Aspiration and sclerotherapy versus hydrocoelectomy for treating hydrocoeles

Behnam Shakiba; Kazem Heidari; Arsia Jamali; Kourosh Afshar

doi:10.1002/14651858.CD009735.pub2

Aspiración y escleroterapia versus hidrocelectomía para el tratamiento del hidrocele

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References

References to studies included in this review

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excluded studies
additional references
other published versions

Agrawal MS, Yadav H, Upadhyay A, Jaiman R, Singhal J, Singh AK. Sclerotherapy for hydrocele revisited: a prospective randomised study. Indian Journal of Surgery 2009;71(1):23‐8. [MEDLINE: 23133104]

Khaniya S, Agrawal CS, Koirala R, Regmi R, Adhikary S. Comparison of aspiration‐sclerotherapy with hydrocelectomy in the management of hydrocele: a prospective randomized study. International Journal Of Surgery 2009;7(4):392‐5. [MEDLINE: 19595803]

Latif U, Bashir MA, Rashid A, Rehman Q, Shah TA. Hydrocele: surgery vs sclerotherapy. The Professional Medical Journal 2008;15(1):125‐8.

Osman M. Aspiration and tetracycline sclerotherapy of hydrocele: can It replace surgical treatment?. Medical Journal of Cairo University 1994;62(3):199‐204.

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References to studies excluded from this review

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included studies
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other published versions

Ali J, Anwar W, Akbar M, Akbar SA, Zafar A. Aspiration and tetracycline sclerotherapy of primary vaginal hydrocoele of testis in adults. Journal of Ayub Medical College, Abbottabad: JAMC 2008;20(2):93‐5. [MEDLINE: 19385467]

Beiko DT, Kim D, Morales A. Aspiration and sclerotherapy versus hydrocelectomy for treatment of hydroceles. Urology 2003;61(4):708‐12. [MEDLINE: 12670550]

Breda G, Giunta A, Gherardi L, Xausa D, Silvestre P, Tamai A. Treatment of hydrocele: randomised prospective study of simple aspiration and sclerotherapy with tetracycline. British Journal of Urology 1992;70(1):76‐7. [MEDLINE: 1638377]

Daehlin L, Tonder B, Kapstad L. Comparison of polidocanol and tetracycline in the sclerotherapy of testicular hydrocele and epididymal cyst. British Journal of Urology 1997;80(3):468‐71. [MEDLINE: 9313670]

Erdas E, Pisano G, Pomata M, Pinna G, Secci L, Licheri S, et al. Sclerotherapy and hydrocelectomy for the management of hydrocele in outpatient and day‐surgery setting. Chirurgia Italiana 2006;58(5):619‐25. [MEDLINE: 17069191]

Fayez A, El Shantaly KM, Abbas M, Hauser S, Muller SC, Fathy A. Comparison of inguinal approach, scrotal sclerotherapy and subinguinal antegrade sclerotherapy in varicocele treatment: a randomized prospective study. Urologia Internationalis 2010;85(2):200‐3. [MEDLINE: 20530957]

Hanif F, Mirza SM, Ali AA, Chaudhry AM. Role of sclerotherapy as primary treatment for hydrocele. Journal of the College of Physicians & Surgeons Pakistan 2001;11(10):611‐613. [EMBASE: 2001407466]

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Lund L, Kloster A, Cao T. The long‐term efficacy of hydrocele treatment with aspiration and sclerotherapy with polidocanol compared to placebo: a prospective, double‐blind, randomized study. Journal of Urology 2014;191(5):1347‐50. [MEDLINE: 24262498]

Moloney GE. Comparison of results of treatment of hydrocele and epididymal cysts by surgery and injection. British Medical Journal 1975;3(5981):478‐9. [MEDLINE: 1156828]

Rencken RK, Bornman MS, Reif S, Olivier I. Comparative trial of sclerotherapy for hydroceles. British Journal of Urology 1990;65(4):382‐4. [MEDLINE: 2187552]

Roosen JU, Larsen T, Iversen E, Berg JB. A comparison of aspiration, antazoline sclerotherapy and surgery in the treatment of hydrocele. British Journal of Urology 1991;68(4):404‐6. [MEDLINE: 1933162]

