Male genital tract injuries after contemporary inguinal hernia repair

Transcription

1 BJU International (2002), 90, REVIEW Male genital tract injuries after contemporary inguinal hernia repair P.F. RIDGWAY, J. SHAH and A.W. DARZI Department of Surgical Oncology and Technology, Imperial College Faculty of Medicine, St Mary s Hospital, London, UK Introduction Inguinal hernia repair is a common disorder affecting 5% of the male population [1]. Moses Maimonides ( ), a Jewish philosopher, practised medicine in several parts of the Arab empire. He wrote widely on the subject and mentions the treatment for a hernia: one takes two measures of juniper nuts, one measure of its leaves, two zuzim of fresh canary grass, and one measure of acacia. One kneads this out while it is still warm on a cloth and places this on the hernia at the time the patient comes out from a steam bath on an empty stomach, and he lies down on his back. On the cloth, one places padding and wrappings. He should sleep on his back until the compress dries. One renews this for 40 days [2]. Edward Bassini originally described the basis of the current open method of inguinal herniorraphy more than 100 years ago [3]. Many modifications have been made to this procedure in the interim, with varying degrees of efficacy [4]. The advent of minimally invasive techniques and synthetic mesh repairs heralded a major change in strategies for herniorrhaphy in recent years. Laparoscopic inguinal hernia repairs are associated with less postoperative pain than open repairs and an earlier return to normal levels of activity [5]. However, acceptance of this technique has been limited, principally because of the increased expense, duration and technical complexity of the procedure. Indeed, initial complication rates were high and reflected the experience and training needed by the surgeon [6 8]. Added to this is a general acceptance of traditional open repair by the public and therefore its adoption by the surgical community has not mirrored the rapid adoption of laparoscopic approaches to cholecystectomy [9]. Despite these problems, many reported benefits, e.g. reduced operating time, have increased the use of minimally invasive techniques in synchronous bilateral inguinal herniorrhaphy [10]. This has implications in considering genital tract injury; unilateral injuries may go unnoticed and Accepted for publication 12 April 2002 therefore under-reported, whereas bilateral injuries may manifest as deficiencies in fertility in later life. In addition, the long-term effect of mesh, whether placed by laparoscopic or open methods, is unknown. The lower recurrence rate associated with synthetic mesh repairs is facilitated by the fibrosis by which the mesh is anchored. Because it is placed close to the spermatic cord, it is possible that this may cause vas deferens dysfunction after surgery. The body of published evidence about the incidence of genital tract injuries is derived primarily from fertility and microsurgical reconstruction studies. Putative mechanisms of iatrogenic genital tract injury in adults after hernia repair are predominately derived from small series and anecdotal reports. Indeed, much of the data available relates to open herniorraphy and therefore laparoscopic issues must be extrapolated. At present, the incidence, mechanisms and implications of these occurrences are unclear. The objective of this review is to elucidate the incidence and putative mechanisms of genital tract injuries in laparoscopic herniorrhaphy and place them into the context of current and future treatment strategies. Anatomy The complex functional anatomy involved in the myopectineal defect that permits herniation is not easily visualized in anterior open approaches to hernia repair. In this instance, mesh placed using a laparoscopic approach may be more accurate, resulting in fewer recurrences [5,11]. The difficulty in identifying important structures to be avoided during laparoscopic suturing, stapling and mesh placement was identified as early as 1991 by Spaw et al. [12], who documented the laparoscopic appearance of the genital tract as unfamiliar to most surgeons; hence the potential for complications is high. These authors also described the triangle of doom as the area between the testicular vessels, vas deferens and the internal ring (Fig. 1). This finding was further clarified by O Malley et al. [13]; in this cadaveric 272 # 2002 BJU International

