LAPAROSCOPIC AND ROBOTIC UROLOGY Evaluation of the Results and Complications of Transabdominal Preperitoneal Laparoscopic Inguinal Hernia Repair in Patients with a History of Radical Prostatectomy Mohammad Hossein Izadpanahi1, Rana Milasi2* Purpose: Radical prostatectomy is one of the most common urological surgeries. Inguinal hernia is a well-known complication of radical prostatectomy. There are many controversies about selection of surgical techniques for re- pair of inguinal hernia. Traditionally laparoscopic approach was contraindicated for patients with history of lower abdominal surgery, but recent studies showed that it could be safe and successful and even has some advantages over open repair. In this prospective study we evaluated outcomes of laparoscopic hernia repair in patients who previously underwent radical prostatectomy. Materials and Methods: In this prospective study, 34 consecutive patients diagnosed with inguinal hernia after radical retropubic prostatectomy underwent laparoscopic transabdominal inguinal repair and followed up for out- comes and complications. Results: The surgery duration was 167.44 ± 52.85 min (75-230 min). No intraoperative complications occurred. Patients were discharged within 20.79 ± 4.76 hours (12-34 hours). 69.8% of cases (30 patients) needed analgesic administration. No conversion to open surgery occurred. There were 9.3% (4 hernias) hernia recurrences. We fol- lowed patients for 9.9 ± 5.33 months (2-19 months). Conclusion: It is concluded that TAPP for inguinal hernia repair after radical prostatectomy has good results and is effective. But according to rate of recurrence, its safeness is conflicting. We notice no major complication in our patients during the time of follow up. This may be due to safety of the operation in the proposed patients. Keywords: inguinal hernia repair; laparoscopy; radical prostatectomy; recurrence; TAPP INTRODUCTION Prostate cancer (PC) is a major worldwide health problem especially among old men. The incidence of PC is increasing by age. Radical prostatectomy (RP) is the gold standard treatment for localized PC(1-4). The 10-year cancer-specific survival rate for patients under- went Radical Retropubic Prostatectomy (RRP) is re- ported to be 96%(5). However, some complications have been reported for RRP such as urinary incontinence, anastomotic stricture, erectile dysfunction, and impo- tence, and developing a recto urethral fistula(6-8). Moreover, studies have reported that RRP increases the risk of postoperative inguinal hernia with reported incidence from 12.4% to 23.9%, depending on the in- stitute’s experience (9, 10) which occur between 6 months and 24 months after operation(11-13). Several laparoscopic techniques have been described to manage inguinal hernia(14-17) such as Transabdom- inal Preperitoneal repair (TAPP)(18) and totally extra peritoneal (TEP)(19). Different indications have been described for both procedures, however the TAPP technique has also been advocated in cases with recur- rent and complicated inguinal hernia (such as sliding or incarcerated inguinal hernias)(20). Moreover, several 1Isfahan Kidney Transplantation Research Center, Department of Urology, Alzahra Research Centers, Isfahan University of Medical Sciences, Isfahan, Iran. 2Isfahan University of Medical Sciences, Isfahan, Iran. *Correspondence: Isfahan University of Medical Sciences,Isfahan, Iran. Tel: +98 913 4814267. Email: ranamilasi@yahoo.com. Received Autgust 2018 & Accepted September 2018 advantages have been reported for TAPP such as sim- pler procedure, larger working space and finally better intraoperative anatomical landmarks(21). Furthermore, the learning curve of TAPP repair is shorter(20). Given that inguinal hernia seen frequently following RRP, few studies evaluated the results of TAPP repair in patients with history of RP compared to those without previous RP(22). As to best of our knowledge, there isn't enough prospective study about this issue, therefore, this study was designed to evaluate the results and complications of laparoscopic inguinal herniorrhaphy in patients with a history of radical prostatectomy. PATIENTS AND METHODS Study design and patients This prospective study was conducted in urology de- partment of Isfahan- Alzahra Hospital, in period April 2015 to April 2018. The recurrence rate and other out- comes in patients who underwent TAPP repair with history of RP were evaluated. The study received ethics approval from the Ethics Committee of Isfahan Uni- versity of Medical Sciences (395657). 