Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Summary

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Abstract

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled "microscopic epididymal exploration and cystectomy". The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (>0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Introduction

Epididymal cysts mostly occur in men aged 20-40 years old, although some literature also exists concerning epididymal cysts in childhood^1,2. Previous reports have covered concerns about surgical destruction and postoperative scarring in patients undertaking nonmicroscopic epididymal cyst resection or epididymal resection^3,4. Other postoperative complexes include seminal tract obstruction, immune infertility, and testicular atrophy. There is also a higher risk for postoperative occurrence, and even recurrence, of hematoma, edema, and a sustaining pain and cyst^5,6. There are also reports that epididymal cysts can resolve spontaneously without surgery⁷. As a result, previous studies have concluded that epididymal cysts do not lead to testicular network expansion without intervention, and puncture or surgical treatment can be considered if epididymal cysts combine with testicular network expansion or damage of the proximal vas deferens^2,4. Further, some investigators believe that patients with large epididymal cysts combined with pain are also suitable for surgical resection⁸. The treatment of epididymal cysts by puncture alone is prone to relapse. Traditional (nonmicroscopic) cyst resection or epididymectomy may destroy the epididymal canal, leading to epididymal obstruction, immune infertility, or even testicular atrophy; therefore, one should be cautious for young patients with fertility requirements^2,9. Patients with childbirth plans are recommended to choose traditional (nonmicroscopic) epididymal cyst surgery as a cautionary measure.

Microsurgical methods have been widely used in the treatment of vas deferens obstruction and epididymal obstruction, with excellent results^10,11. The treatment of male epididymal cysts via microtechnology may be a beneficial option, however the necessity of extending microtechnology treatment to male epididymal cysts is questionable. We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. We carried out retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People's Hospital of Yunnan Province) between September 2017 and April 2019. The patients were younger than 45 years old and required fertility preservation. Based on microscopic manipulation, which largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact.

Protocol

We performed retrospective analysis of the clinical data of male patients, initially diagnosed with epididymal cysts, admitted to the urology inpatient department of the Affiliated Hospital of Kunming University of Technology (the First People's Hospital of Yunnan Province). Written, informed consent must be obtained from patients before surgery.

1. Clinical inclusion and exclusion criteria

1. Include patients who are below 45 years of age and have a need to preserve fertility.
   ​NOTE: The patient in this study was younger than 45 years old.
2. Include patients with a clinician's preliminary diagnosis of epididymal cystic occupancy following examination with type-B ultrasound or computer tomography (CT) imaging.
3. Exclude any patients with severe cardiopulmonary dysfunction, obvious sexual dysfunction, or anaspermia. Exclude patients with a testicular mass, epididymal tuberculosis, and patients who have difficulty to determine the relationship between the testis and the neoplasm.

2. Patient preparation

1. After performing the relevant examination and active preoperative preparation, fully explain the relevant conditions, surgical plans, and related risks.
2. Discuss with the patient and his family members the patient's condition, surgical plan, selection, and possible risks and complications. Obtain consent from the patient and his family members for testicular and epididymal exploration and microscopic cyst resection.
3. Instruments for operation
   1. Make sure that a surgical microscope and microsurgical instruments are available.
4. Preparation for operation
   1. Clean and shave the inguinal/subinguinal skin and scrotum before surgery.
   2. The surgical site need not be sterilized before surgery. As a routine procedure, clean the scrotum with soap and shave the surgical area using a razor.
   3. Place the patient on the operating table in a supine position after general anesthesia.
      ​NOTE: Anesthesia is provided by the anesthetist. The anesthetist chooses the anesthetic agent and the dosage to be used.

