Effects of Previous Hernia Repair on Extraperitoneal Robot-Assisted Radical Prostatectomy: A Matched-Pair Analysis Study

Abstract

Purpose:

To evaluate results of an extraperitoneal robot-assisted laparoscopic radical prostatectomy (e-RALP) series considering patients with previous laparoscopic inguinal hernia repair (LIHR).

Methods:

We investigated our e-RALP database between March 2008 and August 2014. Age, prostate-specific antigen, prostate volume, and Gleason score were considered as criteria of matched pair analyses. Group 1 consisted of 32 patients who underwent e-RALP with previous LIHR using mesh, and Group 2 consisted of a similar 32 patients without previous LIHR. In addition, preoperative, perioperative, and postoperative data were recorded. Complications were evaluated according to the Clavien-Dindo classification. Significance was P≤0.05.

Results:

Mean follow-up was 20.3±3.2 months. In total, 987 patients underwent e-RALP. Preoperative parameters were similar between groups. There were significantly more peritoneum openings, time of anastomosis, trocar placement, preparing Retzius space, pelvic lymph node dissection (PLND), and operative time observed in group 1 than group 2 (respectively, P=0.01, P=0.05, P=0.004, P=0.001, P=0.01, P=0.002). Mean estimated blood loss and time for endopelvic dissection were comparable between groups. In addition, there was no open conversions and pelvic vessel injury. There were, however, two bladder injuries that were treated by using V-loc suture, simultaneously. The most common complication was postoperative fever (Clavien I).

Conclusion:

PLND can be performed safely during e-RALP in patients with previous LIHR. Surgeons should consider careful dissections and possible bladder injury during PLND. Thus, first steps of operation including PLND, could take a longer time in patients with previous LIHR.

Introduction

Laparoscopic inguinal hernia repair (LIHR) has been increasingly popularized for the surgical repair of inguinal indirect and/or direct hernia.^1,2 The percentage of hernia repairs performed by the laparoscopic route varies from 1% to 30%,³ and there are two well-described surgical methods: Totally extraperitoneal patch (TEP) and transabdominal preperitoneal patch (TAPP).^1,2 Regardless of the approach, laparoscopic repair of inguinal hernia is a well-established technique because of its safety, efficacy, and patient satisfaction.³ In addition, the recurrence rate was reduced below 5%.^4,5 The TEP procedure is associated with better results than the floor, whereas the former technique provides access to the contralateral side without further incisions.⁴ Long-term follow-up of the TEP demonstrated good functional results and a low recurrence rate, as well.⁶

On the other hand, prostate cancer (PCa) still has been the most common cancer among men in Europe.⁷ In addition, increasing numbers of patients with D'Amico intermediate and/or high risk factors underwent laparoscopic and/or robot-assisted laparoscopic radical prostatectomy (RALP).⁸ These patients also underwent pelvic lymph node dissection (PLND) during RALP.⁸ There have been published reports that previous LIHR could make preparation of the Retzius space to perform PLND difficult and also some technical challenges might be faced.^9
–11 In view of these factors, it is supposed that performing PLN and to separate tissue planes can be very difficult during extraperitoneal RALP (e-RALP) in patients with previous LIHR. To our best knowledge, studies with matched-pair analysis are lacking on these issues in the published literature.

We aimed to evaluate results of e-RALP series considering patients with previous LIHR, focusing on technical difficulties during preparation of the Retzius space and application of PLND procedures. Our hypothesis was that previous LIHR cannot be a contraindication for e-RALP.

Methods

The present study is a retrospective investigation of prospectively collected data. All patients fully understood the aims of study, and signed consent forms were obtained. All data of the single experienced center were recorded on Microsoft Excel spreadsheets. In addition, the Institutional Review Board of our certificated cancer center approved collected data. Exclusion criteria were lacking data, transperitoneal RALP, previous transurethral prostate resection, neoadjuvant radiotherapy, and previous inguinal surgery and/or RALP, and irregular follow-up.

Data collection

Demographic data including age, body mass index (BMI) kg/m², comorbidities, previous operations, preoperative data including American Society of Anesthesiologists (ASA) score, serum hemoglobin (Hb), prostate-specific antigen (PSA) level, prostate volume, pathologic stage, Gleason score, operative data including operative time and time periods of operation steps, PLND, nerve-sparing (NS) procedure, intraoperative complications, and estimated blood loss (EBL), postoperative data including hospital stay, complications, duration of urethral catheter were recorded.

The tumor, node, metastasis (TNM) classification was used for clinical staging of PCa.¹² Group 1 consisted of 32 patients who underwent e-RALP with previous LIHR using mesh. According to the matched-pair fashion of our analyses (patients who had similar demographic and operative data with Group 1), group 2 consisted of similar 32 patients who underwent e-RALP without previous LIHR. The matched-pair criteria included age, PSA level, prostate volume, and Gleason score.

This allowed us to match the parameters of the 32 patients in group 1 who underwent e-RALP with previous LIHR using mesh and the 32 patients in group 2 without previous LIHR.

