Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature

Totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy for the treatment of obstructive azoospermia caused by pediatric bilateral inguinal herniorrhaphy

BACKGROUND

Pediatric inguinal hernia repair (IHR) is a common cause of obstructive azoospermia (OA). Yet, the surgical treatment for this kind of OA remains difficult with poor fertility outcome.

OBJECTIVES

To evaluate the safety and effectiveness of totally extraperitoneal laparoscopy-assisted microsurgical vasovasostomy (VV) in the treatment of OA caused by pediatric bilateral IHR.

MATERIALS AND METHODS

Totally, 37 patients with OA caused by pediatric bilateral IHR were enrolled in this study from March 2015 to December 2020 in Shanghai General Hospital. The clinical data and fertility outcomes were collected and analyzed.

RESULTS

All patients enrolled had a history of bilateral IHR at the age of 1-10 years old. The mean age of patients was 27 ± 4.31 (range: 18-35) years. Totally extraperitoneal laparoscopy (TEP) was applied in 31 patients for the exploration and retrieval of pelvic vas deferens end, and 30 of them underwent microsurgical VV successfully. Among the six cases where TEP was not applied, five cases underwent microsurgical anastomosis. Intraoperative exploration revealed that the location of vas deferens injuries included scrotum (2.70%, 1/37), inguinal canal (5.41%, 2/37), pelvic cavity (78.37%, 29/37), and multiple sites (13.51%, 5/37). The mean operation time was 339 ± 96.73 min (range: 130-510 min). There were no surgical complications. Thirty-three cases were followed up for 5-48 months with four cases lost to follow-up. The overall patency rate, pregnancy rate, and natural pregnancy rate were 75.86% (22/29), 46.67% (14/30), and 36.84% (7/19, 3 patients without family planning), respectively. And seven couples conceived through the assisted reproductive technique, two of which using fresh sperm in the ejaculate.

CONCLUSION

TEP laparoscopy-assisted microscopic VV is an effective treatment for patients with OA caused by pediatric bilateral IHR.

Laparoscopic Inguinal Hernioplasty with a Polyether Ether Ketone Anchoring Device in Intact Male Horses Does Not Compromise Testicular Perfusion, Sperm Production or Motility Characteristics

A new surgical technique using a polyether ether ketone (PEEK) anchoring device for testicle-sparing laparoscopic inguinal hernioplasty in stallions was described in 2023 and is known as the PEEK harpoon technique (PHT). In breeding stallions, it is essential that the surgery is effective in preventing inguinal hernia but also that it does not impair the testicular function. This study aims to evaluate whether the PHT may affect testicular function. To achieve that, changes in the testicular blood flow, sperm production and motility characteristics were assessed 28 days after use of the PHT. Standing laparoscopic hernioplasty using the PHT was performed unilaterally in eight healthy (non-previously herniated) experimental intact males. The contralateral inguinal canals and testicles were used as control. Pre- and post-surgery Doppler ultrasonographic evaluations of testicular perfusion were performed serially. Bilateral castration was performed at 28 days post-surgery, and epididymal sperm were obtained from both testicles to analyze seminal characteristics. No significant differences were identified in regard to testicular perfusion and the sperm characteristics of the control and operated testicles, suggesting that the PHT-based hernioplasty would not compromise testicular function. Further studies evaluating effects over a longer period are needed, but our data indicate that the PHT is suitable for testicle-sparing inguinal laparoscopic hernioplasties in breeding stallions with a history or predisposing factors of inguinal herniation.