2 MALE GENITAL TRACT INJURIES AFTER INGUINAL HERNIA REPAIR 273 a b Fig. 1. Photographs of: a, a laparoscopic hernia repair where the inferior flap has been mobilized off the vas deferens and the gonadal vessels. The triangle of doom is shown; b, the anatomy of a laparoscopic hernia repair. study, the authors measured the angle between the vas deferens and testicular vessels as they converge on the medial margin of the deep inguinal ring, and the thickness of tissue lateral to the deep inguinal ring where staples are most likely to be placed. They concluded that appreciating these measurements may be useful in the intraoperative prediction of the position of the vas deferens and external iliac vessels. Other anatomical studies in children have been conducted but these are not readily transferable to the adult clinical situation [14]. Mechanisms of injury There are two putative mechanisms involved in genital tract injury, i.e. transection and compression. Transection-related injury accounts for <25% of iatrogenic vasal injuries [15]. This form can be recognized during surgery and therefore an opportunity for immediate reconstruction can be offered in suitable centres. Compression-type injury usually has a delayed presentation and diagnosis unless there is a concomitant nerve injury producing neuralgia or a vascular injury to the gonads. If no associated injury occurs, then presentation is usually delayed, manifesting as malefactor infertility. Although bilateral repair is primarily causative, iatrogenic unilateral injury been implicated in infertility in its own right when any contralateral genital tract deficiency is present [15]. The compression-type injury to the genital tract may be caused by handling of the vas intraoperatively, tight placement of the mesh arms around the cord, or the induced delayed fibrosis of the mesh, which may involve the cord structures secondarily. The sequelae of direct crushing injury during inguinal surgery to the vas deferens has been investigated in a rat model [16]. The results of that study showed a significant difference in patency rates among three groups subjected to three operative manipulations (digital compression for 45 s, clamped for 2 s and clamped for 2 min), suggesting that the degree of manipulation is important for the outcome [16]. Mesh limb encroachment usually affects more than one cord structure. Weber-Sanchez et al. [17] reported a case of a 52-year-old man who presented with left testicular pain 7 days after a laparoscopic bilateral hernia repair in Laparoscopic exploration showed that the mesh limbs enveloped the spermatic cord, thereby compressing the genital branch of the genitofemoral nerve. Neurotomy was performed and the patient was pain-free at the 1-year follow-up. Kavic [18] documented the early experience of 224 laparoscopic herniorrhaphies in 1995 and reported one patient with postoperative cord swelling (0.4%). The implication of this swelling and the consequences are not discussed, although compression injury was the most likely cause. Ischaemic orchitis is another injury that has been described after inguinal hernia repair; this is primarily caused by compression. Intraoperative manipulation and postoperative encroachment by fibrosis associated with the repair are the major causes. One study showed a 0.6% incidence of ischaemic orchitis in primary open hernia repairs [19] and others documented a 0.08% incidence after laparoscopic repair [20]. This increased to 5% in recurrent hernia repairs and is probably related to cord mobilization and recognition of anatomy. This is supported by the observations of Nyhus et al. [21], that testicular atrophy in open hernia repairs occurred less often when the cord was mobilized proximally (as in the Cheatle-Henry PP approach) as there is less trauma to the blood supply and pampiniform plexus of the testis. Although this has undoubted relevance in open repairs, it is less of a consideration in intra-abdominal laparoscopic approaches. There are immunological considerations in obstructive male-factor infertility. The role of antisperm antibodies

