Inseparable interaction of the prostate and inguinal hernia

Transcription

1 International Journal of Urology (2018) doi: /iju Review Article Inseparable interaction of the prostate and inguinal hernia Akira Miyajima Department of Urology, Tokai University School of Medicine, Isehara, Kanagawa, Japan Abbreviations & Acronyms BMI = body mass index BPH = benign prostatic hyperplasia IH = inguinal hernia IPSS = International Prostate Symptom Score LRP = laparoscopic radical prostatectomy LUTS = lower urinary tract symptoms RARP = robot-assisted radical prostatectomy RP = radical prostatectomy TAP = transabdominal preperitoneal TEP = total extraperitoneal repair Abstract: With an increase in their prevalence, it has become apparent that both benign prostatic hyperplasia and radical prostatectomy for cancer can induce inguinal hernia development. An inguinal hernia is a common late complication following radical prostatectomy, with an occurrence rate of 12 25%. Following radical prostatectomy, the space of Retzius can develop adhesions to surrounding tissue, often causing difficulty during inguinal hernia repair. Conversely, inguinal hernia repair before radical prostatectomy also induces severe adhesions around the space of Retzius and causes difficulty during radical prostatectomy. The association between radical prostatectomy and inguinal hernia development is complex and unclear. Both urologists and surgeons are challenged by this interaction. The surgical approaches for prostate cancer have undergone a major transition from open surgery to robotic surgery, and the treatment of inguinal hernia is also changing. Based on historical trends, several preventive and treatment measures have been proposed, although there is no direct evidence for risk factors that lead to inguinal hernia development. This article focuses on the complex interaction between the prostate and inguinal hernia, and considers preventive measures against inguinal hernia development. Key words: inguinal hernia, prostate, surgery. Correspondence: Akira Miyajima M.D., Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa , Japan. akiram@tokai.ac.jp Received 9 April 2018; accepted 22 May Etiology and risk factors for IH IH accounts for 75% of abdominal wall hernias and 97% of groin hernias. 1 IH repair is one of the most common procedures performed in the United States. 2 Risk factors for IH development can be divided into patient risk factors and external risk factors. Patient-dependent risk factors include male sex, older age, a patent processus vaginalis, chronic cough, systemic connective tissue disorders, and a low BMI. 3 While low BMI is a known risk factor for IH, high BMI increases intra-abdominal pressure, and also seems to increase the risk of IH recurrence. BPH and constipation are also patient-dependent risk factors. Conversely, external risk factors include increasing cumulative occupational mechanical exposure, 3 smoking, sports, 4 or lower midline incision surgery. 5,6 BPH is common in the aging male population. The prevalence of BPH increases after the age of 40 years, and BPH prevalence has increased rapidly with the aging of society. 7 Prostate cancer prevalence has also increased. As the prevalence of these prostatic diseases has increased, it is apparent that BPH or RP for prostate cancer may also induce IH development. IH is a common late complication after RP, with an occurrence rate of 12 25%. Reported risk factors for IH after RP include previous IH surgery, age, low BMI, length of lower abdominal incision, previous abdominal surgery, extraperitoneal-approach LRP, urethral stricture, and clinical tumor stage. 8,9 Following RP, the space of Retzius, also known as the retropubic space, develops adhesions with the surrounding tissue, causing difficulty during IH repair. Conversely, IH repair for a previous IH before RP also induces severe adhesions around the space of Retzius and results in some difficulty during RP procedures. The association between RP and IH development is complex and unclear. Both urologists and surgeons are challenged by this interaction. Based on historical trends, several preventive and treatment measures have been proposed, although there is no direct evidence supporting risk factors that lead to IH development. This article focuses on the complex interaction between the prostate and IH and considers preventive measures against the development of IH The Japanese Urological Association 1

2 A MIYAJIMA IH development and LUTS Sanchez-Ortiz et al. performed an analysis of 693 consecutive patients who underwent RARP. 10 Patients with a preoperative IPSS of 15 or greater had a 22.4% chance of requiring IH repair compared to 5% of patients with lower scores. The authors concluded that regardless of prostate size, men with preoperative LUTS and an IPSS of 15 or greater should be counseled on the potential need for IH repair using RARP. This suggests the need for increased caution in patients with LUTS as mesh material may be required for fixation when RARP is performed in these patients. Kaiho et al. noted that responses to question 6 of the IPSS (i.e. Over the past month, how often have you had to push or strain to begin urination? ) were associated with postoperative urinary straining and history of previous hernia repair, both of which were significant risk factors for postoperative IH development. 