The Impact of Previous Laparoscopic Inguinal Hernia Repair on Radical Prostatectomy

Abstract

Background and Purpose:

Laparoscopic inguinal hernia repair has become a frequently performed procedure. It is thus inevitable that some candidates for radical prostatectomy for prostatic carcinoma will have undergone such previous intervention. Mesh placement in the space of Retzius as performed in laparoscopic hernia repair may cause obliteration of the preperitoneal space, complicating radical prostatectomy. The objective of this review was to assess the literature regarding outcomes of radical prostatectomy (open, laparoscopic, robot-assisted) after laparoscopic inguinal hernia repair with mesh placement and to investigate whether key outcomes are compromised.

Methods:

A literature search was conducted in the PUBMED database using the search terms “prostatectomy” and either “hernia repair” or “herniorrhaphy.” A further evaluation of the references cited in the articles that were found was performed. Only publications related to radical prostatectomy after laparoscopic hernia repair were included.

Results:

A total of 15 articles referring to radical prostatectomy after laparoscopic hernia repair were found. These publications included a total of 436 patients. We evaluated operative and long-term outcome parameters such as completion of radical prostatectomy, completion of lymph node dissection, operative complications, and long-term, functional, and oncologic outcome.

Conclusions:

Radical prostatectomy (open, laparoscopic, robot-assisted) is feasible and safe after laparoscopic inguinal hernia repair. The procedure is technically demanding, although perioperative, oncologic, and functional outcomes do not differ from those after radical prostatectomy without previous laparoscopic inguinal hernia repair. Pelvic lymph node dissection may not be safe in some patients and may compromise accurate staging. A potential future need for radical prostactectomy in a male patient with inguinal hernia should not be a determining factor against a laparoscopic approach to inguinal hernia repair.

Introduction

I nguinal hernia repair (IHR) is a common procedure in the United States, with approximately 750,000 to 1 million procedures performed annually. The procedure can be performed using an open or laparoscopic approach.

During laparoscopic IHR (LIHR), a prosthetic mesh is placed over the internal inguinal ring and stapled to the tissue above the pelvic bones.¹ The implantation of synthetic mesh in the preperitoneal space creates a considerable inflammatory response, which leads to substantial adhesions and distortion of anatomic planes.²

The incidence of prostate cancer (PC) is estimated to be approximately 100 per 100,000 in economically developing countries with a lifetime risk (until the age of 75) of 7.8%.³ Treatment options include observation, external or internal radiation, and surgery—namely, radical prostatectomy (RP). The various approaches to performing RP include open, laparoscopic, and robot-assisted.

Considering the patients' similarities in terms of age and sex, the frequency of hernias and prostate cancer, and the recent increase in the laparoscopic approach to IHR, it is not surprising that a considerable number of patients with PC have undergone previous LIHR.

Several case reports^4
–6 published in the early 2000s have described cases of aborted RP because of severe adhesions with obliteration of the preperitoneal space in patients with previous LIHR. These reports spurred a debate regarding the safety and feasibility of RP after LIHR. Moreover, it has raised the question as to whether this issue should serve as an argument against performing LIHR in male patients because of concern of possibly obviating the option of RP in the future. The diverse methods of RP (open, laparoscopic, and robot-assisted) have complicated the issue. The aim of this review was to examine the available data on RP after LIHR.

Methods

We performed a literature search using the PUBMED database with the search terms “prostatectomy” and “hernia repair” or “herniorrhaphy.” The search included all publication types except Letters to the Editor. The search included all relevant papers published until the end of 2011. Cross-referencing was performed to identify additional articles. The search results were screened for RP (open, laparoscopic, and robot-assisted) performed after LIHR. All articles related to prostatectomy for causes other than PC, use of the perineal approach, or those performed concomitantly or before IHR were excluded from this analysis.

Results

The literature search identified 99 articles; of these, 80 were excluded because prostatectomy was performed concurrent with or before IHR and 4 were excluded because they were Letters to the Editor. From the 15 articles identified and included in this review, 3 were case reports and 12 were articles that reported on a larger number of patients.

