To describe the rationale and design of an observational cohort study analyzing the effects of endoscopic Totally Extraperitoneal (TEP) hernia repair on male fertility (MAIN study).The MAIN study is an observational cohort study designed to assess fertility after endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specialized in TEP hernia repair. Male patients of 18-60 years of age, with primary, reducible, bilateral inguinal hernias and no contraindications for endoscopic TEP repair are eligible for inclusion in this study. Patients with an ASA-classification≥III and patients with recurrent and/or scrotal hernias and/or a medical history of pelvic surgery and/or radiotherapy, known fertility problems, diabetes and/or other diseases associated with a risk of fertility problems, will be excluded. The primary outcome is the testicular perfusion before and 6 months after TEP hernia repair (assessed by means of a scrotal ultrasonography). Secondary endpoints are the testicular volume (Ultrasound), semen quality and quantity and the endocrinological status, based on serum levels of the sexual hormones follicle-stimulating hormone (FSH), luteinizing hormone (LSH), testosterone and inhibin B before and 6 months after TEP hernia repair.The use of polypropylene mesh is associated with a strong foreign body reaction which could play a role in chronic groin pain development. Since the mesh in (endoscopic) inguinal hernia repair is placed in close contact to the vas deferens and spermatic vessels, the mesh-induced inflammatory reaction could lead to a dysfunction of these structures. Relevant large and prospective clinical studies on the problem are limited. This study will provide a complete assessment of fertility in male patients who undergo simultaneous bilateral endoscopic TEP hernia repair, by analyzing testicular perfusion and volume, semen quantity and quality and endocrinological status before and 6 months after TEP repair.The MAIN study is registered in the Dutch Trial Register (NTR2208).

To assess the effect of peripheral nerve stimulation on neuropathic testicular pain.A 30-year-old man with a four-year history of chronic testicular pain following scrotal hydrocele surgery had two percutaneous leads implanted in his groin and low-frequency stimulation of the cutaneous branch of the ilioinguinal and genital branch of the genitofemoral nerves.At seven-month follow-up, the pain intensity had declined from 9/10 to 2/10 on the numeric rating scale.We report the successful implantation of an ilioinguinal and genitofemoral nerve stimulator for sustained suppression of intractable neuropathic testicular pain.

The ideal method for treatment of varicocele is still controversial. The techniques of inguinal and sub-inguinal ligation, although less invasive than "high" abdominal ligations (Palomo, Ivanissevich), have been less popular than the former ones. Up to now most authors have considered as mandatory microsurgical techniques for the ligation of spermatic veins at inguinal or sub-inguinal level, or at least instruments of optical magnification in order to preserve testicular arterial supply of the spermatic and cremasteric artery at groin and to prevent testicular atrophia or gonadic ischemia. The aim of this study was to assess clinical outcomes of open surgical technique of varicocele repair compared to results derived from microsurgical series. A retrospective study included 45 patients of mean age 31 years (range 18-39) that underwent open surgical technique of inguinal ligation of spermatic veins in the period 2004-2009; clinical results of this series were compared with those obtained in five relevant studies derived from systematic review of the literature on microsurgical techniques. The pre-operatory evaluation in our series included a physical examination, a minimum of two semen analysis and scrotal color Doppler ultrasound. Post-operative pain, complication rates, days of hospitalization and time to return to work were considered as main outcomes. All patients were evaluated at 1 week, at 3 and 6 months after the operation by means of a physical examination, scrotal Doppler ultrasound and sperm analysis. Most patients (39/45) presented no pain in the first week, 6/45 mild to moderate pain (mean VAS score 2). None of the patients reported pain in the weeks thereafter The hospitalization (1.8 +/- 0.7 days) and the time for return to work (7.2 +/- 3.2 days) were not significantly different in microsurgical and open groups. During follow-up no complications like hydrocele or testicular atrophy were observed. Doppler ultrasound carried out 3 and 6 months after surgery, pointed out no reflux in testicular veins in 41/45 cases while in 4/45 it showed a persistence of reflux grade I, less than the grade before the treatment. Comparing pre-and post-operatory sperm analysis allowed us to observe a significant improvement either in spermatozoa concentration (22 +/- 4 40_+/- 6 millions/ml, p < 0.01), either in motility (33 +/- 4% and 48 +/- 4%, p < 0.05), without significant changes in morphology. No significant differences were recorded comparing these data with those coming from microsurgical series. Our study reported positive clinical outcomes using the technique of sub-inguinal surgical ligature of varicocele without using microsurgical techniques or instruments of optical magnification. The operative time, complication and relapse rates, Doppler flow parameters and semen parameters were not significantly different from those reported in the literature of microsurgical techniques, with the advantage of such a simple surgical technique combined with cost savings and patient's comfort.

