Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial

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1 Hernia (2014) 18: DOI /s ORIGINAL ARTICLE Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial C. M. P. Claus J. C. U. Coelho A. C. L. Campos A. M. Cury Filho M. P. Loureiro D. Dimbarre E. A. Bonin Received: 2 September 2013 / Accepted: 6 December 2013 / Published online: 20 December 2013 Ó Springer-Verlag France 2013 Abstract Introduction Despite inguinal hernia repair being one of the most common elective operations performed in general surgical practice, there are many controversies including indications for repair and selection of the surgical technique. In recent years, laparoscopic repair has gained wider acceptance because it is associated with fewer postoperative complications and less chronic pain when compared with conventional approaches with similar recurrence rate. However, patients with lower abdominal surgery are contraindicated for laparoscopic approach. There are few studies that evaluated whether patients who have been subjected to radical prostatectomy might be subjected to laparoscopic hernia repair with the same benefits as those without previous radical prostatectomy. Methods Between March 2010 and March 2013, 20 consecutive patients, who had been subjected to prior radical prostatectomy, underwent laparoscopic transabdominal inguinal repair and were followed prospectively. Surgical procedure was performed using a standard technique. Results Mean operative time was 67.5 min. There was only one intraoperative minor complication, an injury to the inferior epigastric vessels, which was managed by clipping of the vessels. There were no major C. M. P. Claus (&) A. M. Cury Filho M. P. Loureiro D. Dimbarre E. A. Bonin Minimally Invasive Surgery, Jacques Perissat Institute, Positivo University, R. Comendador Araujo, 143 Cj 113, Curitiba, PR , Brazil christiano.claus@gmail.com J. C. U. Coelho A. C. L. Campos Gastrointestinal Surgery, Federal University of Paraná, Curitiba, Brazil postoperative complications. After 24 h and on the seventh postoperative day, 85 and 90 % of patients had no pain or only complained of discomfort, respectively. Nine patients (45 %) did not need any analgesics postoperatively. The mean time to return to leisure activities and to work was 3.1 and 5.6 days, respectively. There was no conversion to open surgery. All patients were discharged within 24 h. After a mean follow-up of 14 months, none of the patients presented recurrence. Conclusion TAPP after prostatectomy is safe and effective. It seems that patients undergoing laparoscopic repair after radical prostatic resection have the same benefits as those without prostatectomy. Keywords Inguinal repair Laparoscopic TAPP Prostatectomy Introduction Inguinal hernia repair is one of the most common elective operations performed in general surgical practice. An estimated 20 million inguinal hernias are repaired worldwide every year, with a lifetime risk of herniation being 27 % for men and 3 % for women [1]. Several subjects about inguinal hernia surgery remain controversial, including the etiology, indications for repair, risks of complications, and selection of surgical technique. Currently, mesh repair has been advocated because of its low recurrence rate in comparison to non-tension-free repairs. Lichtenstein popularized the tension-free open repair using polypropylene mesh, claiming rapid recovery with a 99 % probability of permanent cure [2]. In recent years, laparoscopic repair, based on the Stoppa s concept of preperitoneal reinforcement, has gained wider

2 256 Hernia (2014) 18: acceptance because it is associated with rapid recovery, fewer postoperative complications and less chronic pain when compared with conventional approaches, with similar recurrence rate [3 5]. Radical prostatectomy is an option for the treatment of patients with prostate cancer. Regardless of the technique used, the preperitoneal space is violated and dissected. Intense fibrosis in the preperitoneal is observed in almost all patients following radical prostatectomy. For this reason, patients presenting with inguinal hernia after radical prostatectomy are considered for anterior (conventional) repairs, avoiding dissection of the preperitoneal space as advised in laparoscopic approaches [6]. There are few studies that evaluated whether patients who have been subjected to radical prostatectomy might be subjected to laparoscopic hernia repair with the same benefits as those without previous radical prostatectomy [7]. The aim of this prospective study was to evaluate the feasibility and surgical outcomes of laparoscopic transabdominal hernia repair (TAPP) in patients who had been subjected previously to radical prostatectomy. Methods Between March 2010 and March 2013, a total of 20 consecutive patients, who had been subjected to prior radical prostatectomy, underwent laparoscopic transabdominal inguinal repair (TAPP procedure). Indications for surgical treatment were symptomatic inguinal hernia in all cases. Exclusion criteria were patients with contraindications for general anesthesia or multiple intra-abdominal pelvic procedures. Patients with incisional hernias, defined by medial defects at the level of the medial umbilical fold, were also excluded. All patients were followed prospectively for at least 3 months. The patients signed informed consent prior to the