40 consecutive patients diagnosed with inguinal hernia after RRP were enrolled in the study. (Figure 1) Urology Journal/Vol 17 No. 1/ January-February 2020/ pp. 24-29. [DOI: 10.22037/uj.v0i0.4751] Vol 17 No 01 January-February 2020 25 Inclusion and exclusion criteria Inclusion criteria consisted of patients with indication for inguinal herniorrhaphy referred to Alzahra Hospital, age between 50-80 years-old, history of RP, operated by same experienced surgeon and in the same method, and exclusion criteria consisted of subjects with age below 50 years or more than 85 years, not available for further postoperative follow up, or patients with in- complete medical data. The criteria for diagnosis of in- guinal hernia after radical retro-pubic prostatectomy in this study was in line with the European Hernia Society guidelines, described previously(23). Procedures The procedure was performed under general anesthesia in all patients. First of all urinary catheter was insert- ed and patients were placed in Trendelenburg position. Then a 10-mm Trocar was inserted exactly above the umbilicus, so that the 0-degree scope was inserted. Af- terwards, two other 5-mm Trocars were inserted from the left and right side on the midclavicular line. The sur- gical procedure started with examining the anatomical conditions inside the abdomen and the defect side, the peritoneum opening position was from the anterior su- perior iliac spine to the medial umbilical fold. After that, peritoneal flap developed by sharp and blunt dissection to reach the psoas muscle and after complete reduction of the hernia sac, dissection continued inferomedially to pubic symphysis. Thereafter, a mesh size of 12 * 15 cm was reconfigured and placed in a way that overlaps around the inguinal ring with at least 3 cm distance and fixed with 2-3 non absorbable or absorbable tackers. At the end, the peritoneal flap was closed by running 2-0 prolene sutures. All patients received Antibiotic (ceftri- axone 1gr intravenous) and analgesic agents (pethidine and Apotel) were prescribed on demand after surgery. Evaluations Different variables were evaluated in patients including age, previous history of smoking, history of previous inguinal hernia, hernia side and classification based on Nyhus Criteria, described previously(24) and variables during surgery such as damage to the bladder and vis- cera, respiratory failure, stroke, damage to the bowel, damage to the lower epigastric vessels, duration of sur- gery, conversion to open approach. The severity of post- operative pain was measured by the Visual Analogue Scale (VAS) (0 = painless and = 10 worst pain during life), which was measured 6 and 24 hours and 2 weeks after surgery. Hematuria, seroma and hematoma, hospi- tal discharge time, orchitis, testis atrophy, urinary tract infection, surgical site infection, examination of hernia Complications of inguinal hernia repair in prostatectomy-Izadpanahi et al. Table 1. Studied variables before and after surgery Variables No. (%) Minimum Maximum Mean SD. Age (year) - 51 80 65.97 8.16 Smoking 13 (30.2%) - - - - Duration between RP and LH (month) - 6 60 22.41 12.42 Side Right 15 (44.1%) - - - - Left 10 (29.4%) - - - - Bilateral 9 (26.5%) - - - - Nyhus Criteria II 11 (25.6%) - - - - IIIA 11 (25.6%) - - - - IIIB 13 (30.2%) - - - - IV 8 (18.6%) - - - - Surgery duration (min) - 75 230 167.44 52.85 Hospitalization duration (hour) - 12 34 20.79 4.76 VAS score After 6 hours - 2 6 4.41 1.11 After 24 hours - 0 4 1.48 0.93 After 2 weeks - 0 2 0.2 0.46 Analgesic administration 30 (69.8%) - - - - Follow up (month) - 2 19 9.9 5.33 Post-operative complication Seroma 1 (2.3%) - - - - Infection 1 (2.3%) - - - - Hematuria 1 (2.3%) - - - - Hernia recurrence 4 (9.3%) - - - - Duration between LH and hernia recurrence (month) - 0 7 0.55 1.84 Abbreviations: RP, radical prostatectomy; LH, laparoscopic herniorrhaphy Figure 1. Patients’ enrollment algorithm. recurrence based on physical examination, hernia type and location in cases of recurrence, time to detect her- nia recurrence and other complications after surgery. All outcomes were measured at baseline, 2 weeks, 3 months, 6 months, and 1 year postoperatively and at the end of study or when they were clinically symptomatic or reported by patients. As several studies demonstrat- ed, most IHs develop during the first 3–4 years after radical retro pubic prostatectomy (RRP)(31), therefore all hernias were considered due to prostatectomy in our follow up. Two weeks after operation, patients were al- lowed to have their routine occupational activity. Statistical Analysis Statistical analysis of data was performed using SPSS version 24 software. Kolmogorov-Smirnov test was used in order to evaluate the normal distribution quan- titative variables. Independent t-test was used for var- iables with normal distribution and Mann-Whitney test for non-normal distribution variables. Chi-square test was used to compare qualitative variables between groups. Two tailed p-value less than .05 were consid- ered significant. RESULTS Thirty-four patients with mean age of 65.97 ± 8.16 years (51-80 years) prospectively entered the study. The duration between RP and laparoscopic herniorrha- phy (LH) was 22.41 ± 12.42 months (6-60 months). Fif- teen cases (15/43, 44.1%) were on the right side. More- over, 30.2 % of subjects were type IIIB inguinal hernia (13/43), 25.6 % (11/43) type II and IIIA respectively and 18.6% (8/43) were type IV inguinal hernia bases on Nyhus Criteria. We found that 30.2% of