Abstract
Background and aims
A systematic review of the literature is presented with regard to urological complications resulting from inguinal hernia surgery. Considering the amount of inguinal hernia operations performed, the resulting complications, which may be urological in presentation, have potential late irreversible and medico-legal implications.
Methods and results
A Pubmed search of ‘urological’ ‘complications’ and ‘inguinal hernia surgery’ was carried out and clinical practice was also taken into consideration.
Discussion
Approximately 75% of hernias occur in the groin; two-third of these are indirect and about one-third direct. Most of these repairs are carried out by the general surgeons and any complication, including urological, are often initially managed by the operating general surgeon. Often a urological opinion is sought late for conditions which may be reversible. We present potential urological complications, their presenting features and management.
Conclusion
Recognition, timely referral and appropriate treatment of urological complications after hernia surgery are necessary to avoid potential consequences and long-term morbidity.
Introduction
Inguinal hernias often present with a swelling in the groin. Over one million abdominal wall hernia operations are performed annually in the United States with 800,000 of these being inguinal hernia repairs. 1
Approximately 75% of hernias occur in the groin; two-third of these are indirect and about one-third direct. 2 Most of these repairs are carried out by the general surgeons hence any complication, some of which may be urological, are initially managed by the operating general surgeon. The true incidence of urological complications of inguinal hernia surgery is thus likely to be underestimated.
We present a review of available literature on urological complications of hernia surgery. In addition to published evidence, clinical practice was also taken into account to ensure recommendations hold clinical validity for example management of post operative scrotal hematoma and hydrocele where little is mentioned in the literature with regards to management. With increasing public awareness, the medico-legal implications of such complications may be huge considering the number of such procedures performed each year.
Intraoperative complications
Damage to vas deferens
In redo inguinal herniorrhaphy operations, spermatic cord entrapment is a recognised complication. 3 This may be evident at surgery with previous adhesions or manifests later as the vas deferens and spermatic vessels become entrapped by the mesh slit that pulls on the structures within the cord. The possibility of vasal obstruction should be considered in any sub-fertile male who had an inguinal hernia operation. 4
It is not clear whether obstructive vasopathy and/or integrity of the testis or spermatic cord is influenced by implantation of mesh or is caused by operative technique. Laparoscopic transabdominal preperitoneal repair (TAPP) procedure using a large-pore mesh made of polyvinylidene fluoride (PVDF) has the least effect on vas deferens compared to other mesh materials when assessed using parameters such as imaging, testicular function (Johnson score) and mesh integration using granuloma size or apoptotic cells as markers. 5
When vasal injury occurs during hernia surgery or adhesive obstruction is identified, primary anastomosis should be attempted if the patient has not had prior vasectomy. Exploration should be performed through a high inguinal incision. If mesh was not employed for repair, the distal vas is often found below the level of the internal ring.
If mesh was used, the vas may be found adherent to the floor of the canal. If dissection proves difficult, it may be helpful to extend the incision above the mesh and enter the retroperitoneum and re-route the vas out directly through the external ring.
It may be noted that some patients may develop concomitant epididymal obstruction. If no sperm can be retrieved from the proximal vas, it is reasonable to repair the inguinal vas first. If the person remains azoospermic after 6 months, the patient may be considered for micro-surgical vaso-epididymostomy. The contralateral non-obstructed vas deferens may be used with a crossover procedure if the contralateral testis is less functional than the one which has the obstruction. 6
Bladder injury
The bladder can constitute part of a sliding hernia. It is usually identified from presence of peri-vesical fat and its surface veins. Prompt recognition of bladder injury and its repair gives excellent results as this is a most forgiving organ.
If an injury is recognised intra-operatively, it should be repaired in two layers using absorbable sutures. Following repair, bladder should be kept on free drainage through a urethral catheter for 7–10 days. A cystogram should be carried out to ensure complete healing before voiding trial.
