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

CHAPTER 1

Hi, I am Dr. Joseph Clark, professor of urology here at the Penn State Health Milton S. Hershey Medical Center. Today, we're about to show you a case of a spermatocelectomy. A spermatocele is a cystic dilation of the epididymal tubules. Sometimes when they become large, they become painful or the patient has discomfort with movement. And so this patient elected to have a spermatocelectomy. This patient probably has a multiloculated or septated spermatocele based on the ultrasound. Basically the ultrasound showed a lot of fluid filled spaces, which can sometimes be confused or mistaken for a hydrocele. But based on the physical exam and the appearance of the cystic spaces abutting the testicle, this was lightly a spermatocele. So to begin with, we would make an incision. I typically make a horizontal incision on the anterior aspect of the spermatocele, We go down through the layers and we then deliver the testicle with the spermatocele. And again, the spermatocele are cystic dilations off of the epididymis. If they're small, we'll call 'em epididymal cysts. But if they're large, we'll call 'em spermatoceles. So I expect that once we deliver the testicle with the spermatocele, we'll inspect it and we'll try to figure out what's the best way to take care of this. If they often are large and have a broad base, sometimes I'll just do an epididymectomy. If the spermatocele is a little bit smaller and we can dissect this thing off, we'll just dissect it off. In fact, I've dissected spermatoceles intact. Although in theory, there should be a little connection around a neck. If it is small, sometimes we can just cut into the spermatocele, drain it, twist the sac, and put a stick tie at the base. Kind of like doing a hernia repair. But again, we'll determine how we fix the spermatocele based on the appearance. Once that is done, we will obtain hemostasis since we're gonna put the testicle back into the scrotum and we don't want any bleeding. We'll try to cover the defects with a layer of tissues or some tunics, and then we'll close the scrotum in layers with an absorbable suture.

CHAPTER 2

[No dialogue.]

CHAPTER 3

All right, so this patient has a - probably a spermatocele. His testicle is on the inferior aspect. We can palpate that and he's got this cystic mass. So this is most likely a spermatocele rather than a hydrocele. But sometimes we're surprised if they have a loculated hydrocele. So what we're gonna do is deliver the testicle with the spermatocele and excise the spermatocele and put the testicle back in. I've kind of marked an anterior horizontal line, and we're gonna take the scalpel. So we're gonna get in.

CHAPTER 4

Incision. And we take two pickups with teeth. All righty, so just get the bleeders while we see them. So we can dab. Okay. Wanna grab the suction? Yep. All right, so we're gonna grab inside and lift up and we're gonna try to get into the hydrocele sac. Okay, I'm gonna wait and do this and grab again. Yep, yeah, yeah, hemostat 'cause I think we're gonna get into the hydrocele sac soon. Are we in there yet? Oh wait, I think we are just- Maybe not, let's see, is that? Is there a little fluid in there or...? Yeah, go in just a little bit more. Okay, hold on. I wanna see if we're gonna get into the spermatocele or the hydrocele. Let's try a different place, go right there. That might be the hydrocele or the spermatocele. Grab. Let me see if it makes it easier. Yeah, I think that'll get into the hydrocele sac. So go ahead and... Yep, keep on going. Okay, let me... So we're now in the hydrocele sac. Suction.

CHAPTER 5

And go... Yep, and then I'm gonna, yep. All right, is that enough? So, is this enough? I don't think this is enough to deliver a testicle with the spermatocele. So let's, yeah, extend the incision. All the way up to the end and sheet up. All right, and is that enough to? Nope, all right. Make the skin incision? Yep, you can use the cut on the... So we're making the incision on the skin just a little bit bigger to see if we can now deliver. All right, here we go. Actually, this is some of the hydrocele sac. Let's just open it up. All right. So the spermatocele is a little bit stuck up here. Let me see if we can... Okay, without puncturing the spermatocele... Can I get a DeBakey's? And see if you can just use this Ray-Tec to kind of get that layer off.

