Hydroceles of the Canal of Nuck in Adults-Diagnostic, Treatment and Results of a Rare Condition in Females

Abstract

Nuck's hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck's canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck's hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck's hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon's skills. If inguinal channel has been widened by the presence of a Nuck's hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.

Keywords: Lichtenstein; Nuck hydrocele; TAPP; cysts of the canal of Nuck; hydrocelectomy.

Figure 1

Sonographic imaging of the right inguinal area: anechoic elongated fluid structure 3.47 × 1.15 cm.

Figure 2

Laparoscopic procedures for hydrocelectomy and TAPP. (a) In the laparoscopic view, a type 2 hydrocele of the canal of Nuck (white arrow) (b) Approach to the inguinal canal and dissection of the hydrocele (white arrow) attached to the round ligament (below blue arrow). (c) Placement of the polypropylene mesh. (d) Sutured peritoneum.

Figure 3

MRI findings. (a) Coronal T2-weighted. (b) axial T2-weighted and (c) sagittal MR images demonstrate a left inguinal hyperintense cystic structure without septation and a smaller (asymptomatic) on the right side. Green arrows: left hydrocele, blue arrows: right hydrocele.

Figure 4

Intraoperative picture of a hydrocele of the canal of Nuck. The round ligament (white arrow).