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Perspectives and Editorials |
Among men presenting with obstructive azoospermia, many suffer from epididymal blockage from a variety of etiologies. There exists, however, a population of men who have suffered iatrogenic injury to the vas deferens, emphasizing the need to obtain a thorough history from male fertility patients. A very informative discussion took place on Androlog regarding the potential for vasal occlusion among men who have undergone hernia repair using mesh. Unlike patients in whom injury to the vas deferens was identified at the time of surgery, the resulting impairment to fertility may be "silent" and likely is unknown until a semen analysis is performed. The current popularity of using mesh in hernia repair makes this a particularly important topic.
Dr Eugene Fuchs posed the initial question:
Colleagues, does anyone have any information or experience with Marlex mesh causing vas obstruction after an inguinal hernia repair? I recently saw a 33-year-old man who is known to have had an adequate sperm count several years ago but who never sired an offspring. Two years ago, he had bilateral inguinal hernia repairs using Marlex mesh. About 6 months ago, he was found to be azoospermic. His hormone levels were normal, and a testicular biopsy showed normal spermatogenesis. A vasogram showed obstruction at or near the internal inguinal ring. Exploration revealed dense scarring encompassing the vas. It was difficult to dissect the vas from the fibrous tissue. The vas was intact but did appear atretic, as if devascularized within the scar. I was able to repair one side, but on the other side, so much vas was damaged that I was unable repair without taking apart the hernia repair, which I was unwilling to do. Is this an isolated case? Should we be warning our general surgical colleagues that this is a potential problem? Has this been documented in the surgical literature? I will appreciate your thoughts on this matter.
Eugene F. Fuchs, MD, Oregon Health Sciences University
Dr Andy Meacham had a similar case to report:
Regarding Dr Fuchs' note pertaining to Marlex mesh used in hernia repair leading to vasal scarring—I saw such a patient in my clinic today. He has unilateral left testicular atrophy that occurred following inguinal surgery in the remote past. He subsequently fathered 3 children without difficulty and then underwent contralateral (right) hernia repair with the use of Marlex. He is now azoospermic. His exam shows epididymal induration consistent with vasal occlusion on the right side. On the basis of the presence of only 1 nonatrophic testis and the challenges associated with vasal repair in such a setting, we are focusing our discussion on sperm retrieval rather than reconstruction. I'll be interested in hearing other Androlog comments.
Dr Jacqmin Didier expressed his opinion on this topic, citing medical-legal issues:
This is one of the usual causes of obstructive-acquired azoospermia. It is not often mentioned because sperm analysis is not performed systematically before hernia repair. The procedure has to be bilateral. This is a case in which frequently patients are asking the urologist for advice before going to the law court.
Jacqmin Didier, MD, Hopitaux Universitaires de Strasbourg, France
Dr Nina Davis felt this to be a well-recognized phenomenon and cited experimental data:
In response to Dr Fuchs' inquiry about mesh used in hernia repair and compromise of the vas deferens, this is a well-documented phenomenon, although much of the material is in the urologic/andrologic literature as opposed to the general surgical literature. One particularly nice study that demonstrates Dr Fuchs' observation was done by Marc Goldstein's group at Cornell (Journal of Urology, April 1999). They performed canine herniorrhaphies using mesh and demonstrated a significant reduction in luminal size in the vasa of the treated animals. This resulted from the exuberant fibrotic reaction induced by the mesh. So, in answer to Dr Fuchs' query, it would seem appropriate to publish and/or present something on this subject in a major surgical journal or at a major meeting to bring it to the attention of our general surgical colleagues.