Surgical technique

The institutional extraperitoneal approach for laparoscopic radical prostatectomy (LRP) and RALP has been previously described in detail.^12,13 Although experienced surgeons from our department performed all operations, surgical challenges such as trocar placement techniques have been described, before.¹⁴ Previous laparoscopic operations could cause fibrosis in extraperitoneal area, specifically for patients in group 1. Thus, all trocars were placed carefully according to previously published techniques.¹⁴ PLND was performed in patients with a PSA level greater than 10 ng/mL and/or Gleason score greater than 6, regardless of the approach.

Complications were evaluated according to the Clavien-Dindo classification.¹⁵ Postoperative analgesic management was similar in each group with the administration of piritramide and metamizol to patients on demand. Normal diet was resumed on postoperative day after stopping intravenous infusions. The urethral catheter was removed on day 5 to 7 after cystography assessment.

Statistical analyses

The Statistical Package for the Social Sciences (SPSS, Chicago, IL) version 16.0 was used for statistical analysis. Paired t tests were used, and statistical significance was accepted when P was≤0.05.

Results

In total, 987 patients underwent e-RALP between March 2008 and August 2014. Mean follow-up was 20.3±3.2 months. Previous surgical histories of groups 1 and 2 are summarized in Table 1. Similar results were observed because of statistical analyses of both groups for criteria including age, BMI, ASA score, serum Hb level, Gleason score, and PSA level. These are presented in Table 2.

Table 1.

Surgery History of Patients

Parameter	Group 1 (n=32)	Group 2 (n=32)
Bilateral LIHR	14	0
Left LIHR	9	0
Right LIHR	9	0
Laparoscopic cholecystectomy	2	2
Appendectomy	3	2

LIHR=laparoscopic inguinal hernia repair.

Table 2.

Criteria of Matched Pair Analyses

Parameter	Group 1 (n=32)	Group 2 (n=32)	P value
Mean age±(SD) (years)	66.3±7.3	65.3±8.6	0.3
Mean BMI±(SD) (kg/m²)	26.7±3.5	26.7±3.2	0.9
Mean PSA±(SD) (ng/dL)	10.2±6.5	9±5.5	0.4
Mean Hb±(SD)	14.9±1.2	14.6±1.3	0.2
Mean ASA score±(SD)	2.1±0.6	2.3±0.6	0.3
Mean Gleason score±(SD)	7±0.8	7±0.8	0.8
pT stage:
2a	2	2	0.2
2b	2	3
2c	13	13
3a	7	8
3b	8	6
Numbers of lymphadenectomy:
Positive	6	6	0.9
Negative	26	26
Numbers of nerve sparing:
None	5	5	0.9
Unilateral	1	1
Bilateral	26	26

SD=standard deviation; BMI=body mass index; PSA=prostate-specific antigen; Hb=hemoglobin; ASA=American Society of Anesthesiologists.

According to clinical stage, PLND and NS techniques were performed in 32 patients in group 1 and 27 patients in group 2 (P=0.9).

There was a statistically significant higher rate of peritoneum opening in group 1 than in group 2 (P=0.01). In addition, mean trocar placement time was significantly longer in group 1 than in group 2 (P=0.004), whereas there was no statistically significant difference for mean endopelvic fascia incision and dissection time between groups (P=0.09). Mean pelvic dissection time (Retzius space preparation), mean PLND time, and mean anastomosis time were statistically significantly higher in group 1 than in group 2 (respectively; P=0.001, P=0.01, and P=0.05; Table 3). Furthermore, mean operative time was statistically significantly higher in group 1 than in group 2 (P=0.002). There was not a statistically significant difference for EBL between groups (P=0.7). The mean numbers of removed lymph nodes were 12±5 in group 1 and 11.5±8 in group 2 (P=0.07).

Table 3.

Operative Parameters of Groups

Parameter	Group 1 (n=32)	Group 2 (n=32)	P value
Mean EBL±(SD)	534.3±300.6	515.6±295.5	0.7
Mean peritoneum opening	0.5	0.2	0.01^*
Mean anastomosis time±(SD)	19±6.1	16.2±5.2	0.05^*
Mean trocar placement time±(SD)	41.6±17.1	30.8±11.1	0.004^*
Pelvic dissection time (Retzius space preparation)±(SD)	14.4±9	5.9±3.6	0.001^*
Mean pelvic lymph node dissection time±(SD)	42.8±17.6	31.3±18.3	0.01^*
Mean endopelvic dissection±(SD)	8±3	10±4.8	0.09
Mean operative time±(SD)	234.3±42.6	217.2±41.4	0.002^*

Statistically significant P value.

EBL=estimated blood loss.

We were able to complete all operations successfully without open conversion. The most common complication was postoperative fever (Clavien I). This occurred in five (15.6%) patients in group 1 and four (12.5%) patients in group 2; these patients were treated with oral antipyretics. Additionally, there were no hernia recurrence, infection, and tissue erosions due to mesh. Lymphocele, however, occurred in three patients in group 1, but there was no need for interventional therapy. The lymphocele had regressed at follow-up. Two bladder injuries were recognized during pelvic dissections because of bladder adhesions with previously placed mesh. These were repaired by using continuous V-loc sutures simultaneously, and no complication was observed during follow-up. Finally, there was no statistical difference for complications in both groups.

