From
Dr. ABHIMANYU KAR.
Post Graduate Trainee in General Surgery.
MysoreMedicalCollege and Research Institute
Mysore
To
THE DEAN AND DIRECTOR
MysoreMedicalCollege And Research Institute,
Mysore.
Through
PROFESSOR AND HOD
Department of Surgery,
MysoreMedicalCollege and Research Insitute,
Mysore.
THROUGH PROPER CHANNEL
Respected Sir,
Subject : Submission of Synopsis titled “A clinical study and management of cystic swellings of scrotum in K.R.Hospital, Mysore”.
I am hereby submitting the above titled synopsis (4 copies), as mentioned kindly accept my application and do the needful.
Thanking you,
Yours faithfully,
(Dr. ABHIMANYU KAR.)
Forwarded to The Dean and Director, MMC & RI, Mysore for further needful action.
Professor and HOD
Department of Surgery
Date : Mysore Medical College & Research Institute
Place : MysoreMysore.
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / : / Dr. ABHIMANYU KARRoom No. 208
Post-graduate & Intern’s Hostel for Men, Near OldExhibitionBuilding,
MysoreMedicalCollege and Research Institute, Mysore-21.
2. / NAME OF THE INSTITUTION / : / MysoreMedicalCollege and Research Institute, Mysore.
3. / COURSE OF STUDY AND SUBJECT / : / M.S. General Surgery
4. / DATE OF ADMISSION TO THE COURSE / : / 25.05.2009
5. / TITLE OF THE TOPIC / : / A Clinical Study and Management of Cystic Swellings of Scrotum in K.R.Hospital, Mysore.
6. Brief resume of the intended STUDY
6.1. Need for the study
Cystic swellings of scrotum constitutes a wide spectrum type, of varied aetiology, which are easily accessible for clinical examination. It is a very common surgical problem with which the patient presents to the clinician.
Most of the cystic swellings of scrotum are benign, but creates a lot of mental agony to the patient more than physical discomfort.
Moreover for some patients it may be a source of embarrassment and creates fears about their capability of reproduction and sexual prowess. Therefore the need for alleviation by early diagnosis and treatment which is very rewarding.
The cystic swellings can present in all age groups and therefore the need to study the agewise distribution of various types of cystic swellings and the predisposing factors related to each age groups.
The wide spectrum of the condition necessitates the importance to find out the most common cause and therefore better understanding for a focused and specialized management of the condition.
Management is done in various methods for each type of cystic swelling of scrotum, hence the necessity to study the ideal modality of management for each type of cystic swelling of scrotum.
6.2 Review of Literature
In 1975 in a study by Moloney GE, a comparison has been made between a series of hydroceles and cysts of epididymis treated by surgery with a complication rate of at least 17% haematoma and 10% sepsis, an average hospital stay of five days, and a much longer time off work, and a series treated by tapping and injection requiring one to three visits to outpatients, an almost negligible complication rate, and no failures in those completing treatment1.
In 1983, Kaye KW et.al, performed 20 hydrocele repairs and 18 spermatocelectomies using Lord’s techniques on outpatients under local anesthesia. The only complication was delayed wound healing early in the series when tight pressure dressings were used. Later, only a simple dressing and a scrotal support was used. This method for these operations reduces the cost by 74 per cent compared to inpatient procedures under general anesthesia. This safety and cost-effectiveness argue strongly for performance of most hydrocele repairs and spermatocelectomies as outpatient procedures under local anesthesia2.
In 1986, Hellstrom P et.al studied seventeen patients with hydroceles or epididymal cysts were treated by tapping and injection with ethanolamine oleate. All 11 patients with hydroceles were cured. Three of six patients with epididymal cysts were cured. There were no cases of haematoma or infection. Sclerotherapy is recommended as primary treatment for all men over 50 years with hydroceles and for selected cases with epididymal cysts3.
In 1990, a study done by Dandapat et.al showed partial arrest of spermatogenesis in 10% and total arrest of spermatogenesis in 8% of cases, the remaining 82% showed normal spermatogenesis in patients with hydrocele4.
In 1992, in a prospective study by Shah PA et.al 50 cases of hydrocele were treated by ambulatory surgery. Lord’s technique was performed under local anaesthesia. A modified simple scrotal dressing was used to facilitate ambulation. In one case (2%), haematoma was reported. There were no wound infections. Patients tolerated the procedure well and ambulation was excellent in all cases. On the grounds of safety and cost effectiveness, most hydrocele repair procedures should be performed on ambulant patients5.
