Hydroceles Modified Scrotal Approach for Correction of Abdominoscrotal Hydrocele in Children: Clinical Presentation and Description of Technique Abdol-Mohammad Kajbafzadeh, Saman Shafaat Talab, Azadeh Elmi, Amir Hassan Mahboubi, Paria Pourmalek, Shadi Abdar Esfahani, and Hamed Emami OBJECTIVES To introduce a modified trans-scrotal approach for treatment of abdominoscrotal hydrocele (ASH) in children. The postoperative outcomes are reviewed with long-term follow-up. METHODS We described a series of 7 boys (mean age, 23.4 months) who underwent surgical repair of ASH. The diagnosis was made based on physical examination, which revealed a tense hydrocele in association with ipsilateral cystic abdominal mass, confirmed by ultrasonography. After exposing the hydrocele sac through a scrotal incision, tunica vaginalis was opened and marsupialization of the hydrocele along with undermined dartos muscle layer was performed. Follow-up ranged from 9-12 months (average, 10.7 months). RESULTS Overall, 10 ASH units (including 3 bilateral) were repaired. All of the affected testicles except one showed some degree of dysmorphism, according to ultrasonography or intraoperative findings, which resolved in all patients 3 months after surgery. There were no early postoperative complications except a mild scrotal edema. Neither recurrences of ASH nor testicular atrophy was observed. CONCLUSIONS The diagnosis of ASH should be considered in a boy with hydrocele and concomitant abdominal mass, and can be established by ultrasonographic evaluation. Our experiment suggests that the modified trans-scrotal surgical method for management of ASH is reliable and effective with definite advantages. The high success rate, no extensive dissection of the inguinal canal, or complete excision of the sac, along with safety and simplicity of the procedure and short hospital stay, are important preconditions for the introduction of this method as a valid option for treatment of ASH. UROLOGY 76: 87–91, 2010. © 2010 Elsevier Inc. A bdominoscrotal hydrocele (ASH) is an uncom- mon clinical entity characterized by a dumbbell- shaped hydrocele that extends from the scrotum into the abdominal cavity and through the inguinal canal and internal inguinal ring. Dupuytren originally described the anomaly as a hydrocele variant, and later it was intro- duced as “abdominoscrotal hydrocele” by Bickle. 1,2 The patients typically present with scrotal swelling and abdominal mass. Currently, physical examination and ultrasonography are practical diagnostic methods for ASH. The reported incidence of this rare condition in children varies from 0.17%-3.1% of all hydroceles. 3,4 An increasing number of ASH has been reported in recent years, which may be a result of the expanding use of ultrasonography in an approach to the groin and scrotal swelling in children. Considering the large size of such lesions, early surgical intervention is recommended to avoid complications. 5 Although, pediatric urologists now agree that inguinal approach is the gold standard for communicating hydrocele management, the surgical ap- proach and the appropriate technique for ASH treatment still remain controversial. 3,6 Complete excision of ASH through an inguinal incision is recommended in several studies. 3,7 However, this method may raise intraoperative problems in identifying the vessels, vas, and epididymis in the wall of the severely thickened tunica vaginalis, which may lead to serious complications. 8,9 Previously, trans- scrotal hydrocelectomy has been introduced as an effec- tive approach for the management of ASH. 6 In the present study, we have described clinical pre- sentations and a modified trans-scrotal technique for management of ASH in 7 patients. The postoperative outcomes were evaluated during 1-year follow-up. PATIENTS AND METHODS We reviewed the medical records of 7 boys in whom ASH was diagnosed and operated at our hospital using modified trans- scrotal technique between February 2006 and October 2008. These patients presented to our institution because of con- cern with scrotal swelling. The main finding on preoperative physical examination was a tense hydrocele in association with From the Pediatric Urology Research Center, Department of Urology, Children’s Hospital, Medical Center, Tehran University of Medical Sciences, Tehran, Iran Reprint requests: Abdol-Mohammad Kajbafzadeh, M.D., 36, 2nd Floor, 7th Street, Saadat-Abad Ave., Tehran 1998714616, Iran. E-mail: kajbafzd@sina.tums.ac.ir © 2010 Elsevier Inc. 0090-4295/10/$34.00 87 All Rights Reserved doi:10.1016/j.urology.2010.02.009