Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. 
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. 
The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. 
General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. 
An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. 
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

/pdf/international-guidelines-for-groin-hernia-management-3otlldvdxc.pdf

International guidelines for groin hernia management

Objective: To investigate the local tissue reactions to meshes that had been removed from humans. Design: Open study Setting: Surgical department of the technical University, Aachen, Germany. Material: Samples of 17 non-absorbable meshes (1 polyester, 10 polypropylene, 2 reduced polypropylene, and 4 polytetrafluorethylene, PTFE) and 1 absorbable mesh (polyglactin 910) that had been implanted for repair of abdominal wall defects. Interventions: Light and transmission electron microscopy, immunohistochemistry, and histological examination. Main outcome measures: Signs of inflammatory response. Results: Light microscopy showed chronic inflammatory tissue reaction, even after years, with pronounced differences among materials. Partial volume of inflammatory cells (%) varied from 32 in polypropylene, to 12 in expanded PTFE, 8 in polyester, and 7 in reduced polypropylene. Formation of connective tissue correlated significantly with the extent of the inflammatory reaction (p < 0.01). In meshes implanted for l...

Foreign body reaction to meshes used for the repair of abdominal wall hernias.

Erectile dysfunction is an important cause of decreased quality of life in men (1,2). Strong epidemiological evidence links the subsequent risk of erectile dysfunction to the presence of well-recognized risk factors for coronary heart disease, such as increased body weight, hypertension, and dyslipidemia (3,4). Some have suggested that a diagnosis of erectile dysfunction is a sentinel event that should prompt investigation for coronary heart disease in asymptomatic men (5). We postulated an association between erectile dysfunction and the metabolic syndrome because four of the five components of the metabolic syndrome are risk factors for erectile dysfunction and are also characterized by abnormal endothelial function (6).\n\nMen were recruited among those attending the outpatient department for metabolic diseases of the teaching hospital at the second University of Naples, Naples, Italy. To be enrolled in the study, subjects had to have three or more of the criteria to meet the diagnosis of the metabolic syndrome, as recommended by the Adult Treatment Panel (7). Exclusion criteria were diabetes or impaired glucose tolerance, impaired renal function, pelvic trauma, prostatic disease, peripheral or autonomic neuropathy, hypertension (blood pressure >140/90 mmHg), cardiovascular disease, psychiatric problems, use of drugs or alcohol abuse, and smoking (both present and past smoking). Endocrine causes of erectile dysfunction were also excluded. A total …

High proportions of erectile dysfuntion in men with the metabolic syndrome

https://www.europeanurology.com/article/S0302-2838(13)00843-9/pdf/a-new-era-of-testosterone-and-prostate-cancer-from-physiology-to-clinical-implications

A new era of testosterone and prostate cancer: from physiology to clinical implications.

Stone formation is proportional to papillary surface coverage by Randall's plaque. Commentary

UNLABELLED What's known on the subject? and What does the study add? Prostate growth is ruled by testosterone. Nevertheless, the paradigm that high testosterone levels induce prostate cancer development or lead to a poor prognosis in prostate cancer is not supported by evidence. A growing number of studies suggest that, on the contrary, low testosterone levels are related to poor prognosis features in prostate cancer such as higher prostate-specific antigen or higher Gleason score. Our experience shows that testosterone levels are related to risk of progression of prostate cancer - those men with lower testosterone levels are at higher risk of progression of their prostate cancer after treatment delivery. OBJECTIVES • Low testosterone levels have been related to a higher diagnosis of prostate cancer (PCa). Hormonal levels have been related to poor prognosis factors in men with PCa, mainly after radical prostatectomy. • Our aim was to determine the relationship between hormonal levels and PCa prognosis factors in men with PCa prior to the onset of treatment. PATIENTS AND METHODS • We prospectively analysed 137 males diagnosed in our centre with PCa with 5+5 core prostate biopsies from February 2007 to December 2009. • As part of our clinical protocol, we performed hormonal determination (testosterone and sex hormone binding globulin) following International Society of Andrology, International Society for the Study of the Aging Male and European Association of Urology recommendations. • Free testosterone and bioavailable testosterone were calculated using Vermeulen's formula. • Age, prostate-specific antigen (PSA), free to total PSA, PSA density, number of previous biopsies, digital rectal examination staging, Gleason score, percentage of tumour in the biopsy sample, bilaterality of the tumour and risk of progression group were prospectively recorded. RESULTS • Higher testosterone levels were related to lower digital rectal examination staging (P= 0.02) and lower PSA level (P= 0.05). Higher testosterone was not related to lower Gleason score (P= 0.08). • Testosterone was inversely related to PCa bilaterality (P < 0.01) and percentage of tumour in the biopsy (P < 0.01). • High testosterone levels were found in patients allocated to the low risk of progression group and inversely (P= 0.03). • In multivariate analysis, higher age and lower testosterone were related to higher D'Amico risk of progression. CONCLUSION • Patients with PCa and lower testosterone levels have poor prognosis factors and higher tumour burden before treatment onset. These findings reinforce the idea that low testosterone levels pretreatment are related to a poor prognosis in PCa.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1464-410X.2012.11232.x

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment.

Introduction
Relationship between prostate cancer (PCa) and testosterone (T) is controversial. Conflicting evidence has been published about T levels and development of PCa.