In 2002, Katz and associates⁴ reported a patient with localized PC and previous LIHR who underwent an open RP. Severe and dense mesh adhesions have obliterated the preperitoneal space and the operation was aborted to avoid damage to adjacent tissues. One year later, Cook and colleagues⁵ reported on a patient with localized PC who elected to undergo RP. This patient had undergone bilateral LIHR 5 years previously. During the operation, dense adhesion between the prostate and the lateral pelvic walls rendered the dissection impossible, and the operation was aborted. A third case report, published by Cooperberg and coworkers⁶ demonstrated the same dissection difficulties in a patient with a previous LIHR 6 months earlier. The operation has to be aborted, and the patient was subsequently treated by brachytherapy.

These case reports spurred a debate as to whether RP is safe or even feasible after LIHR and whether this issue should be taken into consideration when selecting the appropriate surgical approach for IHR in male patients.

In the following sections, we have reviewed the accumulated published articles since these initial case reports. They are divided into three sections, depending on the method of RP used: Open, laparoscopic, and robot-assisted. A table summarizing the important results has been added (Table 1).

Table 1.

Summary of Outcome in Patients with Previous Laparoscopic Inguinal Hernia Repair Undergoing Radical Prostatectomy

Reference	No. patients	Previous hernia repair type	Type of prostate operation	No. of patients with no previous hernia repair (in comparative studies)	Comparative perioperative outcome	% Abortion of PLND in previous hernia repair side	Functional outcome (incontinence+erectile dysfunction)	Long-term oncologic outcome
Neff ⁷	18	Only lap.	Open	38	Minimal Longer op+blood loss	25%	NA	NA
Saint-Elie⁸	21	Only lap.	Open	NA	NA	28%	NA	NA
Hocaglu⁹	51	Mix group (open+lap.)	Open	1415 (2AQ)	Similar	53% Only for previous lap. patients)	Similar rate of continence+erectile dysfunction (12 months follow-up)	NA
Vijan¹⁰	9	Only lap.	Open	26 (matched group)	1 day longer hospital stay	66%	NA	Similar biochemical failure rates (mean follow up 6 years)
Do¹³	92	Only lap.	Lap	NA	NA	86%	Similar continence rates	NA
Erdorgu¹⁴	20	Only lap.	LAP	20 (previous open IHR) 20 (no previous IHR)	Similar	NA	Similar continence rate (12 months follow up)	NA
Stolzenburg¹⁵	14	Only lap.	Lap	NA	NA	NA	NA	NA
Laungani¹⁶	12	Mix group (open+lap.)	Robot- assisted	50 (previous open no mesh repair) 292 (no previous IHR)	Increased console time	NA	NA	NA
Lallas¹⁷	27	Mix group (open+lap.)	Robot- assisted	282	Similar	NA	Similar rate of erectile+continence (12 months follow-up)	NA
Siddiqui¹⁸	166	Mix group (open+lap.)	Robot- assisted	2901	Increased rate of overall and severe adhesiolysis	NA	NA	NA

PLND=pelvic lymph node dissection; lap.=laparoscopic; IHR=inguinal hernia repair.

The effect of LIHR on open RP

A retrospective review of all open retropubic radical prostatectomies (RRP) performed by a single surgeon between 2003 and 2008 was reported by Neff and colleagues.⁷ They identified 18 patients with a history of previous LIHR (5 bilateral and 13 unilateral). The outcome of this group was compared with 38 patients without previous LIHR. RRP was successfully performed in all 18 patients; one patient had a postoperative complication (persistent Jackson-Pratt drainage). The difference in operative times and blood loss between the two groups (with or without previous LIHR) bordered on statistical significance in favor of patients with no previous LIHR. The authors concluded that previous LIHR was associated with slightly longer operative times and higher blood loss, but can be safely performed in these patients.

In another analysis of 21 men who underwent open RPP between 2000 and 2007 and had previous LIHR, Saint-Elie and associates⁸ reported that none of the procedures were aborted and no intraoperative adverse event was recorded. The dissection was more challenging, however, and pelvic lymph node dissection (PLND) was not feasible in six patients (five had undergone bilateral LIHR and one unilateral LIHR). The authors concluded that RPP can be performed safely after LIHR, even though the quality of PLND and thus accurate staging may be compromised.

