Surgical Endoscopy

Case reports Surg Endosc (1996) 10:537-539

© Springer-Verlag New York Inc. 1996

Spermatic granuloma An uncommon complication of the tension-free hernia repair R. C. Silich, C. K. McSherry Department of Surgery, The New York Hospital-Cornell Medical Center, 525 East 68th Street, Suite K707, New York, NY 10021, USA Received: 8 September 1995/Accepted: 22 September 1995

Abstract. A p a t i e n t w i t h a s p e r m g r a n u l o m a f o l l o w i n g a t e n s i o n - f r e e h e r n i a r e p a i r u t i l i z i n g M a r l e x m e s h 4 years p r i o r to p r e s e n t a t i o n is described. T h e m e c h a n i s m o f g r a n u l o m a f o r m a t i o n is b e l i e v e d to b e s e c o n d a r y to vas d e f e r e n s i n j u r y d u e to e r o s i o n b y the cut e d g e s of t h e m e s h at t h e m e d i a l e n d o f t h e slit u s e d to r e c r e a t e the i n t e r n a l i n g u i n a l ring. S p e r m a t i c g r a n u l o m a h a s b e e n rarely d e s c r i b e d in hern i a s u r g e r y a n d r e q u i r e s a p r e v i o u s v a s d e f e r e n s injury. W h i l e the m o r e c o m m o n a n d clinically s i g n i f i c a n t e v e n t s o f hernia recurrence and wound infection should be considered first, t h e o c c u r r e n c e o f s p e r m a t i c g r a n u l o m a as a c a u s e o f p o s t o p e r a t i v e p a i n or a m a s s s h o u l d b e i n c l u d e d in the differential diagnosis.

Key words: S p e r m g r a n u l o m a - - T e n s i o n - f r e e h e r n i a repair - - V a s d e f e r e n s - - P r o s t h e t i c m e s h

S p e r m a t i c g r a n u l o m a is well k n o w n to urologists, p a r t i c u larly w i t h r e s p e c t to v a s d e f e r e n s surgery. T h i s entity was e n c o u n t e r e d 4 years after a t e n s i o n - f r e e i n g u i n a l h e r n i a repair i n a t h e n - 2 5 - y e a r - o l d m a n . H o w e v e r , this entity h a s n o t b e e n p r e v i o u s l y d e s c r i b e d as a c o m p l i c a t i o n o f i n g u i n a l h e r n i a repair.

Case report A healthy 29-year-old man presented to The New York Hospital-Cornell Medical Center with a complaint of right inguinal pain for 48 h prior to admission. Four years ago he underwent a right inguinal hernia repair at an ambulatory surgery center. The type of hernia repair and the possible use of prosthetic material were unknown to the patient. Two years afterward he noted the onset of mild intermittent pain in his right groin. Forty-eight hours prior to admission he had severe pare in his groin during a bowel movement, and subsequently he had recurrence of the pain during unsuccessful sexual intercourse. He was able to ambulate and denied nausea,

Correspondence to: R. C. Silich

vomiting, dizziness, a change in bowel habits, or any recent trauma. His past medical history was uuremarkable. Upon examination the patient had a soft, nontender, nondistended, abdomen with normal bowel sounds. There was a well-healed oblique scar in the right inguinal region from his prior hernia surgery. A 2.5 x 2 cm slightly mobile, firm, tender nodule was palpated deep to the incision. Rectal examination was normal. Screening laboratory studies were all normal. An ultrasound of the right groin and a computed tomography scan of the lower abdomen and pelvis both failed to reveal a recurrence of the hernia. However, both described a subcutaneous nodule with a relatively radiolucent core (Fig. 1). The differential diagnosis included an infected lymph node, granuloma, foreign body, or an abscess. The patient underwent an exploration of the right groin. Dissection in the deep subcutaneous tissue revealed the nodule imbedded m surrounding fibroareolar tissue and synthetic mesh. The lesion measured 2 x 2.5 x 1 cm and was dissected free from the surrounding subcutaneous tissue. A small amount of old blood was expelled from the lesion during dissection. Following excision of the nodule it was noticed that the vas deferens, which coursed directly through the nodule, was divided. A microscopic vasovasostomy was performed without complication by a consulting urologist. An intraoperafive vasogram demonstrated patency of the reanastomosed vas deferens. Microscopic examination of frozen sections of the specimen revealed histiocytes, multiple spermatozoa, and Marlex mesh (Figs. 2 and 3), confirming the diagnosis of spermatic granuloma. The permanent section diagnosis was identical. The patient's postoperative course was uncomplicated with immediate resolution of his symptoms and he was discharged on postoperative day 1. Intraoperative cultures revealed no growth.

