Analiza zmian objętości jąder po zabiegu chirurgicznym przepukliny pachwinowej metodą PIRS – prospektywne badanie pilotażowe

Introduction

The laparoscopic approach is a widely accepted method of treatment for inguinal hernias in the paediatric population [1–5]. One of the techniques is a minimally invasive, video-assisted, percutaneous inguinal ring suturing (PIRS) introduced by Patkowski [6–8]. This method consists of percutaneous closure of the internal inguinal ring with a non-absorbent suture under laparoscopically guided vision.
Whatever the operative method used, one of the potential postoperative complications in boys is testicular atrophy. Iatrogenic injury to the spermatic cord leading to testicular atrophy occurs in 0.1–1.2% of cases [9–11]. The risk of atrophy is higher in cases of incarcerated hernias [9, 11, 12].

Aim of the research

The aim of our study was to evaluate the effect of the inguinal hernia repair using the PIRS method on the testicular volume of the affected and contralateral side.

Material and methods

A prospective study evaluating the changes in the volume of the testicles after unilateral inguinal hernia repair using the PIRS method was conducted in the Department of Paediatric Surgery, Urology, and Traumatology in the Regional Hospital in Kielce between 1 January 2016 and 20 May 2019. Inclusion criteria for the study were as follows: age 0–18 years, male gender, presence of unilateral inguinal hernia confirmed intraoperatively (closed contralateral processus vaginalis). Patients were excluded from the study if the hernia was bilateral, had undescended testes, hydrocele, or other anomalies of the testicles, and if there was a history of past procedures on the testicles or history of orchitis and/or epididymitis.

Study design

The study protocol included the preoperative and postoperative ultrasonographic evaluation of both testicles. Ultrasound exam was completed one day before or on the day of the surgery. Both testicles were measured in 3 dimensions, and volumes were calculated. The follow-up exam was done not earlier than 2 months after surgery. The team of radiologists performing the ultrasound was highly experienced in evaluating paediatric patients with urological conditions. The same high-resolution ultrasound machine and the same diagnostic protocol of scanning was used for all exams. All surgeries were performed by one surgeon who was highly experienced in the PIRS method. Surgeries were either scheduled as elective or performed as an emergency operation if the hernia was incarcerated.
Informed consent for the ultrasound scan and surgical procedure was obtained from the guardian of the patient in all cases. The study was approved by the institutional research committee (Jan Kochanowski University Research Ethics Board, no. 12/2016) and was performed according to the guidelines of the Declaration of Helsinki.

Statistical analysis

Statistical analyses were performed using Statistical Package Statistica software (version for Windows 13.1 TIBCO Software Inc. – StatSoft, Poland). The results were presented in the form of the distribution, frequency, and median. The interquartile range of the studied variables was presented. The normality of the distribution of the studied variables was tested using the Shapiro-Wilk test. Differences between the groups under study were verified using the nonparametric Wilcoxon test and the Kruskal-Wallis test. Spearman’s rank correlation coefficient was used to establish the relationship between age and volume before and after the procedure. The significance level was set at  = 0.05.

Results

Twenty-nine patients qualified for the study. The median follow-up was 28 months (IQR = 17 months). The age distribution, location of the hernia (left or right), and the type of surgery in the study population are presented in Table 1. There were 9 (31.03%) patients less than one year old, 12 (41.38%) between the ages one and 4 years old, and 8 (27.59%) in the range of 4 to 8 years of age. In the studied group there were no patients over 8 years of age. There were 6 cases of left inguinal hernia repair (LIHR) and 23 cases of right inguinal hernia repair (RIHR). In 4 cases, 3 in a right- and one in a left-sided hernia, surgery was performed as an emergency procedure because of incarceration.
There was no statistically significant difference between the volume of the right testicle before and after surgery (p = 0.404). For the left testicle the results were similar, i.e. the difference in volume before and after surgery was not statistically significant. Total testicular volumes before and after surgery were also not statistically significantly different (Table 2, Figure 1).
Volume of the testicle contralateral to the operated side was also analysed. For both LIHR and RIHR the difference between the volume of the testicle before and after surgery was not statistically significant, with p = 0.978 for LIHR and p = 0.726 for RIHR (Table 3, Figures 2, 3).
Emergency operation due to the incarcerated hernia on either side did not statistically significantly affect the testicular volume in the tested group of patients (Table 4).
Nonetheless, a decrease in the right testicular volume after the operation was observed. The median testicular volume decreased by 0.07 ml, which was not statistically significant (p = 0.273). The median left testicular volume after emergency surgery due to the incarcerated hernia decreased after surgery by 0.03 ml. This difference was not statistically significant (p = 0.715) (Table 4).
Analysis of the data for the group of patients in which surgery was performed as an emergency procedure because of incarceration showed that for the operated side the testicular volume increased slightly after surgery, but the difference was not statistically significant. For the contralateral side the median testicular volume also increased slightly after surgery, but again the difference was not statistically significant (Table 5).
For the group of patients operated electively the results were similar. The median testicular volume increased slightly after surgery for both the ipsilateral and contralateral side, but the difference did not reach statistical significance (Table 6).
There is a significant statistical relationship between age and testicular volume, after surgery [ml] (p = 0.029, r = 0.407). However, no statistically significant correlation was found between age and age and left testicular volume, after surgery [ml] (p = 0.056, r = 0.353).
There were no reported complications in the study group after surgery and no recurrences.