Clinical and Laboratorial Evaluation of Male Infertility. A Detailed Practical Approach

Infertility, defined as the inability to achieve pregnancy after one year of unprotected, frequent sexual intercourse, is a global burden that affects approximately 15% of couples, or 190-230 million people worldwide, who are trying to start a family. The male contributes significantly, directly accounting for 30-35% and up to 52% of total couple infertility, affecting approximately 7-8% of all men. This work aims to present, in a didactic and objective way, a standardization of the initial steps toward a thorough evaluation of subfertile and infertile men. We have focused on the evaluation of initial management, emphasizing the need for a comprehensive evaluation that includes a detailed history, physical examination, and semen analysis as the golden triple helix of basic evaluation of the infertile male. General and genital physical examinations are highly valuable due to the wealth of information they provide, from potential diagnoses to pregnancy prognoses. Comprehensive and quality-controlled semen analysis provides reliable information as a baseline test to evaluate the patency of the reproductive tract and to evaluate basic sperm parameters and fertility potential. However, it is not a fertility determinant and should preferentially be complemented with sperm functional tests. like biomarkers of oxidative stress, sperm immaturity and DNA fragmentation. Most cases of infertility require evaluation by a specialist in andrology, nonetheless the understanding and rationale of the initial assessment of the infertile male can be undertaken by non-specialists, thus improving the care and counseling of couples facing this troubling issue and avoiding unnecessary use of assisted reproductive technologies (ART) since most cases of male infertility can be treated and reversed by medical or surgical interventions, and the fertility status can be restored. The ultimate goal is to achieve natural pregnancy, the use of ART should not be the initial offered resource.

Sexual dysfunction between laparoscopic and open inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Sexual dysfunction after inguinal hernia complication is considered rare. However, its consequences impact on quality of life inevitably. Laparoscopic and open inguinal hernia repair may be comparable in terms of recurrent rate, overall complications, and chronic pain. Therefore, its complication is still questionable between these approaches. In this study, we compared sexual dysfunction and related complications between laparoscopic and open inguinal hernia repair.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) studies were performed to compare laparoscopic and open inguinal hernia repair. Risk ratio (RR) and 95% confidence intervals (95% CI) were used as pooled effect size measures.

RESULT

Thirty RCTs (12,022 patients) were included. Overall, 6014 (50.02%) underwent laparoscopic hernia repair, and 6008 (49.98%) underwent open hernia repair. Laparoscopic approach provided non-significance benefit on pain during sexual activity (RR 0.57; 95% CI 0.18, 1.76), Vas deferens injury (RR 0.46; 95% CI 0.13, 1.63), orchitis (RR 0.84; CI 0.61,1.17), scrotal hematoma (RR 0.99; CI 0.62,1.60), and testicular atrophy (RR 0.46; CI 0.17,1.20). Meanwhile, the open inguinal hernia approach seems to perform better for cord seroma complications and testicular pain.

CONCLUSION

There is no advantage of laparoscopic inguinal hernia repair over an open approach concerning sexual dysfunction. On the contrary, there is an increasing risk of cord seroma after laparoscopic inguinal hernia repair with statistical significance.

Self-reported Male Infertility and Metabolic Disturbance: A Cross-Sectional Study

Background

Male infertility is a growing health problem. It is proposed that infertility is associated with some metabolic abnormalities.

Objectives

This study aimed to examine the prevalence of self-reported male infertility and related metabolic disturbances.

Methods

This is a cross-sectional analysis of the Tehran Lipid and Glucose Study (TLGS). A total of 1526 males participated in the study. Logistic regression was used to examine metabolic factors associated with self-reported male infertility.

Results

The total prevalence of self-reported male infertility was 6.42%. The mean (SD) body mass index (BMI) of participants among fertile and infertile males was 26.80 (3.93) and 26.92 (4.36), respectively. The majority of participants in both groups were in the age group of 40-50 years old. In the fully adjusted model, the odds of infertility were significantly increased by each unit increase in total cholesterol [TC; odds ratio (OR), 1.01; 95% CI, 1.01 - 1.01; P = 0.03] and hip circumference (HC; OR, 1.06; 95% CI, 1.00 - 1.12; P = 0.02), respectively.

Conclusions

The prevalence of self-reported male infertility was 6.42%. Male infertility was positively associated with TC and HC, indicating that knowledge about these risks might assist health care professionals and governments in developing and executing measures to change the status quo.

High ligation in adolescents: Is it enough?