cases had history of smoking. The mean operative time was 167.44 ± 52.85 min (75- 230 min) and hospitalization time was 20.79 ± 4.76 hours (12-34 hours). There was no conversion to open surgery. Moreover, the mean pain score based on VAS in 6, 24 hours and 2 weeks after surgery were 4.41, 1.48, and 0.2, respectively. Thirty cases (69.8 %) (Based on hernia) needed analgesic administration. No intraop- erative complications occurred. We followed patients for 9.9 ± 5.33 months (2-19 months) and found that 3 cases (6.97%) showed post-operative complications in- cluding seroma, hematuria due to difficult and traumat- ic urethral catheterization and superficial surgical site infection. Moreover, 4 cases (9.3%) had hernia recur- rence. The duration between LH and hernia recurrence was 0.55 ± 1.84 months (0-7 months). (Table 1). We evaluated different factors affecting the hernia recur- rence rate. We found that history of smoking was sig- nificantly higher in cases with hernia recurrence (75% vs. 25.6%, P = .041). On the other hand, we found that hospitalization time was significantly higher in cases with later hernia recurrence (26.5 ±5 vs. 20.2 ± 4.39 hours, P = .024). (Table 2) We evaluated pain score based on VAS and we did not observed significant differences in VAS score during follow up (P > .05). But by evaluating pain changes during 2 weeks follow up, we found that reduction in pain score in cases with hernia recurrence was lower as compared to other patients especially in first 6 and 24 hours after surgery. (P < .001). History of lymphad- enectomy in previous radical prostatectomy and patho- logical evaluation of the specimens was not available. DISCUSSION We evaluated 43 hernias from 34 cases and we followed patients for mean of 9.9 ± 5.33 months (2-19 months) and found that 6.97% of cases showed post-operative complication and 9.3% had hernia recurrence. Recur- rences were seen more in cases with history of smoking, higher hospitalization duration and lower pain reduc- tion during first 24 hours. In a study performed by Claus et al., mean operative time was reported 67.5 min and 5% of cases had in- traoperative minor complication, without major post- operative complications. Moreover, after 24 hours and on the seventh day after surgery, 85% and 90% of pa- tients had no pain, respectively. Forty five percent of subjects did not need any analgesics postoperatively. There was no conversion to open surgery. After a mean follow-up of 14 months, no recurrence was observed(25). Laparoscopic Urology 26 Table 2. Studied variables before and after surgery based on recurrence Recurrence Variables Negative (n=39) Positive (n=4) P-value Age (year) ; mean ± SD (range) 65.51 ±8.27 70.5 ±5.97 .249 Smoking 10 (25.6%) 3 (75%) .041 Duration between RP and LH (month) 8.5±3.69 23.84 ±12.12 < 0.001 Side Right 14 (45.2%) 1 (33.3%) .922 Left 9 (29%) 1 (33.3%) Bilateral 8 (25.8%) 1 (33.3%) Nyhus Criteria II 10 (25.6%) 1 (25%) .616 IIIA 11 (28.2%) 0 IIIB 11 (28.2%) 2 (50%) IV 7 (17.9%) 1 (25%) Surgery duration (min) 164.61 ± 54.07 195 ± 30.82 .299 Hospitalization duration (hour) 20.2 ± 4.39 26.5 ± 5 .024 VAS score ; mean ± SD (range) After 6 hours 4.53 ± 1.02 3.25 ± 1.5 .091 After 24 hours 1.43 ± 0.88 2 ± 1.41 .557 After 2 weeks 0.15 ± 0.36 0.75 ± 0.95 .227 VAS differences ; Between 24 and 6 hours -3.1 ± 0.64 -1.25 ± 0.5 < 0.001 mean ± SD (range) Between 2 weeks and 6 hours -4.38 ± 0.98 -2.5 ± 0.57 .001 Between 24 hours and 2 weeks -1.28 ± 0.85 -1.25 ± 0.5 .888 Analgesic administration 26 (66.7%) 4 (100%) .167 Follow up (month) ; mean ± SD (range) 9.66 ±5.31 12.25 ± 5.67 .479 Post-operative complication 2 (5.1%) 1 (25%) .259 Abbreviations: TUL, transurethral lithotripsy; RP, radical prostatectomy; LH, laparoscopic herniorrhaphy Complications of inguinal hernia repair in prostatectomy-Izadpanahi et al. Vol 17 No 01 January-February 2020 27 The results of this study were not similar to the results of our study. We did not observed intraoperative com- plication, while 6.97% of cases showed post-operative complication. Moreover, we found that 9.3% had hernia recurrence. These differences may due to different sam- ple size, different types and sizes of hernia, different in- clusion and exclusion criteria, and surgeon experience. Also, two patients which had hernia recurrence in our study had history of previous surgeries including ap- pendectomy and herniorrhaphy. In another study, per- formed by Hawn et al., rate of recurrence after ingui- nal herniorrhaphy was 6.5% and 21.3% of patients had complications at 2 years. The authors stated that most of recurrences occur in first year (32). The laparoscopic inguinal herniorrhaphy after pelvic or abdominal sur- geries is a time consuming procedure because releasing lateral adhesions of bladder to pelvic wall and dissect- ing free the peritoneal flap is technically challenging compared to those patients without history of surgery. Our study showed higher rate of recurrence and longer operative time. Our patients underwent herniorrhaphy with a