11 A possible mechanism remains the fact that patients with LUTS may need to strain to void, and this effort over time may have a direct impact on the abdominal wall contributing to the development of IH. Moreover, repeated urinary straining tends to push the small intestine into the processus vaginalis. In particular, urinary straining is associated with IH development after RP, and LUTS with urinary straining can clearly induce IH development. Such complaints from patients in addition to physical findings should be evaluated before prostatectomy. IH development after RP It is important to consider the results of a Scandinavian study regarding IH after RP. 12 The Kaplan Meier cumulative occurrence of IH development after 48 months was 12.2%, 5.8%, and 2.6% in patients who underwent open RP, patients who underwent RARP, and controls, respectively. Nissen et al. concluded that open RP for prostate cancer leads to an increased risk of IH development, and that RARP may lower this risk when compared to open surgery. They also reported an almost fourfold increase in IH repair after open RP compared with controls, and men who underwent radiation therapy had an almost twofold increase in IH incidence. In addition to postoperative changes in the abdominal wall, there is an increased incidence of IH after RP or radiation therapy for prostate cancer. 13 Zhu et al. performed a meta-analysis of 29 trials, and reported that postoperative IH developed in 15.9% of patients who underwent open RP and 6.7% ( ) of those who underwent laparoscopic RP. Most cases of IH occurred within the first 2 years after surgery, and right-side and indirect-type IH predominated. Moreover, the incidence of IH after retropubic RP was significantly higher than that in patients who had no operation, laparoscopic surgery, radical perineal prostatectomy, minilaparotomy radical retropubic prostatectomy, or pelvic lymph node dissection, but was not significantly higher than that in patients who underwent simple open prostatectomy or cystectomy. Several reports also demonstrated that IH occurrence rate after retropubic RP ( %) was significantly higher than that in controls ( %). 5,12,14,15 In addition, increasing age, low BMI, subclinical IH, previous IH repair, and anastomotic stricture increased the risk of IH after RP. The authors also suggested that damage to the posterior layer of the rectus sheath might be involved in the development of IH after RP. Prophylactic surgery for highrisk subjects is recommended before RP to minimize the incidence of IH. 16 Preventive measures from open surgery to robotic surgery In 1987, Schlegel and Walsh described routine surgery for preperitoneal IH repair in patients with symptomatic or incidentally discovered IH who were undergoing open RP or radial cystoprostatectomy (Table 1). 17 The transversus arch was approximated to the iliopubic tract and Cooper s ligament, and interrupted sutures were then applied to direct the hernia. Indirect hernias were repaired by mobilizing the spermatic cord and dissecting any excess tissue. If the hernia sac was identified, it was dissected free from the spermatic cord and reduced. Finally, the transversus arch was approximated to the iliopubic tract with interrupted sutures. Using this classic approach, they identified 41 cases of IH and were able to repair 32 among the 369 patients in the study. In addition, Choi et al. improved the technique by prosthetic mesh placement for hernia repair during RP in This was the first report of simultaneous hernioplasty using mesh during RP to reduce the development of IH. Stranne et al. also followed the prophylactic procedure first described by Schlegel and Walsh, 17 and analyzed the effects of this simple surgical intervention. Of 254 patients, 127 had the prophylactic procedure on the right side and 127 on the left. The cumulative IH incidence was 3.5% for the intervention side and 9.1% for the controls. Following this trial, several groups challenged the preventive studies. Sakai et al. proposed that a simple procedure able to dissect the internal ring and the spermatic cord from the surrounding tissue was effective. 19 They reported that this procedure resulted in only a 1.6% recurrence rate during a median follow-up period of 41 months. The authors speculated that adhesions involving the internal ring following the procedure might have had a beneficial effect on preventing IH after open RP. Fujii et al. introduced another method to transect the processus vaginalis free from the spermatic cord in addition to the dissection of the spermatic cord itself. 20 Based on these studies, Kanda et al. compared these two methods using the same surgical team. 21 Their results showed that the processus vaginalis transection procedure was superior to the simpler prophylactic procedure for the prevention of IH after RP. Recent trends in surgery for prostate cancer including robotic-assisted surgery have been reported to reduce IH occurrence rates. 13 In the future, we will need to focus on robotic surgery-associated IH. Several studies have described IH repair during RARP. Joshi et al. reported the effectiveness of concurrent robotic TAP hernioplasty using mesh placement during RARP. 22 Upon completing RARP, the peritoneum overlying the myopectineal orifice is opened, the orifice is dissected free, and The Japanese Urological Association