surgery. Operative technique Antibiotic prophylaxis was routinely used and consisted of intravenous administration of cefazolin 1 g at the induction of anesthesia. Operation was performed with the patient in the Trendelenburg position. Urinary catheter was used during the procedure. Pneumoperitoneum was created using a Verres needle and was kept at 12 mmhg using CO 2 insufflation throughout the procedure. A 10-mm trocar was inserted just above the umbilicus for a 30 scope. Then, two other trocars (5 and 10 mm) were inserted at the lateral left and right midclavicular lines, respectively. Surgical procedure was performed using a standard technique. After identification of the anatomical elements and the hernia defect, an opening of the peritoneum was performed from the anterior superior iliac spine to the medial umbilical fold. Then, the lateral space of the spermatic cord was dissected until reaching the psoas muscle, followed by complete reduction of the hernial sac. Medial space was dissected carefully to expose the pubic symphysis. A cm mesh was placed into this dissected preperitoneal space, covering the entire Fruchaud area with overlapping of at least 3 cm from the hernial ring. Mesh was fixed with 4 6 staples, avoiding the area of external iliac vessels and nerves, laterally. The peritoneal flap was closed using absorbable running suture covering the mesh. All patients were subjected to the same anesthetic protocol. Postoperative analgesia was done by a single dose of valdecoxib 40 mg IV and tramadol 50 mg IV at the end of the procedure and dipirone 500 mg IV four times a day. Pain intensity was assessed at 12 and 24 h, and 7 days postoperatively (day 7). Pain was scored using the 10-point Visual Analog Pain Scale (VAS; 0 = no pain, 10 = worst pain imaginable). Results Patients characteristics TAPP after radical prostatectomy was performed in 20 patients with mean age of 65.9 years (range years). There were 15 patients with unilateral and 5 with bilateral hernias (25 inguinal hernia repairs). According to Nyhus hernia classification, 13 defects were 3A, 11 were 3B and 1 was 2. Six patients (eight hernias) had recurrent hernias, previously repaired by the anterior approach. Operative results All procedures were performed by surgeons with large experience in laparoscopic hernia surgery. Mean operative time was 67.5 min (range min). There was no conversion to open surgery. Half of all patients were discharged on the same day of surgery, while the remaining 10 patients were discharged within 24 h. Complications There was only one intraoperative minor complication, an injury to the inferior epigastric vessels, which was managed by clipping of the vessels. There were no major postoperative complications, only four patients presented seroma/hematoma on the seventh postoperative day, which was reabsorbed spontaneously during the first postoperative month. Half of the patients reported no pain after 12 h of the operation. After 24 h, 85 % had no pain or only complained of discomfort, while only 10 % of patients

3 Hernia (2014) 18: Table 1 Evaluation of postoperative pain Postoperative pain No pain (VAS 0) Discomfort (VAS 1) Mild pain (VAS 2 3) Moderate pain (VAS 4 5) Severe pain (VAS 6 7) Very severe pain (VAS 8 9) Worst pain (VAS 10) complained of mild or moderate pain on the seventh postoperative day (90 % had no pain or only complained of discomfort) (Table 1). Nine patients (45 %) did not need any analgesics postoperatively. The mean time to return to leisure activities was 3.1 ± 1.3 days (range 1 7 days) while to return to work was 5.6 ± 2.2 days (range 2 11 days). Six patients who reported some degree of physical activity restriction before surgery were able to return to their normal activity after 2 months. After a mean follow-up of 14 months (range 3 33 months), none of the 25 hernia repairs had recurrence. Discussion Postoperative time 12 h 24 h 7th P.O. 10 patients (50 %) 5 patients (25 %) 4 patients (20 %) VAS Visual Analogic Pain Scale 1s (55 %) 6 patients (30 %) 2 patients (10 %) 1s (55 %) 7 patients (35 %) None None None Inguinal hernia repair is one of the most common procedures in general surgery. Various inguinal hernia repairs have been described, but recently, the so-called tensionfree repair has become the procedure of choice due to the low recurrence rate [2]. Laparoscopic inguinal hernia repair (LIHR) has several advantages over conventional open methods, such as lower incidence of chronic pain, and short recovery period [4, 5, 8, 9]. Experienced surgeons can perform laparoscopic hernioplasty with a recurrence rate inferior to 1 %, less chronic pain, and comparable costs. Therefore, some surgeons advise laparoscopic repair not only for recurrent or bilateral hernias, but also for primary unilateral inguinal hernias [10 12]. There are two standardized techniques for laparoscopic groin hernia repair: (1) transabdominal preperitoneal and (2) totally extraperitoneal (TEP) repair. There are advantages and disadvantages in both TAPP and TEP procedures; however, there is no difference regarding postoperative complications [7, 13]. Although the choice is not based on any solid scientific data, most surgeons prefer open repair or TAPP in complicated cases, including incarcerated hernias, very large scrotal hernias, and for patients who have undergone previous lower abdominal surgery or pelvic surgical procedures [14, 15]. Despite some surgeons