Discussion

Clinicians will see increasing numbers of PCa and inguinal hernia because of increased capabilities of diagnosis.⁷ Thus, despite difficulties in performing radical prostatectomy for patients with previous LIHR, there is no doubt that urologists will also perform increasing numbers of extraperitoneal LRP (e-LRP) and/or e-RALP in patients with previous LIHR, in the near future. PLND is indicated in patients with PCa according to their preoperative clinical stage. Besides, the Heilbronn surgical technique for performing e-RALP includes an ascending part with early division of the urethra and posterolateral side dissection of the prostate, followed by incision of the bladder neck and dissection of the seminal vesicles and vasa deferentia.¹¹ Retroperitoneal ascending e-RALP is currently the standard surgical option for clinically localized prostate cancer at our center, and it has been increasingly accepted worldwide because of function and oncologic results with well-known benefits.^16
–18

To our best knowledge, the present study includes the largest series addressing the feasibility e-RALP in patients with previous LIHR in the published literature, Based on our department's more than 15 years of experience, we compared the results of the operative steps of e-RALP in patients with previous LIHR with a similar group of patients without LIHR in a matched-pair setting. We strongly think that this method of statistical analyses could show us more accurate results when compared with previous published data on these issues.^19

–23

Katz and colleagues⁹ reported that previous LIHR makes open radical prostatectomy difficult. Spernat and associates²⁰ concluded PLND may not be possible in more than 50% of patients who have had LIHR. Haifler and coworkers²¹ noted that PLND might not be safe in some patients and may compromise accurate staging. We do not agree with these studies. The statistical analyses showed that steps of operation were longer in group 1 than group 2 because of difficult dissection and challenging surgical procedures in group 1. Although bladder injuries occurred in two patients, PLND was performed successfully as well as e-RALP without open conversion.

Time of repairing during PLND was 17 and 21 minutes, respectively. The procedures were performed by using nonrobotic laparoscopy, and duration of the catheters was 7 days. There was no negative impact of bladder repairing on patients' follow-up period. In addition, pervious hernia repair did not have a negative impact on PLND/lymph node staging because the numbers of removed lymph nodes were comparable between groups. Thus, there were no understaged patients. In light of the above, these can be proof of feasibility of performing e-RALP in patients with previous LIHR.

Do and associates²² reported that LIHR did not have effects on perioperative and key outcome measures in e-LRP. Picozzi and colleagues²³ reported a similar conclusion in their meta-analyses of 28 studies. In addition, they noted that previous LIHR did not compromise nodal staging. We completely agree with them in light of our results. Besides, e-RALP may allow us to perform the operation well. Nevertheless, all PLND procedures were performed with acceptable complications—minimal lymphocele in three patients and bladder injuries in two patients.

In our opinion, lymphoceles occurred following dissection because of fixed mesh surrounding tissues, notably lymph nodes, in group 1. Therefore, we did not find any lymphoceles in group 2. It is well-known truth that LIHR with mesh can cause inguinal fibrosis. On the other hand, complications can occur because of pelvic fibrosis of inguinal mesh. These adhesions from anterolateral fixed mesh can cause dislocations of the bladder and thus bladder injuries may happen during the dissections in the Retzius space. This problem can be overcome, however, with developed surgical techniques and careful dissections. This has allowed us also to perform PLND successfully in our LIHR cases.

Incomplete PLND may be performed, and this can cause understaging.^19,20 In our experience, no case that had to be abandoned because of previous LIHR.¹⁸ There was not any statistical difference in the groups for pathologic staging. In addition, our series had two bladder injuries. These occurred during PLND because of pelvic fibrosis. Bladder injuries were recognized in the course of operation and were repaired by using continuous V-loc sutures, simultaneously.

Clinicians should be aware of inadequate PLND, understaging, and bladder injuries in patients with PCa who have undergone previous LIHR. In addition, patients should be informed concerning challenges in surgical techniques and possible complications related with these challenges.

Our series has some limitations. The retrospective fashion is one of them, but this study is a part of ongoing e-RALP at our department, and all data were recorded prospectively. Numbers of patients in the groups were not high because of using the matched-pair analyses method. Finally, we did not evaluate functional outcomes, which may be the main topic of another study.

In terms of goals of the present study, PLND was performed successfully in all e-RALP, which were successful despite previous LIHR. In addition, there was no need for open conversion. Moreover, there was no complication because of PLND including hernia recurrence. Acceptable complications, however, such as bladder injury and lymphocele from PLND, were observed. To our best knowledge, this is the first study including matched-pair analyses on patients with PCa who underwent e-RALP, with previous LIHR, in the published literature. In view of these results, we proved the hypothesis, and LIHR seems not to be a contraindication for e-RALP.

Conclusion

In experienced hands, previous LIHR seems not to be a contraindication for e-RALP, During e-RALP in patients with previous LIHR, however, steps of operation can take a longer time. although with acceptable complications such as lymphocele and bladder injury. In addition, these patients should be counseled concerning a more difficult surgical course, complications, and longer operative time.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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