Scrotal Hydroceles not associated with Patent Processus Vaginalis in Children

Background: After the closure of patent processus vaginalis (PPV) in boys with indirect inguinal hernia (IIH) or hydrocele, large scrotal hydroceles can occur on rare occasions despite the complete occlusion of internal inguinal ring (IIR). We present some cases that may help to explain the cause of this rare occurrence. Materials: During last 14 years, six boys exhibited non-communicating large scrotal hydroceles (2 right, 1 left, 3 bilateral) among 352 children who underwent laparoscopic repair for hydroceles. Ages ranged from 7 months to 15 years with a median of 12 years. Five of them had a history of repair for hydrocele or IIH prior to the definitive surgery and one boy underwent an initial operation. Results: In all the patients, laparoscopic inspection at the definitive surgery revealed completely closed IIRs. One infant with primary hydroceles was found to have large hydroceles bulging into the peritoneal cavity. All the patients were treated with subtotal removal of the sac without any recurrence. Marked thickness of the sack walls with abundant lymph vessels was characteristic histopathological findings. Conclusions: The complete occlusion of the PPV does not always prevent the recurrence of hydrocele through alternative pathogenesis. The pathological findings of resected specimens suggested a disturbance in lymph flow in the testicular system. The subtotal removal of the sac is the treatment of choice. Diagnostic laparoscopy prior to a direct cut-down approach to the neck of the seminal cord is advisable to identify non-communicating hydroceles to avoid further impairment of lymph drainage around the IIR