Simultaneous open preperitoneal repair of inguinal hernia with open prostatectomy for benign prostate hyperplasia

Introduction

It is not uncommon for men with urinary outlet obstructive prostate symptoms to develop inguinal hernia (or to suffer more with a pre-existing and unattended inguinal hernia). ¹ It has been common practice to stage treatments when both disorders are present. A common surgical dictum is to address the prostate issue first and then the hernia. But where both resources and surgical skills are limited, it is probably more often true that the surgical skills of healthcare workers will permit a hernia repair and the surgical treatment of prostate disease must be postponed until a higher level of surgical expertise is available. Sometimes the hernia repair is an urgent issue because of incarceration or severe symptoms while the urinary obstruction can be managed with a transurethral or suprapubic catheter. When a hernia is repaired first, urinary catheterisation may be required until the prostate operation can be scheduled. In hospitals with limited resources the delays can be significant, ranging from months to years.

Previous studies have shown a feasibility of performing multiple procedures such as prostatectomy and inguinal hernia repair at the same major operation with endoscopic techniques. ² In our situation, we have had several patients needing prostatectomy who had previous inguinal hernia repair. However in our general hospital with a consultant surgeon we were able to plan simultaneous open operations in a group of patients who had not yet had the operation. We report this small series as an advance in surgical craft.

Two basic problems which need to be addressed in planning open inguinal hernia repair in the same operation with open suprapubic prostatectomy are reliable control of bleeding and prevention of contamination of the inguinal hernia incision site with possibly infected urine. A potential contraindication arises in patients who have required suprapubic catheter drainage because of inflammatory changes in the supravesical space. These patients do best with separately scheduled operations.

Materials and Methods

The first step was thorough medical evaluation to identify patients with hypertension and diabetes and our population was consistent with other reports. ³ All patients underwent cystourethroscopy to exclude several unexpected problems such as stone, stricture or schistosomiasis granulomas. When possible, we changed catheters and gave 1 week of antibiotics before the operation because wound infections and prolonged leak have been found to correlate with pre-existing urine infection. ⁴

Single lower midline incision was performed for all operations. If the patient had been treated with urethral catheterisation, then hernia repair was performed first before the prostatectomy. This was done using a modified preperitoneal repair with permanent sutures 2-0 Nylon. ⁵ Mesh was not used so as to minimise risk of infection from contaminated urine. This part of the operation required only an additional 30–45 min. Patients who had had suprapubic catheter for drainage could be treated in the same way but sometimes there was too much inflammatory change for easy dissection in the supravesical space. In such patients, inguinal hernia repair was scheduled for a subsequent operative session.

After the hernia repair, transvesical Freyer-type suprapubic prostatectomy was undertaken in the usual fashion. Sutures were placed in the bladder neck to aid haemostasis. Frequently a pack was left in prostate fossa. Postoperatively the patients had good fluid balance with given furosemide and no extra bladder irrigation. ⁶ Histopathologic diagnosis was obtained for all patients.

Results

A total of 10 patients had simultaneous hernia repair and prostatectomy during the period when a total of 132 patients underwent prostatectomy alone. All cases were drawn from a retrospective review of patients at Choma General Hospital in the period 2000–2009. Operations were performed by a single surgeon during this period. Data were gathered from the theatre log book, and inpatient and outpatient files.

None of the patients in the group of simultaneous operations had medical co-morbidities although we would not have considered co-morbidities of hypertension and diabetes as contraindications provided they were well controlled. The meticulous attention to haemostasis learned from other reports that includes periprostatic haemostatic suture, bladder neck suture and routine packing of prostate fossa addresses the first concern in simultaneous operations of secure control of the risk of postoperative bleeding. In fact this secure control of the risk of bleeding makes postoperative care for prostatectomy patients easy for many nursing units. The change of catheters, the preoperative use of antibiotics and the avoidance of mesh addresses the second concern of avoiding infection in the prevesical space.

During follow-up, none of our patients had complications of bleeding, significant infection or stricture after prostatectomy. None had unsuspected adenocarcinoma on final histopathologic reports. None have had recurrence of hernia on follow-up ranging from 6 months to 5 years.

Conclusion

We have presented a short series of patients in whom open inguinal hernia repair could be accomplished at the same operative session with open suprapubic prostatectomy. This has made the total care of these patients much more efficient for them and for the hospital. A prospective study could clarify these efficiencies. Nonetheless, it is now our preferred strategy for care of patients who suffer from both benign prostate hyperplasia and inguinal hernia. We recommend its consideration for all those surgeons who visit regions of limited surgical service. It does require surgeons who are well experienced both in techniques of open prostatectomy and in preperitoneal hernia repair.