3 Interaction of the prostate and IH Table 1 Preventive measures for IH development during RP Reported year Authors Operation method to prostate Preventive procedure IH recurrence rate prevention vs controls Added operation time (min) 1987 Schlegel & Walsh Open RP, cystectomy Narrowing internal ring 0% (prevention group) 1999 Choi et al. Open RP Mesh placement 0% (prevention group) 2010 Stranne et al. Open RP Narrowing internal ring 3.5% vs 9.1% Joshi et al. RARP TAP 0% (prevention group) Ludwig et al. RARP or LRP TEP 0% (prevention group) Kanda et al. Open RP Processus vaginalis transection 0% vs 24.8% 2017 Rogers et al. RARP TAP Chang et al. Retzius-sparing RARP 3.7% vs 7.8% the hernia is reduced. The mesh is then affixed over the orifice with titanium tacks, and the peritoneum is closed over the mesh. The mean operative time for TAP hernioplasty procedure is 24 min. Moreover, Rogers et al. reported that although TAP hernioplasty during RARP increased surgical time, there was no increase in postoperative complications, suggesting that concomitant performance of both procedures is feasible and safe. 23 Conversely, Ludwig et al. compared concomitant laparoscopic TEP and RARP with similar combined IH repair with LRP. Following standard extraperitoneal RARP with pelvic lymph node dissection, surgeons performed TEP using the same ports. On the side with the hernia, the contents were reduced and the space was cleared for prosthetic mesh. The hernia sac was reduced, and the synthetic mesh was used to reinforce the myopectineal orifice. When compared to standard LRP or RARP, unilateral TEP prolonged operative time by approximately 30 min. 24 Since IH recurrence was not observed, the authors concluded that RARP with concomitant TEP is safe, effective, and comparable to the laparoscopic approach. Thus, simultaneous IH repair during RARP may be justified in patients with IH or subclinical IH. Mechanism of IH development after RP The precise mechanism of IH development after standard RP remains unclear, but several hypotheses have been proposed (Fig. 1). Shimbo et al. postulated that the peritoneum and vas deferens were stretched during urethrovesical anastomosis, resulting in a medial shifting of the internal ring, with subsequent widening leading to IH development. 25 Moreover, Lee et al. reported that a patent processus vaginalis, which is a peritoneal protrusion toward the deep inguinal ring, is an important risk factor for IH after RARP. 26 As discussed above, Kaiho et al. proposed that repeated straining for urination pushes the small intestine into the funnel-shaped processus vaginalis, which can easily occur following release of the vas deferens from the prostate during RP. They postulated that the release of the vas deferens and the increased abdominal pressure after RP can induce development of IH in patients with urinary straining. Chang et al. found that Retzius space preservation with RARP lowered IH incidence compared with standard RARP. 27 They hypothesized that lower IH incidence might be due to the maximum preservation of anatomical structures of the anterior component including the space of Retzius, maintenance of the anatomical attachment of the entire bladder to the anterior abdominal wall fascia, and an undisturbed external prostate-vesicular angle. 28,29 In addition, the preservation of these anatomical structures may also preserve the myopectineal orifice and its components by avoiding medial stretching of the internal ring. Indeed, perineal RP resulted in a lower incidence of IH, compared with standard open RP. 30 In summary, Retzius space preservation may play a role in the (a) Peritoneum (b) Peritoneum Internal iliac ring Internal iliac ring Bladder Bladder Prostate Proposed hypotheses regarding mechanisms of inguinal hernia development after radical prostatectomy. (a) Before prostatectomy; (b) after prostatec- Fig. 1 tomy The Japanese Urological Association 3

4 A MIYAJIMA pathogenesis of IH development. Although these hypotheses may explain the exact mechanism in part, they are still merely speculation. Impact of prior IH repair on subsequent RP Katz et al. experienced a case in which bilateral laparoscopic IH repair complicated a subsequent RP (Table 2). 31 This case report drew attention from many urologists and led to some discussion. Subsequently, several publications have described the severe fibrotic reaction that obliterates the retropubic space, making the operation very difficult Foley and Kirby suggested that this situation might be encountered more frequently in urological practice because of the increasing number of RPs being performed. Conversely, Kennedy-Smith successfully performed RP in a similar situation and suggested that a previous IH surgery contributed only minimally to the technical difficulty of the RP, while such patients need to be warned of the potential for additional morbidity. Siddiqui et al. evaluated the experience with RARP in the setting of previous inguinal or abdominal surgery. 