Hocaoglu and coworkers⁹ retrospectively compared 51 patients who underwent open RP after IHR with prosthetic mesh placement performed either laparoscopically or in an open fashion with 1415 patients who had not undergone previous IHR. No statistically significant difference was found between the groups regarding operative time, positive surgical margins, continence rates, or erectile dysfunction (ED) rates. PLND was more feasible when IHR was unilateral and performed using the open rather than bilateral or laparoscopic approach.

Another retrospective analysis compared 9 patients who underwent open RP after LIHR with 26 patients without previous LIHR.¹⁰ The patients were matched for age, operation type, year of surgery, and PC pathologic stage. Operative time, number of lymph nodes sampled, and duration of urinary drainage were similar in both groups. The surgeons reported a more tedious and difficult dissection in patients with previous LIHR, and PLND was aborted because of potential iliac vessels injury bilaterally in two cases and unilaterally in three cases. However, the rate of biochemical failure at 2 years was identical in both groups, however (11%). The authors concluded that open RP is more difficult after LIHR, even though the perioperative parameters (operative time and duration of catheterization) and oncologic outcomes are similar.

The effect of LIHR on laparoscopic RP

In 2004, Brown and Dahl¹¹ reported the first two cases of laparoscopic RP after LIHR. In these two cases, the surgeons reported on adhesion of the anterior bladder wall to the mesh; however, these adhesions were lysed without substantial difficulty and the remainder of the procedure proceeded uneventfully.

Another case of laparoscopic RP in a patient with previous LIHR was reported 1 year later.¹² Here as well, fibrosis detected in the preperitoneal space did not compromise mobilization of the bladder, and the patient did not experience any postoperative complications.

Do and associates¹³ reported on a very large group of 92 patients who underwent endoscopic extraperitoneal radical prostatectomy (EERP) after previous LIHR. The complication rate was higher compared with patients who had not previously undergone LIHR (12% vs 5.85%, respectively), although the difference did not reach statistical significance. Of the 92 patients, 51 needed PLND and of these, 39 underwent unilateral PLND because the procedure could not be completed safely on the other side. Five patients in whom PLND was not performed had all undergone previous bilateral LIHR. The percentage of patients with prostate-specific antigen (PSA) that was lower than 0.1 ng/mL at 6 and 12 months was similar between those who did and those who did not undergo previous LIHR. In addition, rates of continence at 3, 6, and 12 months and potency at 6 and 12 months were similar in both groups. The authors concluded that EERP after previous LIHR is more difficult, even though the perioperative parameters, risk of complications, and short-term oncologic and functional outcomes are similar to those for EERP without previous LIHR.

Erdogru and coworkers¹⁴ compared three groups of patients who underwent laparoscopic radical prostatectomy (LRP) with previous LIHR, with previous open IHR, and without previous IHR. The data were obtained from a prospectively collected database of all RP cases. Each group consisted of 20 patients matched for the rate of PLND and nerve sparing performed, pathologic stage, Gleason score, prostate volume, and the patient's age. No statistically significant differences were found in operative time, urethrovesical anastomosis time, urinary drainage duration, or amount of blood loss. Analgesic dosage and duration of use were greater in the LIHR group. Positive surgical margin rates were similar among the three groups, and no difference was identified in continence rates at 12 months. The authors stated that previous LIHR did not compromise LRP and had no influence on oncologic and functional outcomes.

Another report¹⁵ on 14 patients with previous LIHR who underwent EERP revealed some complications related to adhesions (two bladder injuries and epigastric vessel injury). These complications, however, were managed intraoperatively and did not cause further postoperative problems. PLND was performed when indicated, but only on the contralateral side to the mesh.

The effect of LIHR on robot-assisted RP

There were three published reports on robot-assisted RP (RARP) after LIHR. All of them, however, included patients with previous laparoscopic and open IHR with no differentiation between the two types of patients.