Shan CJ, Lucon AM, Arap S. Comparative study of sclerotherapy with phenol and surgical treatment for hydrocele. Journal of Urology 2003;169(3):1056‐9. [MEDLINE: 12576845]

Shan CJ, Lucon AM, Pagani R, Srougi M. Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis. International Brazilian Journal of Urology 2011;37(3):307‐12. [MEDLINE: 21756377]

Additional references

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included studies
excluded studies
other published versions

Epstein A, Novicki D. Management of hydroceles. American Urological Association (AUA) Update Series1988; Vol. VII lesson 19:145‐9.

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Fracchia JA, Armenakas NA, Kohan AD. Cost‐effective hydrocele ablation. Journal of Urology 1998;159(3):864‐7. [MEDLINE: 9474170]

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Higgins JP, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Hu KN, Khan AS, Gonder M. Sclerotherapy with tetracycline solution for hydrocele. Urology 1984;24(6):572‐6. [MEDLINE: 6506398]

Levine LA, DeWolf WC. Aspiration and tetracycline sclerotherapy of hydroceles. Journal of Urology 1988;139(5):959‐60. [MEDLINE: 3361674]

Micallef M, Torreggiani WC, Hurley M, Dinsmore WW, Hogan B. The ultrasound investigation of scrotal swelling. International Journal of STD and AIDS 2000;11(5):297‐302. [MEDLINE: 10824938]

Ozkan S, Bircan K, Ozen H. Treatment of testicular hydrocele with tetracycline sclerotherapy. International Urology & Nephrology 1990;22(1):67‐9. [MEDLINE: 2380004]

Rubenstein RA, Dogra VS, Seftel AD, Resnick MI. Benign intrascrotal lesions. Journal of Urology 2004;171(5):1762‐72. [MEDLINE: 15076274]

Rudkin SE, Kazzi AA. Hydrocele in emergency medicine. http://emedicine.medscape.com/article/777386‐overview (accessed 23 October 2014).

Savion M, Wolloch Y, Savir A. Phenol sclerotherapy for hydrocele: a study in 55 patients. Journal of Urology 1989;142(6):1500‐1. [MEDLINE: 2585624]

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Sigurdsson T, Johansson JE, Jahnson S, Helgesen F, Andersson SO. Polidocanol sclerotherapy for hydroceles and epididymal cysts. Journal of Urology 1994;151(4):898‐901. [MEDLINE: 8126821]

Sirpa A, Martti AO. Results of fibrin glue application therapy in testicular hydrocele. European Urology 1998;33(5):497‐9. [MEDLINE: 9643670]

Stattin P, Karlberg L, Damber JE. Long‐term outcome of patients treated for hydrocele with the sclerosant agent sodium tetradecyl sulphate. Scandinavian Journal of Urology & Nephrology 1996;30(2):109‐13. [MEDLINE: 8738055]

Tammela TL, Hellstrom PA, Mattila SI, Ottelin PJ, Malinen LJ, Makarainen HP. Ethanolamine oleate sclerotherapy for hydroceles and spermatoceles: a survey of 158 patients with ultrasound followup. Journal of Urology 1992;147(6):1551‐3. [MEDLINE: 1593687]

Yamamoto M, Hibi H, Miyake K. A new sclerosant therapy for testicular hydrocele with aspiration and injection of OK‐432. International Urology & Nephrology 1994;26(2):205‐8. [MEDLINE: 8034432]

Yilmaz U, Tatlisen A, Ekmekcioglu O. Talc sclerotherapy for hydroceles. British Journal of Urology 1998;82(3):440‐1. [MEDLINE: 9772886]

Yilmaz U, Ekmekcioglu O, Tatlisen A, Demirci D. Does pleurodesis for pleural effusions give bright ideas about the agents for hydrocele sclerotherapy?. International Urology & Nephrology 2000;32(1):89‐92. [MEDLINE: 11057781]

References to other published versions of this review

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included studies
excluded studies
additional references

