Influence of inguinal hernia repair on male fertility

Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique

BACKGROUND

The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used.

METHODS

A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS).

RESULTS

Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes.

CONCLUSION

Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes.

TRIAL REGISTRATION

Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

Analysis of the efficacy of laparoscopic high hernia sac ligation in adolescent indirect hernia

OBJECTIVE

Inguinal hernias are a common disease that may present at all ages. Adolescents are a unique patient population between children and adults. The etiology and the surgical treatment strategies of adolescent indirect hernias are not clear. Specifically, whether these kinds of hernias should be treated by high ligation or mesh repair remains controversial. We aimed to evaluate the efficacy of laparoscopic high hernia sac ligation in adolescent indirect hernia.

METHODS

The data of adolescent patients who underwent laparoscopic high hernia sac ligation at the The First People's Hospital of Foshan,China, from January 2012 to December 2019 were analyzed retrospectively. Data collected included their age, gender, weight, surgical method, hernia ring diameter, operation time, postoperative recurrence rate and postoperative complications.

RESULTS

A total of 70 patients were enrolled, including 61 males (87.14%) and 9 females (12.86%),all patients were aged 13-18 years old (mean 14.87 ± 1.56years), weighed 28-92 kg (mean 53.04 ± 10.60 kg). All 70 patients underwent laparoscopic surgery except 2 patients with irreducible hernias who converted to laparotomy.The hernia ring diameter ranged from 0.5 to 3 cm (mean 1.39 ± 0.49 cm), and was ≤ 2 cm in 68 cases (97.14%).The operative length ranged from 12 to 105 min (average 24.96 ± 12.61 min), There were 37(52.9%) right-sided hernias, 32 (45.7%) left-sided hernias, 1 (1.4%) bilateral hernia.There were 67(95.7%)reducible hernias,2(2.9%)irreducible hernias ,and 1(1.4%)incarcerated hernia.Hospital stays ranged from 1 to 5 days (mean 2.37 ± 1.05 days). Follow-ups were performed from 30-119months (mean 74.27 ± 28.14months). There were no cases of recurrence, howere, incision infection occured in 1 patient, who underwent a second operation 6 months after surgery, and 4 (5.7%) patients had complaints of intermittent pain around the ligation incision site, mostly during exercise .

CONCLUSION

Laparoscopic high hernia sac ligation is feasible for treatment of adolescent indirect hernias with a hernia ring diameter of ≤ 2 cm.

Functional histology of human scrotal wall layers and their overlooked relation with infertility: a narrative review

Male infertility currently contributes to nearly half of the reported infertility cases. Scrotal wall layers play a cardinal role in regulating testicular physiology. However, few studies have focused on the functional histology of these layers and their relations with infertility in humans. The objective of the present narrative review is to collate novel insights into the functional histology of the human scrotal wall layers and their relation with infertility. The data was extracted from articles published between 1946 and 2021. The study was performed between January and December 2021. 71 original studies have been included in this review. Despite the fact that few studies have presented detailed functional histology of the human scrotal wall layers, this narrative review elucidates the possible influence of scrotal histology on infertility. Scrotal wall layers-associated pathologies may induce infertility by various mechanisms. They can impose mechanical forces that may affect the testicular histology and stimulate testicular inflammation. Moreover, they may induce testicular hyperthermia. Various unanswered clinical questions have been identified in this narrative review. More clinical studies are needed to assess the effect of alterations in the components of the scrotal wall layers on fertility (e.g., due to the exposure to metabolic and/or psychological stressors). In addition, testing the effectiveness of various pharmacological/surgical interventions to treat scrotal wall layers-associated pathologies will provide more insights into infertility treatment.

Laparoscopic iliopubic tract repair to treat recurrent pediatric inguinal hernia

BACKGROUND

Congenital defects, such as open processus vaginalis and the canal of Nuck, are common causes of primary pediatric inguinal hernia (PIH). However, in some patients, PIH occurs via acquired defects rather than congenital defects. The most representative cause of PIH is recurrent hernia. Recurrent PIH is treated with high ligation (HL), which is the same method that is used to treat primary PIH. However, the re-recurrence rate of recurrent PIH is high. This study aimed to compare laparoscopic iliopubic tract repair (IPTR) with laparoscopic HL for the treatment of recurrent PIH after primary PIH repair.

METHODS

From June 2013 to March 2019, 126 patients (< 10 years old) with recurrent PIH were retrospectively enrolled. Patients were divided into two groups according to the operative technique: laparoscopic HL (58 patients) and laparoscopic IPTR (68 patients). With HL, the hernial sac was removed and the peritoneum closed. With IPTR, iliopubic tract and transversalis fascia sutures were applied.

RESULTS

There were no cases of conversion to open surgery. Re-recurrence only occurred in the HL group; no patients in the IPTR group developed re-recurrence (8.6% [5/58] vs. 0.0% [0/68], respectively; p = 0.044). The mean duration from re-operation to re-recurrence in these five patients was 10.6 months. Other surgical outcomes and complications did not differ between the two groups.

