Radical Prostatectomy Does Not Increase the Risk of Inguinal Hernia

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1 Article ID: WMC ISSN Radical Prostatectomy Does Not Increase the Risk of Inguinal Hernia Corresponding Author: Dr. Dan Spernat, Senior Lecturer University of Adelaide Urological Surgeon, Department of Urology The Queen Elizabeth Hospital, 28 Woodville Rd,, Australia Submitting Author: Dr. Dan Spernat, Senior Lecturer University of Adelaide Urological Surgeon, Department of Urology The Queen Elizabeth Hospital, 28 Woodville Rd,, Australia Article ID: WMC Article Type: Original Articles Submitted on:07-oct-2012, 05:49:10 AM GMT Article URL: Subject Categories:UROLOGY Keywords:Prostatectomy, Inguinal Hernia, Hernia, Laparoscopy Published on: 08-Oct-2012, 06:57:11 PM GMT How to cite the article:roth H, Spernat D, Tay YK, Frydenberg M, Appu S. Radical Prostatectomy Does Not Increase the Risk of Inguinal Hernia. WebmedCentral UROLOGY 2012;3(10):WMC Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None Competing Interests: None WebmedCentral > Original Articles Page 1 of 5

2 Radical Prostatectomy Does Not Increase the Risk of Inguinal Hernia Author(s): Roth H, Spernat D, Tay YK, Frydenberg M, Appu S Abstract Introduction Inguinal hernia has been reported to occur in 12 to 20% of patients after Radical Prostatectomy (RP). Herein we present our Australian experience with inguinal hernia (IH) risk post RP. Methods We conducted a retrospective audit of all cases of RP in our unit from 1/1/2004 to 1/1/2009. We then audited all patients undergoing IH repair at all 4 campuses of our tertiary referral centre between 1/1/2004 to 31/7/2011. The databases were then cross checked for matching patient record numbers. Results inguinal hernia post ORP is increased in patients with previous IH and increased age [5], and decreased with a smaller midline incision [6]. We present our experience with inguinal hernia (IH) risk post RP at an Australian tertiary centre. Methods We conducted a retrospective audit of all cases of RP on our unit from 1/1/2004 to 1/1/2009. Operation reports were analysed for approach and technique. We then audited all patients undergoing IH repair at all 4 campuses of our tertiary referral centre between 1/1/2004 to 31/7/2011. The databases were then cross-checked for matching patient record numbers. As this was a retrospective audit, ethics approval was not required by our institution. Results 233 RPs were performed at our institution from 1/1/2004 to 1/1/2009, excluding those patients who underwent cystoprostatectomy. This group consisted of 195 ORPs and 38 LRPs. From 1/1/2004 to 31/7/2011 a total 2574 incisional and IH repairs were performed. None of our patients required hernia repair during this period. Conclusion It is postulated RP may weaken the normal fascia structures at the internal inguinal ring leading to an increased risk of IH. However the exact mechanism of post-rp IH remains unknown. As none of our 233 RPs developed IH requiring surgical repair we postulate that the association between RP and IH is weaker than previously thought. Introduction Inguinal hernia has been reported to occur in 12 to 20% of patients after Radical Prostatectomy (RP) [1-3]. The risk of Inguinal Hernia (IH) is higher in patients undergoing Open Radical Prostatectomy (ORP) versus Laparoscopic Radical Prostatectomy (LRP) [4]. Furthermore, it has been reported that the risk of 264 consecutive RPs were performed at our institution from 1/1/2004 to 1/1/ cases involving cystoprostatectomy were excluded from this series. Of the remaining 233 cases, 195 were performed as ORP; and 38 were performed as LRP. Furthermore, Lymph Node Dissection (LND) was carried out in D'Amico intermediate and high-risk groups. Thus, 84 LNDs were performed in those who underwent ORP; and 2 LNDs in those who underwent LRP (figure 1). In those patients undergoing ORP a lower midline incision was used as described by Walsh et al [7]. Figure 1 From 1/1/2004 to 31/7/2011 a total 2574 hernia repairs were performed. This number includes incisional and IH. None of our patients required hernia repair during this period. The mean follow-up time in this period was 57 months (range 31-90). The average patient age at the time of RP was 61.3 years (range 44-80). Discussion It is postulated RP may weaken the normal fascia structures at the internal inguinal ring leading to an WebmedCentral > Original Articles Page 2 of 5