Shakiba B, Heidari K, Jamali A, Afshar K. Aspiration and sclerotherapy versus hydrocoelectomy for treating hydrocoeles. Cochrane Database of Systematic Reviews 2012, Issue 3. [DOI: 10.1002/14651858.CD009735]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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excluded studies

Agrawal 2009a

Methods	Study design: parallel RCT Study duration: NS Duration of follow‐up: 6 months
Participants	Country: India Setting: NS Male patients with unilateral hydroceles Mean age ± SD: 45.0 ± 13.8 years Mean maximum diameter of the scrotal swelling ± SD: 123.0 ± 36.5 mm Mean volume of the hydrocoele ± SD: 212.9 ± 106.5 mL Number: treatment group 1 (29); treatment group 2 (29); control group (28) Mean age (years): treatment group 1 (47.7); treatment group 2 (44.1); control group (54.2) Mean maximum diameter of scrotal swelling (mm): treatment group 1 (124.1); treatment group 2 (129); control group (116.7) Mean volume of the hydrocoele (mL): treatment group 1 (195.6); treatment group 2 (200.7); control group (242.5) Exclusion criteria: secondary hydrocoele (secondary to trauma, malignancy or infection); communicating hydrocoele; children < 12 years; history of previous intervention (either sclerotherapy or surgery)
Interventions	Treatment group 1 Phenol sclerotherapy Aspiration and sclerotherapy with 5 to 10 mL of 5% aqueous phenol Treatment group 2 Polidocanol sclerotherapy Aspiration and sclerotherapy with 2 to 4 mL of 1% polidocanol Control group Hydrocoelectomy Jaboulay’s procedure
Outcomes	Cure rate Pain score Durations of hospital stay Time to work resumption Complications: oedema, haematoma, wound infection
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The study was carried out on 86 patients with unilateral hydroceles who were randomised into three groups
Allocation concealment (selection bias)	Unclear risk	The study was carried out on 86 patients with unilateral hydroceles who were randomised into three groups
Incomplete outcome data (attrition bias) All outcomes	Low risk	There was no significant evidence of attrition bias
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement
Other bias	Unclear risk	Insufficient information to permit judgement
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding of participants and personnel are not consistent for this study
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Insufficient information to permit judgement

Khaniya 2009

Methods	Study design: parallel RCT Study duration: NS Duration of follow‐up: 6 months
Participants	Country: Nepal Setting: university hospital Adult males with unilateral primary vaginal hydrocoele (testicular hydrocoele); diagnosis was confirmed by physical examination and ultrasonography Number: treatment group (30); control group (30) Mean age ± SD (years): treatment group (39 ± 16.7); control group (36.5 ± 16) Duration of disease (median, range (years)): treatment group (2.7, 0.25 to 16); control group (2.5, 0.25 to 30) Volume of the hydrocoele (mean ± SD (mL)): treatment group (219.6 ± 186.47); control group ( 318.3 ± 194.97) Exclusion criteria: patients with fertility concerns; coexisting scrotal haematocoele, spermatocoele or testicular malignancies
Interventions	Treatment group Aspiration and sclerotherapy with sodium tetradecyl sulphate Volume instilled was 50% of the aspirated fluid up to the maximum of 80 mL Control group Hydrocoelectomy Jaboulay’s procedure
Outcomes	Recurrence Post‐operative complications: fever, pain, infection, ulceration, haematoma Total cost Loss of working days Satisfaction of the patients
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Patients were divided into two groups of thirty patients each with the help of computer generated random numbers
Allocation concealment (selection bias)	Unclear risk	Insufficient information to permit judgement
Incomplete outcome data (attrition bias) All outcomes	High risk	Missing data in satisfaction assessment are present.
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement
Other bias	Unclear risk	Insufficient information to permit judgement
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding of participants and personnel are not consistent for this study
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Insufficient information to permit judgement

