UroToday – Laparoscopic mesh herniorrhaphy: Impact on outcomes associated with radical retropubic prostatectomy

Source: Urotoday

Eighteen patients with a prior LMH underwent RRP. Five of the 18 had bilateral LMH, with unilateral LMH in the remainder. Outcomes in this group were compared with 38 patients without prior LMH. There was no difference between the groups in terms of age, preoperative PSA, prostate size, preoperative Gleason score, or body mass index, and RRP was successfully performed in all 18 LMH patients. One of 18 patients had a postoperative complication (persistent JP drainage). Compared with the control group, differences in operative time and blood loss bordered on statistical significance.

Prior LMH is not a contraindication to RRP. While resulting in slightly longer operating times and higher blood loss, our experience suggests that RRP can be safely performed in these patients.

This study from the Medical College of Wisconsin showed how radical prostatectomy can be performed safely after laparoscopic hernia surgery with mesh. My experience with robotic surgery has been similar. Robotic prostatectomy after laparoscopic hernia surgery takes a little more time, but is not too much of a problem.

The first step where the bladder is moved out of the way is more complicated and performing a pelvic lymph node dissection is more complicated as well. Patients of mine who are at risk of developing prostate cancer sometimes develop inguinal hernias. If they are considering undergoing laparoscopic hernia surgery with mesh, I am comfortable with given them the OK.

UroToday – Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair – Abstract

Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair

We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

Robotic Inguinal Hernia Surgery at the time of Robotic Prostatectomy

Source: Journal of Robotic Surgery, Volume 1, Number 4 / February, 2008

Urological surgeons should be encouraged to perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical hernias. Inguinal herniorrhaphy done concurrently at the time of RALP is safe, with no added morbidity and should be routinely performed.

This is a paper Dr. Ahlering and I wrote which is a review of our results and techniques of fixing hernias during dvP.
Since conferring with Dr Ahlering on this paper, I have changed my technique to resemble his more.
The main point of the article is that hernias are common and it is beneficial for patients to have them fixed.