Totally extraperitoneal laparoscopic inguinal hernia repair post-radical prostatectomy

Abstract

Background: Previous radical prostatectomy (RP) is considered a relative contraindication to the laparoscopic approach for inguinal hernia repair (LIHR). This study aimed to compare feasibility, safety and outcomes for patients undergoing totally extraperitoneal (TEP) LIHR who have previously undergone RP.

Methods: This single surgeon, case-control study was performed using a prospective database of all patients undergoing TEP LIHR between 1995 and 2020. Patients who underwent previous RP were identified and compared to matched controls. Pre-operative, operative and post-operative data were analysed. The type of RP, open, laparoscopic or robotic, was identified and operative outcomes compared between the three groups.

Results: 6532 LIHR cases were identified. 165 had previously undergone RP and 6367 had undergone primary LIHR without prior RP. The groups were matched for age, demographics and co-morbidities. All operations were commenced laparoscopically, three converted to open in the LIHR + RP group and none in the LIHR group. Median operative time in patients with previous RP was longer, for unilateral (40 min vs. 21 min, p < 0.0001) and bilateral (71 vs. 30 min, p < 0.0001) LIHR. The majority of cases were performed as day stay procedures. There was no difference in immediate recovery parameters including time to discharge, complication rates, return to normal function, return to driving or post-operative analgesia. At 3 months of follow-up there was no difference in hernia recurrence for unilateral (2/128 vs 6/2234, p = 0.0658) or bilateral (0/24 vs 3/1490, p ≥ 0.999) LIHR, nor chronic pain as measured by patient awareness or restriction of activity. No differences in operative and post-operative outcomes were identified between the three types of RP, other than difference in operative time (p = 0.0336).

Conclusions: Previous RP should not be an absolute contraindication for TEP LIHR. Although previous RP adds complexity, in experienced hands TEP LIHR can be done safely, with outcomes equivalent to patients who have not previously undergone RP.

Keywords: Laparoscopic hernia repair; Laparoscopic inguinal hernia repair; Radical prostatectomy; Totally extraperitoneal trans-abdominal preperitoneal.

Fig. 1

Consort diagram of patients undergoing TEP LIHR

Fig. 2

Radical prostatectomy operation type: trends over time. A line graph of which prostatectomy technique was utilised, open, robotic or laparoscopic, in the operations included in the TEP LIHR + RP group. The year recorded is of hernia repair, not the year the radical prostatectomy, as date of original operation was not always available, resulting in trend lines being shifted out of phase

Fig. 3

Hernia characteristics. It is a pie graph demonstrating the hernia characteristic in the groups, simple laparoscopic inguinal hernia repair operations compared to laparoscopic inguinal hernia repair operations in the context of prior radical prostatectomy. This is further stratified by bilateral and unilateral herniations to allow for accurate comparative analysis. Inguinal hernia characteristics were recorded by the surgeon as indirect or direct