Archivio Italiano di Urologia e Andrologia 2013; 85, 144 INTRODUCTION Abdominoscrotal hydrocele (ASH) is a rare entity with unclear etiology. It extends into the abdominal cavity through the inguinal canal (1, 2). Mostly observed in pediatric patients, ASH is scarcely described in adult population with only a few cases associated with one sided hydronephrosis reported in the literature (3, 4). We present a case of ASH with bilateral hydronephrosis. CASE PRESENTATION A 49-year-old male was admitted to our clinic with pro- gressively increasing left scrotal swelling along a period of one year. During initial physical examination lower abdominal mass on the left and hydrocele of the left testis were observed (Figure 1). Hydrocele had simultaneous fluctuation with the lower abdominal swelling. In spite of clinical diagnosis based on physical findings and ultra- sound imaging an urethral Foley catheter was inserted to rule out the presence of urinary retention and associated hydronephrosis demonstrating an empty bladder. Bilateral hydronephrosis occurred as a result of the compression of the bladder and the left ureter by the sac (Figure 2, 3). Surgery was scheduled by inguinal approach in order to perform an high ligation of the processus vaginalis with complete excision of the abdominal component of the CASE REPORT Abdominoscrotal hydrocele with bilateral hydronephrosis in an adult: Case report Bircan Mutlu, Yusuf Ozlem Ilbey, Alper Bitkin, Ali İhsan Taşçı Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. Abdominoscrotal hydrocele is a rare entity with unclear etiology which may be diag- nosed with general examination and ultrasound imaging. During examination it may misinterpreted as acute urinary retention of the bladder (globe-like) especial- ly if associated with hydronephrosis. It should be treated surgically. Here we pres- ent a case of left abdominoscrotal hydrocele with accompanying left grade 2 and right grade 1 hydronephrosis. KEY WORDS: Hydrocele; Hydronephrosis; Ultrasound. Submitted 10 January 2013; Accepted 28 February 2013 No conflict of interest declared Summary lesion. During the abdominal dissection of the sac we injured the peritoneum and it was repaired. We also mobilised the scrotal part of the sac in order to excise the Figure 1. Mutlu_Stesura Seveso 18/04/13 12:05 Pagina 44 45Archivio Italiano di Urologia e Andrologia 2013; 85, 1 Abdominoscrotal hydrocele with bilateral hydronephrosis in an adult: Case report leg edema in pediatric patients (6, 7). In our case at ini- tial diagnosis we have observed bilateral hydronephrosis. ASH should be considered for the differential diagnosis of bilateral hydronephrosis. Mostly, it is one sided but in the literature bilateral ASH is also reported (8). Paratesticular malignant mesothelioma associated with ASH has also been reported in a 14-year-old boy (9). Ultrasound, magnetic resonance imaging (MRI) and com- puted tomography (CT) may be used for the diagnosis. During surgical treatment of ASH, dilated inguinal ring due to large sac shoud be repaired and mesh method should be used to avoid secondary herniation. Although open sur- gery is generally a preferred option, as we did, Bouhadiba et al. reported laparoscopic excision of ASH (10). Figure 2. A: Computed tomography images demonstrating right grade one and left grade two hydronephrosis. B: Abdominal part of abdominoscrotal hydrocele. A. B. Figure 3. A: Compression of abdominoscrotal hydrocele on left side of the bladder. B: bladder - H: hydrocele. B: Inguinal and scrotal part of abdominoscrotal hydrocele. B: bladder - H: hydrocele - T: testicle. tunica vaginalis of the testis and suture the edges of the remaining tunica vaginalis posterior to the testis. Mesh (Lichtenstein) method was used for inguinal hernia repair. Testis and cord were normal. The postoperative period was uneventful. DISCUSSION The etiology of ASH is not clear but there is general con- sensus on the need of surgical treatment. According to a Pubmed search there is only one case which Authors successfully managed by conservative approach (5). ASH is not a real benign condition, because it may be com- plicated with acute appendicitis, and it may lead to ureterohydronephrosis, testicular dismorphism and even A. B. Mutlu_Stesura Seveso 18/04/13 12:05 Pagina 45 Archivio Italiano di Urologia e Andrologia 2013; 85, 1 B. Mutlu, Y. Ozlem Ilbey, A. Bitkin, A. İhsan Taşçı 46 6. Halilbasic A, Hotic N, Skokic F, et al. Both-sided large abdomino- scrotal hydrocele associated with testicles atrophy. Med Arh. 2011; 65:182-4. 7. Faure A, Bouali O, Chaumoitre K, et al. Abdominoscrotal hydrocele with leg edema in a 4-month-old boy. Prog Urol. 2009; 19:639-42. 8. Arslan AS, Incesu L, Yalin T, et al. Bilateral abdominoscrotal hydrocele. Abdom Imaging. 1996; 21:177-178. 9. Velasco AL, Ophoven J, Priest JR, Brennom WS. Paratesticular malignant mesothelioma associated with abdominoscrotal hydrocele. J Pediatr Surg. 1988; 23:1065-7. 10. Bouhadiba N, Godbole P, Marven S. Laparoscopic excision of abdominoscrotal hydrocele. J Laparoendosc Adv Surg Tech A. 2007; 17:701-3. REFERENCES 1. Celayir AC, Akyüz U, Ciftlik H, et al. A critical observation about the pathogenesis of abdominoscrotal hydrocele. J Pediatr Surg. 2001; 36:1082-4. 2. Kaplan M, Atakan IH, Aktoz T, Inci O. Giant unilateral abdominoscrotal hydrocele in an adult: case report.Int Urol Nephrol. 2006; 38:667-70. 3. Avolio L, Chiari G, Caputo MA, Bragheri R. Abdominoscrotal hydrocele in childhood: is it really a rare entity? Urology. 2000; 56:1047-9. 4, Singh D, Aga P, Goel A. Giant unilateral hydrocele "en-bisac" with right hydronephrosis in an adult: A rare entity. Indian J Urol. 2011; 27:142-3. 5. Upadhyay V, Abubacker M, Teele R. Abdominoscrotal hydrocele- -is there a place for conservative management? Eur J Pediatr Surg. 2006; 16:282-4. Correspondence Bircan Mutlu, MD (Corresponding Author) Tevfik Saglam Cad. No:11 Zuhuratbaba, Istanbul, Turkey mutlubircan@yahoo.com Yusuf Ozlem Ilbey, MD ozlemyusufilbey@hotmail.com Alper Bitkin, MD alperbitkin@gmail.com Ali İhsan Taşçı, MD aliihsantasci@hotmail.com Bakırköy Dr.Sadi Konuk Training and Research Hospital, Istanbul, Turkey Mutlu_Stesura Seveso 18/04/13 12:05 Pagina 46