3. Procedure

1. Expose and explore the testis and epididymis in the incision.
   1. Perform a 2.5-3 cm scrotal skin incision with a surgical knife. Cut the scrotal flesh membrane and testicular sheath membrane layer by layer with an electric knife.
   2. Carefully explore the testis and epididymis to find and confirm the epididymal cyst. Change/stop the surgical plan if solid epididymal tumors or masses derived from the testis are found.
   3. Lift the epididymis out of the incision. Find the epididymal cyst.
2. Microscopic cyst resection
   1. Bring an operating microscope into the operating field and examine the cord under a 6x-10x power magnification.
   2. Use an electric knife to cut the epididymal capsule at the base of the epididymal cyst and normal epididymal tissue. Open up the epididymal capsule carefully and avoid opening the epididymal cyst cavity (see Figure 1).
   3. Carefully explore the space between the epididymal cyst wall and the epididymal tissue (epididymal tubule). Based on this anatomical level, gradually microseparate the epididymal cyst along the cyst wall with microscissors and microscopic forceps. Carefully isolate the epididymal tissue (epididymal tubule) surrounding the epididymal cyst to the base of the epididymal cyst (see Figure 2).
   4. Microseparate the epididymal cyst from its base and the gap between the cyst and normal epididymal tissue. Excise the epididymal cyst from the base with microscissors or an electric knife after occlusion of the epididymal tissue with a microvascular clamp or ligation by a microsuture (7-0 or 6-0) (see Figure 3).
   5. Carefully dissect the separation and avoid epididymal cyst wall breakage, especially on blood epididymal cysts (see Figure 4) or large epididymal cysts with clear cystic fluid inside (see Figure 5). If the cyst wall is damaged, carefully clamp the breach with microvascular forceps to avoid fluid overflow in the cyst. Remove the epididymal cyst completely and preserve the noninvasive epididymal tubular patency as much as possible.

4. Finish the operation

1. Carefully perform micro hemostasis. Stitch the incisions on the epididymal capsule and periorchium in layers. Then suture the scrotal wound.
2. Send the mass (cyst) to the pathology department for pathological examination.
3. Leave the patients in bed for 1 day after surgery and discharge them 1-3 days after the surgery.

5. Postoperative follow-up

NOTE: The postoperative follow-up lasts for 3-50 months. Conduct the below tests/examinations in the follow-up.

1. Check the patient for scrotal swelling, pain, and other clinical symptoms after surgery.
2. Perform a detailed physical examination, Including checking the scrotal wound, testis, and epididymis.
3. Perform type-B ultrasound examination on the testis and epididymis.

Representative Results

From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled "microscopic epididymal exploration and cystectomy."

Here, we show the data from a single patient as a representative example. The patient was operated on for descending surgery (testicular and epididymal exploration and microscopic cyst removal) under general anesthesia. A scrotal incision was made, the testicular sheath was cut, the scrotum was explored, and the epididymis on the surgical side was isolated under a microscope. The epididymal mass (cyst) was sought, and the epididymal capsule was cut microscopically and carefully microseparated along the boundary of the normal epididymal tubular tissue. The base part of the epididymal mass (cyst) and the mass were completely removed. The noninvasive epididymal tubular patency was preserved as much as possible. After achieving micro hemostasis carefully, the incisions on the epididymal capsule and periorchium were stitched in layers. Then the scrotal wound was routinely sutured. The mass (cyst) was sent for disease examination. The patients were left in bed for 1 day after surgery and were discharged 1 to 3 days after surgery.

The following data are all derived from the 41 patients included in this study. The procedure time was 30-50 min (38.9 ± 8.5 min). All epididymal cysts were completely removed. Bleeding during the operation was significantly reduced (2-3 mL); wound drainage was no longer required. The postoperative follow-up lasted for 3-50 months. It must be noted that the operation time is longer than the traditional operation because of the use of the surgical microscope and fine microscopic operation.This may present as a limitation to the widespread use of the technique. No patient had a recurrence of the epididymal cyst by type-B ultrasound, and no patient developed postoperative scrotal hematoma. Only one patient had scrotal surgical site pain. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention³ (see Table 1 and Table 2).

Figure 1: Opening the epididymal capsule. The epididymal capsule is opened, avoiding opening the epididymal cyst cavity Please click here to view a larger version of this figure.

Figure 2: Epididymal cyst isolation. The tissue surrounding the epididymal cyst was isolated carefully. Please click here to view a larger version of this figure.

Figure 3: Epididymal cyst excision. The epididymal cyst was excised from the base. Please click here to view a larger version of this figure.

Figure 4: Blood epididymal cyst. Separation of the blood epididymal cyst without cyst wall breakage. Please click here to view a larger version of this figure.

Figure 5: Large epididymal cyst. A large epididymal cyst with clear cystic fluid inside was carefully separated without cyst wall breakage. Please click here to view a larger version of this figure.