To determine the role of ultrasonography in diagnosis of scrotal disorders.This study was carried out after institutional review board approval was granted, and informed consent was waived. Between January 2005 and January 2007, 144 patients aged 12 years and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analysed. The presentation symptoms were divided into three groups including scrotal pain, painless scrotal mass or swelling, and others. Surgery was performed in 32 patients.Of 144 patients, 110 had clinical follow-up and constituted the material of this study. The patients ranged in age from 13 to 82 years (mean 38.6 years). Of 110 patients, 84 (76.4%) presented with scrotal pain, 21 (19%) had painless scrotal mass or swelling and 5 (4.5%) had other symptoms. Of the 84 patients with scrotal pain, 52 had infection, 4 had testicular torsion, 7 had testicular trauma, 10 had varicocele, 4 had hydrocele, 1 had epididymal cyst, 1 had scrotal sac and groin metastases, and 5 had unremarkable results. Of the 21 patients who presented with painless scrotal mass or swelling, 18 had extratesticular lesions and 3 had intratesticular lesions. All the extratesticular lesions were benign. Of the 3 intratesticular lesions, one was due to tuberculous epididymo-orchitis, one was non-Hodgkin's lymphoma, and one was metastasis from liposarcoma. Of the 5 patients who presented with other symptoms, 4 had undescended testes, and 1 had gynaecomastia. US gave incorrect diagnosis in only one patient with scrotal pain.The most common cause of scrotal pain was infection. The most common cause of scrotal mass or swelling was extratesticular lesion. US plays an important role in the diagnosis of scrotal disorders and in planning for proper management.

Objective:

To compare anterior tension-free approach with posterior preperitoneal repair for complications and early recurrence.

Design:

A randomized clinical trial. Place and Duration of Study: Combined Military Hospital, Muzaffarabad and Rawalpindi, from March 1997 to December 2002. Patients and

Methods:

Sixty-seven patients with unilateral recurrent inguinal scrotal and irreducible hernias, were randomized to either anterior tension-free or posterior preperitoneal repair. Patients with primary inguinal hernia, patients with class11/111 obesity (BMI > 35) and ASA grade 3 and beyond were excluded. For posterior repair, preperitoneal space was entered through a transverse lower abdominal incision placed 3 cms above inguinal ligament. Anterior repair was done by standard Lichtenstein technique. Forty-two patients were operated under spinal anesthesia while 25 patients had general anesthesia. Follow-up was on 7th and 12th postoperative day, at third month, and then yearly for two years. Main outcome measures were postoperative pain and recovery; postoperative complications related to wound, testicles, sensory nerves; and recurrence.

Results:

Thirty-four patients had anterior tension-free hernioplasty while 33 patients had posterior preperitoneal repair. Mean operating time was longer for anterior preperitoneal repair as compared to posterior repair (70.1min vs. 62.6 min, p = 0.1). Pain score and hospital stay was same for both groups. Return to normal activity was not significantly different being 14.1 days for anterior and 13 days for posterior repair (p= 0.07). Heavy duties were also resumed after statistically non-significant interval, 34.6 days for anterior, and 33 days for posterior repair (p = 0.09). Complication rate in anterior hernioplasty group was 17.6% while in preperitoneal group it was 3% ( p=0.001). There was no recurrence in either group after a mean follow-up of 2 years.

Conclusion:

Open preperitoneal repair and anterior tension-free repair were equivalent in terms of postoperative pain, recovery and early recurrence rate. Considering fewer testicular complications with posterior repair, it should be the procedure of choice for repair of recurrent groin hernia in men.

We report a case of epididymal microlithiasis that was diagnosed sonographically in a 75-year-old man undergoing scrotal sonographic examination to investigate right groin pain associated with an inguinal hernia. The sonographic appearance was that of multiple comet-shaped foci of microcalcification throughout both epididymides, with associated comet-tail artifacts. The testes had normal appearance with no evidence of testicular microlithiasis. The patient subsequently remained well after hernia repair. To our knowledge, epididymal microlithiasis has only previously been reported in a cadaveric study; the authors of that study hypothesized that the condition is caused by aging, with ischemia likely implicated in the pathogenesis. There are many other patterns of extratesticular calcification, including sperm granuloma, hematoma, and chronic epididymitis. We discuss how these differ in appearance from epididymal microlithiasis. Epididymal microlithiasis is a completely separate entity from testicular microlithiasis and should be recognized and dismissed by sonographers and radiologists.

The objective of this work was to describe the clinical and therapeutical aspects of pathology of the peritoneo-vaginal process. We have performed a retrospective study including 160 patients operated between January 1990 up to December 1996. Mean age at diagnosis was 8 years, ranged from 1 month to 13 years old. All patients were male. The abnormality was located in the right side in 60% of cases and was bilateral in 6.7% of cases. The main clinical features were scrotal mass (81%) and scrotal pain (13.46%). The diagnosis was made at birth only in 20% of cases. A maldescended testis was associated in 7.5% of cases. A groin incision have been used in 91.25% of patients. The average hospital stay after surgery was 1 day. Thus, the pathology of the peritoneo-vaginal process is common and apparently banal. Need for treatment through a groin incision owing to the possibility of associated maldescended testis.