3 274 P.F. RIDGWAY et al. has not been fully elucidated in patients after herniorrhaphy. One study showed no significant increase in serum antibody levels with other nonspecific manipulations of the cord in 96 infertile men, but documented increased levels in those patients who had obstructive azoospermia from previous vasectomy [22]. The emergence of the antibodies may be a late-phase response to the obstruction and therefore can be taken as a surrogate for prolonged genital tract blockage. Incidence Experience from open paediatric inguinal procedures suggests an incidence of iatrogenic injury to the vas deferens of % [15]. The observation by Wantz [19], that bilateral open hernia repair in children is associated with subsequent azoospermia in 2% of all cases, seems to lend credence to this. The incidence of unilateral vas deferens obstruction in subfertile men with a history of paediatric inguinal hernia repair is reported to be as high as 27.8% [23]. Moreover, more than half of patients with vasal obstruction caused by infant inguinal hernia repairs have serum antisperm antibodies and oligozoospermia [24,25]. Yavetz et al. [26], in a large series from Tel Aviv, surveyed 8500 men attending for infertility and reported that 565 (6.5%) after herniorrhaphy had poorer sperm quality and increased serum FSH levels (reflecting increased Sertoli cell function) than fertile men. The incidence rates for genital tract injury after laparoscopic herniorrhaphy are less clear. The largest series (3229 men) assessing complications of patients undergoing laparoscopic inguinal hernia repair did not discuss vas deferens injuries [9]. Thirty-one patients (1%) had testicular tenderness after surgery, suggesting a compromised cord, although this was transient and there were no reported cases of testicular atrophy. In that study the follow-up was limited and it is therefore difficult to draw definite conclusions. Liem et al. [5] randomized 487 patients with inguinal hernias to an extraperitoneal laparoscopic hernia repair and 507 patients to conventional anterior repair. The authors documented two vas deferens injuries, one each in the conventional open treatment and laparoscopic groups. The authors did not discuss the cause or diagnosis of the injuries, but the injuries were presumed to be transectional, in view of the limited follow-up. Notably, three additional cases of epididymitis were seen in the laparoscopic group, but once again there were no comments about the cause of this complication. There is no clear incidence rate published for laparoscopic injury to the vas deferens during herniorrhaphy. This is partly because of the extended interval between occurrence and diagnosis, and that laparoscopic hernia repair is a relatively recent procedure. The incidence at present can only be extrapolated from testicular injuries, spermatic cord injuries and genitofemoral neuralgia to be possibly <1%. Only a longer follow-up of these patients will confirm the actual value. Treatment strategies Iatrogenic injuries to the vas deferens are often associated with a long obstructive interval, frequent secondary epididymal obstruction, an unpredictable length of occlusion and possible obliteration of normal anatomy [15]. Vasovasostomy and vaso-epididymostomy are commonly used to bypass obstructions in the male genital tract, including those that are iatrogenic. Vasovasostomy is indicated if the obstruction is at the level of the vas deferens, whereas an obstruction at the epididymis necessitates a vaso-epididymostomy. These techniques are not new; the first report of a vasoepididymostomy to relieve an obstructed epididymis was made in 1903 [27]. At that time, fine silver wires were used for the anastomosis and this technique was used for almost 75 years. Advances in technology and magnification allowed the direct anastomosis of a single epididymal tubule to the mucosa of the vas deferens. The precise alignment in this technique resulted in improved fertility rates [28]. The first vasovasostomy, reported in 1919, used a strand of silkworm gut that was later removed. The success of vasal anastomosis was revealed by a survey that was carried out in 1948; 18% of urologists had performed at least one vasal anastomosis, with a reported success rate of 40% [29]. In 1977, Silber [30] introduced a two-layered microsurgical vasal anastomosis and reported an overall pregnancy rate of 71% and patency rates of up to 94%. He stated that three factors were