INFANTILE ABDOMINOSCROTAL HYDROCELE 2615

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EDITORIAL COMMENT

It is gratifying that this group found the scrotal approach toabdominoscrotal hydroceles superior to the more compli-cated and risky inguinal approach. Their finding seems tosupport the adage that “simpler is better” (sometimes). How-ever, I do not understand their use of antibiotics in whatshould be a clean case regardless of the surgical approach. Ido not and have never used antibiotics prophylactically forthis procedure or, for that matter, most others that we do asprimary procedures in pediatric urology. Are there data tosupport this use? Additionally, all of these procedures can bedone on an outpatient basis, particularly if the scrotal por-tion is done minimally. As I have gained more experiencewith this method, I have done less and less plicating, findingthat it does not take as much proximal dissection as I hadoriginally thought to resolve this problem.

The diagnosis of this condition can also be made simplyon physical examination. Rarely are imaging studies nec-essary. Bimanual examination demonstrating enlarge-ment of the abdominal portion in response to compression

of the scrotum is pathognomonic. What else could it be? I

certainly agree with the authors that computerized to-mography and magnetic resonance imaging are unneces-sary. We spend far too much money on imaging studies!Finally, it is interesting that the authors report regres-sion of the testicular dysmorphism in many cases, al-though the significance of the dysmorphism and its reso-lution is yet to be appreciated.

A. Barry BelmanDivision of Pediatric Urology

Children’s National Medical CenterWashington, D. C.

REPLY BY AUTHORS

We again acknowledge Belman as the first proponent of thescrotal repair for infantile abdominoscrotal hydrocele (refer-ence 5 in article). Unfortunately that review lacked patientdata and, therefore, our study represents the first availableseries to our knowledge with an emphasis on postoperativeoutcomes in patients treated with this surgical approach.With regard to hospital stay, the table shows that all scrotalhydrocelectomies in our series were performed as outpatientprocedures and no antibiotic coverage was needed. In con-trast, many of the inguinal repairs required longer hospital-ization and antibiotic administration due to postoperativeswelling or hematoma. This policy has also been adopted atother institutions (references 2 and 3 in article).

We agree that diagnosis of this condition is readily madeon physical examination. However, we recommend ultra-sonography because this simple noninvasive investigationmay add some information about testicular morphology andpotential compression of the abdominal component on neigh-boring structures (ie hydroureteronephrosis). In the currentera of endoscopy and minimally invasive surgery it is worth-while to step back and realize that a direct approach to thescrotum may be easier, faster and possibly more cost-effec-tive, with fewer potential complications and an excellent

esthetic outcome.