16.1 Introduction

Scrotal surgeries comprise a small but significant part of a general urologic practice and can include hydrocele repair, spermatocele excision, orchidopexy, orchiectomy, sperm retrieval (epididymal or testicular), and vasectomy. The indications for scrotal surgery can include malignancy, fertility preservation, pain, and a desire for contraception. With the exceptions of vasectomy, which intentionally results in infertility, and sperm retrieval, which is specifically performed for fertility preservation or infertility treatment, the remaining procedures may inadvertently affect fertility. This chapter will review fertility concerns that arise from common scrotal surgical procedures.

16.2 Hydrocelectomy

A hydrocele is an accumulation of fluid between the parietal and visceral tunica vaginalis of the testis. Hydroceles can be congenital or acquired. Congenital hydroceles are generally found in children and are secondary to a patent processus vaginalis, allowing peritoneal fluid to collect within the scrotum. Acquired hydroceles are most commonly idiopathic but can be secondary to trauma, infection, or malignancy [1]. Underlying malignancy can be evaluated with scrotal ultrasound in those cases in which it is suspected. As hydroceles are generally painless and asymptomatic, most do not require intervention but they can grow in size and lead to discomfort or cosmetic concerns. Hydroceles can be treated with surgical excision or aspiration and sclerotherapy. A 2014 Cochrane review found that postoperative complications such as infection and fever were less when aspiration and sclerotherapy was performed. However, the recurrence rate was approximately 50% by 3–6 months with aspiration/sclerotherapy and less than 5% with surgery. Because of the recurrence rates, surgical excision is considered the standard of care with aspiration/sclerotherapy usually reserved for poor surgical candidates [2,3].

Congenital hydroceles often have a patent process vaginalis in the spermatic cord while adult hydroceles generally do not. Because of this difference, when correcting a congenital hydrocele, an inguinal approach is generally taken where the cord is separated from the patent processus vaginalis or hydrocele sac, which is subsequently transected. When performing an adult hydrocele excision, a scrotal approach is generally taken. Once the hydrocele sac is delivered via a scrotal incision, multiple methods for repair can be applied including sac excision and oversewing of the edges, a bottleneck technique (Jaboulay) where edges of the sac are inverted and sewn on the posterior aspect of the cord, or a plication technique (Lord) where the edges of the sac are sewn with radially placed stitches.

In all the methods, the complications associated with hydrocele excision include hematoma formation, infection, persistent swelling, recurrence of hydrocele, injury to the spermatic vessels, and chronic pain. Additionally, a theoretical risk of injury to the epididymis or vas deferens exists with hydrocele excision, which can occur during dissection or resection of the hydrocele sac, suturing of the hydrocele sac, or from electrocautery injury. Anatomically, the epididymis and vas deferens commonly are splayed out over the distended hydrocele sac, especially at the tail of the epididymis. Unless specifically identified, both structures may not be noticed during excision and portions may be inadvertently excised, resulting in obstruction on that side. A 2004 study looked at 378 patients who underwent hydrocelectomy and found that 5.62% had epididymal tissue or a portion of vas deferens in the pathology specimen. The authors also noted that this complication rate likely underestimated the true risk as it didn’t include injuries to the epididymis from electrocautery or ill-placed sutures [4]. Patients with normal testes and ductal systems bilaterally may not demonstrate infertility following injury; however, those patients with preexisting contralateral defects on one side may be rendered azoospermic during hydrocele repair. In addition, unilateral obstruction may result in the development of antisperm antibodies, which may affect fertility.

Aspiration and sclerotherapy is an alternative treatment option for hydrocele that may be appropriate for patients who cannot tolerate anesthesia or refuse surgical treatment. This technique involves aspirating the hydrocele fluid and instilling a sclerosing agent such as tetracycline, alcohol, or phenol. Sclerotherapy avoids a general anesthetic, involving only a needle puncture into the scrotum and therefore rates of hematoma formation and fever are lower than with surgical excision [2]. However, sclerotherapy complications can include recurrence, scrotal pain, and even chemical epididymoorchitis [5]. To our knowledge, no large, randomized studies have looked at the effect of sclerotherapy on fertility, while studies with short follow-up have suggested that sperm counts may decrease following treatment [6]. An uncontrolled study of 69 men looked at postsclerotherapy semen analysis and found reductions in sperm concentration, motility, and morphology but that patients returned to normal parameters by 12 months post-procedure [7]. A randomized trial comparing hydrocelectomy to phenol sclerotherapy reported slight decreased in sperm concentration at 6 and 12 months in both treatment groups but there were no statistical differences between the groups [8]. It should be noted that, in these studies, patients with unilateral and bilateral procedures were included but the effect of bilateral procedures was not controlled for.

