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Damous SHB, Damous LL, Borges VA, Fontella AK, Miranda JDS, Koike MK, Saito OC, Birolini CAV, Utiyama EM. Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique. Surg Endosc 2023; 37:9263-9274. [PMID: 37880447 DOI: 10.1007/s00464-023-10499-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/24/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Sérgio Henrique Bastos Damous
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), 255 Dr Enéas de Carvalho Aguiar Av. Cerqueira Cesar, São Paulo, 05402-000, Brazil.
| | - Luciana Lamarão Damous
- Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), São Paulo, Brazil
- Postgraduate Program in Health Sciences, Instituto de Assistência Médica do Servidor Público Estadual (IAMSPE), São Paulo, Brazil
| | - Victor André Borges
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Jocielle Dos Santos Miranda
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), 255 Dr Enéas de Carvalho Aguiar Av. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - Marcia Kiyomi Koike
- Postgraduate Program in Health Sciences, IAMSPE and Laboratory of Medical Investigation 51 (LIM-51), University of São Paulo, São Paulo, Brazil
| | - Osmar Cássio Saito
- Instituto de Radiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), São Paulo, Brazil
| | - Cláudio Augusto Vianna Birolini
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), 255 Dr Enéas de Carvalho Aguiar Av. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - Edivaldo Massazo Utiyama
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), 255 Dr Enéas de Carvalho Aguiar Av. Cerqueira Cesar, São Paulo, 05402-000, Brazil
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Damous SHB, Damous LL, Miranda JS, Montero EFS, Birolini C, Utiyama EM. Could polypropylene mesh impair male reproductive organs? Experimental study with different methods of implantation. Hernia 2020; 24:1325-1336. [PMID: 32306141 DOI: 10.1007/s10029-020-02186-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/02/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- S H B Damous
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil. .,, Baturite St, 120. Ap 91. Aclimação, São Paulo, 01530-030, Brazil.
| | - L L Damous
- Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - J S Miranda
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - E F S Montero
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - C Birolini
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil
| | - E M Utiyama
- Division of General Surgery and Trauma, Department of Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), Dr. Enéas de Carvalho Aguiar Av. 255. Cerqueira Cesar, São Paulo, 05402-000, Brazil
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Damous SHB, Damous LL, Miranda JDS, Montero EFDS, Birolini C, Utiyama EM. Does a bilateral polypropylene mesh alter the duct deferens morphology, testicular size and testosterone levels? Experimental study in rats. Acta Cir Bras 2020; 35:e202000201. [PMID: 32320995 PMCID: PMC7184941 DOI: 10.1590/s0102-865020200020000001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/10/2020] [Indexed: 11/21/2022] Open
Abstract
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.
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Xu H, Chen M, Xu Q, Wang Z, Qiu Z. Application of tension-free hernioplasty with hernia meshes of different materials and the postoperative effects on the reproductive function of male rats. Mol Med Rep 2014; 9:1968-74. [PMID: 24603965 DOI: 10.3892/mmr.2014.2014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 02/10/2014] [Indexed: 11/06/2022] Open
Abstract
This study aimed to compare the effects of polypropylene (PP), lightweight PP (UP) and expanded polytetrafluorethylene (e-PTFE) hernia mesh on the reproductive function of adult male Sprague-Dawley (SD) rats following open tension-free hernioplasty. Forty adult SD rats were obtained and divided into five groups: A sham-operated (FO) group, an e-PTFE mesh group, a PP mesh group, the UP mesh group and a normal control (NC) group (without any surgical manipulation). Ninety days following open tension-free hernioplasty, hematoxylin and eosin staining and immunhistochemistry were used to observe the pathological changes of the testicular tissue and to compare the expression of hypoxia-inducible factor-1α (HIF‑1α) in the rat testis, respectively. ELISA was used to analyze the serum concentration of antisperm antibodies (AsAbs) and routine semen testing was conducted to measure the percentage of grade a+b sperm from the epididymis. More than 50% of mesh adherence to the spermatic cord was observed in the PP and UP groups, and mild or no adhesion was observed in the NC, FO and e-PTFE groups. In the UP and PP groups, marked congestion of necrotic tissue was observed in the seminiferous tubule cavity, a significant reduction in the percentage of grade a+b sperm and a significant increase in the expression levels of AsAbs and HIF-α. It was concluded that the e-PTFE mesh exhibited a marginal effect on the reproductive function of rats compared with that of the PP and UP mesh and is more suitable for tension-free hernioplasty. The clinical significance of these results requires further elucidation with a multi-centered prospective study.
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Affiliation(s)
- Hao Xu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical College, Xiashan, Zhanjiang 524001, P.R. China
| | - Ming Chen
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical College, Xiashan, Zhanjiang 524001, P.R. China
| | - Qianru Xu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical College, Xiashan, Zhanjiang 524001, P.R. China
| | - Zhenlong Wang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical College, Xiashan, Zhanjiang 524001, P.R. China
| | - Zhidong Qiu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical College, Xiashan, Zhanjiang 524001, P.R. China
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Tekatli H, Schouten N, van Dalen T, Burgmans I, Smakman N. Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature. Am J Surg 2012; 204:503-9. [DOI: 10.1016/j.amjsurg.2012.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/04/2012] [Accepted: 03/04/2012] [Indexed: 01/01/2023]
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Prevention of incisional hernia by mesh implantation after median laparotomy: a preclinical trial. Eur Surg 2010. [DOI: 10.1007/s10353-010-0570-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Influence of a new self-gripping hernia mesh on male fertility in a rat model. Surg Endosc 2009; 24:455-61. [DOI: 10.1007/s00464-009-0596-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 05/31/2009] [Indexed: 10/20/2022]
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