mean time of 22 months after radical prostatecto- my with a range between 6-60 months. Postponing the treatment of inguinal hernia after radical prostatectomy may result in increasing the size of defect or sac and also more adhesions which make subsequent dissec- tion more difficult with higher rates of recurrences. As shown in Table 2 patients with subsequent recurrences have significant delay in diagnosis and or treatment of inguinal hernia (23 versus 8 months). So it seems that patients with radical prostatectomy diagnosed with in- guinal hernias should be treated as soon as possible in follow-up Moreover, Dulucq et al. reported that laparoscopic TEP for inguinal hernia repair in patients with previous low abdominal surgery (such as radical prostatectomy) has good results, similar to those without previous surgery (such as major intraoperative complications, hospital stay, and recurrence rate). However, a longer operative time was observed in patients with previous low abdom- inal surgery. Finally they concluded that TEP repairs can be performed efficiently and safely in patients after radical prostatectomy by skilled and experienced lapa- roscopic surgeons(26). Although the design of the study was not the same as our study, but the results of this study were similar to the results of our study, howev- er, we found that 9.3% of cases had hernia recurrence. It seems history of smoking increases intra-abdominal pressure and higher duration between radical prostatec- tomy and TAPP cause more adhesive bands and make operation more difficult. In follow up patients were al- lowed to have activity about 2 weeks after surgery but all recurrences occurred in patient with back to activity less than one week. In the procedure of operation, the peritoneum opening position was from the anterior superior iliac spine to the medial umbilical fold, as described in Dorga et al. (27) Sakon et al. in 2017 showed that the mean oper- ation time in patients who had previously undergone robot-assisted laparoscopic radical prostatectomy was 99.5 ± 38.0 min. The volume of blood loss was small intraoperatively, and the hospitalization duration was 2.0 ± 0.5 days. No major intraoperative or postoperative complications occurred. During the average 11.2-month follow-up period, no recurrence was observed(28). Wauschkuhn et al. reported that patients with history of prostatectomy were older, had higher duration of opera- tion and higher morbidity (5.7 vs. 2.8%), but recurrence rate was similar (0.8 vs. 0.7%) as compared to group without history of prostatectomy. Finally, they conclud- ed that, even if TAPP after prostatectomy is a difficult operation it can be done efficiently and safely(29). In an- other study, Atmaca et al. showed mean operation time in patient with concurrent repair of inguinal hernia with mesh application during transperitoneal robotic assisted radical prostatectomy was 139 ± 21 minutes. The mean time of hospitalization was 4 ± 0.9 days (range: 2-7). No intra-operative complication was seen. Mean follow up time was 13 months and they did not observe hernia recurrence or mesh infection(33). In the present study, patients experienced inguinal hernia repair (IMHR) with mesh placement. In a sim- ilar study performed by Hocaoglu et al., patients with previous IMHR were compared with patients without previous mesh implantation (nMI) who underwent open radical prostatectomy. Results showed that there was no significant difference between functional outcomes of open radical prostatectomy in study groups(30). One of the limitations of the study was the small size of study population and therefore the limited power to reflect statistical differences. CONCLUSIONS It is concluded that TAPP for inguinal hernia repair af- ter radical prostatectomy has good results and is effec- tive. But according to rate of recurrence, its safeness is conflicting. We noticed no major complication in our patients during the time of follow up. This may be due to safety of the operation in the proposed patients. Moreover, we found that 9.3% of cases had hernia re- currence which depends on different factors such as history of smoking, higher duration between radical prostatectomy and TAPP, higher hospitalization stay and with lower pain reduction during first 24 hours. Therefore, according to the risk factors related to higher incidence of hernia recurrence, we can predict high risk patients to provide preventive conselling and prepara- tions such as performing by skilled and experienced laparoscopic surgeons. This may decrease the rate of hernia recurrence. However, for a definite conclusion regarding recurrence rate or late post-operative compli- cations, longer-term follow up is necessary. ACKNOWLEDGEMENT This study was funded and supported by Deputy of Research, Isfahan University of Medical Sciences, and grant number 395657. We gratefully acknowledge the dedicated efforts of the investigators, and the coordina- tors who participated in this study. 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