BACKGROUND

In adults, the gold standard for surgical repair of an inguinal hernia is a mesh repair, whereas, in children, the standard is high ligation of the hernia sac. However, adolescents represent a "gray zone" between children and adults, and there is no consensus on the most appropriate operation for inguinal hernias in these patients. We aimed to describe the outcomes in adolescents undergoing high ligation for inguinal hernia repair and determine what factors may portend an increased risk of recurrence in this population.

METHODS

A retrospective cohort study was performed of all children that underwent open high ligation for an inguinal hernia at our tertiary children's hospital from January 2000 to January 2018, who were 12 to 18 years old at the time of surgery. We compared the patient demographic data, medical history, and repair characteristics for the cohort of hernias that developed a recurrence to the cohort that did not.

RESULTS

During our study period, 256 adolescent patients underwent repair with 11 of those patients having both sides repaired for a total of 267 hernias repaired. The median age at surgery was 14.7 years, and 83.9% of the hernias were in male patients. There was a 6.0% recurrence rate, and all patients that developed recurrence underwent a reoperation. The median time from surgery to reoperation for recurrence was 3.1 years. Patients with recurrence were more likely to have cardiac (25.0% vs. 5.8%, p = 0.02) and gastrointestinal comorbidities (25% vs. 7.1%, p = 0.01). There were no other significant differences between the two cohorts.

CONCLUSION

High ligation of the hernia sac in adolescents is effective and has an acceptable risk of recurrence while avoiding any additional morbidity that may come from the use of mesh. Patients with cardiac and gastrointestinal comorbidities should be counseled on the higher risk of recurrence.

Contribution of amniotic membrane to the healing of iatrogenic vas deferens injury

Background/aim

Iatrogenic vas deferens injury is one of the most serious complications of operations in the inguinal region. Vasovasostomy is performed as treatment. However, stenosis is common after vasovasostomy. Oligospermia or azoospermia may develop and result in infertility. This study aimed to investigate the effect of amniotic membrane on healing in vas deferens injuries.

Materials and methods

Four groups consisting of 10 rats each were formed. No procedure was performed in Group-I. In Group- II, the left vas deferens was transected and left to spontaneous healing. In Group-III, the left vas deferens was transected, and end- to-end anastomosis was performed. In Group-IV, the left vas deferens was transected, end-to-end anastomosis was performed, and it was closed with a wrapping of amniotic membrane on the anastomosis line. Rats were sacrificed after 60 days, and each left vas deferens was evaluated. Lumen patency was checked by passing methylene blue through the vas deferens. Subsequently, the vas deferens was evaluated both macroscopically and histopathologically. Data were evaluated using SPSS version 21.0. p < 0.05 was considered statistically significant for all variables.

Results

The anastomosis lines in Group-IV healed better than those in Group-III, and less stenosis was observed. There were differences between the groups in terms of luminal patency (p = 0.009), adhesions to surrounding tissues (p = 0.02) and separation of the ends of the vas deferens (p = 0.03).

Conclusion

We observed improvement on luminal patency and histology of rat vas deferens injury after surrounding human amniotic membrane on the transected and repaired surface. Further studies are needed to apply this promising result on human beings.

Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes

The basic principles of vasal reconstruction have endured since their initial description over a century ago, yet the nuances and technical approaches have evolved. Prior to performing vasectomy reversal, the clinician should perform a focused history, physical and laboratory assessment, all of which are critical for patient counseling and preoperative planning. Operative success is contingent on appropriate intraoperative decision making and technical precision in completing a tension-free, watertight, and patent anastomosis. Outcomes of vasectomy reversal differ on the basis of the type of reconstruction required, reconstructive technique, and patient-specific factors. Here we review the indications, surgical techniques, and outcomes of vasectomy reversal.

[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.

A three-arm randomized study to compare sexual functions and fertility indices following open mesh hernioplasty (OMH), laparoscopic totally extra peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair of groin hernia

BACKGROUND

With evolving technology, the focus of groin hernia repair has shifted to sexual function and fertility outcomes.

