Page 63 - International guidelines for groin hernia management

Hernia

Evidence in literature temporary placement of an indwelling urinary catheter.
The incidence of urinary retention following IH repair Prophylactic use of alpha-1 receptors’ antagonists such as
varies widely in published series ranging from less than 1% prazosin, phenoxybenzamine hydrochloride, or tamsulosin
to greater than 20%. 36, 37 The most common predisposing has been shown in some studies to be an effective strategy
factor for postoperative urinary retention (POUR) after an to prevent postoperative urinary retention. 49–51 Overall
IH repair is the use of general or regional anesthesia. 38–42 urinary function as measured by the American Urological
Most authorities feel that regional anesthesia (spinal or Association Symptom Score is improved by hernia repair
epidural) is worse than general. However, in a study providing that a Foley catheter was not used at the time of
pooling data from 70 non-randomized and two randomized the index operation. 52
studies, the incidence of urinary retention with local Sexual dysfunction, testicular hormone function, and
anesthesia was 0.37% (33 in 8991 patients), with regional ischemic orchitis
anesthesia 2.42% (150 in 6191 patients), and with general Inguinal hernia surgery can cause damage to different
anesthesia 3% (344 in 11,471 patients). The need for nerves, disturbances of testicular circulation, and damage
general anesthesia for most laparoscopic IH repairs (LIH) to the vas deferens which can lead to various long-lasting
almost certainly accounts for the higher incidence of harms to the patient. Nerve damage can cause chronic pain
POUR after LIH repair which has been reported to be as that could interfere with sexual activity. Disturbances of
high as 22%. 37 Other factors which have been inconsis- testicular circulation can result in initially severe pain
tently incriminated for POUR (i.e., some studies reporting followed by atrophy of the testicle and thereby impaired
statistically significant differences after LIH, while others hormone production. Division of the vas deferens will
do not) include: over-hydration with intravenous fluid cause obstruction for the passage of sperm. In case of
during surgery, 37 bilateral hernia repairs, 43 increased bilateral injuries of different types, both hormone changes
BMI, 43 use of opioid analgesics, 44 older age, 44, 45 prostatic and infertility could result in a disaster for the patient.
45 43, 45
symptoms, and prolonged operative time. In a meta- Sexual problems after hernia operations are probably
analysis performed by Tam et al., the incidence of POUR under-reported, patients often being unwilling to discuss
was found to be higher in patients with tack fixation pre- their sexual concerns. The heading ‘‘sexual dysfunction’’
sumably because of increased pain (3.1 vs [ 1.0%), but includes several interacting factors, making the topic’s
this difference did not reach statistical significance. 46 Other bounds difficult to delineate. For that reason, it is also
meta-analyses have not demonstrated a difference in uri- difficult to measure the incidence of sexual dysfunction.
nary retention when comparing tack fixation with glue. 47
Meta-analyses of RCTs comparing various hernia tech- Key questions
niques have not shown a difference in urinary retention
rates among the various laparoscopic and open tech- KQ18.g What defines ‘‘sexual dysfunction’’ after IH
niques. 48, 49 Many surgeons routinely place urinary surgery?
catheters for inguinal herniorrhaphy especially when done KQ18.h What is the incidence of sexual dysfunction after
laparoscopically. 43, 45 This seems to be more a surgical IH surgery?
tradition, not an evidence-based practice. A year study KQ18.i Are ischemic orchiditis causes known; and can this
looked at patients in two time periods, an earlier one when complication be prevented?
urinary catheters were used routinely, and a later one when KQ18.j Does hernia repair with heavyweight mesh cause
they were not. A marked improvement in urinary compli- more testicular pain than hernia repair with lightweight
cations (cystitis, urinary retention and hematuria) occurred mesh?
when the practice of routine urinary catheterization was KQ18.k Are methods of repair or bilateral operation
abandoned. 50 One of the largest laparoscopic TAPP series related to risks of impaired spermatogenesis and hormone
also showed that the procedure can be safely conducted production?
without the use of a urinary catheter. 51 Urinary retention KQ18.l Can sexual dysfunction following hernia repair be
can be treated by either intermittent catheterization or treated surgically?

123