Risk to fertility can occur with elective hydrocele surgery and possibly with aspiration and sclerotherapy. Careful counseling prior to elective surgery regarding this risk should be undertaken with any patient still desiring children, bilateral procedures should be avoided in this population and careful counseling should occur with those patients who elect to proceed regarding the risk to fertility. Finally, when proceeding with surgery, surgeons should be meticulous in identifying the scrotal structures prior to excision of the tunica vaginalis.

16.3 Spermatocele Excision

A spermatocele is a cystic dilation of an epididymal tubule. Spermatoceles are benign and common, occurring incidentally in up to 30% of men on high-resolution ultrasound [9]. They are usually asymptomatic and rarely require intervention but can grow in size and occasionally lead to discomfort requiring surgical correction. While aspiration with sclerotherapy has been reported, it is not standard of care and there is no data on the effect of isolated spermatocele sclerosis on semen parameters [10–12]. Spermatocele excision remains the current standard for symptomatic spermatoceles. The procedure involves a scrotal incision, entrance into the tunica vaginalis, delivery of the testicle, and identification of the spermatocele. The spermatocele should be dissected away from surrounding structures with the wall intact until the neck of the spermatocele is identified. The neck may then be ligated and the spermatocele excised. This dissection is aided with the use of optical magnification with either loupes or the operating microscope.

Postoperative complications associated with spermatocele excision include hemorrhage, infection, recurrence, pain, obstruction, and infertility. The epididymis is a tubular structure. The caput consists of multiple separate efferent ductules that coalesce by the corpus (body) of the epididymis into a single epididymal tubule. Given this anatomy, puncture or entrance into the epididymis can result in complete epididymal obstruction. Since most spermatoceles arise in the caput prior to the joining of all efferent ductules, injury in the caput to the epididymis should not completely obstruct the entire epididymis, while injury distal to the caput may completely obstruct the epididymis. Therefore, during spermatocele excision, care must be taken to avoid excising a portion of the epididymis with the spermatocele sac or injuring the epididymis during dissection of the sac. A 2004 study of 96 men sought to determine the actual risk of epididymal injury during spermatocele surgery. The authors found that on careful pathologic review, epididymal tissue was present in the specimen in 17.12% of the patients undergoing spermatocele excision. The authors concluded that the risk of damage to the epididymis during spermatocelectomy was at least 17% and likely greater given the possible additional number who sustained injury to the epididymis during dissection [4].

Given the risk to fertility, elective spermatocele excision should be deferred in any patient interested in future fertility and any patient electing to undergo epididymal surgery should be counseled that the surgery may impair his fertility.

16.4 Orchiectomy/Orchidopexy

Indications for orchiectomy include malignancy, trauma, torsion, and chronic testicular pain. Orchidopexy is most commonly performed in children for cryptorchidism and in adolescents or adults for testicular torsion. When performed for malignancy, orchiectomy should occur via an inguinal approach. Orchidopexy performed in children for cryptorchidism is also commonly performed via an inguinal approach. When performed for trauma, testicular torsion, or chronic testicular pain, a scrotal approach to orchiectomy or orchidopexy can be utilized.