METHODS

This three-arm randomized study was conducted in tertiary care hospital from 1st July 2017 to 30th March 2019. Consecutive patients of groin hernia were randomized into 3 groups, TAPP (Group 1), TEP (Group 2), and OMH (Group 3). Demographic profile and hernia characteristics were assessed preoperatively. Sexual functions (using BMSFI) and fertility (using surrogate fertility indices, viz., semen analysis and anti-sperm antibodies (ASA)) were assessed preoperatively at 3 months after the surgery.

RESULTS

A total of 121 patients were included in the study with 41 patients in TAPP (Group 1) and 40 each in TEP (Group 2) and OMH (Group3) group. All the 3 groups were comparable in terms of demographic profile, hernia characteristics, intra-operative and early post-operative outcomes. Significant improvement was found in most of the domains of BMSFI score in the study population (p value < 0.001) with no intergroup difference. There was significant increase of anti-sperm antibody level in OMH group as compared to TAPP and TEP (p = 0.001), however, the levels were within normal limit.

CONCLUSIONS

In conclusion, this study has shown that inguinal hernia repair whether open or laparoscopic (TEP or TAPP) leads on to improvement in sexual functions and fertility indices and can have a significant impact on pre-op counseling of the patient in terms of choice of repair, depending on the available expertise in a given center.

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.

Computed tomography options in the evaluation of hernia repair outcomes using "titanium silk" mesh implants

BACKGROUND

According to experimental studies, mesh implants may reduce in size up to 50.8% during their integration into soft tissues. This results in impaired mobility of the anterior abdominal wall and hernia recurrences, as well as affects patients' quality of life. Due to unsatisfactory radiographic contrast of polymeric mesh implants, changes in their size can be rarely confirmed using imaging methods. Medical devices made of metal alloys have the best radiographic contrast.

OBJECTIVE

The purpose of this study was to evaluate the radiographic contrast of mesh implants made of titanium filaments and to determine the sizes and locations of the implants after the anterior abdominal wall hernia repair.

MATERIALS & METHODS

The study included 40 patients with inguinal, umbilical, and postoperative ventral hernias. Surgical hernia repair was performed using a mash implant made of titanium filaments, "titanium silk". Multislice spiral computed tomography (MSCT) was performed on Days 3 and 90 after surgery, followed by an assessment of the size and location of the mesh implant.

RESULTS

90 days after the anterior abdominal wall hernia repair, the locations of the titanium silk mesh implants in the tissues corresponded to their intraoperative setting. There were no statistically significant changes in the sizes of mesh implants on Day 90, compared with Day 3.

CONCLUSION

The titanium silk mesh implants have satisfactory radiographic contrast, which allows imaging of their location and size in the tissues using MSCT and comprehensive evaluation of hernia repair outcomes using instrumental methods of examination.

Laparoscopy-assisted vasovasostomy for post-herniorrhaphy vas deferens obstruction

INTRODUCTION

Repair of obstructive azoospermia caused by childhood herniorrhaphy may be difficult. Therefore, intracytoplasmic sperm injection using testicular sperm is performed. However, vasovasostomy combined with laparoscopic surgery is challenging.

CASE PRESENTATION

A 42-year-old man underwent inguinal hernia repair at age 3. He had normal testicular size, azoospermia, normal hormone levels (follicle-stimulating hormone, luteinizing hormone, and testosterone), absence of Y chromosome micro deletion, and karyotype:46XY, t(1:21)(p34.1:q22.3). He was diagnosed with obstructive azoospermia. Repeated intracytoplasmic sperm injections using testicular sperm resulted in miscarriages. Vasovasostomy combined with laparoscopic surgery was subsequently performed. Postoperative semen analysis result was almost normal. After intracytoplasmic sperm injection of ejaculated sperm, his wife got pregnant.

CONCLUSION

Even if patients have chromosomal abnormalities, performing microsurgical re-anastomosis first is recommended. To our knowledge, this is the first case of a laparoscopy-assisted vasovasostomy for post-herniorrhaphy vas deferens obstruction in Japan.

