Abstract
Background
Radical prostatectomy (RP) is associated with an increased risk of subsequent inguinal hernia (IH). Because prior pelvic surgery may disrupt the preperitoneal plane and cause adhesions, hernia repair in this setting can be technically challenging. However, the clinical outcomes of open partial preperitoneal tension-free repair for IH after RP have not been well described in consecutive case series.
Objective
To evaluate the clinical outcomes of open partial preperitoneal tension-free repair for inguinal hernia after radical prostatectomy.
Method
We retrospectively reviewed 64 consecutive patients with IH after RP who underwent open partial preperitoneal tension-free repair at our institution between January 2013 and January 2024. Data collected included demographic and hernia characteristics, operative time, drain placement, postoperative length of stay, postoperative complications, chronic groin discomfort, and recurrence during follow-up.
Results
The mean operative time was 67.6 ± 28.5 min. Nine patients (14.1%) underwent selective drain placement, with a mean drain duration of 3.44 ± 0.88 days. The median postoperative hospital stay was 4 days (IQR, 4–7 days). One patient (1.6%) developed postoperative hematoma/seroma, and two patients (3.1%) reported chronic postoperative groin discomfort or foreign body sensation during follow-up. No surgical site infection was observed. The mean follow-up duration was 34.7 ± 22.2 months. One patient reported a suspected recurrence during telephone follow-up, but this was not clinically confirmed because the patient declined further evaluation.
Conclusion
Open partial preperitoneal tension-free repair may be a feasible option for selected patients with inguinal hernia after RP when performed by surgeons familiar with this technique. In this retrospective surgeon-specific, center-related series, the procedure was associated with acceptable perioperative outcomes and a low rate of unconfirmed recurrence, although the findings should be interpreted cautiously given the study design, limited sample size, and limited generalizability.
Trial registration
This retrospective study was approved by the Institutional Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 098RS), which waived the requirement for informed consent because of the retrospective design and the use of anonymized data. The study was registered on Medicalresearch.org (Registration No. ChiCTR2500101225).
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12893-026-04036-2.
Keywords: Open partial preperitoneal tension-free hernia repair, Lichtenstein, Radical prostatectomy, Inguinal hernia, Prostate, Hernia
Introduction
Prostate cancer is one of the most prevalent cancers among men, with Radical Prostatectomy (RP) being the preferred treatment for localized cases [1]. RP can be performed via open surgery, laparoscopic surgery, or robotic-assisted surgery. The procedure usually involves removal of the prostate and seminal vesicles through the preperitoneal space and sometimes removal of the surrounding lymph nodes. The risk of Inguinal Hernia (IH) is increased after RP surgery, with approximately 12–25% of patients developing an IH after RP [2, 3]. In cases of IH after RP, the preperitoneal space has already been disturbed by the prior surgery, and adhesions have developed, increasing the difficulty of subsequent hernia repair. Therefore, performing a laparoscopic tension-free IH repair after prostate surgery is considered difficult and risky. Preperitoneal repair is reported to have a lower recurrence rate than the Lichtenstein repair, but it is technically more challenging to perform. In our institution, selected patients with inguinal hernia after RP have been treated using open partial preperitoneal tension-free repair performed by surgeons familiar with this technique. Therefore, we retrospectively reviewed the clinical outcomes of this approach in post-RP patients over an 11-year period.
Materials and methods
Study design
This was a retrospective single-center study conducted at the Department of Hernia and Abdominal Wall Surgery, the First Affiliated Hospital of Ningbo University. The study was approved by the Institutional Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 098RS), which waived the requirement for informed consent because of the retrospective design and the use of anonymized patient data. The study protocol was registered under ChiCTR2500101225.
During the inclusion period from January 2013 to January 2024, a total of 1053 patients who underwent inguinal hernia repair performed or managed by the two dedicated surgeons were retrospectively screened. This screening cohort mainly represented inguinal hernia repairs performed or managed by these two surgeons during the study period and should not be interpreted as the total number of inguinal hernia repairs performed by all surgeons in our department or in the entire hospital.
