What are the consequences of not replacing the testis in the scrotum after inguinal hernia repair?

Consequences of Not Replacing the Testis in the Scrotum After Inguinal Hernia Repair

Failure to replace the testis in the scrotum after inguinal hernia repair can lead to iatrogenic cryptorchidism, which significantly increases the risks of infertility, testicular malignancy, and testicular atrophy.

Risks of Undescended Testis

Increased Cancer Risk

• An undescended testis has approximately 2.75-8 times higher risk of developing testicular cancer compared to normally descended testes 1
• Orchiopexy performed before puberty significantly reduces this risk by two to six-fold compared to postpubertal orchiopexy 1
• The risk of malignant degeneration in an undescended testis is 17 times greater than in the normal population 2

Impaired Fertility

• Cryptorchidism is associated with significant impairment of fertility potential 1
• The higher temperature in the inguinal region (compared to the scrotum) damages the developing seminiferous tubules
• Men with a history of bilateral cryptorchidism have a six-fold increased risk of infertility compared to the general male population 1
• Even unilateral cryptorchidism can negatively impact overall fertility

Testicular Atrophy

• Failure to place the testis in the scrotal position can lead to testicular ischemia and subsequent atrophy 3
• The abnormal position can compromise blood supply to the testis
• Testicular atrophy may necessitate testosterone replacement therapy due to decreased hormone production

Ascending Testis Phenomenon

• In some cases, even when the testis is properly placed in the scrotum during hernia repair, it may spontaneously ascend back to the inguinal area 4
• This "ascending testis" occurs in approximately 0.43% of patients following inguinal hernia repair 4
• Risk factors include:
  • Scrotal hypoplasia
  • Retractile testes
  • Young age (1-3 years)
• Patients with these risk factors may benefit from concurrent orchiopexy during herniorrhaphy 4

Management of Iatrogenic Cryptorchidism

If the testis is not replaced in the scrotum after inguinal hernia repair:

1. Early intervention is crucial: Orchiopexy should be performed as soon as the condition is recognized
2. Hormonal therapy: Some cases may respond to human chorionic gonadotropin (hCG) therapy in the early postoperative period 4
3. Surgical correction: Scrotal orchiopexy is the definitive treatment
4. Post-pubertal management: In post-pubertal males with cryptorchidism, orchiectomy should be considered due to the high risk of malignancy 1

Long-term Follow-up

• Patients with a history of cryptorchidism require long-term monitoring
• After puberty, patients should be taught testicular self-examination for early cancer detection 1
• Fertility counseling should be provided regarding potential subfertility 1

Prevention

• Always verify testicular position at the conclusion of inguinal hernia repair
• Patients with retractile testes or scrotal hypoplasia in addition to inguinal hernia need orchiopexy together with herniorrhaphy 4
• Careful dissection of the spermatic cord during hernia repair helps prevent adhesions that could contribute to testicular ascent 5

Proper placement and verification of testicular position in the scrotum during inguinal hernia repair is essential to prevent these serious long-term complications that significantly impact morbidity, mortality, and quality of life.