Long-term results after robot-assisted radical prostatectomy of a simplified inguinal hernia prevention technique without artificial substance use

Novel clipping procedure for preventing post-operative inguinal hernia in robot-assisted radical prostatectomy

OBJECTIVES

Inguinal hernia (IH) is a common postoperative complication after robot-assisted radical prostatectomy (RARP). We developed a novel clipping technique for the prevention of IH developing after RARP.

METHODS

This cohort included 759 consecutive patients who underwent RARP for prostate cancer at the University of Tokyo Hospital between January 2011 and December 2018. We reviewed clinical parameters and identified the risk factors of postoperative IH. The prophylactic preventive procedure of IH development was performed by clipping the peritoneum and underlying tissue around the internal inguinal ring using Hem-o-Lok clip to prevent the prolapse of the intestine through the internal inguinal ring.

RESULTS

In total, 236 patients received the clipping procedure. The median follow-up time was 50 months. The incidence rate of IH was 10.8% (78/720). The median time to the diagnosis of IH was 10 months. Univariate analysis revealed that patients with higher age (age ≥ 63), low BMI (BMI < 25 kg/m2), and lower number of surgical experiences (Surgical experience < 40) showed a significantly higher odds ratio of developing IH. Multivariate analysis showed that "BMI < 25 kg/m2" and "Surgical experience < 40" were independent predictive factors of IH. Among the patients with a high risk of IH due to receiving surgery from inexperienced surgeons, there was a statistically significant preventive effect for the patients with "BMI ≥ 25 kg/m2" by the novel clipping procedure.

CONCLUSIONS

The novel clipping procedure reduced the risk of post-operative IH in obese patients when the RARP was performed by inexperienced surgeons.

A novel anterior approach that involves Retzius space development between the umbilical ligaments is associated with a lower incidence of postoperative inguinal hernia in robotic radical prostatectomy

Background

To facilitate robotic radical prostatectomy (RP), we developed a novel anterior approach that utilizes a peritoneal incision between the umbilical ligaments to develop the Retzius space without contacting the internal inguinal rings, followed by closure of this space prior to prostatectomy and vesicourethral anastomosis. This approach could decrease the incidence of postoperative inguinal hernia (IH), similar to a Retzius-sparing RP (RS-RP). We compared the incidence of IH following this novel approach with that following conventional anterior RP and RS-RP.

Methods

We retrospectively reviewed 532 patients who underwent robotic RP from September 2017 to August 2022. We compared the incidence of IH following novel anterior RP (n = 153) to that following conventional anterior RP (n = 284) and RS-RP (n = 95). We also assessed the independent factors associated with postoperative IH using Cox hazard models.

Results

The 12- and 24-month cumulative incidences of postoperative IH following novel anterior RP were 1.3% and 1.3%, significantly lower than those associated with conventional anterior RP (8.0% and 12.6%, p = 0.009) but not significantly different from those following RS-RP (1.1% and 2.1%, p = 0.782). In multivariate analysis, use of the novel anterior RP approach, RS-RP, and body mass index were independent factors negatively associated with the occurrence of postoperative IH.

Conclusions

This novel anterior approach involves developing the Retzius space between the umbilical ligaments and closure of this space following prostatectomy and vesicourethral anastomosis. It can decrease the incidence of IH compared to the conventional anterior approach. Prospective comparative studies are necessary to confirm the benefits of this approach.

Incidence and risk factors of inguinal hernia after robot-assisted radical prostatectomy: a retrospective multicenter cohort study in Japan (the MSUG94 group)

To investigate the incidence and risk factors of inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) using a multicentric database. The present study used a multicentric database (the MSUG94) containing data on 3,195 Japanese patients undergoing RARP between 2012 and 2021. Surgical procedures utilized for IH prevention were as follows: isolation of the vas deferens, transection of the vas deferens, isolation of the spermatic vessels, and separation of the peritoneum from the internal inguinal ring. The primary and secondary endpoints were IH-free survival and any association between post-RARP IH and clinical covariates. The prophylactic effect of the above procedures were also assessed. IH prevention was attempted in 1,465 (46.4%) patients at five of the nine hospitals. During follow-up (median 24 months), post-RARP IH developed in 243 patients. The post-RARP IH-free survival rates at years 1, 2, and 3 were 94.3%, 91.7%, and 90.5%, respectively. Old age (hazard ratio [HR] 1.037; 95% confidence interval [CI] 1.014-1.061; p = 0.001), low BMI (HR 0.904; 95% CI 0.863-0.946: p < 0.001), and low hospital volume (HR 1.385; 95% CI 1.003-1.902; p = 0.048) were independently associated with IH development. None of the procedures for IH prevention were associated with IH development. Our findings may represent the current, real-world status of post-RARP IH in Japan. The prophylactic effects of the surgical procedures for IH prevention should be further investigated in well-designed, prospective studies to optimize the surgical technique.