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

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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, NCT 05799742. Enrollment of the first subject in January 2016.

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Data availability

All individual participant data that underlie individual participant data that underlie collected during the trial, after deidentification (text, tables, figures, and appendices) will be shared. Study Protocol also will be available. Data will be available immediately following publication, no end dates, to anyone who wishes to access the data, for any types of analyses. Proposals should be directed to sergio.damous@hc.fm.usp.br.

Abbreviations

USG:

Doppler ultrasound

FSH:

Follicle stimulating hormone

TAPP:

Laparoscopic transabdominal preperitoneal

HC/FMUSP:

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

CAPPesq:

Ethics Committee for the Ansalysis of Research Projects

RCT:

Randomized clinical trial

DCC-III:

Division of Clinical Surgery-III

PO:

Postoperatively

QoL:

Quality-of-life

VAS:

Visual analog scale

PF:

Physical function

PR:

Physical role

ER:

Emotional role

EN:

Energy

EH:

Emotional health

SF:

Social functioning

BP:

Bodily pain

GH:

General health

TEP:

Totally extraperitoneal-preperitoneal

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Acknowledgements

We thank Toshiko Oya for help with data collection.

Funding

Supported by (1) Fundação de Amparo à Pesquisa do Estado de SãoPaulo (FAPESP) for project support (Process Number 2015/08472-4) and Scientific Initiation Scholarships (2020/05993-1); and (2) Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Programa Institucional de Bolsas de Iniciação Cientifica (PIBIC) 2020/2021, Scientific Initiation Scholarships.

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Authors and Affiliations

  1. 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

    Sérgio Henrique Bastos Damous, Jocielle dos Santos Miranda, Cláudio Augusto Vianna Birolini & Edivaldo Massazo Utiyama

  2. 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

    Luciana Lamarão Damous

  3. Postgraduate Program in Health Sciences, Instituto de Assistência Médica do Servidor Público Estadual (IAMSPE), São Paulo, Brazil

    Luciana Lamarão Damous

  4. Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil

    Victor André Borges & Amanda Karsburg Fontella

  5. Postgraduate Program in Health Sciences, IAMSPE and Laboratory of Medical Investigation 51 (LIM-51), University of São Paulo, São Paulo, Brazil

    Marcia Kiyomi Koike

  6. Instituto de Radiologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC/FMUSP), São Paulo, Brazil

    Osmar Cássio Saito

Authors
  1. Sérgio Henrique Bastos Damous
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  9. Edivaldo Massazo Utiyama
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Contributions

SHBD: participated in study conception and design, execution, manuscript drafting and critical discussion; LLD: participated in study conception and design, data analysis, critical discussion and revised the article critically for important intellectual content; VAB and AKF: participated in study execution and data collection; JSM and CAVB: participated in study execution and critical discussion; MKK: participated in data analysis, revised the article critically for important intellectual content and final approval of manuscript; OCS: participated in data collection and analysis and critical discussion; EMU: study conception and design, critical discussion, and final approval of manuscript.

Corresponding author

Correspondence to Sérgio Henrique Bastos Damous.

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Disclosures

Sergio Henrique Bastos Damous, Luciana Lamarão Damous, Victor André Borges, Amanda Karsburg Fontella, Jocielle dos Santos Miranda, Marcia Kiyomi Koike, Osmar Cássio Saito, Cláudio Augusto Vianna Birolini and Edivaldo Massazo Utiyama have no conflicts of interest or financial ties to disclose.

Ethical approval

This study was ethically approved by The Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015 and was registered at Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT 05799742. Enrollment of the first subject in January 2016.

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Not applicable.

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Informed consent was obtained by each of the patients enrolled.

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Damous, S.H.B., Damous, L.L., Borges, V.A. et al. Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique. Surg Endosc 37, 9263–9274 (2023). https://doi.org/10.1007/s00464-023-10499-8

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