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

Previous inguinal hernia surgery does not limit the likelihood of choosing prostatectomy as primary prostate cancer therapy

We evaluated whether previous inguinal hernia repair may affect the choice of prostate carcinoma treatment in a population-based cohort. It has been suggested that previous laparoscopic inguinal hernia repair (LIHR) could limit the subsequent possibility of performing a prostatectomy. Several small studies have suggested otherwise. The study cohort included all new prostate cancer cases in Finland 1998-2015 identified through the Finnish cancer registry. Data on the treatment of prostate cancer and surgical inguinal hernia repairs in 1998-2016 was obtained from the HILMO hospital discharge registry. After linkage, the study cohort included 7206 men. Of these, 5500 had no history of inguinal hernia, 1463 had an open hernia repair, and 193 had a minimally invasive repair (LIHR). Compared to men with no history of hernia repair, those with previous hernia repairs were more likely to undergo prostatectomy over radiation therapy as the primary treatment for prostate cancer HR 1.34 (CI 95% 1.19-1.52). The association did not depend on the method of hernia repair, HR 1.58 (CI 95% 1.15-2.18), in men with previous LIHR. The increased likelihood of choosing prostatectomy over radiation therapy concerns all type prostatectomies. Previous hernia repair is not a limiting factor when choosing treatment for prostate cancer.

Single-port robot-assisted perineal radical prostatectomy with the da Vinci XI system: initial experience and learning curve using the cumulative sum method

BACKGROUND

To evaluate the early functional and oncological outcomes of single-port robot-assisted perineal radical prostatectomy (sp-pRARP) using the da Vinci XI system and analyze its learning curve using the cumulative sum (CUSUM) method.

METHODS

The clinical data of 50 patients who underwent sp-pRARP for localized prostate cancer between May 2020 and May 2022 in our center by a single surgeon were analyzed retrospectively. Demographic information, preoperative and postoperative variables, complications, early functional and oncological outcomes of patients were recorded. The CUSUM method was used to illustrate the learning curve based on operation time.

RESULTS

All surgeries were completed without conversion. The median (interquartile range, IQR) operation time was 205.0 (82.5) min, whereas the median (IQR) docking time was 30.0 (15.0) min and the console time was 120.0 (80.5) min. The median (IQR) estimated blood loss (EBL) was 50.0 (137.5) mL. Positive surgical margins were detected in five patients (10.0%). The continence rate was 40.9%, 63.6%, 88.4%, and 97.7% at the 1, 3, 6, and 12 months after surgery. According to the CUSUM plot, the inflection points of the learning curve were 20 cases, splitting the case series into "early phase" and "late phase." In "late phase" cases, there was less time spent on each step of the operation and less EBL.

CONCLUSIONS

Sp-pRARP using the da Vinci XI system was verified to be a feasible and reliable surgical approach. According to the CUSUM plot, 20 cases was considered the turning point for surgeons to master the novel technique.

Evaluating the incidence, management, and recurrence of inguinal hernia during robotic prostatectomy: A literature review

Objectives:

Robotic radical prostatectomy (RARP) is a well-established treatment for localised prostate adenocarcinoma. The benefits of this minimally invasive technique include shortened operative time and improved patient recovery. However, the development of inguinal hernia (IH) before, during, and following RARP has been reported. The aim of this study is to evaluate the incidence, management, and recurrence of IHs in patients undergoing RARP for prostate cancer.

Methods:

A literature search was conducted using the PubMed database from August 2007 to October 2020 using the keywords ‘robotic prostatectomy’ and ‘inguinal hernia’. Studies evaluating the incidence and recurrence of IH in patients undergoing RARP were identified and included. The initial search identified 77 articles. After excluding one duplicate, six case reports, three editorial comments, four articles not in English, eight review articles, and 14 studies that did not mention hernia incidence, 41 studies were included in our final literature review.

Results:

Concomitant IH repair (IHR) during RARP resulted in decreased symptomatic hernia recurrence during the follow-up period. When compared to patients who had not undergone hernia repair, the patients who underwent IHR during RARP did not experience greater complications in the postoperative period.

Conclusions:

Patients that undergo an intraoperative IHR during RARP did not experience significant adverse postoperative complications. Although operative time can slightly increase compared to RARP alone, we recommend a thorough preoperative physical examination in all patients scheduled to undergo RARP to evaluate for IH in addition to a thorough discussion with the patient of the risks and benefits of intraoperative repair.

Level of evidence:

Not applicable

Influence of previous laparo-endoscopic inguinal hernia repair on performing radical prostatectomy: a nationwide survey among urological surgeons

BACKGROUND

There is considerable demographic overlap of inguinal hernia patients and prostate cancer patients. Previous laparo-endoscopic inguinal hernia mesh repairs can complicate subsequent radical prostatectomies due to adhesions and distortion of anatomic planes. This study aims to assess the experience of urological surgeons on the safety and feasibility of performing radical prostatectomies after laparo-endoscopic inguinal hernia mesh repair.