It is important to check the integrity of ureteral orifices before repair of the bladder injury. If in doubt an on table retrograde study should be performed. Any bladder injury close to the ureteric orifice should be stented or the ureter re-implanted. Late presentations of extra-peritoneal missed bladder injuries include urinoma formation, which may require catheter drainage for 2–3 weeks, drainage of urinoma, debridement of the bladder and repair along with antibiotics. Unrecognised primary intra-peritoneal injuries usually present with peritonitis and require laparotomy, bladder repair, catheter drainage and antibiotics. 7
Ureteric injury
The ureter can be injured when it is part of a large sliding hernia. Injuries can be complete or partial. In case of injuries above the level of pelvic brim a tension free, spatulated primary anastomosis should be performed over a double-J-Stent. Injuries below the pelvic brim are ideally managed with reimplantation of ureter. 8
Vascular injuries of the cord
Risk of vascular injury depends on surgical technique and composition of the mesh. In general, more distal the dissection, the higher the risk of vascular injury as arterial collaterals are limited. This however, does not always result in testicular atrophy because of the presence of other spermatic cord arteries such as vasal and cremasteric.
Repair of giant inguino-scrotal hernia (GISH) in male infants is a difficult operation, even in experienced hands and this requires attention to detail to avoid damage to sac, vessels and vas. Banieghbal has described a technique whereby exteriorising the testis and the cord in infants led to fewer vascular injuries. 9
Post operative complications
Acute urinary retention
This is a well recognised but poorly understood phenomena. Its incidence varies from 4–25%. 10 Broadly, causes of acute urinary retention can be divided into three categories; Firstly, any process which increases outflow resistance which can be mechanical obstruction (e.g. bladder outflow obstruction, urethral stricture), or dynamic obstruction (resulting from an increase in smooth or striated muscle tone), or both. Secondly, urinary retention may result from interuption of neurological pathways. This may be sensory afferents, motor efferents or both. This may be secondary to drugs. 11 Lastly, any situation which permits or causes the bladder to over-fill such as may be encountered after any operation performed under general anaesthesia in which the patient is not catheterised and the bladder allowed to distend.
This is frequently complicated by any combination of the following: opiates or opioid analgesia that inhibits bladder sensation or anticholinergic medication inhibiting detrusor contractility. Increased α-adrenergic activity that invariably follows an operation may also increase urinary sphincter tone. 12 The risk is significant after hernia repair and increases with advancing age. Certain anaesthetic and analgesic modalities especially spinal and epidural analgesia promote development of post operative urinary retention. 13 Michelson et al. 14 have suggested bladder decompression with urinary catheterisation for 18–24 hours postoperatively, which decreases its incidence by 52% and is recommended.
Acute orchalgia
The aetiology of testicular pain after hernia repair is often varied and frequently idiopathic. This may be vascular or nerve entrapment injury. 15 As with all acute testicular pains, testicular torsion needs to be excluded on clinical grounds and any doubt mandates testicular exploration. Although referred to as testicular pain, the aetiology can originate from para-testicular structures such as the epididymis, vas or surrounding tissues. Immediate postoperative pain is usually vascular and prompt intervention may salvage the testis however by the time the patient seeks a urological opinion, ischemic injury has usually already set in and the patient has established testicular iscemic changes. This symptom complex can become chronic and often ends with a patient complaint. There is neither defined treatment nor any protocol for evaluation or treatment. Fortunately it is not a frequent complication; Morecroft et al. 16 identified only 1 case (0.2%) in a retrospective series of 556 boys.
Scrotal haematoma
There are no scrotal care pathways identified after inguinal hernia surgery. Scrotal haematoma, oedema and infection may occasionally be seen. Although frightening for the patients, these usually resolve on their own. This is especially seen after large or recurrent hernia repairs. 17
Postoperative hydrocele
This is a recognised complication and puts the patient in distress unless warned preoperatively. Its management has not been adequately discussed in the literature. The complication is more likely to result after closure of the distal sac during the hernia repair rather than after conventional herniotomy. 18 Surgery is required in up to 0.5% of patients as most cases resolve spontaneously 19 and is reserved for cases where there is concern about recurrent hernia. 20
Chronic orchalgia
Chronic orchalgia is defined as intermittent or constant testicular pain lasting 3 months or longer in duration that significantly interferes with the daily activities of the patient, necessitating medical attention. 21 As hernia recurrence has become less of an issue following tension-free repair of inguinal hernia, quality of life has become increasingly important. Chronic pain in particular may have a major effect on the quality of life and is associated with significant healthcare costs. 22
Chronic pain after inguinal hernia repair is an adverse outcome that affects around 12% of patients. 23 Patients typically present a few weeks to months after hernia surgery to their general surgeons with this complication. Many of these patients become frustrated and often strain the patient-doctor relationship. Nerve entrapment may resolve with conservative management but if pain persists than inguinal exploration with removal of non-absorable material or suture may become necessary. Using absorable sutures to fix the mesh results in less long-term pain (p. 1108). 10 Orchidectomy should be left as a last resort.
