Comparative outcomes of minimal-incision versus standard hydrocelectomy: reduced bleeding and healthcare utilization in a multi-surgeon cohort

Introduction

Background

Hydrocele is a common urologic condition affecting approximately 1% of adult males (1,2). Symptomatic hydroceles are typically managed with hydrocelectomy (1). Although considered low-risk, hydrocelectomy carries reported complication rates of 15.8–34%, with the most common being epididymitis, hematoma, infection, and wound dehiscence (2-4). Standard techniques involve open sac eversion, which may increase postoperative morbidity compared to other scrotal surgeries that do not require sac eversion (5).

Rationale and knowledge gap

Scrotal anatomy allows for extracorporeal surgical approaches. Our institution has previously described the minimal-incision modified fenestration technique (MIMFeT) for symptomatic hydroceles, which does not require delivery of the testis (6). This technique is feasible under local anesthesia and may be safely performed in the in-office setting. This option has several advantages for both patient and surgeon compared to standard open technique and operating room (OR) procedures under sedation or general anesthesia. Office-based procedures provide the ability to communicate findings in real-time, eliminate risks associated with general anesthesia, and are more cost-effective (7).

Despite the benefits of minimally invasive techniques, comparative data remain limited (8-11). The only randomized trial (Saber et al.) demonstrated reduced complications with minimally invasive hydrocelectomy but was limited to a single surgeon and did not evaluate healthcare utilization, operative setting, or anticoagulated patients (12).

Objective

To address these gaps, we evaluated postoperative outcomes, bleeding risk, and healthcare utilization in a large, multi-surgeon cohort comparing MIMFeT to standard hydrocelectomy. We hypothesized that MIMFeT reduces bleeding and healthcare utilization without increasing recurrence. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0397/rc).

Methods

Participants and variables

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Mayo Clinic Institutional Review Board (IRB) (No. 21-010258) and individual consent for this retrospective analysis was waived.

After IRB approval, we performed a retrospective review of all patients ≥18 years of age who underwent hydrocelectomy at Mayo Clinic in Rochester, Minnesota between January 2018 and July 2024. All patients underwent a preoperative history, physical exam, and scrotal ultrasound. Inclusion criteria were symptomatic hydroceles causing pain or mass effect. Perioperative antithrombotic management was determined by the prescribing physician. Demographic information, intraoperative variables, and postoperative outcomes were recorded. Surgical complications included hematoma, prescription of antibiotics for suspected infection, wound dehiscence, or need for reoperation within 30 days. Post-operative healthcare utilization was defined as any unplanned patient contacts (calls, messages, visits) within 90 days. Outcomes were assessed based on available follow-up data within the electronic medical record.

Procedure technique

Patients underwent hydrocelectomy either in the OR under sedation or general anesthesia, or in the office setting under local anesthesia. Surgical techniques included standard hydrocelectomy and the MIMFeT. Technique selection was surgeon-dependent. Three surgeons preferentially performed MIMFeT for routine hydroceles, reserving the standard technique for hydroceles associated with prior infection or hematoma. All remaining surgeons exclusively performed standard hydrocelectomy. Office-based hydrocelectomy was most commonly performed using the previously described MIMFeT, which does not require delivery of the testis (6,13). Standard hydrocelectomy involves testicular delivery, sac excision/eversion, and closure. Drains were placed selectively in large hydroceles or high bleeding-risk patients. All patients had a jock strap dressing placed at the end of the procedure.

Post-operative management

Patients were instructed to avoid lifting greater than 20 lbs, straining, and strenuous physical activity for four weeks. They were also instructed to wear supportive underwear, such as compression shorts, during this time. Patients on antithrombotic therapy that was held for surgery were instructed to resume their medication within 2–7 days of surgery (48 hours for Eliquis and 7 days for warfarin). A postoperative follow-up appointment was scheduled according to surgeon preference and patient travel distance.

Statistical analysis

Baseline clinical and demographic characteristics were summarized using descriptive statistics. Continuous variables were reported using median and interquartile range (IQR). Fisher’s exact test was used to compare 30-day complications, post-operative healthcare utilization, and 1-year recurrence between the MIMFeT and standard cohorts. A sensitivity analysis restricted to surgeons performing MIMFeT was performed for 30-day complications and post-operative healthcare utilization. Hydrocele recurrence was defined as clinician-documented recurrent hydrocele on physical exam or imaging. Univariable and multivariable Cox proportional hazards regression models were used to compare overall recurrence of MIMFeT relative to standard technique. Time to recurrence was calculated from date of index hydrocelectomy to documented recurrence, with patients without recurrence censored at the last date of available follow-up. Analysis of recurrence was restricted to patients with available recurrence follow-up data. Covariables were selected based on clinical relevance and included age and body mass index (BMI). Additional clinically relevant variables were considered but not included because of limited event counts and concern for model overfitting. The proportional hazards assumption was evaluated using Schoenfeld residual testing and inspection of scaled Schoenfeld residual plots. Fisher’s exact test was also used to compare complication and healthcare utilization rates between types of antithrombotic therapy stratified by hydrocelectomy technique. Statistical analyses were performed using R version 4.5.1 (R Foundation for Statistical Computing, Vienna, Austria).