Latif 2008

Methods	Study design: parallel RCT Study duration: April 2001 to March 2002 Duration of follow‐up: 3 months
Participants	Country: Pakistan Setting: Department of Surgery of a tertiary care hospital Male patients with minimum age of 13 years with the clinical diagnosis of hydrocoele; aged 15 to 75 years Number: treatment group (25); control group (25) Mean age ± SD: NS Exclusion criteria: history of hydrocoele more than five year; hydrocoele more than 15 cm in maximum diameter; patients with history of previous scrotal surgery
Interventions	Treatment group Aspiration and sclerotherapy with 2 to 5 mL 1 % sodium tetradecyl sulphate. The volume instilled was calculated according to size of the hydrocoele sac 2 mL for < 100 mL aspirate 3 mL for 100 to 200 mL aspirate 5 mL for > 200 mL aspirate Control group Hydrocoelectomy Jaboulay’s procedure, plication or subtotal excision
Outcomes	Recurrence Success rate Post‐operative complications: pain, infection, haematoma Total cost involved Loss of working days
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Patients were randomly divided into two groups for sclerotherapy (group A) or surgery (group B)
Allocation concealment (selection bias)	Unclear risk	Insufficient information to permit judgement
Incomplete outcome data (attrition bias) All outcomes	Low risk	There was no significant evidence of attrition bias
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement
Other bias	Unclear risk	Insufficient information to permit judgement
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding of participants and personnel are not consistent for this study
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Insufficient information to permit judgement

Osman 1994

Methods	Study design: parallel RCT Study duration: July 1991 to December 1992 Duration of follow‐up: 12 months
Participants	Country: Qatar Setting: general hospital 79 patients with a total of 86 hydroceles (7 patients with bilateral hydroceles and 72 patients with unilateral hydroceles); diagnosis confirmed by physical examination and ultrasonography Number: treatment group (42; 46 hydroceles); control group (37; 40 hydroceles) Mean age ± SD (years): treatment group (44 ± 16.7); control group (41 ± 16.7) Volume of the hydrocoele (mean, range (mL)): treatment group (180, 18‐800); control group (166, 35‐630) Exclusion criteria: coexisting hernia or spermatocoele
Interventions	Treatment group Aspiration and sclerotherapy with 100 mg of tetracycline diluted in 1 mL 1% xylocaine solution. The volume instilled was variable according to the volume of aspirate 2 mL for < 20 mL aspirate 3 mL for 20 to 50 mL aspirate 5 mL for 51 to 100 mL aspirate 10 mL for 101 to 200 mL aspirate 15 mL for 201 to 300 mL aspirate 20 mL for > 300 mL aspirate Control group Tunical eversion or excision
Outcomes	Recurrence Post‐operative complications: pain, wound infection, haematoma Loss of working days
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The patients were divided on a random into two groups: Group (A) 37 patients (40 hydroceles); Group (B) 42 patients (46 hydroceles)
Allocation concealment (selection bias)	Unclear risk	Insufficient information to permit judgement
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Insufficient information to permit judgement
Selective reporting (reporting bias)	Unclear risk	Insufficient information to permit judgement
Other bias	Unclear risk	Insufficient information to permit judgement
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding of participants and personnel are not consistent for this study
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Insufficient information to permit judgement

RCT ‐ randomised controlled trial

Characteristics of excluded studies [ordered by study ID]

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included studies

Study	Reason for exclusion
Ali 2008	Not RCT
Beiko 2003	Not RCT
Breda 1992	Intervention not relevant to the review
Daehlin 1997	Intervention not relevant to the review
Erdas 2006	Not RCT
Fayez 2010	Included patients with varicoceles
Hanif 2001	Not RCT
Lund 2014	Sclerotherapy versus placebo not surgery
Moloney 1975	Not RCT; included patients with epididymal cysts
Rencken 1990	Intervention not relevant to the review
Roosen 1991	Included patients with recurrent hydrocoele after aspiration
Shan 2011	Not RCT
Shan 2003	Included patients with post surgery and secondary hydrocoele