Treatment, as most urologists know, can be a therapeutic dilemma. Analgesia should follow the step ladder approach with non steroidal antiinflammatory drugs and/or antibiotics if infection is suspected. Other treatments include antidepressants, anticonvulsants and opioids. A nerve block with or without steroids can be tried and if encouraging results are obtained, long-term relief can be achieved with neurectomy. 24 This approach naturally spares the testis with its psychological and hormonal advantages. The aim is to denervate structures but spare the arteries, lymphatics and the vas if the patient has not had a vasectomy. Psychological counselling may be beneficial to help the patient deal with the pain, but when this fails surgery is frequently the next option. Epididymectomy should be used when the pain is localised to the epididymis only and appears to have its best outcomes following post vasectomy pain. 25 It cannot be over emphasised that preoperative documented discussion is needed to the possibility of persistence of pain even after the operation.
Lower urinary tract symptoms
Use of titanium clips to secure synthetic mesh has resulted in subsequent migration of either structure into the bladder with subsequent lower urinary tract symptoms. Treatment involves removal of the eroding agent usually by open surgery along with repair of bladder with 4–6 weeks of urinary drainage. 26 This complication has not been widely reported in the literature but as case reports and it appears that it is frequently under reported. Other cases where symptoms are treated conservatively have resulted in bladder stone formation. 27 Persisting lower urinary tract symptoms after hernia surgery are best referred to a urologist whereby timely intervention can address a lot of future complaints and/or complications.
Laparoscopic hernia repair
As minimally invasive surgery continues to take hold over traditional open surgery, specific issues and problems continue to be recognised. Oehlenschläger has, however, reported fewer urological complications after transabdominal preperitoneal laparoscopic surgery for inguinal hernia (TAPP) with incidence of around 5% prior to 2008 and 1% after. 28 Reports on minimally invasive surgery in the pelvis after previous surgery in the inguinal region with prosthetic mesh have been published regarding varying difficulties encountered by pelvic surgeons for radical surgery in the region. These range from abortion of procedure, inability to perform lymph node dissection, bleeding, bladder injury and requirement of additional surgery such as mesh removal. This no doubt creates difficulties during subsequent intervention and may necessitate change in operative planning. Nevertheless, the surgery is feasible and should not be ruled out. 29 Similar problems during radical cystectomy have been reported, most annoying being scarring which can compromise the extent and safety of pelvic lymph node dissection. 30
Discussion
In view of the paucity of reported urological complications after inguinal hernia surgery, considering the number of such operations performed worldwide with potential medico-legal implications, the need to properly document, report and communicate with the patient is of paramount importance.31 Timely communication to the patient is the single most effective way of addressing complications. Doctors with better communication and interpersonal skills are able to detect problems earlier, can prevent medical crises and expensive intervention, and provide better support to their patients. 32
Most patients who unfortunately develop complications present to their primary care physicians or their general surgeon and are generally referred late to urologists when treatment is either damage limiting relating to chronic issues or needing subsequent surgery with removal of tissue /organ and very dissatisfied patients.
The last decade has seen the introduction of minimally invasive surgery for a wide variety of procedures, radical pelvic surgery in patients with previous mesh implants present challenging circumstances for urologists as regards adequate dissection and nodal clearance, which are of prime importance in oncological safety. New dimensions have emerged and the need to modify primary technique, mesh material or subsequent treatment may need to be addressed.
Conclusion
Recognition, timely referral and appropriate treatment of urological complications after hernia surgery is needed to avoid possible treatable complications and prevent long-term morbidity.
Footnotes
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.