Surgical Implications of Prior Inguinal Hernia Repair in Extraperitoneal Radical Prostatectomy

Abstract

Background:

Inguinal hernia repair (IHR) is a common procedure, and patients with a history of IHR may later require radical prostatectomy. Prior IHR can complicate prostatectomy by altering anatomy, but its impact on extraperitoneal laparoscopic radical prostatectomy (ELRP) remains unclear. This study evaluates the feasibility and outcomes of ELRP in patients with prior IHR.

Materials and Methods:

This retrospective cross-sectional study included male patients aged 40–80 who underwent ELRP for localized prostate cancer between 2019 and 2024. Patients were stratified into two groups based on prior IHR status (group 1: without IHR; group 2: with IHR). Comparative analyses were performed on demographic data, perioperative metrics, and oncological outcomes to assess the impact of prior IHR on ELRP. Statistical significance was accepted as P < .05.

Results:

A total of 255 patients (group 1: 220, group 2: 35) were included. No significant differences were found between the groups in terms of age and demographic characteristics. However, the operation duration was longer in group 2 (194.86 vs 176.87 minutes, P = .002), and peritoneal opening occurred more frequently (34.3% vs 9.1%, P < .001). There was no significant difference in the rates of pelvic lymph node dissection (PLND) (25.9% vs 28.5%, P = .149).

Concluison:

ELRP outcomes in patients with a history of IHR are similar to standard ELRP. However, when planning surgery for this group, the risk of peritoneal opening, prolonged operation time, and the careful execution of lymph node dissection should be considered.

INTRODUCTION

Inguinal hernia repair (IHR) constitutes one of the most prevalent surgical operations performed across the world. Although laparoscopic approaches have been increasingly adopted in recent years, open surgery is still widely practiced.^1,2

In European Union countries, prostate cancer stands as one of the most prevalent malignancies in men and ranks third in mortality among male-specific cancers. Radical prostatectomy constitutes the standard surgical treatment for localized prostate cancer. Surgical approaches to this procedure include open, laparoscopic, and robot-assisted methods. There are two different methods of laparoscopic approach: extraperitoneal laparoscopic radical prostatectomy (ELRP) and transperitoneal laparoscopic radical prostatectomy (TLRP). Although TLRP is more commonly preferred, there is evidence in the literature that ELRP offers certain advantages.^3–5

Since inguinal hernia and prostate cancer are commonly observed in patients of a similar age group, those who undergo IHR may have an increased likelihood of requiring radical prostatectomy in the future. The literature suggests that a history of IHR may complicate radical prostatectomy by hindering access to anatomical structures, increasing surgical complexity, and posing technical challenges in pelvic lymph node dissection (PLND). The scarcity of research in this area highlights the necessity for more comprehensive studies to establish conclusive evidence.^6–8

The study was designed to evaluate the suitability of ELRP following prior IHR and to expand current knowledge by analyzing associated surgical results.

MATERIALS AND METHODS

Patient Selection and Data Collection

In this retrospective cross-sectional comparative study, patients aged 40–80 years who underwent ELRP for localized prostate cancer in our clinic between 2019 and 2024 were included. Exclusion criteria encompassed patients with metastatic prostate cancer, those who had undergone radiotherapy, and patients with abdominal surgeries other than IHR. Data were obtained from physical patient records and the electronic health records of our hospital.

Study Design and Data Analysis

Patients were divided into two groups according to their history of IHR: group 1 comprised individuals who underwent ELRP without prior IHR, while group 2 included those with a history of IHR. In addition to demographic characteristics such as age and body mass index (BMI), both groups were compared in terms of pre- and postoperative prostate-specific antigen (PSA) levels, prostate volume, operative time, PLND rates, International Society of Urological Pathology (ISUP) grade, intraoperative blood loss, visual analog scale (VAS) scores, peritoneal opening status, timing of drain and catheter removal, and length of hospital stay.

