Parastomal hernias after radical cystectomy and ileal conduit diversion

Abstract

Parastomal hernia, defined as an "incisional hernia related to an abdominal wall stoma", is a frequent complication after conduit urinary diversion that can negatively impact quality of life and present a clinically significant problem for many patients. Parastomal hernia (PH) rates may be as high as 65% and while many patients are asymptomatic, in some series up to 30% of patients require surgical intervention due to pain, leakage, ostomy appliance problems, urinary obstruction, and rarely bowel obstruction or strangulation. Local tissue repair, stoma relocation, and mesh repairs have been performed to correct PH, however, long-term results have been disappointing with recurrence rates of 30%-76% reported after these techniques. Due to high recurrence rates and the potential morbidity of PH repair, efforts have been made to prevent PH development at the time of the initial surgery. Randomized trials of circumstomal prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have shown significant reductions in PH rates with acceptably low complication profiles. We have placed prophylactic mesh at the time of ileal conduit creation in patients at high risk for PH development and found it to be safe and effective in reducing the PH rates over the short-term. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors associated with its development, and the use of prophylactic mesh placement for patients undergoing ileal conduit urinary diversion with the intent of reducing PH rates.

Keywords: Abdominal hernia; Cystectomy; Postoperative complication; Urinary diversion.

Fig. 1. Radiographic classification of parastomal hernia: (A) type 1, hernia sac that contains prolapsed bowel forming the stoma; (B) type 2, hernia sac contains abdominal fat or omentum herniating through the abdominal wall defect created by the stoma; (C) type 3, hernia sac contains herniated loops of bowel other than that forming the stoma.

Fig. 2. Progression in years from type 2 to type 3 radiographic parastomal hernia (n=90 patients). A type 2 radiographic parastomal hernia contains abdominal fat or omentum herniating through the abdominal wall defect created by the stoma. A type 3 parastomal hernia contains herniated loops of bowel other than that forming the stoma.

Fig. 3. Four basic approaches for mesh-based hernia repairs. (A) Onlay – mesh is placed on the anterior fascial aponeurosis; (B) inlay – mesh is cut to the size of the defect and sutured to the wound edge at the margins of the stomal defect; (C) sublay (retro-rectus) – mesh is placed dorsal to the rectus muscle, anterior to the posterior rectus sheath; and (D) intraperitoneal onlay – mesh is placed intraperitoneally on the peritoneum.