RCT ‐ randomised controlled trial

Data and analyses

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Comparison 1. Aspiration and sclerotherapy versus hydrocoelectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Clinical cure Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.1 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 1 Clinical cure.
1.1 One round of sclerotherapy	3	215	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.18, 1.10]
1.2 Two rounds of sclerotherapy	2	129	Risk Ratio (M‐H, Random, 95% CI)	0.58 [0.21, 1.65]
1.3 Osman 1994 removed (one round of sclerotherapy)	2	136	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.64, 0.85]
2 Recurrence Show forest plot	3	189	Risk Ratio (M‐H, Random, 95% CI)	9.43 [1.82, 48.77]
Open in figure viewer Analysis 1.2 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 2 Recurrence.
2.1 Follow‐up at 3 months	2	110	Risk Ratio (M‐H, Random, 95% CI)	5.26 [1.04, 26.75]
2.2 Follow‐up at 6 months	1	79	Risk Ratio (M‐H, Random, 95% CI)	25.55 [3.66, 178.47]
3 Fever Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.3 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 3 Fever.
4 Infection Show forest plot	4	275	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.09, 1.06]
Open in figure viewer Analysis 1.4 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 4 Infection.
5 Haematoma Show forest plot	3	189	Risk Ratio (M‐H, Random, 95% CI)	0.57 [0.17, 1.90]
Open in figure viewer Analysis 1.5 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 5 Haematoma.
6 Time to work resumption Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.6 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 6 Time to work resumption.
7 Satisfaction Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.7 Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 7 Satisfaction.
7.1 At 3 months	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
7.2 At 6 months	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Figure 1

Study selection flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 1 Clinical cure.

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Analysis 1.2

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 2 Recurrence.

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Analysis 1.3

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 3 Fever.

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Analysis 1.4

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 4 Infection.

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Analysis 1.5

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 5 Haematoma.

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Analysis 1.6

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 6 Time to work resumption.

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Analysis 1.7

Comparison 1 Aspiration and sclerotherapy versus hydrocoelectomy, Outcome 7 Satisfaction.

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Comparison 1. Aspiration and sclerotherapy versus hydrocoelectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Clinical cure Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 One round of sclerotherapy	3	215	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.18, 1.10]
1.2 Two rounds of sclerotherapy	2	129	Risk Ratio (M‐H, Random, 95% CI)	0.58 [0.21, 1.65]
1.3 Osman 1994 removed (one round of sclerotherapy)	2	136	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.64, 0.85]
2 Recurrence Show forest plot	3	189	Risk Ratio (M‐H, Random, 95% CI)	9.43 [1.82, 48.77]

2.1 Follow‐up at 3 months	2	110	Risk Ratio (M‐H, Random, 95% CI)	5.26 [1.04, 26.75]
2.2 Follow‐up at 6 months	1	79	Risk Ratio (M‐H, Random, 95% CI)	25.55 [3.66, 178.47]
3 Fever Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Infection Show forest plot	4	275	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.09, 1.06]

5 Haematoma Show forest plot	3	189	Risk Ratio (M‐H, Random, 95% CI)	0.57 [0.17, 1.90]

6 Time to work resumption Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7 Satisfaction Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

7.1 At 3 months	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
7.2 At 6 months	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Aspiration and sclerotherapy versus hydrocoelectomy

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References

References to studies included in this review

Agrawal 2009a {published data only}

Khaniya 2009 {published data only}

Latif 2008 {published data only}

Osman 1994 {published data only}

References to studies excluded from this review

Ali 2008 {published data only}

Beiko 2003 {published data only}

Breda 1992 {published data only}

Daehlin 1997 {published data only}

Erdas 2006 {published data only}

Fayez 2010 {published data only}

Hanif 2001 {published data only}

Lund 2014 {published data only}

Moloney 1975 {published data only}

Rencken 1990 {published data only}

Roosen 1991 {published data only}

Shan 2003 {published data only}

Shan 2011 {published data only}

Additional references

Epstein 1988

Fracchia 1998

Higgins 2003

Higgins 2011

Hu 1984

Levin 1988

Micallef 2000

Ozkan 1990

Rubenstein 2004

Rudkin 2012

Savion 1989

Schulz 2010

Sigurdsson 1994

Sirpa 1998

Stattin 1996

Tammela 1992

Yamamoto 1994

Yilmaz 1998

Yilmaz 2000

References to other published versions of this review

Shakiba 2012

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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