Surgical Technique

In the modified Trendelenburg position, a subumbilical incision of approximately 2 cm was made to access the anterior preperitoneal space. The preperitoneal space was expanded using a balloon trocar, and the Retzius space was exposed. Two 10-mm trocars were placed on the lateral margins of the rectus abdominis muscle with the guidance of index finger and an additional 5-mm trocar was inserted two fingers medially and superiorly to both iliac crests. After this step, the endopelvic fascia and puboprostatic ligaments were incised, and the Santorini plexus was ligated to achieve hemostasis. Bladder neck dissection, seminal vesicle release, apical dissection, and prostate and vesicle transection (depending on whether the neurovascular bundles were preserved) were then performed. PLND was also performed in necessary cases (in patients with a calculated risk of lymph node metastasis above 5% according to the Briganti 2012 nomogram).⁹ The extended PLND approach involved dissection of lymph nodes located on the external iliac vessels, around the obturator nerve in the fossa (both above and below), and along the medial and lateral margins of the internal iliac artery.¹⁰ Finally, the urethrovesical anastomosis was performed utilizing a barbed suture method. This procedure represents a modified version of the classic retropubic radical prostatectomy technique.¹¹ Complications were evaluated using the Clavien-Dindo classification.¹²

Statistical Analyzes

A priori power analysis was performed using G*Power software (version 3.1.9.7) to estimate the required sample size. Assuming a moderate effect size (Cohen’s d = 0.50), a power of 80%, and a Type I error rate (α) of 0.05, the minimum required total sample size was calculated to be 120 participants. Based on an expected group allocation ratio of approximately 1:3, at least 90 patients were planned for group 1 and 30 patients for group 2. Assessment of variable normality was conducted via the Shapiro-Wilk test. Numerical variables were presented as mean ± standard deviation and range (Min-Max), while categorical variables were expressed as number (n) and percentage (%). Group comparisons were conducted through the use of the independent sample t test. The χ² test was employed to analyze the relationship between categorical variables. When the ratio of expected frequencies less than 5% exceeded 25%, the Fisher-Exact test was preferred. All statistical analyses were conducted using IBM SPSS Statistics version 22 (SPSS Inc., Chicago, IL), with a P-value of less than .05 regarded as statistically significant.

RESULTS

Comparison of Demographic Data of the Groups

A total of 255 patients were included in the study (group 1: 220, group 2: 35). Group 1 consisted of ELRP patients with no history of IHR, while group 2 consisted of ELRP patients with a history of IHR. In group 2, 14 (23.7%) IHRs were performed via open surgery, 21 (35.6%) using the laparoscopic method, 11 (18.6%) on the right side, 17 (28.8%) on the left side, and 7 (11.9%) as bilateral IHRs. No statistically significant differences were observed between the groups regarding age, BMI, preoperative PSA, postoperative 3-month PSA, VAS scores, intraoperative blood loss, drain duration, catheter removal time, or hospital stay. Nonetheless, the operative time was significantly longer in group 2 (P = .002; Table 1).

Table 1.

Demographic and Follow-up Data of the Groups

	Overall (N = 255) (Mean ± SD)	Group 1(N = 220) (Mean ± SD)	Group 2(N = 35) (Mean ± SD)	P-Value
Age (years)	65.18 ± 6.51 (45–80)	65.32 ± 6.11 (45–78)	67.14 ± 5.71 (55–80)	.134
BMI2 (kg/m²)	25.32 ± 3.02 (18–34)	25.36 ± 2.99 (19–34)	25.11 ± 3.22 (18–31)	.661
Prostate volume (mL)	52.40 ± 24.09 (18–220)	52.57 ± 25.09 (18–220)	51.35 ± 16.47 (25–85)	.785
Preoperative T PSA (ng/mL)	10.22 ± 7.51 (2.12–68)	11.07 ± 4.28 (2.12–33.3)	13.19 ± 10.44 (4.72–68)	.078
Operative time (minutes)	179.35 ± 32.33 (50–260)	176.87 ± 32.05 (50–250)	194.86 ± 30.4 (140–260)	.002
Postoperative 3-month PSA	0.12 ± 0.02 (0.00–1.69)	0.11 ± 0.39 (0.00–1.69)	0.09 ± 0.41 (0.01–0.81)	.067
Blood loss (mL)	178.90 ± 101.8 (50–600)	175.14 ± 98.17 (50–500)	159.86 ± 102.6 (50–600)	.054
Drain duration (days)	4.37 ± 0.93 (2–6)	4.38 ± 0.94 (2–6)	4.29 ± 0.86 (3–6)	.581
Hospital stay (days)	6.67 ± 1.71 (4–10)	6.62 ± 1.69 (4–10)	6.94 ± 1.80 (4–10)	.302
Catheter duration (days)	11.22 ± 2.27 (7–14)	11.17 ± 2.31 (7–14)	11.69 ± 1.98 (7–14)	.217
VAS	5.91 ± 1.23 (0–8)	5.94 ± 1.22 (0–8)	5.74 ± 1.31 (3–8)	.311

Group 1: ELRP in patients without a history of IHR; group 2: ELRP in patients with a history of IHR; SD, standard deviation; BMI, body mass index; PSA, prostate-specific antigen; VAS, visual analog scale.