Low testosterone bioavailability is related to prostate cancer diagnose in patients submitted to prostate biopsy

Purpose

Up until now there were no specific questionnaire translated into Spanish for evaluating urinary disorder specific health-related quality of life (HRQoL) associated with multiple sclerosis (MS). Qualiveen is recommended by the European Association of Urology guidelines as a tool for evaluating neurogenic lower urinary tract dysfunction. The objective was to translate the Qualiveen into Spanish, adapt it cross-culturally and validate it against the currently available tools.



Materials and Methods

A bidirectional translation of Qualiveen was undertaken by professional translators. One hundred two Spanish MS patients were sent the Qualiveen and the ICIQ-SF questionnaires twice within a month. The questionnaires were sent and received by mail and reviewed when the patients came for the scheduled visit.



Results

Eighty-one patients participated. The validation study showed that the Spanish version of Qualiveen has good internal consistency with Cronbach's coefficient superior to 0.80 for all the questionnaire's subdomains and also for the entire Qualiveen demonstrating high discriminative power. Also the test–retest analysis proved internal stability of the Qualiveen (kappa coefficient between 0.81 and 0.89). Finally, all the Qualiveen scores correlated with the ICIQ-SF final score.



Conclusions

The Spanish version of Qualiveen functions similarly to the English language version retaining its discriminating power. It has shown it could be a valid instrument for discriminating between patients in a cross-sectional survey, as well as for measuring within subject changes over time thus evaluating the extent to which MS patients' HRQoL is impaired by urinary-related problems. Neurourol. Urodynam. 31:517–520, 2012. © 2012 Wiley Periodicals, Inc.

Quality of life of multiple sclerosis patients: translation and validation of the Spanish version of Qualiveen.

Objetivos

La disfuncion erectil (DE) es un estado muy comun entre la poblacion. Esta en clara relacion con la hipertension arterial (HTA), la diabetes mellitus (DM), la dislipemia (DLP) y el sindrome metabolico (SM). El objetivo del presente estudio es esclarecer si la presencia y severidad de la DE estan en relacion con el numero de factores de riesgo cardiovascular (FRCV).

Material y metodos

Analizamos retrospectivamente las caracteristicas de 242 varones derivados a nuestro centro para la realizacion de biopsia prostatica entre septiembre de 2007 y diciembre de 2009. Se recogieron prospectivamente las siguientes variables: edad, altura, peso, indice de masa corporal (IMC), HTA, DM, DLP y obesidad (IMC<30kg/m2). Para describir la funcion erectil utilizamos el cuestionario Erection Hardness Score. Analizamos la relacion entre la presencia y severidad de DE y la presencia de HTA, DM, DLP y obesidad. Analizamos las variables clinicas en funcion de la presencia o ausencia de DE y en relacion con su severidad.

Resultados

La presencia de DE se relaciona con HTA (OR: 1,805 [1,128-2,887]; p=0,013), DM (OR: 3,585 [1,613-7,966]; p=0,001) y DLP (OR: 1,928 [1,062-3,500]; p=0,029). La funcion erectil no se relaciono con obesidad (OR: 0,929 [0,522-1,632]; p=0,795). Los pacientes con DE eran mas susceptibles de tener mas FRCV (p=0,009) y la severidad de la DE se encontro en relacion con HTA (p<0,001), DM (p<0,001), DLP (p=0,001) y el numero FRCV (p<0,001).

Conclusiones

La presencia y severidad de la DE se encuentra en relacion con la HTA, la DM, la DLP y el numero de FRCV.

La disfunción eréctil y su severidad están en relación con el número de factores de riesgo cardiovascular

Aim Erectile dysfunction (ED) is a very common condition in the general population. ED is closely related to hypertension (HT), diabetes mellitus (DM), dyslipidemia (DLP) and metabolic syndrome (MS). This study has aimed to clarify whether the presence and severity of ED are related to the presence and number of cardiovascular risk factors (CVRF). Material and methods We retrospectively analyzed the characteristics of 242 males referred to our center for a prostate biopsy from September 2007 to December 2009. The following variables were collected prospectively: age, height, weight, body mass index (BMI), AHT, DM, DLP and obesity (BMI  2 ). The Erection Hardness Score Questionnaire was used to assess erectile function. We analyzed the relation between the presence and severity of ED and the presence of HT, DM, DLP and obesity. We analyzed the clinical variables based on the presence or absence of ED and in relationship to its severity. Results The presence of ED was related to HT (OR: 1.805 [1.128–2.887]; p  = 0.013), DM (OR 3.585 [1.613–7.966]; p  = 0.001) and Dyslipidemia (OR: 1.928 [1.062–3.500]; p  = 0.029). Erectile function was not related to Obesity (OR: 0.929 [0.522–1.632]; p  = 0.795). Patients with ED were more likely to have more CVRF ( p  = 0.009) and the severity of ED was related to the presence of HT ( p p p  = 0.001) and the number of CVRF ( p Conclusions The presence and severity of ED correlate with the presence of HT, DM, Dyslipidemia and the number of DVRF.

Agustín Franco

Papers

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment.

Low testosterone bioavailability is related to prostate cancer diagnose in patients submitted to prostate biopsy

Quality of life of multiple sclerosis patients: translation and validation of the Spanish version of Qualiveen.

La disfunción eréctil y su severidad están en relación con el número de factores de riesgo cardiovascular

Erectile dysfunction and its severity are related to the number of cardiovascular risk factors