Conservative Management Favored for Pediatric Epididymal Cysts; Routine Prolonged Ultrasound Surveillance QuestionedConservative Management Options for Pediatric Epididymal Cysts

PURPOSE: To systematically synthesise current evidence on the epidemiology, clinical characteristics, natural history, and outcomes reported under different management approaches for epididymal cysts (ECs) in boys. METHODS: A PRISMA 2020-compliant systematic review was conducted using PubMed, Embase, and Scopus from inception through 31 August 2026. Observational studies including males younger than 18 years with ECs and reporting clinical outcomes were eligible. Random-effects meta-analyses of single-arm proportions were performed for key prevalence outcomes. RESULTS: Nine retrospective studies published between 2002 and 2025 were included, comprising 492 paediatric patients. No controlled comparative studies were identified. ECs were most frequently detected incidentally or during evaluation for painless scrotal swelling. Lesions were predominantly unilateral (79-90%), most were located in the epididymal head, and reported cyst size ranged from 2 to 40 mm. Associated conditions included hydrocele, varicocele, and testicular microlithiasis, with no reported link to malignancy. Conservative management was the preferred initial strategy in contemporary cohorts, whereas earlier series reported higher surgical rates. Surgery was mainly indicated for persistent pain or progressive enlargement and involved open excision, with high rates of symptom resolution and low reported morbidity. Meta-analysis showed that bilateral cysts occurred in 8% (95% CI 7-9%; I = 12.5%) of patients, complete spontaneous regression occurred in 12.2% (95% CI 8.3-16.1%; I = 88.1%), and 7.4% (95% CI 3.1-11.7%; I = 94.7%) of children required surgery. Postoperative complications were uncommon (3.4%; 95% CI 1.1-5.6%; I = 0%), and reported torsion events were rare (1.6%; 95% CI 0.7-2.5%; I = 0%); the available data did not establish that ECs predispose to testicular torsion. CONCLUSION: Paediatric ECs are benign lesions with a favourable natural history. Many lesions remain clinically stable, while complete spontaneous regression occurs in a minority. A conservative-first approach is appropriate in most cases, reserving surgery for selected patients with persistent symptoms, clinically meaningful enlargement, or diagnostic uncertainty. WHAT IS KNOWN: • Epididymal cysts in children are benign extratesticular lesions, usually detected incidentally and commonly managed conservatively. • Surgical indications and follow-up strategies remain inconsistent across paediatric studies. WHAT IS NEW: • To the best of our knowledge, and on the basis of the searches performed, this is the first systematic review and meta-analysis specifically evaluating paediatric ECs. • Our findings support a conservative-first approach, with low rates of surgery and reported complications, and question the value of routine prolonged ultrasonographic surveillance.