Crossover transseptal vasovasostomy: alternative for very selected cases of iatrogenic injury to vas deferens

Inguinal herniorraphy is a possible cause of iatrogenic seminal tract obstruction. Diagnosing and correcting these vasal injuries can be challenging. Successful re-anastomosis is technically challenging, with relatively low success rates. An uncommon alternative for selected cases is the crossover transseptal vasovasostomy. We herein report a case of a 36-year-old male patient with vas deferens injury after herniorraphy and a contralateral hypotrophic testis. He was successfully treated through microsurgical crossover transseptal vasovasostomy, with spontaneous pregnancy achieved, and the technique is presented in details.

Effectiveness comparison of a Chinese dicitraditionalmene formula Wuzi Yanzong Pill and its analogous prescriptions for the treatment of oligoasthenozoospermia: A systematic review and meta-analysis protocol

BACKGROUND

Among male sterility factors, oligoasthenozoospermia is the most common. As people's lifestyle changes and the population ages, the incidence of oligoasthenozoospermia continues to increase. The studies have shown that about 15% of married couples in the world are affected by infertility, among which infertility caused by male factors alone accounts for about 50%. Many clinical trials have proven that Wuzi Yanzong Pill has a significant effect in the treatment of oligoasthenozoospermia. In this systematic review, we aim to evaluate the effectiveness and safety of Wuzi Yanzong Pill for oligoasthenozoospermia.

METHODS

We will search for PubMed, Cochrane Library, AMED, EMbase, WorldSciNet; Nature, Science online, and China Journal Full-text Database (CNKI), China Biomedical Literature CD-ROM Database (CBM), and related randomized controlled trials included in the China Resources Database. The time is limited from the construction of the library to April 2019. We will use the criteria provided by Cochrane 5.1.0 for quality assessment and risk assessment of the included studies, and use the Revman 5.3 and Stata13.0 software for meta-analysis of the effectiveness, recurrence rate, and symptom scores of oligoasthenozoospermia.

ETHICS AND DISSEMINATION

This systematic review will evaluate the efficacy and safety of Wuzi Yanzong Pill for treating oligoasthenozoospermia. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process Trial.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42019119170.

Self-fixing parietex progrip versus the standard sutured prolene mesh in tension-free repair of inguinal hernia: effect on testicular volume and testicular blood flow

Our study was conducted to compare self-fixing lightweight polyester mesh (group I) to the standard heavy weight polypropylene mesh (group II) using tension-free Lichtenstein hernioplasty as regard to the effect of mesh implantation and perimesh fibrosis on testicular blood flow. 80 patients with uncomplicated inguinal hernia were divided in two groups. Doppler ultrasonography measured testicular volume, testicular artery velocity preoperative and 3rd month post operative. Blood flow in the testicles was represented by resistive index (RI). No case of testicular atrophy occurred in either group, however, in both groups a significant postoperative decrease in testicular volume (p = 0.001 in group I and p < 0.001 in group II) was accompanied by a significant increase in RI as compared to their pre-operative values (p < 0.001 in group I and p = 0.009 in group II). Comparing the two groups, patients in group I showed higher values of decrease in testicular volume accompanied by more increase in RI values postoperatively compared to group II patients, but these values did not reach a significant value (p = 0.107, p = 0.136). There was a significant increase in the number of post-operative varicocele and hydrocele in group I compared to group II. Mesh implantation has an effect on testicular size and blood flow by decreasing the testicular size and increasing the RI. This effect was more obvious in the parietex progrip. Although there is an indirect relation between RI and the sperm count, testicular blood flow alone is not enough to judge fertility.

Does the use of hernia mesh in surgical inguinal hernia repairs cause male infertility? A systematic review and descriptive analysis

OBJECTIVE

The aim of this study was to systematically review the available clinical trials examining male infertility after inguinal hernias were repaired using mesh procedures.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, and Chinese Biomedical Medicine Database were investigated. The Jada score was used to evaluate the quality of the studies, "Oxford Centre for Evidence-based Medicine-Levels of Evidence" was used to assess the level of the trials, and descriptive analysis was used to evaluate the studies.

