Minimal-incision hydrocelectomy reduces bleeding, but has it solved recurrence?—a look back at a century of technique

On paper, hydrocele repair looks like a solved problem. It is among the oldest operations in scrotal surgery, the anatomy is uncomplicated, and most urology trainees learn some version of it in their first year. Surgeons nevertheless continue to disagree, at times sharply, about what should be done with the tunica vaginalis once it has been opened. Deliver it fully out of the wound, or leave it largely alone? Excise it widely, or barely touch it? Fix it to the dartos, or keep it well away? The report by Shi and colleagues in this issue of Translational Andrology and Urology (1) brings a large multi-surgeon dataset to that argument, setting a minimal-incision modified fenestration technique (MIMFeT) against standard hydrocelectomy in 313 men. Bleeding was lower with MIMFeT, and unplanned patient contact fell. Recurrence was not clearly improved, however, and the numbers drift in a direction that deserves a second look. We would like to use this space to put that finding back into the surgical history it came from, because the recurrence question raised here is older than is generally appreciated, and the way earlier generations framed it may still have something to offer.

Two philosophies, one open question

Long before the vocabulary of minimally invasive surgery reached urology, hydrocele surgeons had already divided into two camps. Jaboulay’s operation of 1895 everted the excised sac and sutured its edges behind the testis, deliberately creating a reconfigured space (2). Winkelmann’s technique, described a few years later and usually grouped with Jaboulay’s in comparative series, followed the same logic of active repositioning (3,4). A German variant took another route. Bramann, reporting Volkmann’s radical operation in 1885, described resection of the sac without eversion, the cut edges being closed in place; this is broadly the approach that later German-language series attach to von Bergmann’s name (3,5). Lord went furthest of all in 1964 with his “bloodless operation”, in which the sac was never delivered at all but simply plicated in situ through a small opening (6).

Tsai and colleagues later reviewed 276 hydrocele operations performed over 11 years. The overall recurrence rate was 6%, with no significant difference among Jaboulay’s repair, excisional hydrocelectomy and Lord’s technique, although Lord’s repair did carry the lowest overall complication rate and the lowest rate of postoperative hematoma (7). We keep returning to that result, because it captures something this literature repeats: how aggressively the surgeon reconstructs the potential space alters bleeding and wound morbidity far more reliably than it alters the chance of fluid coming back.

Two further strands run alongside this surgical argument. Aspiration and sclerotherapy, in use for more than four decades, does away with the incision altogether. It costs less and produces fewer wound problems, but recurrence after a single session is high, commonly quoted in the range of 15–50%, and repeat treatment is often needed (8). A meta-analysis of five small randomized trials reproduced the same trade-off, fewer complications and lower cost set against more recurrence, and judged the evidence base still thin (9). Shi and colleagues raise sclerotherapy as a competing resource-conscious option, and they are right to. As far as we can establish, it has never been compared head to head with any minimally invasive hydrocelectomy.

The other strand is geographic. Idiopathic disease dominates the literature discussed here, but lymphatic filariasis remains the single largest cause of hydrocele worldwide, with a World Health Organization (WHO) baseline estimate of roughly 25 million affected men (10). In one Nigerian programme of mass surgery weeks, 425 repairs were carried out by general practitioners, almost all by the eversion technique; hematoma occurred in 3.7% and recurrence in 7% of the 115 men followed for 1 to 3 years (11). A systematic review of surgery for genital filariasis found the published evidence sparse and inconsistent (12). Local anaesthesia, a 2-cm incision, no operating room: these are exactly the features such programmes need, which makes the long-term durability of minimal-incision repairs more important rather than less.

From Onol to Rochester

The modern minimally invasive era is largely the same argument conducted through smaller incisions. Onol and colleagues described a pull-through technique in 2009 in which the sac was still fully mobilised and excised at its base, but through a 15-mm transverse scrotal incision (13). Saber took the opposite tack. Working through a 2-cm incision, he excised only a disc of parietal tunica roughly twice the size of the skin incision, then sutured its cut edge to the dartos and scrotal subcutaneous tissue in an everted manner so that the visceral tunica came to lie against lymphatic-rich subcutaneous tissue and skin. In his original series of 42 patients, no hematoma and no recurrence were recorded over a mean follow-up of 14 months, against an overall complication rate of 13.5%, most of it wound-related rather than a matter of bleeding or fluid reaccumulation (14).

He then tested the technique against Jaboulay’s procedure in a randomized trial of 124 men, 62 per arm. Operative time was roughly halved, from a mean of 32.5 to 15.1 minutes; overall complications fell from 37% to 12.9%, and postoperative hematoma dropped from three cases to none. Recurrence came out identical: one patient per arm, 1.6% on both sides, no significant difference (15). As far as we can tell, this remains the only randomized comparison in the field that includes a genuinely minimally invasive hydrocelectomy, and the shape of the result is instructive. A large and statistically robust reduction in dissection-related morbidity, and no detectable change whatever in the likelihood that the fluid returns.

The Mayo Clinic group’s own experience adds a wrinkle to this history, because their technique changed shape between 2017 and 2020. In the earlier office-based series, the sac was pulled substantially through the wound, incised in several regions and trimmed of excess; the wound edges were then oversewn with the dartos muscle deliberately included in the closure, precisely so that no dissection plane would be left open (16). A through-and-through Penrose drain was placed in every case, intended, in the authors’ own words, to let the testis and the remaining sac scar together in a decompressed state. Recurrence in that series was 4% at a mean follow-up of only 4.2 months, and the single recurrence was ascribed to incomplete excision of the sac (16).