	Clinical data	Median	Least value	Maximum value
Enrolled No.	41	/	/	/
Age (years)	24.89 ± 4.46	25	18	40
Operation time (min)	38.95 ± 8.51	40	30	50
Bleeding during operation (mL)	2.50 ± 0.46	2.5	2	3
Follow-up time (months)	22.73 ± 14.56	18	3	50
Recurrence of epididymal cysts	0	/	/	/
Scrotal hematoma	0	/	/	/
Scrotal edema	0	/	/	/
Short-term Scrotal surgical site pain	1(2.44%)	/	/	/
Long-term postoperative pain	0	/	/	/

Table 1: Clinical data of epididymal cyst patients.

Surgical method	Microtechnology Treatment of Male Epididymal Cysts	Non-microscopic surgery(by  scrotal mirror)
Enrolled No.	41	57
Recurrence of epididymal cysts	0	2(3.4%)
Scrotal hematoma	0	2(3.4%)
Scrotal edema	0	7(12.3%)
Short-term Scrotal surgical site pain	1(2.44%)	10(17.54)
Long-term postoperative pain	0	2(3.4%)

Table 2: Table of surgical complications.

Discussion

As we mentioned previously, epididymal cysts mostly occur in men aged 20 to 40 years, while there is also some literature on epididymal cysts in childhood^1,2. To date, the cause of epididymal cysts is not clear, and there is no specific medicine for its treatment. In addition to a few reports that epididymal cysts can resolve spontaneously without surgery⁷, most epididymal cysts, although their progression and enlargement are relatively slow, are unable to be absorbed and eliminated by themselves. Although a benign lesion, a large epididymal cyst can cause damage to the proximal vas deferens, obstruction, and even secondary azoospermia. Due to the small diameter of the epididymal tube (about 0.5 mm), without the amplification effect of the surgical microscope, it is difficult to avoid traditional epididymal cyst resection, the destruction of the epididymal tube around the cyst, or obvious scar hyperplasia after surgery. As a result, patients who have undergone traditional (nonmicroscopic) epididymal cyst resection surgery or epididymectomy are prone to postoperative complications, including seminal tract obstruction, immune infertility, postoperative scrotal hematoma, persistent pain, and even testicular atrophy^3,4,5. Therefore, some scholars believe that caution should be taken in the resection of epididymal cysts for young patients with fertility needs^2,9.

We took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. According to the follow-up data derived from the 41 patients included in this study, the visualization of the subtle tissue structure of the epididymis was greatly improved by microscopic manipulation, and the cysts could be clearly separated and completely removed. The high precision of microsurgical techniques and low damage to the surrounding tissue have achieved good results in the treatment of vas deferens and epididymal obstruction^10,11. In addition, our experience suggested that microscopic epididymal exploration and cystectomy can effectively preserve epididymal patency with fine treatment, while achieving a better preservation of sperm delivery pipelines and unobstructed prognosis. At the same time, according to the follow-up data of this study, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain; thus, it also promises higher surgical success rates and the prevention of recurrence due to scar obstruction.

We have also noted the following limitations of this technique. Firstly, the operating surgeon needs to master microsurgical skills. Secondly, if the cyst wall of the epididymal cyst is destroyed during the operation, it will result in difficulty in the precise and complete removal of the cyst, which will increase the destruction of the surrounding epididymal tissue. Therefore, one should immediately close the rupture with a microvascular clamp and a microsuture (7-0 or 8-0 ) if finding that the cyst wall is damaged.

Based on our preliminary experience, we recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (>0.9 cm in diameter) could cause complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Finally, we hope that microscopic epididymis exploration and resection of microscopic epididymis cysts can be recognized and improved by more surgeons to treat patients diagnosed with epididymal cysts.

Materials

Name	Company	Catalog Number	Comments
Ablation electrode	Baisheng Medical Devices Co., Ltd. China	OBS-Db
Anesthesia apparatus	Datex-Ohmeda,Inc.USA	Aespire View, Datex-Ohmeda
Compact Anesthesia Monitor	GE Healthcare Finland OY.Finland	S/5 Compact
Electric knife	Valleylab.USA	Valleylab Force FX-8C
Surgical (operation) microscope	Lecia Microsysterms (Schweiz) AG. Germany	Lecia M525 F20