METHODS

For this cross-sectional study, an online 24 question survey was developed regarding the experience in performing a radical prostatectomy and pelvic lymph node dissection (PLND) with a prior preperitoneal inguinal hernia mesh repair. Between June 2016 and December 2017, the questionnaire was sent to all 68 urological surgeons performing radical prostatectomy in the Netherlands.

RESULTS

The response rate of urological surgeons was 69% (n = 47). The majority (77%) of urological surgeons perform robot-assisted laparoscopic prostatectomies. A previous preperitoneal inguinal hernia repair was reported by 40% of urological surgeons in 10-30% of patients undergoing radical prostatectomy. Radical prostatectomy with prior preperitoneal inguinal hernia mesh repair is considered more difficult by 49%, predominantly because of (occasionally to always) experienced longer operating times (88.4%), increased blood loss (46.5%), difficult dissection of Retzius space (88.4%), nerve-sparing difficulties (32.6%), less adequate PLND (69.8%), and bladder- (16.3%) or peritoneal perforations (27.9%). Additionally, 11.6% had performed mesh explantation, 16.3% had aborted radical prostatectomies, and 35.7% experienced increased inguinal hernia recurrences after radical prostatectomies with prior preperitoneal inguinal hernia mesh repair. More experienced urological surgeons reported an increased difficulty for all outcomes.

CONCLUSIONS

Laparo-endoscopic inguinal hernia mesh repair has a significant impact on performing a radical prostatectomy and PLND. Surgeons should postpone the inguinal hernia repair of patients in the workup for a radical prostatectomy, with the preferable option of performing the radical prostatectomy and inguinal hernia repair in the same procedure. Alternatively, a Lichtenstein repair can be performed.

The relationship between inguinal hernia and minimally-invasive surgery for prostate cancer: A systematic review of the literature

OBJECTIVE

We aimed to perform a systematic review about the relationship between inguinal hernia and surgery for prostate cancer.

BACKGROUND

Diagnosis of abdominal wall defects and prostate cancer may be either synchronous or metachronous. The convenience and safety of combined prostatectomy and hernioplasty, the incidence of hernias after prostatectomy and the feasibility of prostatectomy in patients with previous laparoscopic hernioplasty are still debated.

METHODS

PubMed and Embase were queried by dedicated search strings. Two researchers independently reviewed the pooled references and selected the articles of interest, including reviews.

RESULTS

Sixty-five studies were evaluated, 22 of them analysed the feasibility and the outcomes of a combined surgery, namely one-stage radical prostatectomy and herniorrhaphy or hernioplasty. Literature evidences support the combined intervention to patients suffering from an inguinal hernia and a prostate cancer amenable of radical prostatectomy. Sixteen studies addressing the potential increase in the occurrence of inguinal hernia after radical prostatectomy were evaluated. Approximately 15% of patients who undergo retro-pubic radical prostatectomy will develop inguinal hernia. It is suggested that the incidence might be lower in laparoscopic prostatectomy series, particularly in case of transperitoneal approach. The median time to the appearance of the hernia is around 6 months. After evaluation of 14 studies, it is concluded that laparoscopic hernioplasty does not preclude prostatectomy but hinders further pelvic surgery.

CONCLUSIONS

One-stage combined hernioplasty and radical prostatectomy may be accepted except in cases of lymph-nodes dissection and/or positive hydro-distress test of the urethro-vesical anastomosis. Accurate patient's counselling and dedicated consent form are mandatory, in the setting of an experienced multidisciplinary team.

Endoscopic extraperitoneal radical prostatectomy after radical resection of pT1-pT2 rectal cancer: a report of thirty cases

INTRODUCTION

Endoscopic extraperitoneal radical prostatectomy (EERPE) has gained popularity for the treatment of localized prostate cancer. However, prior complex lower abdominal or pelvic surgery can complicate subsequent EERPE. To date, there have been few reports on patients who underwent EERPE after radical resection of pT1-pT2 rectal cancer.

AIM

To present our experience with EERPE in patients after radical resection of pT1-pT2 rectal carcinoma and introduce a simple and effective way to create an extraperitoneal working space.

MATERIAL AND METHODS

Thirty patients after radical resection of pT1-pT2 rectal carcinoma were treated with EERPE for biopsy-proven localized prostate cancer. Operation time, estimated blood loss, conversion to open surgery rate, transfusion rate and transurethral catheter time were recorded. Meanwhile, functional outcome (continence and potency) and oncological outcome were reviewed.

RESULTS

The average operative time was 168 min. Mean blood loss was 195 ml. There was no need for conversion to open surgery or transfusion. The catheter was removed on postoperative day (POD) 7.8. After a mean follow-up time of 53.1 months, 3 patients had a prostate-specific antigen level relapse over 0.1 ng/ml. At the follow-up time, 26 patients were completely continent, and 4 needed 1-2 pads/day. Of the 6 patients who underwent neurovascular bundle preservation, none have experienced return of erections at the last follow-up time.

CONCLUSIONS

Endoscopic extraperitoneal radical prostatectomy after radical resection of rectal carcinoma appears promising, with feasibility in experienced hands. The operative data, postoperative urinary incontinence and oncological outcomes appear encouraging, but the rate of erectile dysfunction seems to be disappointing.