By 2020, when MIMFeT was formally described, the technique had moved in the other direction (17). The sac is everted and excised sequentially, in leaflets, through a small upper hemiscrotal incision, and the testis is never delivered through the wound. Roughly 2 cm of tunica is deliberately left undissected near the testis to protect the epididymis, vas and testicular vessels. Most tellingly, the authors state that the oversewing should take tunical tissue only and should avoid incorporating any appreciable amount of dartos, which is close to the reverse of the 2017 protocol. Their stated reasoning is that limiting dissection between dartos and tunica prevents the creation of a potential space capable of filling with blood or fluid. Routine drainage was abandoned as well. Among the 48 men with follow-up data in that cohort of 54, recurrent swelling was seen in 8% at a median of 9 months, and the authors were candid that this period was short and that the natural history of recurrence after such a repair remains unclear (17).

What the new cohort adds, and what it leaves open

Set against that background, the 2026 multi-surgeon paper (1) advances the field in one clear respect. It is, to our knowledge, the largest reported comparison of MIMFeT with a standard technique, and the reductions in bleeding and in unplanned postoperative contact are convincing. The recurrence data ask for a closer reading. At 1 year, recurrence was 10.0% after MIMFeT and 8.2% after standard hydrocelectomy: not statistically different, but numerically higher with the newer operation, with a hazard ratio of 1.75 in unadjusted analysis and 1.47 after adjustment for age and body mass index, neither significant. Median follow-up for the cohort as a whole was 32 days. That is shorter, not longer, than in the 2020 MIMFeT description, whose authors had already flagged 9 months as insufficient for characterising recurrence (17). A hazard ratio leaning, even non-significantly, toward more recurrence with the newer technique, measured over a window shorter than the one its own developers considered inadequate, is not something an editorial can settle. It is, though, exactly the sort of signal that ought to be named rather than folded into a summary message of less bleeding and similar outcomes.

Is the space really gone, or has it simply moved?

Here the mechanical history is genuinely useful, because it maps almost exactly onto the tension in the current data. Philosophically, MIMFeT belongs with the resection-without-eversion lineage rather than with Jaboulay, Winkelmann or the Mayo group’s own 2017 protocol: minimal disturbance, no active reconstruction of the space, no fixation to the dartos. That philosophy accounts plausibly for the lower bleeding rate, since less dissection leaves fewer raw surfaces, a fairly direct mechanical relationship. What it does not obviously account for is how the small, undissected cuff of tunica preserved near the testis behaves months or years later, once fibrosis and adhesions have had time to form. A cuff left alone rather than everted and fixed might, in principle, reconstitute a small and partly enclosed compartment of its own, particularly if lymphatic drainage from that residual pocket turns out to be inadequate. This is a different mechanism from the potential space between dartos and tunica that the MIMFeT authors set out to eliminate, and we can find no study that has examined it directly in this technique.

Recurrence in this condition may also not be a purely mechanical event. Work from our own group has shown that aquaporin 1 (AQP1) is overexpressed in the tunica vaginalis of men with non-communicating hydrocele (18), and a subsequent epigenetic analysis found reduced methylation at a specific CpG site within the AQP1 gene in hydrocele tissue compared with control tissue, a change that could plausibly drive that overexpression (19). A more recent study from our group goes one step further, and although its findings are still preliminary they seem worth raising here. Using a polygenic risk score built from a European genome-wide association study of adult hydrocele, we found that a higher score was associated with increased susceptibility when cases were compared with one control group, though not when compared with a second, and that among the hydrocele cases themselves a higher score went with a smaller fluid volume rather than a larger one (20). Read cautiously (the cohort was small, and we described the finding ourselves as hypothesis-generating), this raises the possibility that the genetic susceptibility to developing a hydrocele in the first place and the acquired factors that govern how large it eventually becomes are not quite the same thing. Should that prove correct, constitutional loci tied to genitourinary embryogenesis and the more local, secretory AQP1 pathway may sit on different branches of the same disease rather than one simply explaining the other, and no amount of technical refinement of the excision or the closure would be expected to prevent recurrence in every patient.

What would actually settle this

Three things would move the question forward. First, follow-up has to be counted in years rather than weeks, with a pre-specified and objective definition of recurrence, preferably ultrasound-based rather than dependent on unplanned patient contact; the outcome measures in the present paper are weighted toward early events, and early events are precisely what MIMFeT is well placed to reduce. Second, there is still no randomized trial of MIMFeT itself. Saber’s study remains the only randomized comparison of a minimally invasive hydrocelectomy against a conventional one, and it tested a technique that fixes the tunica to the dartos, the opposite design choice from MIMFeT. Even that trial found identical recurrence rates in the two arms, which ought to make us cautious about assuming that any particular design choice here has a clear effect on recurrence at all (15). How MIMFeT would fare against Jaboulay’s procedure or a resection-only repair in a randomized setting, with recurrence as an adequately powered primary endpoint, is simply unknown. Third, the biology of the tunica, and not its geometry alone, may eventually be needed to explain why hydrocele recurs in some men whatever the operation.

Conclusions

This multi-surgeon cohort adds real value to a debate more than a century old, one argued mostly through incision length and hematoma rates rather than through recurrence itself. It confirms what the comparisons among Jaboulay’s, excisional and Lord’s repairs already suggested decades ago: less dissection tends to mean less bleeding. Whether it also means less recurrence is a separate question, and the data reported here (short follow-up, a recurrence hazard ratio pointing the wrong way, albeit not significantly so) do not yet answer it. Surgeons who adopt MIMFeT on the strength of its bleeding advantage should be candid with patients that its long-term recurrence profile is still open, a question this literature has been circling, under one name or another, since Jaboulay described his repair in 1895.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0742/coif). The 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.

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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