Discussion

According to literature reports, inguinal hernia and hydrocele testis with open processus vaginalis are associated with worse testis development on the affected side. However, one of the known complications of inguinal hernia repair is testicular atrophy. Testicular ischaemia also might result from an incarcerated inguinal hernia.
Dandapat et al. provided similar results [13]. Patients with big unilateral hydrocele of the tunica vaginalis testis have been studied for the effect on the testis’ structure and function, taking the contralateral side as a control. In 70% of cases, there was no pressure effect from the hydrocele on the structure of the testis, although there was a flattening of testis in 22% and testicular atrophy in 8% of cases. Also, it was detected that in 10%, there was partial and in 8% of cases there was total arrest of spermatogenesis. The remaining 82% showed normal spermatogenesis [13]. In the study of Gurbulak, patients with unilateral inguinal hernia were operated on with the TEP method (64 cases) and the Lichtenstein procedure (70 patients). Both groups had no detected differences in vascular flow or testicular volume before and after the surgery [14].
A study of the influence of unilateral hydrocele testis on the volume of affected testis and resistive and pulsatility index of intratesticular arteries of both sides was presented by Mihmanli et al. [15]. The authors showed significant differences in the testicular volumes before and after surgery on the operative and contralateral sides. After hydrocelectomy, there was a 21% mean decrease in the affected testis volume. There were also statistically significant differences in intratesticular arteries’ resistive and pulsatility index on the operated side [15].
The analysis of 44 surgeries on adult patients compared Doppler flow parameters for the preoperative period, day one, and the early postoperative (day 7) period. There were 29 patients operated by open approach and 15 by laparoscopic approach. The study did not show any statistically significant differences between the 2 groups. The authors also compared Doppler flow parameters of the testicular artery in which statistically significant differences were found between preoperative and very early postoperative values. The flow parameters of the testicular, capsular, and intratesticular arteries of the laparoscopic group showed statistically significant differences between preoperative and very early postoperative values [16].
In Parelkar’s study, laparoscopic inguinal hernia repairs were performed using 3 ports in males. There were 100 cases, 75 of whom had a unilateral hernia. The analysis showed that there were no significant differences between preoperative and late postoperative volumes of testis on the operated side [17].
Another study on paediatric patients with unilateral inguinal hernia compared the testicular volume of the affected and healthy sides. The analysis was performed on 173 boys aged 0–179 months operated with an open approach. There was 1 case with a 50% drop in the testicular volume. However, no significant difference in testicular volume was found [18].
A similar study was done by Adaletli et al. in children [19]. This study showed a decrease in testicular volume in 15% of patients after unilateral communicating hydrocelectomy compared to the contralateral side. However, there was no significant difference in the testicular volume of the side without hydrocele [19].
It was observed that surgical manipulations during inguinal hernia repair in children cause transient changes in vascularization of the testes in the early postoperative period; however, late postoperatively it returns to normal [20].
A study by Schier included 65 boys (52 with unilateral inguinal hernia) operated with a laparoscopic approach. During the analysis, 4 parameters were measured 10 times each. First, oxygen saturation at the venous end of the capillaries was checked, where values of less than 10% indicated hypoxia. Second, the amount of haemoglobin within microvessels was measured. Values less than 20 patients indicated reduced perfusion. Third, the blood flow within microcirculation was controlled, and values of less than 5 patients were considered critically low. Last, the velocity of the blood in microcirculation was calculated. The authors, after meticulous calculations, concluded that laparoscopic inguinal hernia repair using suture closure of the internal ring does not impair testicular perfusion [21].
An analysis similar to our study was presented by Tuncer et al. on 23 cases. The authors presented results in which preoperative testicular blood flow in the right testicle was significantly reduced in patients with right-sided pathologies compared to the left testicle. In contrast, there was no statistically significant difference in postoperative early and late testicular blood flow for right and left testicle comparison. In our study, the blood flow was not measured quantitatively, only volumes. However, the testicle volume is derived from the blood flow within the testicle.