After exclusion of 128 female patients, 925 male patients were assessed. Among them, 836 had no history of radical prostatectomy and were excluded. Because the present study was designed to evaluate inguinal hernia after radical prostatectomy, detailed procedure-level data for these excluded female patients and male patients without previous radical prostatectomy were not systematically extracted in the original study database. Based on the available operative records and surgical practice during the study period, these excluded patients were mainly treated using standard inguinal hernia repair methods, including Lichtenstein repair, laparo-endoscopic posterior repair such as TEP or TAPP, and open preperitoneal repair.
The remaining 89 male patients had inguinal hernia after radical prostatectomy. Of these, 64 underwent open partial preperitoneal tension-free repair and were included in the present study, whereas the remaining 25 underwent other repair methods, including Lichtenstein repair in 13 patients and TEP in 12 patients. No other repair methods were used in this post-RP subgroup. Because these subgroups were small and treatment allocation was based on clinical judgment rather than randomization, no comparative analysis was performed.
All 64 procedures included in the present study were performed by two dedicated hernia surgeons. One surgeon performed 26 procedures and the other performed 38 procedures.
Patients
Patients were eligible if they met all of the following criteria: (1) underwent IH repair surgery in the Department of Hernia and Abdominal Wall Surgery of the First Affiliated Hospital of Ningbo University from January 2013 to January 2024; (2) were over 18 years old; and (3) had a history of RP.
Patients were excluded if they: (1) were under 18 years of age; (2) had an IH before undergoing RP; and (3) did not have a history of RP.
The patient selection process is shown in Fig. 1.
Fig. 1.
Study flow diagram
Materials
Bilayer mesh systems from Johnson & Johnson, including UHSOV1, UHSOV, and UPPL6, were used according to availability during the study period. Their use reflected institutional practice and surgeon preference in selected post-RP cases.
Methods
Surgical methods
After induction of anesthesia, patients were placed in the supine position. Among the 64 patients, 18 underwent general anesthesia and 46 underwent neuraxial anesthesia.
A 7 cm transverse skin incision is made in the inguinal region. For a left-sided hernia, the incision is centered approximately 2 cm above the midpoint of the line between the left anterior superior iliac spine (ASIS) and the pubic tubercle, extending medially to the pubic tubercle. (For a right-sided hernia, the incision is made analogously on the right side.). The skin and subcutaneous tissue are incised, and the wound edges are protected with retractors. The external oblique aponeurosis is then opened, exposing the superficial (external) inguinal ring on the affected side, while carefully protecting the iliohypogastric and ilioinguinal nerves. Next, the upper and lower flaps of the incised external oblique aponeurosis are bluntly separated (lifted) to expose the underlying structures—extending the dissection superiorly to the conjoint tendon and inferiorly to the inguinal ligament. The spermatic cord is identified and mobilized, and the hernia sac is isolated. The size of the hernia sac and the diameter of its neck are then estimated. The dissection is carried into the preperitoneal space lateral to the inferior epigastric vessels, while only minimal medial dissection is done due to adhesions from the previous prostate surgery (Fig. 2B). After the lateral aspect of the preperitoneal space is adequately exposed (Fig. 2A), the hernia sac neck is ligated and excised to ensure complete hemostasis. Next, a Johnson & Johnson UHSOV1 mesh patch is placed preperitoneally (anterior to the peritoneum). The lower piece of the mesh is trimmed as needed (Fig. 2C) and laid flat in the preperitoneal space. The tissue near the internal (deep) inguinal ring is sutured to the mesh’s cylindrical extension (the ‘patch column’) using a 2–0 absorbable suture or 3–0 Prolene (Fig. 2D). The upper piece of the mesh is trimmed to accommodate the spermatic cord and is placed deep to (behind) the cord. The mesh is then sutured continuously with 3–0 Prolene to the inguinal ligament, conjoint tendon, and arcuate line, reinforcing the posterior wall of the inguinal canal (Fig. 2E, F). One of these sutures is placed through the mesh and the abdominal wall (above the pubic tubercle) to further secure the patch in position. During surgery, hemostasis is achieved, the aponeurosis of the external oblique muscle is sutured, and the external ring is reconstructed. After verifying the correct count of instruments and gauze, the incision is closed layer by layer.