CHAPTER 6

So we had initially entered the hydrocele sac, which contained the testicle and the epididymis. The spermatocele is a cystic dilation of tubules of the epididymis. That's why we call it a spermatocele. It has some sperm in it. If it's small, I will call it an epididymal cyst. If it's large, I'll call it a spermatocele. And on ultrasound, again, there's black areas which signify fluid. But again, we had to enter the hydrocele sac to get to the testicle and the spermatocele. We're still kind of... Actually it looks like there's a little, yeah. So I can do this and you can... So some of the hydrocele sac that surrounds the testicle is kind of plastered to the spermatocele. So, is that enough to kind of see if you can peel that off. And after we got it exposed, actually let me just... You got the Bovie? Just burn and burn. Let's see, and just edge burn, yep. And keep on dissecting that out. And is there a little... Let's see, I don't know if... Actually why don't you just buzz there maybe we will... There we go. And then actually... All right, you can just kinda use this. Again, see some of his hydrocele sac was kind of plastered onto the spermatocele. So we're just kind of trying to dissect that away... And... Go this way towards you? Yeah, let's see. Is there... Just go with just a little bit because it's really kind of fused here. Let me see if... Just gonna do this. And let's have it on this side. So this is the vas deferens. This is what transfers sperm from the testicle to epididymis to the outside world. All right, so we... So let's see. So this is the normal anatomic lie of the testicle. This is a testicle with the tunica albuginea, and this is his epididymis here. And he's got some cystic collection of fluid here, as well as this large fluid collection up there. What we're gonna do is we're gonna try to dissect a little bit more of the layers off the spermatocele in which we'll try to see if we can isolate it. If the spermatocele can be dissected off to a base, we can drain it and twist the sac and put a suture. Sometimes if the base is wide, we will probably just, you know, excise that portion of the epididymis. So it'll all depend on what we see. I think we have to go... Do you see a plane? I think I can go this way. All right, let's just see. So this is also a spermatocele, which we'll take. So Linda, you'll see this is called the lateral cleft. So the normal anatomic position is like this, lateral. So you'll see that when you open up the hydrocele sac on other patients. So I think, again, this is a hydrocele sac and again, I'm not sure how wide the base is. So yeah, we'll take that. We're gonna try to see if we can kind of get to the base by... Hopefully we won't... Yep. Suction the Bovie smoke. Yeah. We can decrease the Bovie to maybe 20-20. Is there something finer than this? I have a 3-0. Yeah, we'll try that. Again, now anytime during... Great, anytime during this case, we may end up making a hole in the spermatocele. All right, so there's still a little layer around this spermatocele that we're trying to dissect. And let me just take this and see if it is possible to... Let me see if there's any other area. Yeah, is there - I'll just make a little nick. Yeah, lift that and I'll lift up there. Just make a little nick. Yes. All right. All right, so this is the vas deferens. This transports the sperm. Should we try to dissect that off? Okay, some blood vessels there. Maybe we can try to... With a Ray-Tec, or...? Yeah, try to sweep that vas off. All right, so let's see if we can get this vas swept off. Yeah. All right, so this is the vas deferens. There's still like a little layer. Yeah. Still a base. All right, so again, some of the epididymis, I'm wondering if we should just end up doing an epididymectomy. We can try to see if we can dissect this off. So try to do a little pickup of the epididymal tunics, kind of... Can I get Adsons. Yeah, make a small nick. All right, let's see if we can now... Yep. All right, so this is a spermatocele by itself and this is the epididymis. Let's see if we can find the base of this. Let's see is this...? Let's try this layer first. So, is this...? So yeah, let me just take, yeah. I was gonna try to sweep it off with a Ray-Tec, but if we see it, we can take it. I can go treat laterally. All righty. I wonder, so this is all that's gonna be left of the epididymis. I'm just wondering if it's better to just do an epididymectomy. Let me see. So this is part... this is the epididymis. He's got another cystic fluid collection here at the head of the epididymis. This is what's remaining of the epididymis with a cystic dilation. Maybe