INTRODUCTION The lymphatic drainage of the testis follows the vessels around the spermatic vein until the retroperitoneal nodes between the lower thoracic and lumbar vertebrae. For this reason testicular cancer spreading usually involves the lymph nodes in the retroperitoneum as primary landing site. However, atypical lymphatic sites may be involved and a 2% incidence of inguinal metastases in testicular cancer has been reported (1-4). This atypical spreading has been related to history of previous surgery in the inguinal region or scrotum. A modified lymphatic drainage can be created by surgical violation during orchi- dopexy, relief of hydrocele or varicocelectomy (5-10). In 47Archivio Italiano di Urologia e Andrologia 2012; 84, 4 CASE REPORT Inguinal polypropylene plug: A cause of unusual testicular tumor pelvic metastasis Marco Grasso 1, Salvatore Blanco 1, Angelica Anna Chiara Grasso 2, Luca Nespoli 3 1 Department of Urology, Azienda ospedaliera San Gerardo, Università degli Studi di Milano-Bicocca, Monza, Italy; 2 Department of Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy; 3 Department of General Surgery, Azienda ospedaliera San Gerardo, Università degli Studi di Milano-Bicocca, Monza, Italy. We report the case of a patient who had undergone polypropylene plug placement 3 years before and referred to our institution with testicular tumor. CT scan demonstrated an enlargement of pelvic lymph nodes on the tumor side while retroperitoneal nodes were normal. Orchifunicolectomy was performed and histopatho- logical examination showed a mixed germ cell tumor involving the tunica vaginalis, rete testis, epididymis and spermatic cord. After surgery the patient was addressed to adjuvant chemotherapy according to PEB scheme. Clinical re-staging showed a decrease of the pelvic bulk disease whereas retroperitoneal nodes were still normal and tumor markers were negative. Left external, internal and common iliac lymphadenectomy as well as left modified template nerve- sparing retroperitoneal lymph node dissection was performed. Intraoperatively the node bulk was firmly adherent to the external iliac artery and extended until the common iliac bifurcation. In the deeper part of this enlarged and firm lymphatic chain the polypropylene plug placed at the time of hernioplasty was found. Behind the plug all retroperitoneal nodes appeared normal and resulted negative on histopathologic examination. The patient had an unusual metastatiza- tion, probably due to the plug. KEY WORDS: Testicular tumor; Polypropylene plug; Metastasis. Submitted 2 November 2012; Accepted 31 December 2012 No conflict of interest declared Summary these cases direct lymphatic drainage to the inguinal nodes can be developed. We report a case of unusual lymphatic spreading of tes- ticular cancer after previous hernioplasty in which a polypropylene plug was deeply placed into internal inguinal ring according to the the Lichtenstein tension- free mesh onlay repair (11). CASE REPORT A 26 years old man was examined on March 2001 for left testicular mass which appeared as clinically malignant. He Grasso_Stesura Seveso 18/04/13 12:06 Pagina 47 Archivio Italiano di Urologia e Andrologia 2012; 84, 4 M. Grasso, S. Blanco, A.A.C. Grasso, L. Nespoli 48 lene plug placed at the time of hernioplasty was found (Figure 3). Behind the plug all retroperitoneal nodes appeared normal and resulted negative on histopatho- logic examination. External iliac and otturatory lymph nodes however showed large tissue necrosis and focal mature teratoma. After 3 years the patient underwent left inguinal lymphadenectomy for lymphnodes enlarge- ment. Hystopathologic examination showed no recur- rent cancer. At the last follow-up the patient was healthy and free of disease, father of a child spontaneously con- ceived two years ago. DISCUSSION Inguinal hernioplasty represents one of the most fre- quently performed surgical operations. The recent intro- duction of prosthetic mesh made Bassini operation obso- lete, with more space