When preoperative, early postoperative, and late postoperative testicular volumes and blood flow of the testes with a pathological condition were compared using the Friedman test, there was no statistically significant difference in testicular blood flow (p > 0.05 in all groups). A slight increase in testicular blood flow in the pathological testes during the early postoperative period returned to normal during subsequent postoperative measurements; however, this difference was not statistically significant [22].
In the literature, many studies show testicular ischaemia after incarcerated inguinal hernias. In the study by Ozdamar et al. [23] there were 738 male patients treated for inguinal hernia, and 44 of them had incarcerated hernias. Emergency surgery was required for 16 patients due to irreducible hernias. Consequently, in 9 cases, testicular ischaemia and haemorrhagic necrosis were observed. Testicular ischaemia was found more in younger children with a longer duration of incarceration. Among patients with incarcerated hernias, 20% of testicular ischaemia was noted, and children with irreducible hernias raised the proportion to 56% of patients. In 2 patients postoperative testicular atrophy occurred [23].
A recent study was conducted on 2184 children who underwent inguinal hernia repair. There were 24 cases noted with irreducible incarcerated hernias. There was 1 case of sonographic-identified testicular atrophy in this group 6 years after the surgery [24].
Turgut et al. [25] presented a study on the incidence of acute testicular ischaemia in 147 patients with incarcerated inguinal hernias. The authors reported that 6.8% of cases had a decrease or absence of testicular blood flow. Testicular ischaemia incidence was high in children younger than 6 months (20% of cases). Testicular size did not significantly differ between the ipsilateral and contralateral sides for patients without disrupted testicular blood flow. Unlike in cases with testicular ischaemia, testicular size increase was noted for the testicle ipsilateral to the inguinal hernia (p = 0.012) [25].
Inguinoscrotal hernias are associated with testicular infarction and might cause male infertility [26]. Sonderman et al. analysed the TRICARE database in a large retrospective study, including more than 3 million children. Of 69,682 patients who underwent inguinal hernia, 8897 met the inclusion criteria for the study. There were 18 patients with testicular atrophy, and consequently orchiectomy was performed in 11 cases. Authors reported that all patients who developed testicular atrophy were aged 5 years or less, while 72% were under 13 months old. It was noted that an undescended testis was a significant factor in developing testicular atrophy [9].
The study of Mishra et al. [27] showed similar results in which, after incarcerated inguinal hernia, testicular atrophy occurred in 1 patient after laparoscopic reduction (3.7% of patients) and 1 after open surgery (2.2% of patients).
However, Esposito et al. [11], in 46 patients operated due to incarcerated inguinal hernia, did not report testicular atrophy. Similarly, Gokcora et al. [28] did not observe any testicular atrophies during 6 years of follow-up after surgical treatment of inguinoscrotal pathologies.
In another study, Chen et al. [29] emphasized the significant correlation between prolonged waiting time of patients with incarcerated inguinal hernias and a higher rate of complications.
The findings of this study must be considered in light of some limitations. First, this is a small single-centre study; therefore, the composition of the catchment population potentially limits the generalisability of our results. Because we based our predictions on a dataset, we should take into account that past performance is no guarantee of future results. Second, sonographic examination and, consequently, testicular volume measurements are operator-dependent, even though in our study the examinations were performed by radiologists specializing in children’s care following the same protocol.

Conclusions

Regardless of laparoscopic inguinal hernia repair on the left or right side, the testicular volume did not decrease on the ipsilateral or on the contralateral side. Testicular volume change was not affected by the type of surgery: elective or emergency. Testicular volume change was not affected by the age of patients at the time of surgery.

Acknowledgments

This work was supported by the program of the Minister of Science and Higher Education under the name “Regional Initiative of Excellence” in 2019-2022, project number: 024/RID/2018/19, financing amount: 11.999.000,00 PLN.

Conflict of interest

The authors declare no conflict of interest.

References