Surgery · Medical Literature
Sex-Related Quality of Life After Totally Extraperitoneal Versus Lichtenstein Inguinal Hernia Repair: A Randomized Controlled Trial.
Abstract
Comparative randomized evidence specifically evaluating totally extraperitoneal (TEP) and Lichtenstein repair is limited. This study compared sex-related and general health-related quality of life following these two techniques. In this prospective randomized controlled trial, sexually active adult men with primary uncomplicated inguinal hernias were randomized to TEP or open Lichtenstein repair. The primary endpoint was pain during sexual activity at 1 year, measured using the Sexual Inguinal Hernia Questionnaire (SexIHQ). Secondary outcomes included additional SexIHQ domains and health-related quality of life measured by the 36-Item Short Form Health Survey (SF-36). A total of 105 patients were analyzed, including 50 undergoing TEP and 55 undergoing open repair. Baseline demographic, clinical, SF-36, and SexIHQ measures were comparable between groups. At 1 year, pain during sexual activity was reported less frequently after TEP than after open repair (16.0% vs. 43.6%; risk ratio 0.37, 95% CI 0.18-0.74; p = 0.003). Among patients reporting pain during sexual activity, the degree of impairment in sexual activity did not differ significantly between groups. SF-36 scores at 1 year were significantly higher after TEP across all measured domains. TEP repair was associated with a lower rate of pain during sexual activity at 1 year compared with Lichtenstein repair. However, other SexIHQ domains were not significantly different. These findings suggest a possible benefit of avoiding anterior inguinal canal dissection, but do not establish broad superiority of TEP for overall sexual function.
Clinical relevance
In sexually active adult men with primary uncomplicated inguinal hernias, does totally extraperitoneal (TEP) repair result in less pain during sexual activity at 1 year compared with open Lichtenstein repair, as measured by the Sexual Inguinal Hernia Questionnaire (SexIHQ)? __SNAPSHOT__ {"studyDesign":"Prospective randomized controlled trial","setting":"Not reported (country/institution not specified in abstract; authors' affiliations suggest an Indian tertiary surgical center based on author names and journal context)","sampleSize":"n=105 analyzed (TEP: n=50, Lichtenstein: n=55); enrolled sample size not reported in abstract","population":"Sexually active adult men with primary, uncomplicated inguinal hernias; baseline demographic, clinical, SF-36, and SexIHQ measures reported as comparable between groups","intervention":"Totally extraperitoneal (TEP) laparoscopic inguinal hernia repair","comparator":"Open Lichtenstein tension-free mesh repair","primaryOutcome":"Pain during sexual activity at 1 year, measured using the Sexual Inguinal Hernia Questionnaire (SexIHQ)","followUp":"1 year","fundingSource":"Not reported"}
Key findings
At 1-year follow-up, pain during sexual activity was reported by 16.0% of patients in the TEP group versus 43.6% in the Lichtenstein group (absolute risk difference: −27.6 percentage points [calculated]; risk ratio [RR] 0.37, 95% CI 0.18–0.74; p=0.003), representing a statistically significant and clinically meaningful reduction in favor of TEP. The number needed to treat (NNT) to prevent one additional case of pain during sexual activity is approximately 4 (calculated: 1/0.276). Among patients who did report pain during sexual activity, the abstract states that the degree of impairment in sexual activity did not differ significantly between groups — however, the relevant point estimates, confidence intervals, and p-values for this secondary comparison are not reported in the abstract. Results for additional SexIHQ domains (pain frequency, pain intensity, erectile impairment, ejaculatory dysfunction, depression symptoms) and SF-36 subscale scores are not reported in the abstract. No safety data, adverse events, recurrence rates, or intraoperative complications are reported in the abstract.
Practice implications
This RCT provides direct randomized evidence that TEP repair is associated with a substantially lower prevalence of pain during sexual activity at 1 year compared with Lichtenstein repair in sexually active men with primary uncomplicated inguinal hernias. The absolute risk reduction of approximately 27.6 percentage points (calculated) and an NNT of ~4 (calculated) are clinically significant if confirmed in larger trials — this magnitude of benefit, if real, would be directly relevant to preoperative counseling and shared decision-making for sexually active male patients. However, several important limitations preclude immediate, unqualified practice change. The trial is small (n=105), and the 43.6% rate of sexual pain in the Lichtenstein arm is notably higher than the 10–15% postoperative rates reported in prior large European RCTs (e.g., TEPLICH trial: ~12.5% at 1 year for Lichtenstein), raising concerns about population differences, surgeon technique, or measurement approach. The abstract does not report whether TEP conferred any advantage in the degree of pain-related impairment among those already experiencing pain, nor does it report SF-36 outcomes, secondary SexIHQ domain results, complications, or recurrences. The trial appears restricted to men, and findings are not applicable to women or patients with bilateral or recurrent hernias. Only an abstract is available for review, precluding assessment of randomization methodology, allocation concealment, blinding procedures, statistical analysis plan, or fidelity to TEP and Lichtenstein technique standards. Confirmation in an adequately powered, methodologically transparent multicenter trial is warranted before this finding drives a technique preference recommendation based on sexual QoL alone. __LIMITATIONS__ Small sample size (n=105) substantially limits precision; the 95% CI for the RR (0.18–0.74) is wide, indicating considerable uncertainty around the true effect magnitude.,The 43.6% rate of pain during sexual activity in the Lichtenstein arm is markedly higher than rates reported in comparable European RCTs, suggesting possible selection bias, differences in surgical technique (e.g., nerve handling, mesh type/fixation), or measurement artifact that limits generalizability.,Abstract-only availability precludes assessment of allocation concealment, randomization sequence generation, blinding (blinding of outcomes assessors is feasible and important for patient-reported outcomes), or protocol adherence.,Unequal group sizes (n=50 TEP vs. n=55 Lichtenstein) raise questions about the randomization process not addressed in the abstract.,Secondary SexIHQ domain outcomes (pain intensity, frequency, erectile and ejaculatory impairment, depression) and all SF-36 data are not reported in the abstract, preventing comprehensive QoL assessment.,No adverse event, complication, or hernia recurrence data are reported, limiting safety comparability.,Follow-up is limited to 1 year; longer-term durability of the sexual QoL advantage and recurrence rates remain unknown.,Exclusion of women, bilateral hernia patients, and recurrent hernias limits generalizability.,Funding source is not reported, and potential for conflict of interest cannot be assessed.,The SexIHQ, while purpose-built for this clinical question, has limited published psychometric validation data compared to more established PROMs, introducing measurement uncertainty.,Single-center design (likely) and geographic/institutional specificity further limit external validity. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This small RCT (n=105) found that TEP repair was associated with a significantly lower rate of pain during sexual activity at 1 year compared with Lichtenstein repair (16.0% vs. 43.6%; RR 0.37; NNT ~4 [calculated]), representing a potentially important patient-centered benefit worth incorporating into preoperative counseling for sexually active men. However, the notably high pain rate in the Lichtenstein arm, small sample, abstract-only data, and absence of safety and secondary outcome reporting necessitate cautious interpretation. Confirmation in a larger, methodologically rigorous multicenter trial reporting full outcomes is required before this finding can be considered practice-changing.