35 From a prospective cohort of 2950 consecutive patients who underwent transperitoneal RARP, they identified 1049 (27%) with a history of abdominal or inguinal surgery. Adhesiolysis at the time of surgery was graded and the grade was based on time required to take down adhesions, density of adhesions, and area of coverage of adhesions. Any adhesiolysis taking more than 30 min or involving a minilaparotomy incision was considered extensive. They found that patients with previous surgery required adhesiolysis compared with patients with no previous surgery, and especially noted that patients with a history of bilateral hernias with mesh frequently required extensive adhesiolysis. Nevertheless, they concluded that previous inguinal surgery is not a contraindication to RARP because accessing the prostate through the peritoneum with the precision of robotic instruments allows for successful completion of RARP, regardless of the type or extent of mesh hernia repairs. Picozzi et al. performed a meta-analysis and systematic review of 7497 patients to evaluate the feasibility and outcomes of open, laparoscopic, and robotic strategies for RP in patients with previous synthetic mesh IH repair. 36 They concluded that prior IH repair with mesh placement might complicate subsequent RP in terms of perioperative parameters Table 2 Unfavorable impact of preceding surgery to the following surgery including blood loss, catheterization duration, and extent of lymph node dissection. This suggested that a transperitoneal robotic approach may be technically easier than an open approach for these patients. However, patient provision of adequate informed consent still may be required for these multiple aspects, which may be influenced by mesh placement. Should patients be informed of the risk of IH following prostatectomy? How many urologists have noticed the increase in IH development after RP? Were prostate cancer patients aware of the potential risk of IH before undergoing RP? The mean occurrence rate of IH after RP is approximately 15%, and urologists have observed that patients are at risk of IH development. Nevertheless, the potential of IH occurrence is unpredictable as definite risk is difficult to determine in the absence of subclinical IH. The IH occurrence rate for the latter is not low and may be comparable to the urinary incontinence rate observed in patients following RP. Since RP may increase the risk of IH development regardless of the approach used, this complication should be discussed with patients who are scheduled for RP. 37 Are urologists aware of how a surgeon approaches IH repair after prostatectomy? Urologists tend to focus on how to manage RP with perioperative IH development. It is obvious that RP induces IH development, while IH repair complicates RP. Understandably, most urologists face difficulties in such cases, albeit to different degrees. It would be interesting to know how surgeons approach IH repair in patients with prior RP. Le Page et al. reported the modest impression that TEP and IH repair in experienced hands required a slightly longer operative time for patients who had previously undergone RP than in those who had not undergone RP, while other outcomes were equivalent in both groups. 38 Nevertheless, they mentioned that the most difficult and adherent area is superior to the iliac vessels, especially when a Hem-o-lok â clip had previously been applied to the vas deferens during RP. They also stated that other operative repair approaches should always be considered for these difficult cases, even for experienced and skilled surgeons, while open approaches to IH repair are still recommended for a less experienced surgeon. IH repair before RP RP before IH repair Need to dissect adhesions and prolong operation (Siddiqui et al.) 35 Becomes very difficult RP (Katz et al.) 31 Complicates future pelvic surgery (Hsia et al.) 34 Decrease numbers of resected lymph node, prolong hospital stay and catheterization in open RP while marginally affecting LRP (Picozzi et al.) 36 Safe, but prolong operative time of IH repair (Le Page et al.) 38 Conclusions Although RP is currently performed with robotic surgery, the development of IH remains an ongoing concern. We need to inform patients undergoing RP of the potential risk of developing IH, regardless of the surgical method chosen. A patient who is at risk of a subclinical hernia requires consultation with a specialist surgeon before RP, and simultaneous mesh placement may be recommended during RP. Conversely, it may also be useful for the surgeon to determine the patient s The Japanese Urological Association

5 Interaction of the prostate and IH prostate-specific antigen level prior to IH repair. Furthermore, surgeons need to be aware that dissection of the space of Retzius during RP may lead to adhesions, and this may have a significant impact on the development of IH, although the exact mechanism remains speculative. Conflict of interest None declared. References 1 Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Nationwide prevalence of groin hernia repair. PLoS ONE 2013; 8: e Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ. Open or endoscopic total extraperitoneal inguinal hernia repair?: a systematic review. Surg. Endosc. 2007; 21: Oberg S, Andresen K, Rosenberg J. Etiology of inguinal hernias: a comprehensive review. Front. Surg. 2017; 4: Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic literature review. Br. J. Sports Med. 2008; 42: Stranne J, Hugosson J, Lodding P. 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