Fig. 2.
Open partial preperitoneal tension-free hernia repair surgical anatomical diagram. Preperitoneal space dissection—lateral (A). Preperitoneal space dissection—medial (B). After trimming the Johnson UPPL6 mesh (C). Mesh cylindrical body fixation (D). After placing the mesh (E, F)
When a Johnson & Johnson UPPL6″straw hat” mesh was used, the lower circular component was trimmed and placed preperitoneally, whereas the upper component was removed and a separate flat mesh was used for anterior reinforcement.
A surgical drain was not routinely placed. No drain was used in 55 patients, whereas 9 patients underwent postoperative drain placement according to the surgeon’s intraoperative judgment, particularly in cases with relatively extensive dissection, larger dead space, or concern about postoperative fluid collection.
Data collection
Data collected included age, body mass index (BMI), hypertension, diabetes, smoking history, hernia type, hernia laterality, operative time, drain placement, drain duration, postoperative length of stay, postoperative complications, chronic groin discomfort, and recurrence during follow-up.
Postoperative pain and groin discomfort were assessed from routine follow-up records and patient-reported symptoms during outpatient visits and structured telephone interviews (Supplementary Table 1); In patients who reported chronic postoperative pain or discomfort and returned for reassessment, pain severity was further evaluated using the Numeric Rating Scale (NRS) and the Visual Analogue Scale (VAS). No hernia-specific assessment instrument was available in our clinical setting during the study period. Chronic postoperative discomfort was defined as persistent pain, discomfort, or foreign body sensation lasting for more than 3 months after surgery.
Postoperative follow-up data were obtained from outpatient visits and telephone interviews. Recurrence was assessed on the basis of patient-reported symptoms, physical examination findings when patients returned for evaluation, and imaging when clinically indicated. Patients with symptoms suggestive of recurrence were advised to return for further clinical assessment.
Statistical analysis
In all analyses, a significance level of 5% (two-tailed test) was used. To assess the normality of the data, the Kolmogorov–Smirnov test was applied. For quantitative variables, data were presented as mean and standard deviation (SD) if they followed a normal distribution; otherwise, they were presented as median and interquartile range (25th-75th percentiles). Categorical variables were expressed as frequencies and percentages. Data analysis was performed using SPSS Statistics version 29.
Results
During the study period, 1053 patients who underwent inguinal hernia repair performed or managed by the two dedicated surgeons were retrospectively screened. After exclusion of 128 female patients and 836 male patients without a history of radical prostatectomy, 89 male patients with inguinal hernia after radical prostatectomy were identified. Of these, 64 underwent open partial preperitoneal tension-free repair and were included in the present analysis, whereas the remaining 25 underwent other repair methods, including Lichtenstein repair in 13 patients and TEP in 12 patients. No other repair methods were used in this post-RP subgroup. Because of the small sample size and the retrospective, non-randomized nature of these subgroups, no comparative analysis was performed. The baseline characteristics of the 64 included patients are shown in Table 1.
Table 1.