just better to do an epididymectomy. I'm thinking to get all of that. So let's try to dissect up top here and then we'll have this fluid collection and we'll see what the base is like. Let me... All right, try to see if you can use a Ray-Tec to kind of sweep that off, that cyst... Something that needs to be buzzed, we can buzz it if... Is there stuff here? Let's see. So there's still... I'm gonna lift up here. You can see a little, yep. Looks like there's a blood vessel there. Grab it. Yeah. All right, and then let me see if I can just sweep. There's a little bit more here and again, there's still just another layer. All right. All right, try if you can sweep that off so we can just kind of see where the base of that. Let me get those. Yeah, we can... No. You want to just... So, I can just tap. A little. Let's see, I guess we can. Let me tap that. Let's see. There's some blood vessels here. Let's see. So should I tap right...? See that? Right. Let's see. Yep, if it doesn't come off, we can just make a little nick. So there's another... It's loculated. It looks like there's another cystic collection there. Let's see if that'll sweep off. It's kind of thickened. No, okay, that came off. If I can... Tap it. Let's see if I can go... Cut right here. All right, so let's see. Let's just reassess. So, testicle is this way, lateral cleft. So we know it's this way. We were able to dissect the cystic fluid collection here. Looks like, again, since he also has a cystic fluid collection here, I wonder if you just... I think we can certainly take this part off and then we'll be left with this and maybe we would... So it looks like we can... Let's see. We can go fairly close to free this. All right, so that's pretty free. Now this is showing us itself here. All right, and then maybe, let's see. Is there anything more that we can get before we end up rupturing the spermatocele? Maybe like this? Yeah, I think you can make a little nick right there. And see if that will get us. If not, can we do more? That's the question. Yeah, I guess you can try to do that. Okay. All right, so at this point we're gonna have to make a decision on what to do. Again, if there there was just like one spherical cystic mass that went to a base, we could drain it, twist it, and then put a stick tie. But this is relatively broad based. You think you do right a little bit right over there? We may end up rupturing it, but we'll see. Okay, we did not rupture it. Okay. How about... So that's what we have so far. It looks like we can... Yeah, I think you can kind of go there. Okay. And is that... Okay, try to see if you can sweep to make it more evident where the thing is and where the base of that spermatocele is. So that may be like kind of the rete testis we're... So we may end up... Is there, yeah I can... Yep. You wanna go down or above or below? I mean, I think there's a little window right there. Yeah, I can see it. How much is there? So... There's like a little band there that we could... Right, so we could separate this, but this is also a cystic collection. Yeah. So, we could leave that. Although we could get bigger or we could just do like an epididymectomy and kind of tie that as well. So yeah, I think we can just try to excise this. Yep, try to cheat toward, so we don't look through it here. All right. Because if it is at a base... Yeah, try to lift up. There's still a little fibrinous layer, looks like. Oh, I think we got into it. So I wonder if we can maybe just drain this. You know, if we drain this, we can twist it and stick tie it. Although he still has a separate... Let's see if we can get this. Can I dissect this off? Yeah. See if you can dissect this off, or on the tunica albuginea. What size silk would you like to stick? How about like a 2-0 or 3-0 silk? Doesn't come off easy. Can I have a mosquito? Yeah, is there any more like that we can... Yeah, you can try to see if you can do that. Yep. All right, anything else? Yep, there's a separate layer, excellent. And now there's a plane you can see. So we might be able to get this to even smaller base. Yep. Hold on, hold on, wait. That might get through. There's some fibrinous stuff right there. Yep, yep, get that. All right, and then there's still... Maybe we can get it to a very, very small base. All right, actually let me have, yeah, let me take 'cause I can see from my side when you... Yeah. Let's see. Yeah, I think if I stretch, you can part tap right there. Yep, good, and tap. All right, so that's where we're at. Is there anything here that? I think you can part tap right there. Let me just, yeah, lift that up. Yeah, and tap right there.