CONCLUSIONS

Laparoscopic IPTR is an effective surgical treatment for reducing re-recurrence of recurrent PIH.

[Association of tension-free inguinal hernia repair and pathospermia in fertile men]

OBJECTIVE

To reveal the association of tension-free inguinal hernia repair and pathospermia in fertile men.

MATERIAL AND METHODS

We have retrospectively analyzed medical records of 512 men who appealed to andrologist with complaints of the absence of pregnancy in wife in 2018. We evaluated duration and features of infertility, presence/absence of previous inguinal hernia repair, spermogram data (according to WHO criteria, 2010) in all patients.

RESULTS

Duration of infertility in men after inguinal hernia repair persists for 4.2±2.1 years. Right-sided hernia repair was performed in 36 (48.6%) patients, left-side - 23 (31%), bilateral repair - 15 (20.2%) patients. Men with impaired sperm motility prevailed among patients after right-sided inguinal hernia repair (17 (47.2%) people). Left-sided hernia repair was followed by asthenozoospermia in 8 (34.7%) cases, bilateral hernia repair - in 3 (20%) cases. The most severe abnormalities in semen analysis (azoospemia) develop after bilateral hernia repair.

CONCLUSION

Inguinal tension-free hernia repair is a risk factor for male infertility in 14.4% of cases. It is very important to examine a man in case of infertile marriage. Previous surgical interventions including inguinal hernia repair should be considered.

Could polypropylene mesh impair male reproductive organs? Experimental study with different methods of implantation

PURPOSE

To evaluate the vas deferens and testicles of rats submitted to bilateral inguinotomy and polypropylene (PP) mesh placement.

METHOD

Sixty Wistar rats were randomized into three groups: Control (inguinotomy only), mesh placement over the vas deferens (Mesh-DD) or under the spermatic funiculus (Mesh-SF). The following analyses were performed: vas deferens morphometry (lumen area and wall thickness), quantification of collagen fibers, spermatogenesis, apoptosis (cleaved caspase-3 and TUNEL) and cellular proliferation (Ki67). Quantitative gene expression (qPCR) for apoptosis and inflammatory cytokines were evaluated by RT-PCR.

RESULTS

In the apoptosis pathway, Mesh-DD showed one upregulated gene (Il10) and three downregulated genes (Fadd, Tnfrsf1b and Xiap). In Mesh-SF, 17 genes were downregulated. In the inflammation pathway (Mesh-DD), one gene was upregulated (Il1r1), and one gene was downregulated (Ccl12). In Mesh-SF, three genes were upregulated (Il1r1, Tnfsf13b and Csf1), and two were downregulated (Ccl12 and Csf2). PP mesh placement preserved spermatogenesis and did not alter the vas deferens or the testicle. In the ductus deferens, there was reduced luminal area (30 days), increased wall thickness (90 days), and increased type III collagen and cell proliferation (30 and 90 days) (p < 0.05). In the testicle, cell proliferation was greater in the Mesh-DD (p < 0.05).

CONCLUSIONS

PP mesh, whether or not in direct contact with spermatic funicular structures, induces changes that were not sufficient to cause damage to the evaluated organs.

Does a bilateral polypropylene mesh alter the duct deferens morphology, testicular size and testosterone levels? Experimental study in rats

Purpose

To evaluate the effect of a PP mesh on duct deferens morphology, testicular size and testosterone levels.

Methods

Forty adult male rats were distributed into groups: 1) no surgery; 2) inguinotomy; 3) mesh placed on the duct deferens; and 4) mesh placed on the spermatic funiculus. After 90 postoperative days, the inguinal region was resected, and blood samples were collected for the measurement of serum testosterone (pg/dl). The ducts deferens were sectioned in three axial sections according to the relationship with the mesh — cranial, medial and caudal. The wall thickness and duct deferens lumen area were measured.

Results

The morphology of the duct deferens was preserved in all groups. The mesh placement did not alter this morphology in any of the analyzed segments. Surgery, with or without mesh placement, did not alter the morphology, wall thickness or lumen area (p>0.05). In all operated groups, serum testosterone levels were similar (p>0.05) but there was a decrease in testicle size (p<0.05).

Conclusion

Surgery, with or without mesh placement, did not alter the morphology of the duct deferens and, although this treatment resulted in testicular size reduction, it did not affect serum testosterone levels.

Transplant uretero-inguinal hernia resulting in urosepsis

Uretero-inguinal hernias are rare and can be difficult to diagnose. We present a case of a rare transplant kidney uretero-inguinal hernia. An 81-year-old male presented with urosepsis and was found to have an obstructed transplanted kidney secondary to herniation of the ureter into an inguinal hernia. The patient required interventional radiology decompression of the urinary system with a percutaneous nephrostomy tube. In this case, the patient's uretero-inguinal hernia was the extraperitoneal subtype allowing the diagnosis to be made easily on computed tomography imaging of the abdomen and pelvis which facilitated rapid treatment.