Even during Coronavirus outbreak life keeps moving and other patients are there to be treated. Inguinal hernia repair is one of the most frequently worldwide performed surgeries. All surgeons have already treated patients who ask for possible complications. Some patients they just do not care but is our responsibility as doctors to accurately give information. However, the great majority of preoperative discussions about outcomes and complications focus on surgical site infection (SSI), pain, efforts eviction in the postoperative period, return to work and daily activities, and recurrence rates. Although some surgeons may discuss different techniques (mainly laparoscopic versus open repair), most of the times choice of technique is just a surgeon’s preference. Is there something else we should discuss with patients? Yes, there is.
Sexual disfunction (SD) can decrease Q-o-L.
Sexual disfunction (SD) and pain with sexual activity (PSA) are complications that can promote anxiety, depression and significantly decrease Q-o-L of patients. In worldwide reports there is not much written about these two important complications. Years ago, during University, I read that many patients with prostate cancer deny surgery because of the possible sexual disfunction afterwards. This is an issue that must be carefully assessed by surgeons.
A recent meta-analysis published in the Journal of the American College of Surgeons gives interesting results that should make us think and promote more studies. Ssentongo et al from USA collected data from 12 studies with the objective to determine the incidence of SD (inability to complete intercourse) and PSA (pain with erection/ejaculation) after inguinal hernia repair. A second objective was to analyze if there is any difference between techniques. Only patients with new onset postoperative SD and/or PSA were eligible. A total of 4884 patients were included. Six prospective studies, four retrospective studies, two RCT’s. Only one study included women, even though 96,6 % were male.
From all studies, the reported SD incidence varied from 0% to 11,3%, with a global mean incidence of 5,3%. Interesting to note is that SD rate slightly increases with follow-up time. PSA incidence also varied from 3% to 22%, with a global mean rate of 9,0%. These results show us that these complications are not negligible and must be taken into account.
Minimally invasive surgery has higher rate of SD and less rate of PSA than open repair.
Authors also tried to take conclusion about how type of repair influences SD and PSA. Minimally invasive surgery was associated with a SD incidence of 7,8 % and open surgery with a 3,7%. On the contrary, PSA was lower with minimally invasive surgery (7,4% vs 12,5%). Differences were not significant. TAPP and TEP were both included as laparoscopic techniques. In TEP the mesh was not fixed, but in TAPP the mesh was fixed with fibrin glue, clips or tacks. Is this important? Probably yes, but authors could not compare them according to SD and PSA. However, Ssetongo et al. were able to analyze several articles of open repair. From all patients submitted to open repair complaining of SD and/or PSA, 36% had plug and patch repair (Rutkow-Robbins) and 64% had Lichtenstein. All patients submitted to Onstep repair did not report SD or PSA. The drawback from these data is that authors do not present the total number of patients treated with each technique. So, valid conclusions about advantage or disadvantage of each technique in terms of SD cannot be taken, I think. Additionally, authors could not analyze how the type of mesh influences outcomes. More studies will be necessary.
Did you ever think that anesthesia can influence SD? If not, you should. According to the authors general anesthesia is associated with a 1,9% of SD, while local anesthesia with 6,2%. One more reason why no patient should be submitted to hernia repair by local anesthesia. There is no reference to spinal anesthesia. These outcomes lead the authors state that “it seems likely that the choice of anesthesia modality may prove more consequential than might have been thought, at least with respect to open repair”, since laparoscopic repair is always with general anesthesia.
General anesthesia has lower rate of SD than local anesthesia.
Some explanations are presented by Ssetongo et al. First, exuberant scarring that forms around the mesh may be a cause of trapping and/or torsion of nerves and the vas-deferens. Secondly, suture migration in Lichtenstein can cause strangulation of the nerves and the vas-deferens promoting dysejaculation. How to solve? Decompress the vas-deferens and cut the nerves. How to avoid these complications during surgery is not addressed in the manuscript. In my opinion all efforts must be made to avoid incidental injury to the nerves, avoid strangulation/trapping of nerves with sutures, avoid compression of nerves and vas-deferens with prosthesis and avoid direct contact of mesh with nerves and vas-deferens (do not remove cremaster).
I believe this paper rises how important is to be aware of SD and PSA as possible postoperative complications following inguinal hernia repair. These complications can significantly decrease Q-o-L of male patients and their possibility must be discussed with patients. One way to do it is using scores like the International Index of Erectile Dysfunction (IIEF).
While choosing which technique to use, remember that minimally invasive surgery apparently has higher incidence of SD but less PSA than open repair. I would prefer doing it with pain than not being able to do it. Wouldn’t you? Try to repair the hernia not removing a part of the manhood of the male patient. Does a good surgical technique prevent both complications? I want to think it does…
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
"I would prefer doing it with pain than not being able to do it." No doubt. But, as you say, it is better to discuss the possibility, although it is a remote one, with the patient, previously to the operation.