Discussion S p e r m a t i c g r a n u l o m a is f r e q u e n t l y d e s c r i b e d in u r o l o g i c a l texts as a s e q u e l o f v a s d e f e r e n s injuries a n d surgery. It h a s n o t b e e n d e s c r i b e d p r e v i o u s l y in the g e n e r a l s u r g e r y literature as a p o s t o p e r a t i v e c o m p l i c a t i o n o f i n g u i n a l h e r n i o r r h a phy. T h e p a t h o g e n e s i s o f s p e r m g r a n u l o m a is b a s e d o n the h i g h l y a n t i g e n i c n a t u r e o f s p e r m a t o z o a w h e n f o u n d extral u m i n a l l y f r o m t h e m a l e d u c t a l s y s t e m w h e r e t h e y are reco g n i z e d as a c o m p l e t e l y f o r e i g n tissue. In o u r p a t i e n t t h e r e was n o e v i d e n c e o f a p r e v i o u s o p e r a t i v e i n j u r y to the v a s deferens. T h e c o r d w a s i n t a c t a n d n o suture m a t e r i a l w a s i d e n t i f i e d in t h e g r a n u l o m a . W e b e l i e v e t h a t i n j u r y to the v a s o c c u r r e d at t h e m e d i a l e n d o f t h e slit i n t h e m e s h t h a t

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Fig. 4. Artist's sketch illustrating the mechanism of vas deferens injury from the cut edges of the mesh at the internal ring.

Fig. 1. CT scan. The a r r o w identifies a radiolucent nodule at the anterior abdominal wall at the level of the right inguinal canal. Fig. 2. Sperm granuloma is characterized by an outer epithelioid rim of histiocytes and a multinucleated giant cell engulfing several sperm heads with surrounding granulomatous inflammation. Fig. 3. Two fragments of birrefringent synthetic material are identified, consistent with Marlex.

as high as 70% in some retrospective studies [4]. Similar occurrence rates may be inferred after vas injuries and repair that occur during inguinal herniorrhaphy, but such injuries are fortunately rare. A related condition often found with sperm granuloma is vasitis nodosa. Benjamin et al. [1] first described this entity as characterized by a proliferation of multiple epithelial lined ductules of the vas deferens. It is often confused with malignancy of the vas deferens. Kiser et al. in 1986 reported a 66% occurrence of vasitis nodosa after vasectomy [4]. While usually seen after vasectomy, there have been case reports of spontaneous occurrence. Civantos et al. [3] reported two cases of vasitis nodosa found at autopsy in patients who had undergone herniorrhaphy. These individuals were completely asymptomatic during life. Vasitis nodosa is believed to occur with spontaneous recanalization of the vas deferens following vasectomy. There is a 70% association in vasitis nodosa with granulomatous inflammation which most c o m m o n l y includes spermatic granuloma. Pain may accompany both vasitis nodosa and spermatic granuloma, although the largest study of vasitis nodosa [4] suggests that pain is infrequent. In fact only 1 of 20 post vasectomy subjects reported by Kiser and colleagues had pain, and that patient had only vasitis nodosa without spermatic granuloma. In contrast, our patient had no pathological evidence of vasitis nodosa.

Conclusion was created to reconstruct the floor of the canal and the internal ring (Fig. 4). The cut edges of the mesh are presumed to have gradually eroded the vas and permitted the escape of spermatozoa into the surrounding tissue. Carey et al. [2] described sperm granuloma formation after vasovasostomy as early as 1 month after surgery. The incidence of sperm granuloma formation after vasectomy is

A patient with a sperm granuloma following a tension-free hernia repair utilizing M a r l e x mesh is described. The mechanism of granuloma formation is believed to be secondary to vas deferens injury due to compression and erosion by the cut edges of the mesh at the medial end of the slit used to recreate the internal inguinal ring. Correction of

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this defect by excision of the granuloma and repair of the vas deferens by microsurgical anastomosis is recommended. Spermatic granuloma, rarely described in hernia surgery and necessitating a previous vas deferens injury, is a possible occurrence in patients after hernia repair. While the more common and clinically significant events of hernia recurrence and wound infection should be considered first, the occurrence of spermatic granuloma as a cause of postoperative pain should be included in the differential diagnosis.

References 1. Benjamin JA, Cheetham JG, Robertson TD (1943) Vasitis nodosum: a new clinical entity stimulating tuberculosis of the vas deferens. J Urol 49:575-578 2. Carey PO, et al. (1988) Effects of granuloma formation at site of vasovasostomy. J Urol 139:853-857 3. Civantos F, Lubin J, Rywlin A (1972) Vasitis nodosa. Arch Pathol 94: 355-360 4. Kiser GC, Fuchs EF, Kessler S (1986) The significance of vasitis nodosa. J Urol 136:42-44 5. Kwart A, Coffey D (1973) Sperm granulomas: an adverse effect of vasectomy. J Urol 1 1 0 : 4 1 6 4 2 2