Nina S. Davis, MD, MCP-Hahnemann University
Dr Marc Goldstein reported his own clinical and experimental data and gave advice for using mesh in hernia repair:
I have seen at least 3 cases of vasal obstruction associated with Marlex mesh hernia repair. These cases were included in a larger series of iatrogenic vasal injuries, of which 30 were from hernia repair. As was Gene Fuchs' experience, the injuries associated with Marlex mesh repair were almost impossible to reconstruct. One testicle atrophied after attempted repair due to transection of a testicular artery embedded in the mesh. The best results were when the other vas was okay and associated with an atrophic testis or obstructed epididymis, and we could do a crossed venovenous and avoid digging around in the mesh. Because of these experiences, we did a study of mesh repair in dogs. Although all 12 vasograms were patent, there was significant luminal narrowing and severe reaction around the vas and in the cord. Some of the dogs had impaired spermatogenesis, perhaps from arterial narrowing or injury. One dog had a traumatic neuroma. No sutures were used to sew in the mesh, so injury from suturing could be excluded as a cause. One problem in sorting this out is that most surgeons use nonabsorbable sutures to sew in the mesh. Therefore, we don't know if the injury is from the mesh or from entrapment of the vas in one of the sutures. I suspect that mesh hernia repair is associated with a small but significant risk of injury to the cord structures. I do hernia repairs with mesh; however: 1) I avoid nonabsorbable sutures; 2) I avoid putting plugs in the internal ring where they would directly push on the cord; 3) I use only plugs for direct hernias and cover the plug with a flat patch; and 4) I use preformed patches (from Bard) with a large keyhole (about 1.5 cm in diameter) for the cord to exit through.
(Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol. 1998;159:139-141.
Uzzo RG, Lemack GE, Morrissey KP, Goldstein M. The effects of mesh bioprosthesis on the spermatic cord structures: a preliminary report in a canine model. J Urol. 1999;161:1344-1349.)
Sincerely, Marc Goldstein, MD, The New York Hospital, Cornell Medical Center
Dr James Barada noted that general surgeons should be made aware of this important issue:
Excellent case presentation. Was the Marlex used as a sheet to reinforce the floor or the Plug (parachute) reduction method or hernia reduction/fixation? Marlex is known for its intense fibroblastic response with tissue incorporation (thus, localized inflammation), which may have contributed to the obstruction. Given the way that the Marlex inguinal hernia repair has proliferated, along with the copious amounts of mesh being used, I would imagine that this will be coming up more often. Basic research in this area is warranted. For now, I would make the general surgeons aware of this serious potential complication. I would suggest that, in this case, cord skeletonization may be a factor.
James H. Barada, MD, FACS, Center for Male Sexual Health
Dr Stan Honig also reported clinical experience with this topic:
I also had such a case last week with bilateral inguinal vasal injury. The vasal injury from childhood was reconstructible; however, the side with the Marlex mesh—related vasal injury (hernia repair 2 years ago) was fibrotic, scarred, and not reconstructible. Maybe we can combine these cases for a more valuable study.
Stanton C. Honig, MD, University of Connecticut
Dr Sidney Glina also reported experimental data regarding the use of Marlex mesh in animals:
Regarding Dr Fuchs' note pertaining to Marlex mesh used in hernia repair leading to vasal scarring, we used the Marlex mesh just underlying the right vas in 10 rabbits and a sham operation on the left side. We got a vas obstruction in 9 of them. The inflammatory reaction went over the epididymis in 6 animals. The lesion was due to the contact between the mesh and the vas, as we did not use sutures.
Sidney Glina, MD, Hospital Israelita Albert Einstein
Finally, Dr Stewart McCallum reported that he had seen a similar patient in his clinic:
I also had such a case a couple of months ago of a young man with a solitary right testicle, his cryptorchid left testicle having been removed years earlier. He had blood in his ejaculate after his surgery and was advised that there was nothing to worry about and that it would go away. He subsequently had a semen analysis that demonstrated very poor semen parameters, and on a follow-up, he was azoospermic. We opened the hernia repair, but he had extensive scarring of his vas and was also unreconstructible.
Stewart McCallum, MD, Stanford University and Medical Center
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