In 1993, Ho GT et.al described a new endoscopic technique that was used for the treatment of symptomatic scrotal hydroceles in 10 men. Through a small skin incision, the parietal surface of the tunica vaginalis was ablated endoscopically using either electrocautery or the KTP:YAG laser. This approach permitted visual inspection of the scrotal contents with minimal manipulation and was performed using monitored local anesthesia with bilateral spermatic cord blocks. With a mean follow-up interval of 6.1 months, no hydrocele recurrences, wound infections, or hematomas have been detected. The mean operative time was comparable (53 minutes) to that in a historical control group consisting of 15 men who had undergone open hydrocelectomy at the same institution (46 minutes). Postoperative scrotal discomfort was minimal with 6 of the 10 patients requiring no analgesics. Patients were able to resume their preoperative lifestyles an average of 2 days after surgery.In contrast, 11 of the 15 men in the control group was still complaining of scrotal pain, requiring oral analgesics, at their 2 week follow-up visit. Thus, endoscopic hydrocele ablation appears to be an effective and well tolerated alternative to treat hydroceles with minimal postoperative discomfort6.
In 1993 in a study by Jahnson S et.al, in a pilot study the window operation for hydrocele was safely done on an out-patient basis and the rate of complications (8%) was comparable to that of other procedures. However, 21/23 evaluated hydroceles relapsed and retreatment with a second window operation led to further relapses within a short time. Eight patients with 11 hydroceles required another procedure. Therefore the window operation for hydrocele repair was abandoned7.
In 1994 in a study by Sigurdsson T et.al a total of 87 patients with 63 hydrocceles and 29 epididymal cysts underwent injection sclerotherapy with polidocanol on an outpatient basis. In the hydrocele group the cure rate after 1 treatment was 67% and the overall cure rate was 87% after a median followup of 14 months. In the group treated for epididymal cyst the corresponding cure rates were 46% and 64%, respectively, with a median followup of 12 months. A low rate of complications was observed. Of 86 evaluable patients 81 (94%) were satisfied with the procedure and the treatment results. Therefore, they recommended injection sclerotherapy with polidocanol as primary treatment for hydroceles and epididymal cysts in patients older than 40 years8.
In a study in 1999 by Jelloul L et.al studied epididymal cysts in adolescents. Epididymal tumours are uncommon in children and adolescents and are usually benign. Epididymal cyst is exceptionally reported in the literature, although it is certainly underdiagnosed. The authors report 3 cases of epididymal cyst in 3 children, 12, 14 and 16 years of age. These children presented with an uncomfortable scrotal mass and were treated by excision of the cyst in every case. The aetiology of epididymal cysts is unclear. It is probably a congenital abnormality related to hormonal disorders during embryonic life. Physical examination is very important, but not sufficient for the diagnosis and must be completed by scrotal ultrasonography, which shows an echo-free cystic epididymal structure. Despite ultrasonography, the differential diagnosis of other scrotal cystic masses and even some solid epididymal tumours, which may present all of the sonographic characteristics of a cyst, must be considered. The treatment of symptomatic epididymal cyst in children must be surgical. For asymptomatic cysts diagnosed by sonography, clinical follow-up to document stability of the mass is justified9.
In 2000 a study done by Micallef M et.al showed ultrasound examination distinguishes extratesticular (almost always benign) from intratesticular (potentially malignant) causes of scrotal swelling. Infection, trauma and torsion mimic the ultrasound appearance of tumour as do rare benign entities10.
In 2004 in a study by Zahalsky MP et.al showed the risk of epididymal injury during hydrocelectomy and spermatocelectomy is significant. Patients must be informed of this risk since epididymal injury may lead to infertility11.
6.3 Aims and objectives of the study
The aims and objectives of the study are
1. To study agewise distribution and predisposing factors of cystic swellings of scrotum.
2. To study the different patterns of clinical presentation of cystic swellings of scrotum.
3.To study the various treatment modalities for a given type of cystic swelling of scrotum.
7. Materials and Methods
7.1. Source of data
The cases who will be admitted in K.RHospitalMysore, attached to MysoreMedicalCollege and Research Institute, Mysore from December 2009 to May 2011, will form the material of this study. During this period cases admitted in various surgical units, selected at random will be studied in detail. This study will be of 100 cases.
7.2. Methods of collection of data
1)Detailed History of the case.
2)Clinical examination.
3)Routine laboratory investigations.
4)Relevant special investigation.
5)Detailed pre-operative evaluation of the patient and appropriate preparation for surgery.
6)Surgical treatment according to the merit of the case decided by the attending surgeon under suitable anaesthesia.
7)Operative findings.
8)Post-Operative course, complications and their management.
9)Follow up.
7.3. Inclusion criteria
Cystic swellings from testis, and its coverings, epididymis, spermatic cord and from the scrotal skin are included in this study.