Baseline characteristics of the patients (n = 64)
| Variable | Value |
|---|---|
| Age (years, mean ± SD) | 73.45 ± 6.11 |
| BMI (kg/m2, mean ± SD) | 23.16 ± 2.91 |
| Hypertension, n (%) | 38 (59.38) |
| Diabetes mellitus, n (%) | 8 (12.50) |
| Smoking history, n (%) | 13 (20.31) |
| Other comorbidities, n (%) | 22 (34.38) |
| Hernia type, n (%) | |
| Indirect hernia | 52 (81.25) |
| Direct hernia | 6 (9.38) |
| Pantaloon hernia | 6 (9.38) |
| Hernia laterality, n (%) | |
| Right-sided | 29 (45.31) |
| Left-sided | 19 (29.69) |
| Bilateral | 16 (25.00) |
Abbreviation: BMI Body mass index
The mean age of the 64 patients was 73.45 ± 6.11 years, and the mean body mass index (BMI) was 23.16 ± 2.91 kg/m2. Comorbidities were common, including hypertension in 38 patients (59.38%), diabetes mellitus in 8 (12.50%), a smoking history in 13 (20.31%), and other underlying diseases in 22 (34.38%). Regarding hernia type, indirect inguinal hernia was the most common, occurring in 52 patients (81.25%), while 6 patients (9.38%) had direct inguinal hernia and 6 (9.38%) had pantaloon hernia. With respect to laterality, 29 patients (45.31%) had right-sided hernia, 19 (29.69%) had left-sided hernia, and 16 (25.00%) had bilateral hernias.
The perioperative clinical outcomes are summarized in Table 2. All 64 patients successfully underwent open partial preperitoneal tension-free hernia repair without conversion to another surgical procedure. Among them, 18 patients underwent general anesthesia and 46 underwent neuraxial anesthesia. The operative time ranged from 35 to 165 min, with a mean operative time of 67.57 ± 28.55 min.
Table 2.
Perioperative clinical outcomes of the patients (n = 64)
| Variable | Value |
|---|---|
| General anesthesia, n (%) | 18 (28.13) |
| Neuraxial anesthesia, n (%) | 46 (71.88) |
| Operative time (min, mean ± SD) | 67.57 ± 28.55 |
| Operative time range (min) | 35–165 |
| No drain placement, n (%) | 55 (85.94) |
| Selective drain placement, n (%) | 9 (14.06) |
| Drain duration (days, mean ± SD) | 3.44 ± 0.88 |
| Postoperative hospital stay (days, median [IQR]) | 4 (4–7) |
| Incisional hematoma/seroma, n (%) | 1 (1.56) |
| Surgical site infection, n (%) | 0 (0.00) |
| Chronic groin pain with foreign body sensation, n (%) | 2 (3.13) |
| Conversion to another procedure, n (%) | 0 (0.00) |
A surgical drain was not routinely placed. Postoperative drainage was used in 9 patients (14.06%), whereas 55 patients (85.94%) did not require drainage. The drains were removed 3 to 5 days after surgery, with a mean drainage duration of 3.44 ± 0.88 days. The median postoperative hospital stay was 4 days (IQR, 4–7 days).
Overall, perioperative complications were infrequent. Only one patient (1.56%) developed postoperative incisional hematoma and seroma. Ecchymosis, localized swelling, and bulging at the operative site were observed during postoperative ward rounds, and the diagnosis of hematoma was subsequently confirmed by computed tomography and ultrasonography. Ultrasound-guided puncture and catheter drainage were performed, and the patient subsequently improved. In addition, 2 patients (3.13%) reported chronic groin pain accompanied by foreign body sensation during follow-up. Both patients returned to the outpatient clinic for reassessment, and pain severity was graded as mild using the NRS and the VAS. One patient had more noticeable foreign body sensation, and the symptoms improved after 6 months of follow-up. No surgical site infection was observed in this series and no patient required conversion to another surgical procedure.
All 64 patients completed follow-up through outpatient visits and telephone interviews. The mean follow-up duration was 34.70 ± 22.20 months, and the follow-up outcomes are shown in Table 3. During follow-up, 1 patient (1.56%) reported a possible reappearance of local bulging in the operative area during a telephone interview, raising suspicion of hernia recurrence. However, this patient refused to return for further evaluation, and therefore recurrence could not be definitively confirmed by physical examination or imaging.
