, there were left epididymal cysts, with the largest cyst measuring about 7 cm in the head of the left epididymis.

Spermatoceles are typically benign and indolent with most remaining asymptomatic, requiring no intervention. Generally, spermatoceles remain stable in size, but may slowly grow over time. Rapid enlargement of spermatoceles is uncommon. Spontaneous resolution of spermatoceles is rare. Occasionally, spermatoceles can progress to the point of causing pain or discomfort. Fertility is largely unaffected by spermatoceles.⁵ Intervention including excision, aspiration, and sclerotherapy have low recurrence rates.³

Available treatment options for spermatoceles include spermatocelectomy and percutaneous aspiration with sclerotherapy. Spermatocelectomy involves excising the entirety of the spermatocele. Percutaneous aspiration with sclerotherapy is an alternative to excision. Sclerosing agents can include doxycycline, sodium tetradecyl sulfate, ethanolamine oleate, 100% alcohol, and polidocanol.^3,4,5

The goals of treatment for spermatoceles are to relieve symptoms of pain and discomfort. However, for some patients, treatment is chosen due to cosmetic purposes.⁶

Spermatoceles are a common form of extratesticular cyst. Frequently asymptomatic, spermatoceles can also become large and painful. In such cases, as seen in our patient, spermatocelectomy is a common procedure utilized to treat symptomatic spermatoceles.

The general approach to a spermatocelectomy can be via a scrotal incision made through the median raphe or unilateral transverse anterior incision to deliver the testis. The tunica vaginalis is then opened, and the spermatocele is identified and dissected free from the epididymis. The epididymis to spermatocele attachment is ligated and divided to complete the procedure.  If the spermatocele is large and broad-based, then epididymectomy can be considered for complete removal of the spermatocele. Thorough hemostasis is obtained prior to closing the incision. The tunica vaginalis is then closed, and the dartos fascia and scrotal skin are reapproximated in separate layers.⁷ In this case, the larger spermatocele was able to be completely dissected off the epididymis and tied off for excision. There was a smaller epididymal cyst present that could not be entirely dissected off as it was attached to an atrophic portion of the epididymis. The decision was made to perform a partial epididymectomy for this patient given the findings intraoperatively. 

The patient was brought to the operating room and underwent general anesthesia for his spermatocelectomy and partial epididymectomy. Estimated blood loss during the case was minimal at 1 mL. There were no surgical complications during this case. Total surgery time was 64 minutes. The patient was discharged the same day of his surgery. 

The patient in this case was seen for follow-up four weeks after his procedure. He noted that postoperatively, he only took acetaminophen and used ice packs for his pain. His left scrotal incision was well-healed with mild left hemiscrotal swelling. His pathology was reviewed and consistent with spermatocele.

Complications of spermatocelectomy include bleeding, chronic pain, infection, damage to surrounding structures, recurrence, and possible fertility impairment in bilateral cases.^8,9 Fortunately, the patient presented in this case did well postoperatively and did not experience any complications.

• Electrocautery device
• Yankauer suction
• Adson forceps
• DeBakey forceps
• Metzenbaum scissors
• Curved Kelly forceps
• 15 blade scalpel
• 3-0 silk ties
• 3-0 chromic suture
• Gauze fluffs
• Mesh briefs

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.