Acute scrotum in children is generally a symptom. Several pathologies of the testis, scrotum or groin may cause it, including inflammatory as well as ischaemic processes. Testicular torsion with ischaemia of the testis is an emergency requiring prompt surgical intervention. Even experienced paediatric surgeons and urologists may have difficulties differentiating an ischaemic from an inflammatory aetiology solely on the basis of clinical signs and symptoms. In cases of aetiologic uncertainty, operative exploration has to be performed to rule out ischaemia, which led in the past to a high rate of surgery. More recently, colour Doppler ultrasonography (CDUS) has become an imaging modality for the examination of the acute scrotum with the purpose of detecting ischaemia, thus reducing the need for explorative surgery. In this study we examined the reliability of CDUS, comparing the sonographical diagnoses with both the intraoperative findings and the clinical course. We present here 132 consecutive cases of acute scrotum in children, who were admitted from 01/98 through 10/02 to our hospital. All patients underwent CDUS. Patients with ultrasonographic signs of ischaemia of the testis (group A) and patients with demonstrated perfusion and suspicious or severe clinical symptoms (group B) were operated immediately. Patients with demonstrated perfusion without suspicious or severe symptoms (group C) were treated conservatively. Thirty-eight patients (28.8%) were treated operatively. Eleven cases of testicular torsion in group A (12 pat.) could be confirmed intraoperatively, in one case there was no testicular torsion but a severe inflammation of the testis with torsion of the appendix testis. In group B (26 pat.) operative exploration revealed one case of testicular torsion. In group B two cases of sonographically suspected torsions of the appendix testis also emerged as epididymitis intraoperatively. In the other cases postoperative diagnosis was in agreement with the preoperative CDUS. The clinical course of 94 conservatively treated patients (71.2%) (group C) confirmed in all cases a non-ischaemic aetiology. There was a total of 12 cases (9.1%) where acute scrotum was caused by testicular torsions. This relatively low rate underlines the necessity to differentiate between ischaemic and other aetiologies, thus avoiding operation in many patients. 71.2% of our patients could be treated conservatively. However, it is essential to exclude an ischaemic cause before opting for conservative therapy. Even though CDUS is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum.

Acute scrotal pain in children presents a major diagnostic and therapeutic challenge. Epididymitis has been considered uncommon in childhood. The clinical spectrum and therapeutic policy of the acute scrotum in children is continually being reassessed.To determine whether there has been an increase in the incidence of epididymitis in children and to advocate a more selective surgical approach to the acute scrotum.We conducted a retrospective review of 65 children admitted to our department of pediatric surgery with the diagnosis of acute scrotum during a 5 year period.Of the 65 children admitted with the diagnosis of acute scrotum, epididymitis was diagnosed in 42 (64.6%). The remaining cases included torsion of the testis in 12 patients (18.5%), torsion of the appendix testis in 5 (7.7%), scrotal pain and minimal physical findings in 4 (6.1%), and scrotal hematoma and idiopathic scrotal edema in one patient each. Doppler ultrasound of the groin, color Doppler ultrasound of the testis and testicular nuclide scintigraphy (Tc-99m scan) examinations were performed on 49, 30 and 57 occasions, respectively; the Tc-99m scan was the most effective tool. All the patients with epididymitis were diagnosed before surgical intervention and were treated conservatively.We observed an increasing frequency of epididymitis in children admitted with the diagnosis of acute scrotum.

The aim of this study is to analyze the results of a group of patients who underwent subinguinal microsurgical varicocelectomy using local anaesthesia in one-day-surgery.From 1997 to 1998 150 patients were selected from the whole group of patients who underwent surgical treatment for varicocele. The varicocele was always on the left side and the mean age was 27.1 years (range: 16-43). The diagnosis was based on clinical features (testicular pain or scrotal sensation), physical examination and Doppler ultrasound. Where there was infertility with abnormal semen analysis and/or patient's intolerance to the symptoms, surgery was suggested. The patients underwent varicocelectomy by sub-inguinal approach using local anaesthesia. The microsurgical technique of dissection was performed.All operations were performed on an outpatient basis (post-operative stay: 3-7 hours) and the operating time was 20 to 45 minutes. Follow-up was performed by physical examination, doppler ultrasound and semen analysis. Immediate and long-term complications were: 7 (4.7%) transient pain, 3 (2.0%) ecchymosis, 1 (0.7%) transient hydroceles and 1 (0.7%) permanent hydroceles, 2 (1.3%) palpable recurrence, 2(1.3%) doppler recurrence and 1 (0.7%) long-term recurrence, 0 testicular atrophy. 120/150 (80%) patients showed an improvement of semen analysis and 19/41 (46.3%) patients with infertility achieved a pregnancy with the partner.Microsurgical treatment of varicocele in outpatients by subinguinal approach is a safe and reliable procedure. It is performed in local anaesthesia, preserves the lymphatics, spermatic artery and vas and in our experience showed an improvement of semen analysis and pregnancy rates with minimal morbidity.