Results

A total of 313 patients underwent hydrocelectomy, including 181 (58%) using a standard technique and 132 (42%) using MIMFeT. Median follow-up was 32 days (IQR 2–385), with recurrence assessed up to 1 year. Median hydrocele size was similar between groups [300 cc (IQR 150–500)]. Previous genitourinary surgery did not differ significantly between groups (P>0.90). Postoperative drains were placed more frequently in the standard group compared to MIMFeT (37.4% vs. 13.6%, P<0.001). Procedures were performed by 32 surgeons, with MIMFeT performed by three high-volume operators. Overall, 147 (47%) cases were performed in-office and 166 (53%) in the OR. MIMFeT was predominantly performed in-office (90.2%), whereas standard cases were primarily performed in the OR (84.5%). Baseline characteristics are summarized in Table 1.

Post-operative complications and healthcare utilization

The overall 30-day complication rate was 9.9% (31/313), with a lower rate observed in the MIMFeT group compared to standard technique (6.1% vs. 13%, P=0.057, Table 2). Infection and reoperation rates were similar between groups. Most postoperative infections were Clavien-Dindo grade II (82.6%) and managed with antibiotics, while four cases (17.4%) Clavien-Dindo grade III requiring surgical intervention. Bleeding events occurred exclusively in the standard group (6.1% vs. 0%, P=0.003). The majority of bleeding events were classified as Clavien-Dindo grade I–II (90.1%), with only one Clavien-Dindo III bleeding event requiring surgical intervention. Notably, no bleeding events were observed in the MIMFeT cohort, including among patients receiving antithrombotic therapy. MIMFeT was also associated with fewer unplanned postoperative patient contacts within 90 days (43% vs. 59%, P=0.008). Sensitivity analysis restricted to surgeons performing MIMFeT demonstrated similar 30-day complication and postoperative healthcare utilization rates between the standard hydrocelectomy and MIMFeT cohorts (Table S1).

Recurrence

Among 301 patients with recurrence follow-up, including 130 MIMFeT (98.5%) and 171 standard technique patients (94.5%), the overall recurrence was 12.0% (36/301), with 27 occurring within 1 year. Median time to recurrence was 267 days (IQR 90–340).

One-year recurrence rates were similar between groups (standard 8.2% vs. MIMFeT 10.0%, P=0.70). On univariable Cox regression, MIMFeT was not associated with increased recurrence risk [hazard ratio (HR) 1.75, 95% confidence interval (CI): 0.89–3.46, P=0.10, Table 3], which remained non-significant on multivariable analysis adjusting for age and BMI (HR 1.47, 95% CI: 0.72–3.00, P=0.30). No significant violations of the proportional hazards assumption were observed.

Antithrombotic therapy

Ninety-seven patients (31.0%) were on antithrombotic therapy. The overall hematoma rate in this subgroup was 4.1% (4/97), with all events occurring in patients undergoing standard hydrocelectomy in the OR.

Within the standard cohort, bleeding rates did not differ between patients on antithrombotic therapy and those not on therapy (6.8% vs. 5.7%, P>0.99). However, stratified analysis demonstrated increased bleeding risk among patients on warfarin or high-dose antiplatelet therapy (P=0.03). Detailed results are presented in Table 4.

Discussion

In this multi-surgeon, real-world cohort, MIMFeT provided comparable efficacy to standard hydrocelectomy while eliminating bleeding events and reducing postoperative healthcare utilization. These findings extend prior work by demonstrating that the benefits of minimally invasive hydrocelectomy persist outside controlled, single-surgeon settings. Prior studies of MIMFeT have been limited. Ziegelmann et al. reported outcomes in 54 patients without a comparator group, demonstrating low complication rates but limiting conclusions regarding relative efficacy (6). Our study builds on this work by providing a direct comparison to standard hydrocelectomy in a contemporary, multi-surgeon cohort. While our cohort reflects the practice of a single-institution, as a tertiary referral center, referred patients often reflect a more complex presentation and higher-risk surgical candidacy, the feasibility of MIMFeT in a complex patient population.