CHAPTER 7

Yep, and I can actually, I think we could... You know, we could either put a drain this, twist it and stick tight like a hernia sac. Or we could just put one tie here. Just cut it off here and then twirl it. I think there's a lot of different ways we could handle this, and then we can kind of deal with this a smaller spermatocele there. I wonder if we can just do this, right? Yeah. So if we stick tie this, can you... Is there enough of a space to stick tie this? You can stick tie right above it. It's gonna be leaking. Is there a kidney basin we can just put underneath? All right, so I'm gonna do this and you can try to put a stick tie just above it. Once you stick the needle, it'll start leaking. All right, you can go around it. Yep, suture scissors. Yep, good? Yep. Yep. All right, I mean, what we can also do is we can just drain this thing and stick tie, you know, twist it a little bit more and put a second stick tie above it. So maybe we'll just do that. So we're gonna just cut into it, drain it, and we will have a specimen. It'll just be a segment of spermatocele. So this should theoretically have sperm in it. All right, and I am gonna twirl this and just put another stick tie above it and we can... Cut the suture off. So we we're gonna lop off the specimen, and then cut his suture. So, you got some Metz? Or actually, why don't we use Bovie to cut off the specimens. Here, let's cut off this specimen first. All right, you can cut that. All right, this is the specimen. It's just the, you know, wall of the spermatocele. And then, I don't know, he's got a smaller spermatocele. Yeah, we could... I mean, we could also try to dissect it off or we could just try to take the epididymis here, remove these spermatocele. All right, so we could certainly leave this, but it could get bigger. Let's see. I'm trying to think the best way to take care of this is, I think, we can try to dissect this thing off and then we can just put a throw there. So you can actually see it where it's kind of connected to the tunica albuginea. Yeah. Yeah, you can either... Yeah, let me see if I can, hold on. Can I... Suction the Bovie Smoke coming up. All right, and then here, let's see. All right, and now are you able to dissect off to a base or not? Or... I think if we got through here... Yeah. All right, and then how much of a base is there? How about the... Yeah, you can actually kind of see. Yeah, that we have another like a 3-0 or... All right, so again now, this is connected to the epididymis. So, we can... We could like go underneath this and tie it. Yeah, actually, let's dissect it off here. Yep. Yeah, and I think you can kind of see it's diaphanous, You can just kind of... But see right here, it's diaphanous right there. So you take the epididymis off? Yeah, to me, it'll just tie off the epididymis. All right, so this was the... Maybe it looks like a two-centimeter spermatocele at the head. It's kind of connected to the epididymis. And let me see if we're going to take the epididymis here. 'Cause other than that it's a very... I think from the large spermatocele there has been a little atrophy of the epididymis right there. Yep, and then... So maybe we'll end up doing an epididymectomy as well. So can you...? Yep. All right, and is there. Okay, let me see. Let's apply to the testicle still there. This will go to the tail. So I think, yeah, we're just doing an epididymectomy. So again you can kind of see in between. All right, so at some point we're gonna just take... should we just like ligate it right here? Actually, can you dissect a little bit more? Yeah, kind of... All right, so I think we can just leave a little remnant. Okay, so it was like this. And that's the way we're gonna put it back in 'cause there's like a raw area. And we can dissect, continue to dissect this or we can just put like a tie here. So let's just put a sick tie here. We'll take that silk. What is this, like a 3-0 silk? Yep, 3-0. All right. So we'll label this specimen separately. We can put it as epididymis with epididymal cyst. All right, why don't put one more stick tie. Is there enough length on that suture above it, or...? Okay, yeah, let's get another 3-0 silk. Big, high pressure artery going through this. But let's just do one more and then lop it off there. And then we'll have to look here and see if there's anything that we can use to kind of cover. Yep, put one right above that. All right, we can use a cautery. Just lop this specimen off. Let me cut this first. Here's a specimen. All right, let's see. How about a little squirt of irrigation?