Laungani and colleagues¹⁶ retrospectively compared three groups of patients who underwent RARP, for a total of 354 patients; 292 without previous IHR, 50 with previous IHR without mesh placement, and 12 with previous IHR with mesh placement. The latter group consisted of both patients with previous laparoscopic and open hernia repair. The authors compared body mass index, console operative time, estimated blood loss, and length of hospital stay. The only statistically significant difference among the three groups was found in the mean console operative time between those with no previous IHR and those with previous IHR and mesh placement. The authors concluded that previous IHR performed using any method does not represent a significant barrier to the performance of transperitoneal robotic prostatectomy.

Lallas and associates¹⁷ reported their experience with RALP subsequent to IHR with mesh (open and laparoscopic) in 27 patients. A comparison with patients with no previous hernia repair revealed no difference regarding amount of blood loss, operative time, length of hospital stay, and rate of positive surgical margins. No increase in difficulty of performing PLND was noted during the dissection; continence and ED rates were similar for both groups.

Siddiqui and coworkers¹⁸ examined the effect of a previous inguinal or abdominal surgery on the bowel and vascular complications from a prospective cohort of 3950 patients who underwent RARP. There were 4.2% of the patients (166) who had previous bilateral or unilateral IHR with mesh. The authors did not report on the surgical approach of the IHR (open or laparoscopic). Generally, patients with previous abdominal surgery or IHR had higher rates of difficult adhesiolysis, as assessed by the time needed for adhesiolysis and the density and area of adhesions. Patients with previous bilateral IHR with mesh had specifically higher rates of severe adhesiolysis. The authors did not find any increase in the amount of blood loss or rate of complications in patients with previous abdominal or inguinal surgery, however. The authors stated that previous inguinal surgery is not a contraindication to RARP and that the procedure can be completed safely.

Discussion

The possibility of undergoing RP, after LIHR, regardless of the approach is feasible. All recent literature states that the procedure can be performed safely.^{7

–18} The available data are composed of retrospective cohorts and retrospective comparative studies with no comparative studies between the different RP approaches (open, laparoscopic, or robot-assisted) in this particular group of patients, and we are left to draw conclusions from the available literature.

First, we found that RP, using any of the three approaches, can be performed safely in patients after LIHR.^8,14 Second, most of the literature demonstrates that RP after LIHR is technically demanding.^10,13,15 The technical difficulty is thought to stem from the dense fibrotic reaction caused by the mesh.⁶ No differences in perioperative parameters (eg, operative time, amount of blood loss, duration of urinary drainage, or rates of positive surgical margins) were observed, however.^{9,10,14,17,18} Third, short-term oncologic outcomes (evaluated by PSA levels) seem to be comparable between patients with and without previous LIHR.^10,13 Fourth, potency and ED rates (considered functional outcomes) were also similar between the two groups.^9,13,14,17

Fifth, PLND is extremely problematic in patients with previous LIHR. The mesh usually covers the obturator fossa, thus preventing adequate lymph node sampling and complete staging. Most of the studies reviewed described this as the “Achilles heel” of RP after LIHR.^8,9,10,13,15 In contrast, one study examining the effect of LIHR on RALP stated that there was no increase in the difficulty of PLND.¹⁶ A possible explanation for this discrepancy is the increased degree of freedom and better visualization using the DaVinci^® Surgical System. The possibility of missing a diagnosis of lymph node positive disease should be considered by the treating physician because positive nodes may impact the decision on adjuvant treatment.¹⁹ The possibility of inadequate PLND should be discussed with the patient before the operation. Nevertheless, the possibility of failed PLND must be understood in the correct perspective because approximately only one half of patients will have intermediate or high-risk disease necessitating PLND²⁰ and the risk of lymph node involvement after PLND in PC is only about 6%.²¹

When all factors are considered, including the lifetime risk of PC development, which is treated by RP, the available data on the safety and outcome of RP in patients with previous LIHR and the discussed aspects of PLND in these patients, the risk of a healthy male patient who undergoes LIHR to have PC subsequently develop and then have a suboptimal treatment because of the previous LIHR is extremely low.

Based on this data review, we conclude that the argument against performing a LIHR (vs an open approach) in a male patient because of potential future compromised RP is negligible. RP after LIHR, however, may be a more challenging procedure with longer operative times. PLND may not be possible in most cases.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

Javid

, Brooks

. Hernias. Zinner

, Ashley

. Maingot's Abdominal Operations, 11th. New York, NY: McGraw-Hill Professional, 2007.

