Epididymal Cyst - Overview and Treatment

What is it?

• Very common - found in ~31% of men aged 20-39 and up to 43% of asymptomatic men aged 40-59
• Usually multiple and vary in size
• Often bilateral, most common in middle age
• Feel like tiny bunches of grapes posterior to and separate from the testis
• They transilluminate on examination

Ultrasound Appearance

Ultrasound of an epididymal cyst - well-defined, anechoic (dark), thin-walled lesion - Bailey & Love's Short Practice of Surgery, 28th Ed.

Treatment

1. Conservative (Watch and Wait) - First Line

• Most epididymal cysts are asymptomatic and require no treatment
• Treatment is only indicated for: discomfort, infection, disability due to size, or infertility concerns
• Diagnosis should be confirmed by ultrasound to rule out intratesticular pathology

2. Aspiration - Generally Avoided

• Aspiration alone is ineffective because epididymal cysts are usually multilocular - fluid reaccumulates
• Not recommended as a standalone treatment

3. Surgical Excision (Spermatocelectomy / Epididymal Cyst Excision)

• Indicated when cysts are large, symptomatic, or causing significant discomfort
• Approach: Trans-scrotal incision, dissection to the tunica vaginalis, opening the tunica, exposing the cyst, dissecting it down to its stalk, and ligating it with absorbable suture
• Single large cysts can be excised individually
• Recurrent or multilocular cysts often require partial or total epididymectomy

4. Special Considerations - Fertility Counselling (Very Important)

• Men of reproductive age must be counselled about the risk of obstructive azoospermia following surgery
• Risk is highest when the cyst is in the corpus or cauda of the epididymis
• Excision is expected to interfere with sperm transport from the testis on that side

Summary

Recurrence Rates: Open vs. Endovascular Varicose Vein Surgery

Defining Recurrence

• Clinical recurrence - visible, symptomatic varicose veins returning
• Duplex-detected recurrence - reflux or varicosities seen on ultrasound even without symptoms
• PREVAIT (Presence of Varices After Interventional Treatment) - a more standardised modern definition

Open Surgery (High Ligation + Stripping - HLS)

• Recurrence is more common after short saphenous vein (SSV) surgery than great saphenous vein (GSV) surgery
• Higher BMI increases recurrence risk
• Stripping of the incompetent axial vein reduces recurrence compared to ligation alone

1. Neovascularisation - most common mechanism (new valveless veins bridging the ligated junction to tributaries); range 29.8-91% of recurrences
2. Residual/refluxing axial vein
3. Inadequate initial surgery (missed junctions)
4. New junctional reflux

Endovascular Methods

Endovenous Laser Ablation (EVLA)

• Mean PREVAIT rate: ~16.6% (follow-up 112 days to 5 years)
• Most common recurrence mechanism: development of new varicose veins (40-81.6% of cases)
• Re-intervention rates after recurrence: 0-57% across studies

Radiofrequency Ablation (RFA)

• Lowest reported PREVAIT rate: ~6.7% (follow-up 106 days to 5 years)
• Dominant recurrence mechanism is different: recanalization of the occluded saphenous trunk (accounts for up to 67% of RFA recurrences, vs. neovascularisation for HLS/EVLA)
• Re-intervention rate in one study: 6.67%

Head-to-Head Comparison Summary

Key point from Schwartz's Surgery: "Endovenous laser treatment and RFA result in durable ablation of the GSV, with rates of varicose vein recurrence and clinical severity scores comparable to those seen with open surgery" - though a 2023 systematic review found HLS had the highest recurrence numerically.

Recurrence After Re-do Open Surgery

Causes of Recurrence (All Techniques)

1. Neovascularisation at the groin junction
2. Recanalization of the treated vein (especially RFA)
3. Progression of disease in untreated segments
4. New tributary incompetence
5. Inadequate initial treatment

• [Bailey & Love's Short Practice of Surgery, 28th Ed.](p. 1060) - clinical and duplex recurrence figures, causes
• Schwartz's Principles of Surgery, 11th Ed., p. 2455
• Mulholland & Greenfield's Surgery, 7th Ed., p. 5234-5235
• Miranda et al., 2023 (PMID 37795801) - Systematic review of PREVAIT after HLS, EVLA and RFA across 14 studies, 2795 patients

Herniotomy vs Herniorrhaphy - Age, Indications & How They Are Done

The Core Distinction

Herniotomy - Age Limit & Rationale

• Children up to puberty - herniotomy (high ligation) is the standard
• Post-pubertal males - anatomy resembles adults (larger inguinal ring, possible transverse fascia defects), so floor reconstruction may be needed
• Textbooks acknowledge: "It is unclear as to which age/size a child becomes an adult with respect to principles of hernia repair" - individualized assessment is required for adolescents, especially those with weak inguinal floors or direct hernias

Key rule: Herniotomy alone is rarely used in adults - it would not address the floor weakness that exists in adult hernias.