After orchiectomy for malignancy, the remaining testicle has traditionally been considered sufficient to maintain normal fertility and hormonal functions. However, evidence has shown semen abnormalities in patients with testicular cancer even before orchiectomy [13,14]. At the time of diagnosis, >50% of patients have evidence of impaired spermatogenesis, with 10–35% experiencing some degree of infertility [15]. Additionally, loss of one testicle could have psychosocial implications. Finally, adjunct treatments for testicular malignancy also have effects on fertility. Cisplatin-based chemotherapy results in azoospermia immediately following treatment in most patients. This is reversible in at least 50% of patients receiving standard-dose chemotherapy up to four cycles [16]. Radiation therapy, used in seminoma treatment, can also negatively affect fertility with impairments in spermatogenesis [17]. High doses of radiation therapy (20 Gy) can result in permanent sterility from eradication of the germ cell epithelium [18]. Lastly, retroperitoneal lymph-node dissection (RPLND), required in some testicular cancer patients, can lead to disruption of the sympathetic nervous system and may lead to impaired ejaculatory function and fertility [19]. Counseling regarding fertility preservation should be provided and sperm banking should be offered to all patients undergoing orchiectomy for malignancy prior to chemotherapy or radiation therapy. In patients with unilateral tumors and normal contralateral testes, sperm cryopreservation may be deferred until after the orchiectomy but prior to additional therapy. In patients with an absent or nonfunctioning contralateral testis, sperm cryopreservation from an ejaculated semen sample should be attempted prior to orchiectomy. Testicular sperm extraction from the normal tissue surrounding the tumor with sperm cryopreservation may be considered at the time of radical orchiectomy in those who have nonobstructive azoospermia and absent contralateral testes.

Although radical orchiectomy is considered the standard of care for testicular malignancy, partial orchiectomy can be considered for select patients including those with a small testicular mass in the setting of a solitary testicle or bilateral concurrent malignancies [20]. In fact, the current European Association of Urology guidelines support the practice of partial orchiectomy in patients with bilateral germ cell tumors [21]. Of note, the incidence of bilateral testis cancer, occurring synchronously or metachronously, is only 1–5% of testis cancer patients highlighting the fact that this applies to a small population [22]. Although no randomized controlled trials have compared partial orchiectomy with radical orchiectomy, studies have shown partial orchiectomy to be safe and feasible in patients with tumor size less than 2 cm [23,24]. Partial orchiectomy requires meticulous dissection to maintain testicular blood supply, and intraoperative biopsy of adjacent testicular parenchyma to ensure negative margins and evaluate for the presence of intratubular germ cell neoplasia (ITGCN). Local recurrence is approximately 30% following surgery alone [25]. Therefore radiation to the testis is often recommended following surgery, particularly if ITGCN is identified, which will further reduce fertility [20]. For this reason, if fertility preservation is desired after partial orchiectomy, warm ischemia time should be minimized and adjuvant radiation should be postponed until after reproduction with close follow-up [26]. Given the surgical risk to the testicle and the need for subsequent radiation, or increased risk of recurrence without it, sperm banking should be encouraged in all patients prior to partial orchiectomy.

The effect of orchiectomy or orchidopexy on fertility when performed for trauma or torsion is not fully understood. Much research exists regarding orchidopexy for cryptorchidism in the pediatric population. While current guidelines recommend earlier orchidopexy in the hope that it leads to improved fertility potential, more data is needed to validate this approach [27–29]. Of note, the cryptorchid testis is possibly abnormal at baseline and fertility in this population may not be applicable to a postpubertal testis requiring orchiopexy or one removed secondary to trauma or torsion. A study of 24 patients evaluated after testicular torsion found that both those patients who underwent orchidopexy and those who required orchiectomy had no differences in mean sperm count and average sperm motility when compared to age-matched controls. Interestingly, those who underwent orchiectomy had significantly better sperm motility than those who underwent orchidopexy. No differences in endocrine profiles were noted [30]. When placing sutures into the tunica albuginea, it is prudent to avoid subtunical vessels if possible since they are end vessels. However, there have been no studies examining whether this approach actually improves subsequent semen parameters or fertility.

The use of orchiectomy for chronic testicular pain is poorly studied and should be reserved for patients who have failed all conservative therapies and have been carefully counseled on the risks and benefits including the risk of failure and risk to fertility potential [31].

Any patient undergoing orchiectomy or orchidopexy should have a discussion regarding future fertility. In those patients with a normal contralateral testis, undergoing orchiectomy or orchidopexy for testicular torsion, trauma, or chronic pain, the risk to fertility is likely low. However, in those patients undergoing orchiectomy for malignancy, consideration should be given to fertility preservation prior to treatment and all patients should be offered sperm banking prior to chemotherapy or radiation.