CHAPTER 8

Do you wanna look at these specimens anymore? Or may I pass them off? Yeah, you can pass it off. All right, give you this back, and let me take a Ray-Tec and just dab things off. All right, see if we need to get hemostasis anywhere. Anything?

CHAPTER 9

All right, and then, so here's the spermatic cord with the vas deferens, which usually comes to the tail of the epididymis which we left. I'm just trying to think. Let me have some DeBakeys. I just wanna see if there's any suture that we can use to cover things like raw areas. Yeah, there's a little... You bring that to that. Yeah, I just don't wanna strangulate the cord but this is like loose enough. Bring that. I think we can put... What absorbable sutures do we have? Whatever you want. How about like 3-0 chromic? 'Cause we'll use that for the skin and the dartos anyway. I think we'll just try to kind of cover up this raw area. Let me see. How about like this? Can we cover up this? How about like, kinda like this? Like that. Leave that, but just a layer to kind of cover. Trying to think where, again, so this... That to that? Yeah. Let me start with... Yeah, take a little bit of that tunica albuginea and we'll just... And this is not like a strength layer or anything. It's just kind of keeping some tissue over that area. All right. Cut that. Let's see, maybe we'll just... We can just do simple interrupted all around. So we're just going to cut that. Cut this a little bit. Cut this. We're just gonna do simple interrupteds? All right, so then again there's this kind of raw area. And can we do like this? All right, cut. And let's see, is there enough? Yeah, maybe just like that to that. And maybe like that. Do you want any Vicryl or anything besides that chromic to close? No, I think because I think I'm gonna close the dartos with a 3-0 chromic. We'll do the skin with 3-0 chromic. And then if you could just make up some fluffs and if we have some mesh shorts for compression. I don't know, maybe just like one more right there. Oh yeah, she's counting Ray-Tec. Yeah, there. Yeah. Yeah. There's three on the field, I guess. I see three. All right, so again, just to make sure. So the testicle is gonna go back in this way. And hemostasis is pretty good. We got raw areas covered. I mean I think you can probably do one more. See this, just light. All right, first count's good. Oh, excellent. So we're not gonna put a drain in, we're just gonna put the testicle back in and close the incision. Two more? Yeah, maybe two more. You know, I'll just scar in. All right, maybe just like one more there. We will take a little squirt after this to make sure that there's no bleeding anywhere. All right, see if there's any more sutures to kind of cover raw areas. I don't wanna strangulate the cord - I think... How about just one more because there's a very small blood vessel there and, yep. And then just get some stuff there, yep. Very small bite 'cause again, this is just not a strength layer, it's just kind of keeping things in that area to scar it in place. And cut. And maybe one more right here. Did we do the red phone already? Yep. All right, so we're just... And then we're just gonna evert here and make sure there's nothing. So, we didn't dissect the hydrocele sac off, we entered it. And so this is the parietal layer of the tunica vaginalis. We just wanna see if, you know, we had got gotten into it. If there's anything that's bleeding, we're just gonna get hemostasis. Can we have our suction back on? Anything here? So this looks very different from when we do a hydrocelectomy 'cause we dissect this off, and usually that hydrocele sac is very thickened. And I think, I don't see anything bleeding. I think we're gonna be done soon. All right, one final squirt and then we'll put the testicle back in. And then do you have a couple of Allises? Give you that back. All right, so the testicle is going back in here. Hopefully it should go back in 'cause it's smaller. Yeah, why don't you get... Can I get an Adson? And I'll take a Adson to me, would... All right, put it back in. All right, and then one Allis to me and I'm just gonna grab the... And one more dartos, or...? Chromic. All right, and then Linda, why don't you come over here you and... Come over here and you can help him. All right, so we're going to take, make sure we get the big thick dartos layer. We're gonna run that. And once you tie that, I can take this off, and Linda can hold this up for you. I'll take this off, and he's gonna tie it, and you're just gonna kind of hold it up for him, and he's gonna grab the inside and do running sutures. So, I think that's, I'm gonna... Oh yeah, yeah. Let's call it left spermatocelectomy and left partial epididymectomy. Yes. All right, yep, that sounds good. Two specimens, clean, contaminated. Our specimens are wall of spermatocele and epididymis with epididymal cyst. Yeah, just make it a clean case 'cause we didn't enter the urinary tract, so it'll be a class one case. All right, maybe I can... The next patient is in pre-op. All right. He speaks some English, but he speaks Spanish. Let me see if I can... Anytime, we're on our second-to-last layer. Yeah, so it'll be this dartos layer, then it'll be a running horizontal, and then it'll be simple interrupteds in between. Like three layers. Oh, wow. Yeah, yeah. It's kind of all skin, isn't it? Yeah, it is. And there's no drain. Whatever you want. I'm ready. All right, so we're gonna do the running horizontal closure using 3-0 chromic. So we used 3-0 for everything, right? 3-0 silk for the... Yeah. All right. 3-0 everything. All right. See, it makes it easy when I dictate. Yeah. Can you get a little bit of Basi? Yeah. So this patient already has a post-op followup appointment to see me. I asked him about narcotics. He said he won't need narcotics, so he'll just take like ibuprofen and Tylenol at home. Can I take it in one bite? Take it in two just to make sure you get just the skin edge. Okay, now you can do it in one, yep. Oh, let me get the consents outta here. Just interrupted? Yeah, just do like an interrupted. Yeah, jut so that if that running suture comes out, the wound won't fall apart. That's why I gave him the Bacitracin ointment. So the Bacitracin ointment, the used tube is in here. I'm gonna call his... Yeah, actually I put it, yep. See, I'm always thinking. All right, and then we're gonna put the... We have fluffs already made up. Yep. Oh my god. Lots of fluffs. And we have the mesh shorts there we're gonna put on for little compression. All right, I think I'm gonna just get the next patient ready.

