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Reports show that left testis in inguinal region. Suggested inguinal hernia. Is surgery required?
Question: Hi Doctor, One of my relative has one un-descended testis from birth.All these days he thought he had only a single testis as that was the only one he could feel in his sanctum.He is 30 years old.When he was a child his parents had shown to doctor and they said no treatment is required as the testis will automatically come down in Sac.when he was around 8 years old his parents again showed to doctors as the testis did not come down and again the doctors said it will come down later in life and said no treatment is necessary.Now in last 1 year he felt the presence of another testis in his sac when he sits in stools position.When he stands it is partially down in sac and when he sleeps its completely not felt in sac.So after getting advice to consult a urologist through health magic he got it diagnosed in manipal.So after ultra sound done he came to know some new revelations.The egg shaped mass with identical shape of testis which he thought was his undescended testis was told to him was a inguinal hernia.And the ultrasound doctor said that he has a left testis in inguinal region.The report says following "Realtime UltraSonography of the Scrotum and color dropler study" "Right testis measures 4.9 X 2 X 2.9 cm(Volume 15 cc).Normal in size and echotexture.No focal lesion.No surrounding free fluid.RIght epididymis measures 1 X 0.9 cm. Normal in size, no lession noted.Left scrotal sac is empty.Left testis is seen in the deep inguinal region.It measures 3.7 X 2 X 2.7cm (volume 11CC).There is herniation of omental fat into the left scrotal sac.The defect measures approx 1.8 cm. Impression:Undecended left testis.Left testis in inguinal region.Left inguinal hernia with omentum as its content." Now here are few of my questions: 1.He has no pain as accompanied with hernia.So is any kind of surgery or treatment required? Is this hernia size as in report small or large? I read that if the size of hernia is small then no surgery is required and healthy lifestyle is sufficient.Please advice. 2.Does his left testis which is undescended need to be operated on and brought down into sac at this age of 30.The doctors had said they were no problems seen in testis.So even in case the undescended testis is not fertile does it need to be removed or can it be brought down and kept in sac.? 3.If hernia does not need to be operated on then can undecended testis needs to be operated or its ok to leave it as it is? 4.In case you opt for surgery which of the surgeries do you suggest the best for his case? 5.What is the recovery period(how many days of leave he needs to apply from job and how many days he need to stay in hospital) and what are the pros and cons of the surgery ? When should it be really opted? Only in case of pain? 6.Does all these problems have impact on his sexual life and his ability to have children.He is unmarried so more concerned..? 7.Does congenital hernia(which he is not sure of) can stop the testis from undescending in sac? Any of your suggestions.Please provide a detailed reply for each points.You may ask any question if you have to get more clearity of his situation.
Brief Answer: He needs to get operated. Detailed Answer: Hello Thanks for your query.Based on the facts that you have posted it appears that your relative has got congenital Hernia with undescended testis on Lt side which is confirmed on ultrasound scanning and on clinical examination. I shall answer all your queries in details point to point. 1) Surgery is the only treatment for hernia no matter whether it is small or large as it involves the risk of bowel getting trapped in to hernial sac which may lead to life threatening situation any time in future.So better to get operated at earliest. 2) Undescended testis if not placed in scrotal sac has 90 % chances of getting malignant changes (Cancer ) more than normally situated testis and there is risk of arrest of spermatogenesis (Production of sperms) .Since his Lt testis is of near normal size as reported on ultrasound scanning there are high chances of normal spermatogenesis on left testicle. Hence I would suggest to get it placed in scrotal sac at earliest... 3) Both Hernia and undescended testis are operated in one sitting through same incision.No separate surgery is required . 4) Since both the surgeries are done in same sitting I would advice to go for open surgery rather than Laproscopic surgery as open surgery is less time consuming and can be performed with ease . 5) Ideally this surgery is advised a to be done latest at the age of 5-6 years .Since he is now 29 years old I would suggest to get surgery done immediately.He will be hospitalised for 3days and will need rest for one more week after discharge from the hospital. 6) Since he has normal right testis he may not have problem of infertility.But since he has normal left testis which if left untreated ,there are chances of loosing it for no reason. 7) Yes congenital hernial sac can prevent testis from descending down in scrotal sac because of band of adhesions. Hope I have answered your query. If you have any more questions please feel free to ask me I shall be happy to help you . Thanks and Regards. Dr.Patil.