How Herniotomy is Done (Steps)

1. Incision - transverse skin crease incision over the inguinal canal, starting at the pubic tubercle extending laterally
2. Expose external oblique - incise Scarpa's fascia, clear fat, expose external oblique aponeurosis
3. Open external oblique - incise in line of its fibres through the external ring; free the lower leaf from the spermatic cord
4. Isolate the cord - lift spermatic cord, pass a Penrose drain around it for retraction
5. Open cremaster - separate cremasteric fibres to expose the hernia sac (which lies anteromedial to cord structures); ilioinguinal and iliohypogastric nerves are preserved
6. Dissect the sac - carefully dissect the sac free from the vas deferens and testicular vessels
7. High ligation - the sac is dissected to its neck at the internal ring (proximally), twisted to reduce any contents, and transfixed + ligated at the internal ring (this is the "high ligation")
8. Divide and excise - the sac is divided distal to the ligature and excess sac removed
   • Optional: the sac can be opened before ligation to allow digital examination of the abdominal cavity and femoral ring
   • Alternative: the sac may simply be inverted (not opened) - less pain as the highly innervated peritoneum is not violated
9. Close in layers - external oblique, Scarpa's fascia, skin

For laparoscopic herniotomy in children: an encircling purse-string suture is placed laparoscopically at the internal ring to obliterate the processus vaginalis.

How Herniorrhaphy Differs (Adults)

• Tissue repairs (Bassini, Shouldice) - native tissues are used to reinforce the posterior wall of the inguinal canal
• Tension-free mesh repair (Lichtenstein) - a flat mesh is sutured to the inguinal floor; this is the gold standard in adults, with recurrence rates <2%
• Preperitoneal repairs (open or laparoscopic - TEP, TAPP) - mesh placed in the preperitoneal space to cover all groin hernia defects

For large indirect inguinoscrotal hernias in adults: complete sac removal risks cord/testicular complications, so the sac is transected at the midpoint of the canal and the distal sac left in situ.

Summary

Child (indirect hernia, normal floor)
→ HERNIOTOMY = high ligation of sac only

Adult / post-pubertal (floor weakness ± indirect/direct)
→ HERNIORRHAPHY = herniotomy + floor reconstruction (mesh or tissue)

Why Open Biopsy is Not Done in Thyroid (and What is Done Instead)

Part 1 - Why Open/Incisional Biopsy is Avoided

• Anatomical risk - the thyroid is closely related to the recurrent laryngeal nerve, parathyroid glands, and major vessels; incisional biopsy carries a real risk of inadvertent injury to these structures
• Unnecessary - in most cases the diagnosis can be established by FNAC and the treatment is surgical removal anyway; if malignancy is confirmed or suspected, the correct step is total/hemi-thyroidectomy, not a prior biopsy
• Open biopsy is also cosmetically and surgically disruptive to a field that will need formal resection later

Part 2 - Why Even FNAC Has a Fundamental Limitation in Thyroid (The Key Exam Point)

"FNAC cannot distinguish between a benign follicular adenoma and follicular carcinoma, as this distinction is dependent not on cytology but on histological criteria, which include capsular and vascular invasion."

• Bailey & Love's Short Practice of Surgery, 28th Ed.

"The distinction between follicular adenoma and carcinoma requires extensive histologic sampling of the tumour capsule-thyroid interface for evidence of capsular and/or vascular invasion."

• Robbins' Pathology

"Cytologic analysis... is insufficient to distinguish between a follicular adenoma and carcinoma. Histologic findings are necessary to distinguish benign and malignant lesions. Malignant lesions are differentiated by the identification of capsular invasion and potential microvascular invasion. Frozen-section analysis is often inadequate, and definitive diagnosis requires complete assessment of permanent sections."

• Cummings Otolaryngology, Head & Neck Surgery

Why capsular invasion cannot be assessed on cytology/biopsy:

• The entire capsule must be examined in permanent histological sections - you cannot sample just part of it
• Frozen sections intraoperatively are also unreliable because the capsule cannot be fully assessed in real time
• This is why a follicular lesion on FNAC (Thy3/Bethesda III-IV) leads to diagnostic lobectomy - the specimen is sent for permanent histology, and only then can malignancy be confirmed or excluded

What IS Done Instead

Summary

1. Risk of capsule disruption, tumour seeding and implantation metastasis
2. Structural injury risk (RLN, parathyroids)
3. It is unnecessary - FNAC is the standard tool, and if surgery is needed it should be formal thyroidectomy, not piecemeal biopsy