CHAPTER 10

So now that we've done the spermatocelectomy, let me just go through some of the points. You will notice that after we made the incision in the scrotum and we dissect it down, we did enter the hydrocele sac. So you can see that once we entered the hydrocele sac, there was a little bit of clear fluid, which we drained. We extended the incision in the hydrocele sac so that we could actually bring the whole testicle with the spermatocele out. Some of that hydrocele sac was kind of plastered onto the spermatocele. And we had to slowly dissect that hydrocele sac off the spermatocele. And once we did that, you could clearly see the testicle. You could see this large cystic mass. And interestingly, you could also see the head of the epididymis with a smaller spermatocele. So the way we elected to take care of the spermatocele is to dissect all around that large septated spermatocele. We did this very slowly to try to get to the base. And once we did this dissection, what we elected to do was to enter the spermatocele, drain it, and then have this kind of floppy sac and we twisted the sac and we put a couple of silk sutures through the base, and we put two ties and we just cut off the spermatocele sac. There was also an interesting finding. You can see that the large spermatocele had caused the epididymis to somewhat atrophy 'cause there's only a thin layer of epididymis. And at the head of the epididymis, there was a smaller spermatocele. And so after we took off that large spermatocele, we elected to do a partial epididymectomy. We elected to remove the head of the epididymis with that smaller spermatocele, and we dissected it down to the body of the epididymis, which in itself was just a thin sliver. And then we put a tie there. So it was a partial epididymectomy. After we did this, we wanted to make sure that we got excellent hemostasis. So you'll see us using the Bovie cautery, and then there's a little bit of a raw area. And so we use chromic sutures to cover that raw area with the tunics. Following that, we again inspected it one more time to make sure that hemostasis was excellent. We put the testicle back into the scrotum and we closed the scrotum in several layers.