important for the return of fertility after vasovasostomy; meticulous technique, the duration that the vas was obstructed, and the presence of a sperm granuloma at the site of the obstruction, suggesting that good quality sperm was present in the vasal fluid at the time of reconstruction. These three factors are still regarded as important predictors of surgical outcome; the duration of vasal obstruction is regarded as the most important. A study of 1469 patients by the Vasovasostomy Study Group reported that if the interval was <3 years, the patency rate was 97% and the pregnancy rate 76%. In contrast, in men who had had the obstruction for >15 years, the rates were 71% and 30%, respectively [31]. Although there is no reported difference in patency or pregnancy rates when comparing one-layered or twolayered microsurgical closures, the pregnancy rate decreases to 30 50% when no magnification is used

4 MALE GENITAL TRACT INJURIES AFTER INGUINAL HERNIA REPAIR 275 (macrosurgical vasovasostomy) [32]. After vasoepididymostomy, the patency rate and pregnancy rate can be up to 85% and 44%, respectively [33]. Many of the iatrogenic injuries to the vas deferens correspond to the area of the original surgery, and until recently an open incision through the scar usually allowed access to the site of the injury. With the use of laparoscopy for the actual herniorrhaphy, it is also increasingly being used in the re-operation of patients, although at present published reports are few. Laparoscopy has been used successfully to relieve genitofemoral neuralgia and in a case of spermatic cord entrapment [17,34]. Laparoscopy allows visualization of structures, location of the lesion, facilitates neurectomies and removal of the prosthesis or staples with minimal tissue damage [17]. Another change in the management of patients with genital tract injuries has followed the development of sophisticated assisted-reproductive techniques, e.g. intracytoplasmic sperm injection (ICSI). This has called into question the role of surgical bypass procedures. ICSI was first introduced in 1992 and has since revolutionized the management of male infertility [35]. To date, recorded patency rates and pregnancy rates suggest that efforts to reconstruct iatrogenic injuries are worthwhile. Surgical reconstruction appears to be safer when concerns about ovarian hyperstimulation syndrome are considered, and they offer an economic advantage over ICSI; the cost per newborn for ICSI was $51 024, compared with $ for vaso-epididymostomy [33]. The future of repair and reconstruction of iatrogenic genital tract injuries is likely to lie in robot-assisted techniques. The master-slave robot system (e.g. the da Vinci system, Intuitive Surgical Inc., Mountain View, CA, USA) has been used in many different surgical specialities. When used for tubal anastomoses the patency rate and pregnancy rates were 89% and 50% at 6 weeks, with no complications. The technology not only magnifies the surgical field but eliminates fine tremor, and thus micro-anastomoses can be made more accurately. In time it will be adopted for genital tract reconstructions [36] to improve the pregnancy rates of 39% after conventional treatment for iatrogenic vasal injury [15]. Conclusions Inguinal hernia repair is a common procedure; the advent of laparoscopic and mesh repair techniques have heralded several improvements in recurrence rates and perioperative discomfort. The effect of inadvertent urological tract injury has not been clarified, although the emerging evidence suggests at least parity with open techniques [5]. Further assessment of mesh repair techniques, which induce fibrosis adjacent to the spermatic cord, needs to be considered. The use of mesh for hernia repairs in young men who have not completed their reproductive goal is a subject requiring urgent investigation. References 1 Maingot R. Operations for Inguinal Hernia. New York: McGraw-Hill, Rossner F, Munter S. The Medical Aphorisms of Moses Mainmonides. New York: Yeshiva University Press, Bassini D. Nuovo metodo per la cura radicale dell ernia inguinale. Padua: R Stabilimento Prosperini, Danielsson P, Isacson S, Hansen MV. Randomised study of Lichtenstein compared with Shouldice inguinal hernia repair by surgeons in training. Eur J Surg 1999; 165: Liem MS, van der Graaf Y, van Steensel CJ et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997; 336: Crawford DL, Phillips EH. Laparoscopic repair and groin hernia surgery. Surg Clin North Am 1998; 78: Quilici PJ, Greaney EM Jr, Quilici J, Anderson S. Laparoscopic inguinal hernia repair: optimal technical variations and results in 1700 cases. Am Surg 2000; 66: Schultz C, Baca I, Gotzen V. Laparoscopic inguinal hernia repair. Surg Endosc 2001; 15: Phillips EH, Arregui M, Carroll BJ et al. Incidence of complications following laparoscopic hernioplasty. Surg Endosc 1995; 9: Krahenbuhl L, Schafer M, Schilling M, Kuzinkovas V, Buchler MW. Simultaneous repair of bilateral groin hernias: open or laparoscopic approach? Surg Laparosc Endosc 1998; 8: Leibl BJ, Schmedt CG, Ulrich M, Kraft K, Bittner R. Laparoscopic hernia repair the facts, but no fashion. Langenbecks Arch Surg 1999; 384: Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg 1991; 1: O Malley KJ, Monkhouse WS, Qureshi MA, Bouchier- Hayes DJ. Anatomy of the peritoneal aspect of the deep inguinal ring: implications for laparoscopic inguinal herniorrhaphy. Clin Anat 1997; 10: Chin T, Liu C, Wei C. The morphology of the contralateral internal inguinal rings is age-dependent in children with unilateral inguinal hernia. J Pediatr Surg 1995; 30: Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol 1998; 159: Abasiyanik A. The effect of iatrogenic vas deferens injury on fertility in an experimental rat model. J Pediatr Surg 1997; 32: Weber-Sanchez A, Garcia-Barrionuevo A, Vazquez-Frias JA, Cueto-Garcia J. Laparoscopic management of spermatic cord entrapment after laparoscopic inguinal herniorrhaphy. Surg Laparosc Endosc Percutan Tech 1999; 9: Kavic MS. Laparoscopic hernia repair. Three-year experience. Surg Endosc 1995; 9: 12 5

5 276 P.F. RIDGWAY et al. 19 Wantz GE. Complications of inguinal hernial repair. Surg Clin North Am 1984; 64: Vanclooster P, Smet B, de Gheldere C, Segers K. Laparoscopic inguinal hernia repair: review of 6 years experience. Acta Chir Belg 2001; 101: Nyhus LM, Pollak R, Bombeck CT, Donahue PE. The preperitoneal approach and prosthetic buttress repair for recurrent hernia. The evolution of a technique. Ann Surg 1988; 208: Gubin DA, Dmochowski R, Kutteh WH. Multivariant analysis of men from infertile couples with and without antisperm antibodies. Am J Reprod Immunol 1998; 39: Matsuda T, Horii Y, Yoshida O. Unilateral obstruction of the vas deferens caused by childhood inguinal herniorrhaphy in male infertility patients. Fertil Steril 1992; 58: Matsuda T, Muguruma K, Horii Y, Ogura K, Yoshida O. Serum antisperm antibodies in men with vas deferens obstruction caused by childhood inguinal herniorrhaphy. Fertil Steril 1993; 59: Parkhouse H, Hendry W. Vasal injuries during childhood. Br J Urol 1991; 67: Yavetz H, Harash B, Yogev L, Homonnai ZT, Paz G. Fertility of men following inguinal hernia repair. Andrologia 1991; 23: Martin E, Carnett J, Levi J. The surgical treatment of sterility due to obstruction at the epididymis. Together with a study of the morphology of human spermatozoa. Med Bull Univ Pennsylvania 1903; 15: 2 28 Silber S. Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril 1978; 30: O Connor V. Anastomosis of the vas deferens after purposeful division for sterility. JAMA 1948; 136: Silber S. Microscopic vasectomy reversal. Fertil Steril 1977; 28: Belker A, Thomas A. Results of 1469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991; 145: Belker A. Urologic microsurgery current perspectives. I. Vasovasostomy. Urology 1979; 14: Kolettis P Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol 1997; 158: Perry C. Laparoscopic treatment of genitofemoral neuralgia. J Am Assoc Gynaecol Laparosc 1997; 4: Palermo G, Joris H, Devroey P. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet 1992; 340: Falcone T, Goldberg J, Margossian H, Stevens L. Roboticassisted laparoscopic microsurgical tubal anastomosis: a human pilot study. Fertil Steril 2000; 73: Authors P.F. Ridgway, Clinical Research Fellow. Jyoti Shah, Clinical Research Fellow & Urology SpR. A.W. Darzi, Professor of Surgery. Correspondence: Miss Jyoti Shah, Department of Surgical Oncology and Technology, Imperial College Faculty of Medicine, St Mary s Hospital, 10th Floor, QEQM Building, Praed Street, London W2 1NY, UK. jyoti.shah@ic.ac.uk Abbreviation: ICSI, intracytoplasmic sperm injection.