gained by the newly developed “tension -free” and “sutureless” surgical technique (12, 13) The study proposed by Gandolfo showed the tissutal reaction consequent to the plug. At ultrasonography the mesh presented as a small hyperechoic layer. In some patients a seroma was present above the mesh. The sero- ma disappeared spontaneously between 30 and 90 days postoperatively and was probably related to the size of the hernia and the number of plugs (14). Various studies analyzed the factors associated with post- operative complications and hernia recurrence (15). In about 2% of cases testicular cancer lymphatic metas- tatization is atypical and includes inguinal lymph nodes (1-4). This unusual lymphatic spreading may happen for a significant variation of an otherwise normal anatomical pattern. It has been clearly reported in literature that in almost all cases of atypical lymphatic metastatization patients had previously undergone scrotal or inguinal surgery (orchidopexy, relief of hydrocele, trans-scrotal biopsy or varicocelectomy) (5-10). However, lymph- node metastases in the inguinal region can be found in patients with no previous surgery, mostly in patients with germ cell tumours, and these are probably due to infiltration from metastases of the spermatic cord (9, 16). In our case of atypical node metastatization, the lymphat- had undergone Lichtenstein tension-free mesh onlay repair by a “plug” technique three years before. Alpha-fetoprotein (normal range 0-15 IU) and beta-hCG (normal range 0-5 IU) were both raised to 9.9 IU and 15 IU, respectively. CT scan showed bulk disease of pelvic lymph nodes on the left side while retroperitoneal nodes were normal (Figure 1). Orchifunicolectomy was performed and histopathological examination showed a mixed germ cell tumor involving the tunica vaginalis, rete testis, epi- didymis and spermatic cord. After surgery the tumor markers were still raised. The patient was addressed to adjuvant chemotherapy according to PEB scheme. Clinical re-staging showed a decrease of pelvic bulk dis- ease, retroperitoneal nodes still normal and negative tumor markers. Left external, internal and common iliac lymphadenectomy as well as left modified template nerve-sparing retroperitoneal lymph node dissection was performed (Figure 2). Intraoperatively the node bulk was firmly adherent to external iliac artery and extended until the common iliac bifurcation. In the deeper part of this enlarged and firm lymphatic chain the polypropy- Figure 1. CT scan showing bulk disease of pelvic lymph nodes on the left side. Figure 2. Retroperitoneal lymph node dissection. Figure 3. Polypropylene plug found in the deeper part of the enlarged and firm lymphatic chain. Grasso_Stesura Seveso 18/04/13 12:06 Pagina 48 49Archivio Italiano di Urologia e Andrologia 2012; 84, 4 Inguinal polypropylene plug: A cause of unusual testicular tumor pelvic metastasis node metastases following a Torek orchiopexy. Urology. 1983; 21:300-1. 6. Herr HW, Silber I, Martin DC. Management of inguinal lymph nodes in patients with testicular tumors following orchiopexy, inguinal or scrotal operations. J Urol. 1973; 110: 223-45. 7. Klein FA, Whitmore WF Jr, Sogani PC, et al. Inguinal lymph node metastases from germ cell testicular tumors. J Urol. 1984; 131:497-500. 8. Nishimoto K, Ono H, Hirayama M, et al. Inguinal lymph node metastasis from contralateral testicular origin. Urology. 1993; 41:275-7. 9. Stein M, Steiner M, Suprun H, Robinson E. Inguinal lymph node metastases from testicular tumor. J Urol. 1985; 134:144-5. 10. Wheeler JS Jr, Babayan RK, Hong WK, Krane RJ. Inguinal node metastases from testicular tumors in patients with prior orchiopexy. J Urol. 1983; 129:1245-7. 11. Lichtenstein IL, Shore JM. Simplified repair of femoral and recurrent inguinal hernias by a "plug" technic. Am J Surg. 1974; 128:439-44. 12. Leardi S, Navarra L, Pietroletti R, et al.The use of prosthetic mesh- es in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit. Minerva Chir. 1998; 53:581-5. 