Thanks doctor for detailed answers.I have below followup questions please give detailed point by point answers as you did earlier. 1.Removing of testis should be based on it being functional or not ?Which means he should get that undescended testis tested before surgery? If yes what test? 2.I heard of the risk of testicle cancer ,so does this happen in case of only non-fuctional testis or in case of any undescended testis, irrespective of it being functional or non-functional?Will the damaged cells of his testis lead to cancer? or some other factors lead to cancer?if so what are the factors? 3.What are the symptoms of testicle cancer? and can it spread to other normal testis? 4.You opted for open surgery is it not more painfull and takes longer time to recover? can you suggest the plus and minus(side effects) of the surgeries that can be performed in this case? 5.What are the symptoms of Hernia getting complicated or need faster surgery?(when is that decision needs to be made) 6.Will a person be able to lead a normal life of running,sports etc after the surgery?Will he be able to lead a normal married life? or does the side effects of surgery and illness restrict him in some activities? 7.How do you arrive to the conclusion that the undescended testis is normal from report, as sperms could be producing from the decended testis and the undescended one may have no contribution of it.So what factors are considered? 8.Do you know of any exact similar case in your experience and is it all normal with him after surgery? 9.Can you suggest some good hospitals or surgeons in bangalore or hubli where this can be performed with experts? Is manipal good in this surgery ?(I am asking your personal opinion if you know someone in hubli it would be of great help) 10.As the bulge(of hernia in ingunal area and also felt in sac) goes away when you sleep do you think surgery is required(as i read somewhere if the bulge is retracticle then it can be left as it is)? Will the hernia size/bulge grow with age or is it constant? 11.He feels a egg shaped muslce in his scortum.He had initially thought this to be his left testis as the shape and structure is very similar to testis,but only the size is 3 to 4 times the size of his right testis.Only during ultrasound he found it was not testis.So is it possible for hernia to be of that shape as said above? and does it descend into scortum? (He had said that he feels this in scortum only while he is in standing posture ,while he is sleeping he cannot feel it hence in report it was said the left scortum is empty).So does it grow with time or stay of same size as it is now (hernia and the egg shaped muscle he feels in scortum)?
Brief Answer: Undescended testis has high risk of getting cancer Detailed Answer: Hello Thanks for follow up. 1)Being a near normal testis I have not suggested to remove the testis.Removal of the testis is not needed in this case. 2)if left untreated Undescended testis is more prone to get malignant changes. 3)Testis gets enlarged and becomes hard if it is cancerous. 4)It is my person choice based on my experience .For details about every mode of treatment you have to consult general surgeon and laproscopic surgeon as well.Decision of mode of surgery is your choice 5)Persistent swelling in groin and sever pain in abdomen with vomiting are the preliminary symptoms. 6)Yes he will be able to have normal life and normal married life after surgery. 7)The size of the testis as reported on ultrasound scanning is the factor that determines whether it is normal or not.Scientist have not so far able to find out whether a particular sperm is produced by descended or undescended testis 8)I have treated so many cases in my 40 years of practice with 100 % success. 9)This is very simple surgery and can be done by any experienced general surgeon even in Hubli. 10)This is called as reducible Hernia and if left untreated can increase with growing age. 11) This can not be explained unless I examine him personally. Thanks and Regards. Dr.Patil.
Thanks doctor for answering these questions.I just a little more clarity on 2 points. 1. In point 11 I was trying to understand if the shape of henia can be egg shaped or testis like and can it enter scortum and stay along side the right testis? The reason I am asking it is can hernia and undesdended testis be bundled together in body or are they completely seperate ? 2.Can in lapascropic we have this situation treated and surgery be performed for both hernia and testis with less compications and heigher success rate? Which is more precise, heigher success rate and faster recovery?Need clearity.
Brief Answer: Shape of hernia is not important Detailed Answer: Hello Thanks for follow up. 1)Shape of hernia is not important from clinical and surgical point of view. Shape depends upon the contents of hernial sac.Hernial sac can reach up to top of the testis Hernial sac may contain undescended testis and exist together if testis is located in inguinal canal and not when testis is located in scrotum. 2)This is very simple surgery and gives 100% success in hands of a experienced general surgeon..I can not make comments about laproscopic surgery as I am not doing it .You may take opinion of a surgeons who performs it routinely. Thanks and Regards. Dr.Patil.
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