RESULTS

Twenty nine related trials with a total of 36,552 patients were investigated, including seven randomized controlled trials (RCTs) with 616 patients and 10 clinical trials (1230 patients) with mesh or non-mesh repairs. The Jada score showed that there were six high quality RCTs and one low quality RCT. Levels of evidence determined from the Oxford Centre for Evidence-based Medicine further demonstrated that those six high quality RCTs also had high levels of evidence. It was found that serum testosterone, LH, and FSH levels declined in the laparoscopic group compared to the open group; however, the testicular volume only slightly increased without statistical significance. Testicular and sexual functions remained unchanged after both laparoscopic transabdominal preperitoneal hernia repair (TAPP) and totally extra-peritoneal repair (TEP). We also compared the different meshes used post-surgeries. VyproII/Timesh lightweight mesh had a diminished effect on sperm motility compared to Marlex heavyweight mesh after a one-year follow-up, but there was no effect after 3 years. Additionally, various open hernia repair procedures (Lichtenstein, mesh plug method, posterior pre-peritoneal mesh repair, and anterior tension-free repair) did not cause infertility.

CONCLUSIONS

This systematic review suggests that hernia repair with mesh either in an open or a laparoscopic procedure has no significant effect on male fertility.

The HerniaSurge Group. International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

A prospective randomized comparison of testicular functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs

BACKGROUND

There is very scant literature on the impact of inguinal hernia mesh repair on testicular functions and sexual functions following open and laparoscopic repair. The present randomized study compares TAPP and TEP repairs in terms of testicular functions, sexual functions, quality of life and chronic groin pain.

METHODS

This study was conducted from April 2012 to October 2014. A total of 160 patients with uncomplicated groin hernia were randomized to either trans-abdominal pre-peritoneal (TAPP) repair or totally extra-peritoneal (TEP) repair. Testicular functions were assessed by measuring testicular volume, testicular hormone levels preoperatively and at 3 months postoperatively. Sexual functions were assessed using BMSFI, and quality of life was assessed using WHO-QOL BREF scale preoperatively and at 3 and 6 months postoperatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year.

RESULTS

The median duration of follow-up was 13 months (range 6-18 months). The mean preoperative pain scores (p value 0.35) as well as the chronic groin pain were similar between TEP and TAPP repairs at 3 months (p value 0.06) and 6 months (p value 0.86). The testicular resistive index and testicular volume did not show any significant change at follow-up of 3 months (p value 0.9) in the study population. No significant difference was observed in testicular resistive index and testicular volume when comparing TEP and TAPP groups at at follow-up of 3 months (p value >0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over the follow-up period following laparoscopic inguinal hernia repair. However, sexual function improvement was similar in patients undergoing both TEP and TAPP repairs. All the domains of quality of life in the study population showed a significant improvement at a follow-up of 3 and 6 months. Subgroup analysis of all the domains of quality of life in both TAPP and TEP groups showed a similar increment as in the study population (p value <0.001); however, the mean scores of all the domains were comparable between the two subgroups (p value >0.05), preoperatively and 3 and 6 months follow-up.

CONCLUSIONS

Laparoscopic groin hernia repair improves the testicular functions, sexual functions and quality of life, but TEP and TAPP repairs are comparable in terms of these long-term outcomes.

Effects of single-port laparoscopic percutaneous extraperitoneal closure on the orientation of the vas deferens and testicular perfusion and volume: Experience from a single center

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and testicular perfusion and volume in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys preoperatively diagnosed with a unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular perfusion and volume of these patients were ultrasonographically assessed preoperatively, one month after surgery and six months after surgery.

RESULTS

The surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, there were no perioperative changes in testicular perfusion or volume.

CONCLUSION

Our experience suggests that the single-port LPEC technique can be safe and effective in pediatric patients with an inguinal hernia and that this technique does not affect the orientation of the vas deferens or testicular perfusion or volume.

Incarcerated Inguinal Hernia Mesh Repair: Effect on Testicular Blood Flow and Sperm Autoimmunity

Background

The aim of our study was to determine an influence of incarcerated inguinal hernia mesh repair on testicular circulation and to investigate consequent sperm autoimmunity as a possible reason for infertility.