Comparison of Perioperative and Pathologic Characteristics of the Groups

Both groups predominantly exhibited ISUP stage 1 as the most frequent cancer type. The groups did not differ significantly with respect to the performance of PLND or the distribution of ISUP classifications. PLND was performed in all patients with a Briganti score greater than 5%, with success defined by the number of lymph nodes removed on each side (a minimum of five lymph nodes was considered successful).¹⁰ However, peritoneal opening occurred more frequently in group 2 (34.3% vs 9.1%; P < .001; Table 2). In order to better assess the potential influence of hernia repair technique on surgical outcomes, patients with a history of IHR were further categorized based on the surgical approach as either laparoscopic or open. In the laparoscopic subgroup (n = 21), peritoneal opening was documented in 8 patients (38.1%), whereas this finding was present in 4 patients (28.6%) in the open repair group (n = 14). The mean operative time was slightly longer in the laparoscopic repair subgroup at 197.4 ± 30.1 minutes (140–260) compared to 189.2 ± 30.8 minutes (150–240) in the open repair group. Given the relatively small sample size within each subgroup, these findings were reported descriptively without formal statistical comparison. There were no instances in which laparoscopic surgery had to be converted to an open approach during radical prostatectomy. The most common complication observed was postoperative fever (Clavien I).

Table 2.

Perioperative and Pathological Characteristics of the Groups

	Total (N = 255) (%)	Group 1 (N = 220) (%)	Group 2 (N = 35) (%)	P-Value
Peritoneum opened
No	223 (87.5%)	200 (90.9%)	23 (65.7%)	<.001
Yes	32 (12.5%)	20 (9.1%)	12 (34.3%)
Lymph node dissection
No	72 (28.2%)	57 (25.9%)	10 (28.5%)	.149
Yes	183 (71.8%)	163 (74.1%)	25 (71.4%)
ISUP grade
Grade 1	106 (41.9%)	91 (41.7%)	15 (42.9%)
Grade 2	77 (30.4%)	65 (29.8%)	12 (34.3%)
Grade 3	31 (12.3%)	27 (12.4%)	4 (11.4%)	.508
Grade 4	22 (8.7%)	18 (8.3%)	4 (11.4%)
Grade 5	17 (6.7%)	17 (7.8%)	0 (0.0%)

Group 1: ELRP in patients without a history of IHR; group 2: ELRP in patients with a history of IHR; ISUP, International Society of Urological Pathology.

DISCUSSION

Prostate cancer and inguinal hernia are both conditions commonly diagnosed in older male adults. The coexistence of these diseases may occasionally necessitate the performance of ELRP in patients with a history of IHR and vice versa. In conclusion, the frequency of ELRP in patients with a background of IHR is likely to increase in the coming period. While most existing studies focus on the development of inguinal hernias following radical prostatectomy or on the feasibility of simultaneous surgical repair, our study addresses a clinically relevant yet underrepresented scenario by evaluating ELRP in patients with a prior history of IHR. Herein, by providing practical insights into the feasibility and technical considerations of the extraperitoneal approach in this context, we would like to contribute data that may aid surgical planning and guide informed decision-making in this specific patient population.

In our clinic, particularly over the past five years, ELRP is currently regarded as a primary surgical option for the management of localized prostate cancer. The primary reason for this preference is the absence of contact with the intestines, which results in a lower incidence of related complications. The purpose of this study was to assess the feasibility of ELRP in patients with a prior history of IHR in comparison to those without such history. We found no significant differences in the performance of the surgical procedures or in the time taken to execute them. Additionally, no differences were observed in terms of oncologic and functional outcomes. The main differences identified were in operative time and peritoneal opening rates.

Different results regarding operation time have been reported in the literature. While some studies found no difference in operation times, Al-Shareef et al reported a prolonged operation time in patients with a history of IHR who underwent ELRP.^13–16 Our findings indicated that the duration of surgery was notably longer in group 2 (194 vs 176 minutes, P = .002). Although the 18-minute increase in operative time may not be clinically significant per se, it likely reflects increased surgical complexity in patients with prior IHR. This time difference may be attributed to technical difficulties during trocar placement, development of the Retzius space, and initial dissection steps. Therefore, it may serve as an indirect indicator of operative difficulty, which can be relevant for preoperative planning and patient counseling.

