To the Editor:
We read with interest the article by Drs. Nathan and Pappas tracing the evolution of inguinal hernia repair from the first open tissue-based repairs, to the advent of mesh prosthetics, which ushered in tension-free repairs. Most recently, laparoscopic inguinal hernia repairs (LIHRs) have evolved, promising less postoperative pain and quicker return to work. The authors expressed some reservations over the newer laparoscopic techniques, citing their higher cost and higher recurrence rates in the early phase of the learning curve.1 We are also approaching this operation with a renewed sense of caution, but for slightly different reasons.
Recent studies have shown that LIHR complicates, if not contraindicates, subsequent radical retropubic prostatectomy because of the fibrotic obliteration of the space of Retzius.2 Moreover, since many men undergoing herniorrhaphy are younger than is usually considered for screening, there is the potential for significant numbers of men to have an LIHR prior to suspicion of prostate cancer. This may prevent their ability to undergo curative surgical therapy in the future when their cancer becomes clinically evident.3
To explore the clinical implications, we conducted a prospective study on 137 consecutive male patients presenting for LIHR at the Cleveland Clinic Foundation. Our series detected either prostate cancer or high-grade prostatatic intraepithelial neoplasia, a reputed precursor to cancer, in 4.9% of candidates for LIHR.4 In all of these cases, the prostate cancer was managed before patients underwent a hernia repair. For these reasons, we recommend prostate cancer screening in all men over the age of 30 who are being considered for LIHR. This screening should consist of a digital rectal examination and serum PSA.
Furthermore, we recently encountered a case of muscle-invasive bladder cancer in a patient who had already undergone bilateral laparoscopic hernia repair. The mesh had become integrated into detrusor muscle, requiring that the bladder be shaved away from mesh, removing a segment of the mesh in the process. As seen with a radical prostatectomy performed after LIHR, dense inflammation and fibrotic reaction had essentially obliterated the space of Retzius. The cystoprostatectomy was completed without injury to other structures; however, nerve sparing was not possible. Furthermore, as the bladder was physically attached to the mesh, the risks of incomplete tumor removal, bladder perforation, or tumor spillage were heightened. Given that transitional cell carcinoma of the bladder has been known to spread by seeding, as in the case of perforation or tumor spillage, the mesh could have seriously compromised the patient's chance for cure. Since extirpative therapy is usually required for invasive bladder cancer, the obliteration of the preperitoneal space may be more significant in this setting than it is for patients with prostate cancer. We are currently evaluating the implementation of a screening program for LIHR candidates at higher risk for bladder cancer, notably long-term smokers.
The authors have proposed that ongoing studies will be needed to be define the cost-effectiveness and long-term recurrence rates of LIHR and thereby determine its role “in the armamentarium of the inguinal hernia surgeon.” The potentially significant sequelae of LIHR on future pelvic surgery also needs to be seriously considered. Mesh for LIHR could compromise a pelvic oncologic operation and would certainly make any extirpative surgery difficult, if not impossible.
We would like to suggest the concept that for those patients at risk for developing muscle-invasive bladder cancer, a screening program be implemented prior to proceeding with an LIHR. At minimum, these patients need to be counseled that laparoscopic hernia repair can complicate any future pelvic surgery.
Michael Hsia, MD
Lee Ponsky, MD
Steven Rosenblatt, MD, FACS
J. Stephen Jones, MD, FACS
Glickman Urological Institute
Cleveland Clinic Foundation
Cleveland, OH
joness7@ccf.org
REFERENCES
- 1.Nathan J, Pappas T. Inguinal hernia: an old condition with new solutions. Ann Surg. 2003;238(suppl 6):148–157. [DOI] [PubMed] [Google Scholar]
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