claim that previous radical prostatectomy should contraindicate a laparoscopic approach because of the severe scarring of the preperitoneal space, some groups have used the laparoscopic approach in this situation [16]. To our knowledge, there are only two studies that addressed this issue. Dulucq et al. [17] operated, during a 1-year period, a total of 10 patients after prostatectomy with TEP. Despite similar complication rate, operation time was longer than in uncomplicated repairs and they reported a 20 % conversion rate to TAPP. Wauschkuhn et al. [18] reported 264 patients who underwent TAPP during a 10-year period. They reported longer operation time (59 vs. 40 min) with the laparoscopic approach, similar to our series. We showed an operative time of 57 min for unilateral hernias and 107 min for bilateral repairs (global 67.5 min). The authors reported also a higher morbidity rate (5.7 vs. 2.8 %) with the laparoscopic technique, including major complications such a bowel obstruction due to the incorrect closure of peritoneum. But this complication is not specifically related to prior prostate surgery. However, urinary injury happened in two cases (0.7 %) due to the extensive scar tissue and was managed with suture and urinary catheter. In our series, there were no major intraoperative complications, only one minor complication, an injury to inferior epigastric vessels which was controlled immediately by vessel clipping. Conversion was not necessary in any case. Though a more complex technique, TAPP approach seems to be beneficial to the patients. Our trial is first to report the postoperative outcome of patients, including visual pain scale and returning activities in patients undergoing laparoscopic repair after radical prostate surgery. In this series, 75, 85 and 90 % of the patients complained only of discomfort or had no pain after 12, 24 h and on the seventh postoperative. Forty-five percent of the cases did not use any analgesic. All patients were discharged within 24 h and had a short recovery time (mean time to return to usual activities and to work was 3.1 ± 1.3 and 5.6 ± 2.2 days, respectively). These data are comparable to those patients undergoing surgery without prior prostatectomy. Tolver et al. [19] reported that in 162 patients submitted to TAPP, in uncomplicated cases, the mean time to return to leisure activities and to work was 3 and 5 days, respectively. Recurrence rate in patients with complicated cases appears to be similar to those without prostatectomy, around 1 % [20]. After a mean follow-up of 14 months, no

4 258 Hernia (2014) 18: recurrence was detected in our cases. Patients had no restriction of any physical activity. An important technical aspect concerning laparoscopic herniorrhaphy in patients who had been subjected to previous radical prostatectomy is the creation of a peritoneal flap and dissection of medial space. We recommend starting the dissection laterally to elements of spermatic cord, followed by reduction of the hernia and only perform the medial dissection, i.e. prevesical space, at the end. This was the only change in surgical technique that we performed as compared to uncomplicated cases, where we usually reduce the peritoneal sac at the end of the dissection. This technical change can help reduce the risk of bladder injury that seems to be a main problem during the dissection. Urinary catheter was used routinely due to longer operative time and to allow detection of potential bladder lesion. It is quite remarkable that a multiplicity of studies from urologists exists analyzing the effect of endoscopic extraperitoneal radical prostatectomy in patients with prostate cancer and previous LIHR [21].The same preperitoneal fibrosis caused by prostatectomy could make it difficult to perform the laparoscopic hernia repair in patients undergoing prostatectomy with previous preperitoneal mesh placement. According to the literature, although it is a more technically demanding procedure, previous LIHR does not adversely affect the functional or oncological outcomes of endoscopic extraperitoneal radical prostatectomy [22]. Despite some subjective and operative difficulty, prior TEP/TAPP did not increase the morbidity or mortality of subsequent prostate surgery [23, 24]. Recently, there has been described a higher incidence of inguinal hernia in patients undergoing prostatectomy, from 6.7 to 15.9 % [25]. It was suggested that damage to the posterior layer of the rectus sheath might be involved in the development of inguinal hernia after radical prostatectomy. This finding draws attention to the importance of this matter, since a growing number of patients are undergoing prostate surgery. It is concluded that TAPP after prostatectomy is safe and effective. It seems that patients undergoing laparoscopic repair after prostatic resection have the same benefits as those without prostatectomy. With experience, it is possible to minimize the complication rate, and TAPP is a valuable alternative to open operation. Conflict of interest C C. declares no conflict of interest. J.C. declares no conflict of interest. A.C. declares no conflict of interest. A.C.F. declares no conflict of interest. M.L. declares no conflict of interest. D.D. declares no conflict of interest. E.B. declares no conflict of interest. References 1. LeBlanc K (2003) Hernias: inguinal and incisional. 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