Material/Methods

This prospective study was performed over a 3-year period, and 50 male patients were included; 25 of these patients underwent elective open mesh hernia repair (Group I). Group II consisted of 25 patients who had surgery for incarcerated inguinal hernia. Doppler ultrasound evaluation of the testicular blood flow and blood samplings for antisperm antibodies (ASA) was performed in all patients before the surgery, on the second day, and 5 months after. Main outcome ultrasound measures were resistive index (RI) and pulsative index (PI), as their values are inversely proportional to testicular blood flow.

Results

In Group I, RI, and PI temporarily increased after surgery and then returned to basal values in the late postoperative period. Friedman analysis showed a significant difference in RI and PI for all measurements in Group II (p<0.05), with a significant decrease between the preoperative, early, and late postoperative periods. All final values were within reference range, including ASA, despite significant increase of ASA in the late postoperative period.

Conclusions

Although statistically significant differences in values of testicular flow parameters and immunologic sensitization in observed time, final values remained within the reference ranges in all patients. Our results suggest that the polypropylene mesh probably does not cause any clinically significant effect on testicular flow and immunologic response in both groups of patients.

Surgical management of male infertility: an update

Male factor infertility is common, affecting 7% of the total population and up to half of couples who are trying to conceive. Various surgical and reconstructive options allow biological paternity depending on the etiology of the male factor issues. This article describes historical treatments and newer approaches, discussing the role for traditional open surgery, microsurgery and robotic surgery, as well as interventional radiologic procedures in the management of male infertility.

Two-center Analysis of Long-term Outcomes after High Ligation Inguinal Hernia Repair in Adolescents

High ligation of the inguinal hernia sac is standard practice for many pediatric surgeons in post-pubertal adolescents. Most adult surgeons do not use this technique to repair indirect inguinal hernias because of concerns for higher recurrence rates compared with mesh repairs. Therefore, we examined long-term outcomes of adolescent high ligation hernia repair performed by pediatric surgeons. Telephone surveys were conducted on children over 12 years old at the time of repair, and patients and/or their parents were contacted 18 months postrepair. Patients were identified from two institutions between 1998 and 2010. The incidences of reoperation, recurrence, presence of bulge, chronic pain, or numbness were determined. A total of 210 patients (40.7% response rate) were available for phone interviews at 18.6 to 159.5 months postrepair. Mean age was 14.6 ± 1.8 (range: 12.0–19.0 years). Fourteen patients had pain (6.7%) and five had numbness (2.4%). There were four (1.9%) patients with a second operation, two of which confirmed a recurrent hernia. Three patients expressed concern about possible recurrence. Two report a bulge, but have not been evaluated. Pediatric hernia repair with high sac ligation appears effective in patients anatomically similar to adults with low recurrence rate and low incidence of chronic symptoms. These data suggest that prospective trials on the adequacy of high ligation in adults are warranted.

Protective Effect of Royal Jelly on In Vitro Fertilization (IVF) in Male Mice Treated with Oxymetholone

Objective

This study aimed to investigate the effects of royal jelly (RJ) on catalase, total antioxidant capacity and embryo development in adult mice treated with oxymetholone (OXM).

Materials and Methods

In this exprimental study, 32 male and 96 female adult Naval Medical Research Institute (NMRI) mice (7-9 weeks of age) with a ratio of 1:3 for fertili- zation purposes were randomly divided into 4 groups as follows: i. Control group (n=8) receiving 0.1 ml/mice saline daily by gavage for 30 day, ii. RJ group (n=8) treated with RJ at a dose of 100 mg/kg daily by gavage for 30 days, iii. OXM group (n=8) receiving OXM at the dose of 5 mg/kg daily by gavage for 30 days and iv. RJ+OXM group (n=8) receiving RJ at the dose of 100 mg/kg daily by gavage concomitant with 100 mg/kg OXM adminis- tration for 30 days.

Results

Analysis revealed a significant reduction in catalase, total antioxidant, as well as embryo development in OXM group (P<0.05). However, RJ group showed a salient recovery in the all of the above mentioned parameters and embryo toxicity.