Exclusion criteria
Inguinoscrotal swelling, varicocele, torsion of testis, filarial scrotum are excluded in this study.
7.4. Does the study require any investigations / intervention to be conducted on patients/ humans/animals? If so, please describe briefly.
Yes on the patients.
Investigations
1)Blood – Hb%, BT, CT, TC, DC, ESR, RBS
2)Urine – Albumin, Sugar, Microscopy.
3)Radiological study – Chest X-ray, ultrasound scrotum, Ultrasound abdomen.
4)ECG
5)Specific investigations : Hydrocele / Epididymal cyst fluid analysis.
7.5. Has ethical clearance been obtained from your institution in case of 7.4?
Yes, obtained (Copy enclosed)
8. List of References
1.Moloney GE, “Comparison of results of treatment of hydrocele and epididymal cysts by surgery and injection”. British Medical Journal 1975, August-23; 3 (5981) : 478-9
2.Kaye KW. Clayman RV, Large PH, “Outpatient hydrocele and spermatocele repair under local anaesthesia”. Journal of Urology, 1983 August; 130(2); 269-71.
3.Hellstrom P, Malinen L, Konttur M, “Sclerotherapy for hydroceles and epididymal cysts with ethanolamine oleate” Annals of Chirurgy and Gynaecology. 1986-75(1): 51-4.
4.Dandapat et al, “Effect of hydrocele on testis and spermatogenesis”, British Journal of Surgery, 77:11.
5.Shah PA, Dewoolkar V.V., Changlani TT, “Ambulatory hydrocele surgery = A review of 50 cases”. Journal of RoyalCollege of Surgeons, Edinburgh. 1992 December; 37 (6) 385-6
6.Ho GT, Ball RA, Schuessler W, Kavoussir, “Efficacy of endoscopic hydrocele ablation”. Journal of Endourology. 1993 February; 7(1): 71-4.
7.Jahnson. S, Johansson JE, “Results of window operation for primary hydrocele”. Journal of Urology. 1993 January; 41 (1): 27-8.
8.Sigurdsson T, Johansson JE, Jahnson S, Helgesen F, Adersson SO, “Polidocanol sclerotherapy for hydrocele and epididymal cysts”. Journal of Urology. 1994 April; 151 (4): 898-901.
9.Jelloul L, Billerey C, Ait Ali Simane M, Mboyo A, Aubert D., “Epididymal Cysts in adolescents”. Annals of Urology (Paris). 1999; 33 (2) ; 104-8.
10.Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B, “The ultrasound investigation of scrotal swelling.” International Journal of STD and AIDS. 2000 May; 11 (5): 297-302.
11.Zahalsky MP, Berman AJ, Nagler HM, “Evaluationg the risk of epididymal injury during hydrocelectomy and spermatocelectomy.” Journal of Urology. 2004-June; 171 (6 pt 1): 2291-2.
9 / Signature of the Candidate / :10 / Remarks of the Guide / :
11 / Name and Designation of
11.1. Guide / : / Prof. Dr. B. Jagadish
M.S. (General Surgery)
Professor
Department of Surgery,
MysoreMedicalCollegeand Research Institute,
Mysore
11.2. Signature of Guide / :
11.3. Head of the Department / : / Prof. Dr. Avadhani Geeta K.
M.S. (General Surgery)
Professor and HOD
Department of Surgery,
MysoreMedicalCollegeand Research Institute,
Mysore.
11.4. Signature of Head of the Department / :
12 / Remarks
12.1. Remarks of the Dean and Director / :
12.2. Signature of the Dean and Director / :
ETHICAL COMMITTEE CLEARANCE
1.Title of the Dissertation:A CLINICAL STUDY AND MANAGEMENT OF CYSTIC SWELLINGS OF SCROTUM IN K.R.HOSPITAL, MYSORE.
2.Name of the Candidate:Dr. ABHIMANYU KAR.
3.Subject:M.S. GENERAL SURGERY
4.Name of the Guide:PROF. Dr. B. JAGADISH
MS(GENERAL SURGERY)
Professor
Department of SURGERY
MysoreMedicalCollege and
Research Institute,Mysore.
5.Approved / not approved:
(If not approved, suggestion)
Medical SuperintendentProfessor and HOD
K.R.HospitalDepartment of Surgery
MysoreK.R.Hospital
Mysore
Medical SuperintendentProfessor and HOD
CheluvambaHospitalDept. of Medicine
MysoreK.R.Hospital
Mysore
Medical SuperintendentLaw Expert
PKTBHospital
Mysore
The Dean and director
MysoreMedicalCollege and Research Institute
Mysore
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