3 increased risk of IH [8]. However the exact mechanism of post-rp IH remains unknown [8]. It has been reported that previous IH surgery and age increase the risk of post-rp IH [5]. Furthermore, pelvic lymph node dissection, postoperative anastomotic stricture and duration of surgery have not been associated with an increased risk of post-rp IH [5]. No specific risk factors for post-lrp IH have been identified [4]. As none of our 233 RPs developed IH requiring surgical repair our data indicates that the association between RP and IH is weaker than previously thought. The inclusion of LRPs, comprising of only 38 of our 233 RP cases may have slightly reduced the risk of IH in our cohort. The mean age of our patient cohort is comparable to that of other studies [1,2,5] and hence cannot explain the low risk of IH at our centre. It is important to note that we are a training institution, and the RPs in this audit would have been undertaken by urology residents. We recognise the limitations of our study. Our study is retrospective and was designed to only detect those IHs requiring surgical repair, inevitably some IHs may have gone undetected in the absence of clinical examination. However our lengthy period of follow-up has afforded considerable time for post-prostatectomy IH to manifest, as more than 80% of IHs arising post RP occur within 2 years [2]. Further, having a study design that would detect only those IHs requiring surgical repair, our audit aimed to inform on the extent of significant and symptomatic IHs for which patients sought treatment. Furthermore this study was only able to detect those IH repairs undertaken on patients who remained in our health service s catchment area during the period of follow-up. However, loss to follow-up due to patient relocation would be minimal as our health service covers 32% of the Victorian population (1.39 million people) with 6 major hospitals and 2100 beds [9]. Despite these limitations we suggest given that this pilot audit has failed to demonstrate any cases of IH it is unlikely that there were a significant number of IHs missed. Conclusion 1. Stranne J, Aus G, Bergdahl S, Damber JE, Hugosson J, Khatami A, Lodding P. Post-radical prostatectomy inguinal hernia: a simple surgical intervention can substantially reduce the incidence--results from a prospective randomized trial. J Urol Sep; 184(3): Ichioka K, Yoshimura K, Utsunomiya N, Ueda N, Matsui Y, Terai A, Arai Y. High incidence of inguinal hernia after radical retropubic prostatectomy. Urol. 2004; 63: Regan TC, Mordkin RM, Constantinople NL, Spence IJ, Dejter SW Jr. Incidence of inguinal hernias following radical retropubic prostatectomy. Urol. 1996; 47: Lin BM, Hyndman ME, Steele KE, Feng Z, Trock BJ, Schweitzer MA, Pavlovich CP. Incidence and risk factors for inguinal and incisional hernia after laparoscopic radical prostatectomy. Urol Apr; 77(4): Stranne J, Hugosson J, Lodding P. Post-radical retropubic prostatectomy inguinal hernia: an analysis of risk factors with special reference to preoperative inguinal hernia morbidity and pelvic lymph node dissection. J Urol. 2006; 176(5): Koie T, Yoneyama T, Kamimura N, Imai A, Okamoto A, Ohyama C. Frequency of postoper- ative inguinal hernia after endoscope-assisted mini-laparotomy and conventional retropubic radical prostatectomies. Int J Urol. 2008; 15: Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol. 1998; 160: Taguchi K, Yasui T, Kubota H, Fukuta K, Kobayashi D, Naruyama H, Okada A, Yamada Y, Tozawa K, Kohri K. Simple method of preventing postoperative inguinal hernia after radical retropubic prostatectomy. Urol. 2010; 76(5): Epub 2010 Jul Southern Health, Fast Facts [homepage on the Internet]. Melbourne, Southern Health c2009 [updated 30 June 2008, cited 2 November 2011] Available from: porate_information/ We propose that previous reports of increased incidence of IH may have been overstated. References WebmedCentral > Original Articles Page 3 of 5

4 Illustrations Illustration 1 Figure 1 WebmedCentral > Original Articles Page 4 of 5

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