One of the key advantages of ELRP is the absence of direct contact with the intestines. However, the literature reports that in some patients with a history of IHR, the opening of the peritoneum, which frequently occurs during the creation of the extraperitoneal space, may reduce the effectiveness of this advantage. Furthermore, studies have documented that the rate of peritoneal opening in ELRP procedures involving patients with prior IHR ranges from 30% to 50%.^17–18 The rate of peritoneal opening was notably greater in group 2 than in group 1, according to our findings. (34.3% vs 9.1%; P < .001). Although this did not affect the progression of surgery, it led to a delayed transition to normal feeding in the postoperative period and caused ileus in three patients, which was managed with conservative methods.

In our study, no significant difference was observed between the groups in pain assessment using the VAS on the first postoperative day (5.94 ± 1.22 vs 5.74 ± 1.31; P = .311). A study in the literature evaluated postoperative pain between patients with and without a history of IHR, and similar to our results, the groups did not differ significantly.¹⁵

A review of the literature reveals that one of the most debated topics is the successful applicability of PLND. In our study, for patients with a Briganti score greater than 5%, PLND was conducted, with success determined according to the number of lymph nodes dissected on each side. (with five or more lymph nodes considered successful). The rates of PLND implementation did not differ significantly between the two groups. (74.1% vs 71.4%; P = .149). Several studies have extensively evaluated and compared open surgery, TLRP, and ELRP procedures. Spernat et al reported that PLND would not be feasible in more than 50% of patients with a history of IHR, and other studies have emphasized that PLND is particularly challenging on the side with a history of IHR, making it prone to complications.^6–8,16,19 However, evidence from our study and the existing literature demonstrates that PLND rates do not significantly differ between the groups. We believe that with more careful execution of PLND, laparoscopic and robotic surgical techniques play a crucial role in minimizing this difference. In some studies, ELRP and TLRP were compared with respect to PLND, and no notable intergroup differences were observed, despite TLRP providing a wider field of view and dissection area.^{11,14,15,17,18}

Substratification of the IHR cohort revealed that patients with a history of laparoscopic IHR exhibited a higher rate of peritoneal opening and slightly longer operative times compared to those who had undergone open IHR. Although statistical comparison was not feasible due to the limited sample size, these findings suggest that alterations in surgical planes following laparoscopic IHR may contribute more significantly to technical challenges during ELRP than those following open IHR. These preliminary observations underscore the clinical importance of considering the type of prior hernia repair when planning an extraperitoneal radical prostatectomy.

ELRP performed in patients with a history of IHR is a procedure that requires more attention and surgical experience compared to standard ELRP procedures due to anatomical changes and fibrosis. In 2020, a survey conducted among urological surgeons aimed to evaluate experiences regarding the safety and feasibility of radical prostatectomy following IHR. According to the results of the survey, urological surgeons reported encountering radical prostatectomy in 10–30% of patients who had undergone IHR, and 49% considered this procedure more difficult. The main reasons for these difficulties were longer operative times (88.4%), challenging dissection of the Retzius space (88.4%), bladder perforation (16.3%), peritoneal opening (27.9%), and inadequate PLND (69.8%). These findings largely overlap with the significant comparisons found in our study.²⁰ In our study, no patients with a history of IHR developed bladder perforation. However, in some cases, the tissues surrounding the bladder were mobilized when necessary to ensure optimal anastomosis. Furthermore, anastomotic failure was not observed in any patient.

The frequency of the association between inguinal hernia and prostate cancer, along with the challenges associated with radical prostatectomy after IHR, has brought the issue of simultaneous repair of these two conditions to the forefront. Studies conducted in this context have emphasized that concomitant IHR can be feasibly performed during laparoscopic or robotic radical prostatectomy in patients with a history of inguinal hernia.^21–23 However, no patients in our study underwent simultaneous surgical intervention.

There are certain constraints inherent to our study. First, the relatively small number of patients in group 2 may affect the reliability of the statistical analysis. Second, as our study is retrospective in design, it provides a lower level of evidence compared to prospective randomized studies. Prospective randomized studies with a larger patient population will contribute to obtaining more reliable and precise results. Third, due to the institutional preference for the extraperitoneal approach in recent years, a direct comparison with the intraperitoneal approach could not be performed.

CONCLUSION

The results of this study show that previous IHR does not greatly impact the cancer-related or functional outcomes of ELRP compared to regular cases. However, when planning surgery for this patient group, the risk of peritoneal opening, prolonged operative time, and the feasibility of lymph node dissection should be carefully evaluated, with the procedures being carried out with increased attention and precision.