Our findings also expand upon the randomized trial by Saber et al. While Saber demonstrated reduced complication rates with minimally invasive hydrocelectomy, that study was limited to a single surgeon and did not evaluate healthcare utilization or outcomes in anticoagulated patients (12). In contrast, we identify two clinically meaningful advantages not previously reported: elimination of postoperative bleeding events—including in patients on antithrombotic therapy—and a significant reduction in unplanned postoperative communication. These findings position MIMFeT not only as a technical alternative, but as an approach that improves both patient safety and healthcare efficiency. Our cohort included three high-volume surgeons performing MIMFeT hydrocelectomy, as well as more than 20 surgeons performing the standard technique, improving the generalizability of our findings relative to prior the single-surgeon series. However, despite this multi-surgeon experience, differences in surgeon preference, perioperative management, and patient selection may still have influenced treatment allocation and outcomes and should be considered when interpreting these findings. MIMFeT was the preferred technique among the three surgeons and was used in most of their cases. Standard hydrocelectomy was reserved for select scenarios, including post-hematoma hydroceles, post-infectious hydroceles, or cases with concern for distorted tissue planes that could complicate dissection, supporting the feasibility of MIMFeT in a broad range of patients.

The absence of bleeding events in the MIMFeT cohort is particularly notable. Bleeding and hematoma formation are among the most common complications following hydrocelectomy and may be exacerbated in patients on antithrombotic therapy. In this context, MIMFeT may represent a safer surgical option for patients at elevated bleeding risk, an area where clinical guidance remains limited.

We also demonstrate a significant reduction in unplanned postoperative communication, representing a novel contribution to the literature. Reducing patient calls and unscheduled visits has important implications for clinical workflow and resource utilization. Many factors may contribute to postoperative communication, such as operative setting, surgeon counseling practices, patient expectations, access to care, and follow-up protocols. Therefore, while the observed association between the MIMFeT cohort and reduced healthcare utilization may partially reflect differences in procedural invasiveness and postoperative recovery, alternative explanation should also be considered. Notably, unplanned contact remained common even in the MIMFeT group, highlighting an opportunity to further improve patient counseling and perioperative education.

Importantly, the absence of bleeding events was maintained even among patients on antithrombotic therapy. Given limited guidance for scrotal surgery in anticoagulated patients, MIMFeT may represent a safer alternative in this population. Given the strong body of evidence that suggests a relatively high rate of postoperative complications at time of hydrocelectomy, this underscores the importance of preoperative counseling, patient selection, and postoperative management (4).

MIMFeT is readily performed in an office-based setting, reducing anesthesia exposure, cost, and reliance on OR resources—an increasingly important consideration in the post-coronavirus disease (post-COVID) era. This shift toward office-based surgical care may improve access while optimizing healthcare resource utilization. Prior work from our institution demonstrated that office-based approaches across three male infertility procedures significantly reduced procedural cost without compromising outcomes (7). Similarly, Ricapito et al. evaluated office-based endoscopic procedures, finding that patients undergoing bladder procedures, stent/nephrostomy exchanges, and ureteroscopy largely preferred the office-based setting, with cost savings of up to $6,009 (14). Outpatient standard hydrocelectomy under local anesthesia has been previously evaluated, with complication rates comparable to those seen with procedures performed under general anesthesia (15). Collectively, these findings support further exploration of the feasibility, patient acceptability, and financial impact of office-based hydrocelectomy.

Another consideration in cost- and resource-conscious management of hydroceles is sclerotherapy. While sclerotherapy has been associated with reduced healthcare costs and patient burden, it has also been reported to carry higher rates of postoperative complications (16). Similar to sclerotherapy, MIMFeT represents a less invasive alternative to standard hydrocelectomy, with potentially favorable perioperative outcomes. Further studies are warranted to directly compare minimally invasive hydrocelectomy techniques with sclerotherapy to better define their relative roles in clinical practice.

This study has several limitations. First, its single-institution, retrospective design limits generalizability and introduces potential selection bias, and there is overlap between surgical technique and operative setting. Additionally, variation in surgeon practices—including drain placement, antithrombotic management, and follow-up protocols and adherence—may influence outcomes. Postoperative healthcare utilization may be influenced by factors beyond surgical technique that were not controlled for, including geographic access to care, adherence to postoperative restrictions, and patient health literacy, which should be acknowledged when interpreting our findings. Finally, given the retrospective design, a formal sample size calculation was not performed and subgroup analyses are limited by sample size; therefore, secondary analyses may be limited by statistical power, and residual confounding cannot be excluded.

Conclusions

MIMFeT offers comparable efficacy to standard hydrocelectomy and was associated with fewer bleeding complications and reduced postoperative healthcare utilization. Its ability to be performed under local anesthesia in an office-based setting further enhances its value as a patient-centered, resource-efficient surgical approach. These findings support broader adoption of MIMFeT, particularly in patients at elevated bleeding risk.

Acknowledgments

This work was accepted and presented as an abstract to the USANZ Annual Scientific Meeting 2026 and AUA Annual Meeting 2026.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0397/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0397/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0397/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0397/coif). S.H. reports a consulting fee from Coloplast Corp. T.K. serves as President of the Sexual Medicine Society of North America (SMSNA), as a Board Member of the American Urological Association (AUA), and reports involvement with the patent application Catheter Valve Devices and Related Methods (PCT/US2026/029494). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Mayo Clinic Institutional Review Board (IRB) (No. 21-010258) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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