Conclusion

The results of this study indicated a partially protective effect of RJ against OXM-induced embryo toxicity.

[Azoospermia and a history of inguinal hernia repair in adult]

BACKGROUND

Inguinal hernia repair is one of the most performed surgeries in the world. It is recognized that any surgery of the pelvic floor may represent a risk factor of male infertility.

METHOD

Retrospective study of patients with azoospermia and a history of adult inguinal hernia repair surgery and referred to our center between January 1990 and January 2011 for infertility.

RESULTS

Among 69 azoospermia patients with history of adult inguinal hernia repair surgery, 60 patients underwent surgical extraction of sperm that was successful in 75% (45/60). Positive extraction rate decreases in the subgroup of patients with risk factors for infertility (61.4%) as well as in the group with bilateral inguinal hernia (67.9%). There was no statistically significant difference in the positive rate of sperm retrieval according to surgical technique or according to the use of polypropylene mesh (P>0.05).

CONCLUSION

The obstruction of the vas deferens due to an inguinal hernia repair was a potential iatrogenic cause of male infertility that was rare and underestimated. The influence of using a polypropylene mesh was not clearly demonstrated. The management of these patients is based on prevention in order to identify patients with risk factors of infertility in order to propose a presurgery cryopreservation of sperm.

LEVEL OF EVIDENCE

5.

Current treatment concepts for groin hernia

PURPOSE

The purpose of this study is to review the latest evidence on operative and perioperative management of patients with groin hernia.

METHODS

A literature review of medical databases was undertaken. Recent scientific evidence provided by quality reports was selected and discussed critically.

RESULTS

The Shouldice repair results in low recurrence rates compared to other tissue reconstructions. However, mesh repairs are superior to tissue reconstruction in terms of recurrence. Lichtenstein's technique remains the gold standard, with low incidence of hernia recurrence and minimal morbidity. Endoscopic techniques have been popularized during the past decades, as alternative approaches to open surgery. Both transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) are effective in the treatment of groin hernia, although the steep learning curve precludes popularization and may account for increased perioperative morbidity.

CONCLUSIONS

Groin hernia surgery remains an evolving field of investigation. Mesh application remains the mainstay of durable results. Individual patient factors and hernia characteristics need to be taken into account when considering the most appropriate surgical practice.

Association of body mass index with some fertility markers among male partners of infertile couples

BACKGROUND

The available evidence on the role of obesity and body mass index (BMI) on male infertility has been controversial or inconclusive to some extent.

OBJECTIVES

The aim of this study was to investigate the role of BMI on some male-fertility laboratory indicators both among infertile and fertile men in an Iranian population.

METHODS AND MATERIALS

A total of 159 male patients who had lived as a partner in an infertile couple for at least 1 year, after regular reproductive activity in their married life, and who sought infertility consultation, were investigated. BMI was assessed, and a morning blood sample was taken assessing serum levels of testosterone, sex hormone-binding globulin, prolactin, luteinizing hormone (LH), follicle-stimulating hormone, and estradiol. Semen-analysis parameters were also measured.

RESULTS

In this study, it was found that the likelihood of oligospermia was increased at higher BMI values. Obese men were found to be 3.5 times more likely to have oligospermia than those with normal BMI. BMI was not found to be associated with mean numeric values of the semen-analysis parameters, including sperm count, sperm morphology, and sperm motility. BMI was not significantly correlated with some hormone levels, such as LH, prolactin, and LH/follicle-stimulating hormone ratio. However, a statistically significant association was observed between BMI and estradiol (P < 0.01), sex hormone-binding globulin (P < 0.001), and also the testosterone/estradiol ratio (P < 0.001). A different pattern of associations in this study was observed when the associations between BMI and sexual hormone levels were compared between fertile and subfertile/infertile men.

CONCLUSION

The association explored between BMI and some sexual hormones and semen characteristics, as well as different patterns of this association between fertile and subfertile/infertile men, will be of help to broaden our understanding of the effect of obesity on some male reproductive physiologic characteristics among fertile and infertile men.