13. Nathan JD, Pappas TN. Inguinal hernia: an old condition with new solutions.Ann Surg. 2003; 238(6 Suppl):S148-57. 14. Gandolfo L, Donati M, Privitera A, et al. Ultrasound tissue mod- ifications after polypropylene prosthesis apposition in inguinal her- nia. Chir Ital. 2007; 59:835-41. 15. Richard D. Matthews et al. Factors associated with postopera- tive complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Am J Surg. 2007; 194:611-617. 16. Daugaard G, Karas V, Sommer P. Inguinal metastases from tes- ticular cancer. BJU Int. 2006; 97:724-726. ic spreading was very unusual since it only involved nodes in the pelvic area. This can be explained by the alteration of normal lymphatic drainage pattern in the spermatic cord during inguinal hernioplasty as well as during tissue healing in the post-operative period. The polypropylene plug deeply placed in the internal inguinal ring might have played a role in the alteration of the normal lym- phatic circulation in the spermatic cord. The blockage of normal lymphatic up-flow probably caused a chronic extravasation and created new lymphatic communications with the pelvic nodes. As a consequence, the bulk pushed the plug deeper, up to the common iliac bifurcation. The absence of involved nodes above confirms the lymphatic barrier effect caused by the plug. Another point of discussion is the left inguinal node enlargement that occurred three years later. As above men- tioned, the inguinal node involvement in cases of previ- ously scrotal or inguinal surgery or in cases of locally advanced disease is well known. For this reason the patient underwent inguinal lymphectomy, without evi- dence of disease. The treatment of these rare cases is matter of debate. On one hand Mianne does not consider ipsilateral node dis- section necessary, owing to the efficacy of primary or sec- ondary chemotherapy in non seminomatous testicular tumors, while for testicular seminoma, he suggests addi- tional inguinoscrotal radiotherapy (2). On the other hand Van Ahlen considers as therapy of choice the adjiuvant chemotherapy and salvage lymphadenectomy in case of residual tumor, including peri-iliac lymphadenectomy (3). CONCLUSION In the case reported we stress that a polypropylene plug located near iliac vessels could induce an important tis- sutal reaction and alter the lymphatic flow, with the con- sequent metastatic involvement of pelvic nodes preserv- ing the common iliac and paraortic nodes. In this case the massive local diffusion of the disease could allow a simple diagnosis, but nowadays in many cases the lymph nodes involvement is only microscopic, therefore not clinically evaluable. On the other hand the use of propylene plug for hernio- plasty is very frequent. We think that is mandatory to con- sider the opportunity of extending surgical or radiant approach to iliac and obturator region in patients suffer- ing from testicular germ cell cancer if they had previous- ly underwent hernioplasty with polypropylene plug. REFERENCES 1. Stein M, Steiner M, Suprun H, Robinson E. Inguinal lymph node metastases from testicular tumor. J Urol. 1985; 134:144-53. 2. Mianne DM, Barnaud P, Altobelli A, et al. Inguinal lymphatic metastasis of cancer of the testis: staging and therapeutic approach. Ann Urol. 1991; 25:199-202. 3. Van Ahlen H, von Stauffenberg, Porst H, Vahlensieck W. Inguinal metastasis of stage I testicular tumors. Urologe A. 1988; 27:275-8. 4. Daugaard G, Karas V, Sommer P. Inguinal metastases from tes- ticular cancer. BJU Int. 2006; 97:724-6. 5. Crawford ED, Cain DR, Black WC, Borden TA. Inguinal lymph Correspondence Marco Grasso, MD grasso.m@virgilio.it Salvatore Blanco, MD sblanco_74@yahoo.it Luca Nespoli, MD l.nespoli@hsgerardo.org Azienda Ospedaliera San Gerardo, via Pergolesi 33 - 20900 Monza, Italy Angelica Anna Chiara Grasso, MD (Corresponding Author) Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Via della Commenda 15 - 20100 Milano, Italy angelica_grasso@yahoo.it Grasso_Stesura Seveso 18/04/13 12:06 Pagina 49