LeBlanc

, Booth

, Whitaker

, Baker

. In vivo study of meshes implanted over the inguinal ring and external iliac vessels of uncastrated pigs. Surg Endosc, 1998; 12:247–251.

Jemal

, Bray

, Center

et al. Global cancer statistics. CA Cancer J Clin, 2011; 61:69–90.

Katz

, Patel

, Sokoloff

et al. Bilateral inguinal hernia repair can complicate subsequent radical retropubic prostatectomy. J Urol, 2002; 167:637–638.

Cook

, Afzal

, Cornaby

. Laparoscopic hernia repairs may make subsequent radical retropubic prostatectomy more hazardous. BJU Int, 2003; 91:729.

Cooperberg

, Downs

, Carroll

. Radical retropubic prostatectomy frustrated by prior laparoscopic mesh herniorrhaphy. Surgery, 2004; 135:452–454.

Neff

, See

. Laparoscopic mesh herniorrhaphy: Impact on outcomes associated with radical retropubic prostatectomy. Urol Oncol, 2011; 29:66–69.

Saint-Elie

, Marshall

. Impact of laparoscopic inguinal hernia repair mesh on open radical retropubic prostatectomy. Urology, 2010; 76:1078–1082.

Hocaoglu

, Bastian

, Buchner

et al. Impact of previous mesh hernia repair on the performance of open radical prostatectomy—complications and functional outcomes. BJU Int, 2010; 106:1628–1631.

10.

Vijan

, Wall

JCH

, Greenlee

, Farley

. Consequences of endoscopic inguinal hernioplasty with mesh on subsequent open radical prostatectomy. Hernia, 2008; 12:415–419.

11.

Brown

, Dahl

. Transperitoneal laparoscopic radical prostatectomy in patients after laparoscopic prosthetic mesh inguinal herniorrhaphy. Urology, 2004; 63:380–382.

12.

Joseph

, Madeb

, Wu

et al. Laparoscopic radical prostatectomy following laparoscopic bilateral mesh hernia repair. JSLS, 2005; 9:368–369.

13.

, Turner

, Dietel

et al. Previous laparoscopic inguinal hernia repair does not adversely affect the functional or oncological outcomes of endoscopic extraperitoneal radical prostatectomy. Urology, 2011; 77:963–967.

14.

Erdorgu

, Teber

, Frede

et al. The effect of previous transperitoneal laparoscopic inguinal herniorrhaphy on transperitoneal laparoscopic radical prostatectomy. J Urol, 2005; 173:769–772.

15.

Stolzenburg

, Anderson

, Rabenalt

et al. Endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair. World J Urol, 2005; 23:295–299.

16.

Laungani

, Kaul

, Muhletaler

et al. Impact of previous inguinal hernia repair on transperitoneal robotic prostatectomy. Can J Urol, 2007; 14:3635–3639.

17.

Lallas

, Pe

, Patel

et al. Transperitoneal robotic-assisted laparoscopic prostatectomy after prosthetic mesh herniorrhaphy. JSLS, 2009; 13:142–147.

18.

Siddiqui

, Krane

, Bhandari

et al. The impact of previous inguinal or abdominal surgery on outcomes after robotic radical prostatectomy. Urology, 2010; 75:1079–1082.

19.

Swanson

, Thompson

, Basler

. Treatment options in lymph node-positive prostate cancer. Cancer, 2006; 106:2531–2539.

20.

Tanaka

, Fujimoto

, Hirayama

et al. Trends of the primary therapy for patients with prostate cancer in Nara uro-oncology research group (NUORG): A comparison between the CaPSURE data and the NUORG data. Jpn J Clin Oncol, 2010; 40:588–592.

21.

Klein

, Platz

, Thompson

. Epidemiology, etiology and prevention of prostate cancer. Wein

, Kavoussi

, Novick

, Partin

, Peters

. Campbell-Walsh Urology, 9th. Philadelphia: Saunders, 2007; 2854–2873.