Table 3.
Follow-up outcomes of the patients (n = 64)
| Variable | Value |
|---|---|
| Follow-up duration (months, mean ± SD) | 34.7 ± 22.2 |
| Completed follow-up, n (%) | 64 (100.00) |
| Follow-up modality | Outpatient visits and telephone interviews |
| Suspected recurrence, n (%) | 1 (1.56) |
| Clinically confirmed recurrence, n (%) | 0 (0.00) |
Accordingly, if this case is classified as a suspected recurrence, the overall suspected recurrence rate was 1.56%. If only clinically or radiologically confirmed recurrences are counted, no definite recurrence was observed in this cohort, corresponding to a confirmed recurrence rate of 0%.
Discussion
Prostate cancer accounts for approximately 7% of new cancer cases in men worldwide, with over 1.2 million new diagnoses and 350,000 related deaths each year, and its incidence continues to rise with an aging population [4]. IH is a well-recognized long-term complication following RP, with reported incidence rates ranging from 12 to 25% [2, 3]. In this retrospective single-center series, open partial preperitoneal tension-free repair was associated with acceptable perioperative outcomes, a low rate of postoperative complications, and no clinically confirmed recurrence during follow-up. However, these findings should be interpreted as descriptive outcomes from a center-specific experience rather than as proof of superiority over other repair strategies.
For primary inguinal hernia, international guidelines recommend mesh-based repair using either an anterior open approach or a laparo-endoscopic posterior approach, with Lichtenstein and laparo-endoscopic techniques being the most extensively evaluated options [5]. In patients with inguinal hernia after radical prostatectomy (RP), however, scarring and adhesions in the preperitoneal space may increase the technical difficulty of subsequent repair [6]. Accordingly, Lichtenstein repair remains a widely accepted anterior approach in this setting because it avoids extensive re-entry into the scarred preperitoneal plane, and current guidelines suggest considering an anterior approach in patients with pelvic scarring or previous pelvic surgery [6]. By contrast, minimally invasive posterior approaches, including TAPP and r-TAPP, offer a broad operative view and direct access to the myopectineal orifice, which may be advantageous in experienced hands, but they can be technically demanding after RP because of fibrosis and altered anatomy in the preperitoneal space [7]. In our institution, the present approach was adopted as part of our historical surgical practice in selected post-RP patients and therefore reflects local expertise and accumulated experience rather than a recommendation that it should replace standard anterior or minimally invasive posterior repair in all cases. From the perspective of contemporary hernia repair concepts, preperitoneal mesh placement may provide more direct reinforcement of the myopectineal orifice and may potentially reduce recurrence; however, in the specific setting of post-RP inguinal hernia, this should still be interpreted cautiously and in light of surgeon experience and patient selection.
The use of a bilayer mesh in this series also requires cautious interpretation. From the perspective of contemporary hernia repair theory, placement of mesh in the preperitoneal space may provide stronger support to the myopectineal orifice and may potentially reduce the risk of recurrence. In our hernia center, we have accumulated considerable experience with open preperitoneal repair over many years, and the technique is well established in our practice. We also recognize that current guidelines support Lichtenstein repair as an appropriate option for inguinal hernia after radical prostatectomy. In the present series, however, based on our institutional experience and with the intention of achieving durable reinforcement in this anatomically challenging subgroup, we attempted open partial preperitoneal repair in selected post-RP patients. At the same time, we acknowledge that combined anterior and limited posterior reinforcement is not universally accepted as a standard approach for routine inguinal hernia repair, and that management of any future recurrence after such repair may be more complex. Therefore, we do not propose this technique as a preferred alternative to TAPP, r-TAPP, or Lichtenstein repair, but rather as a center-specific option that may be considered in carefully selected patients by experienced surgeons.
With regard to perioperative outcomes, all 64 patients in this series successfully underwent the planned operation without conversion to another procedure. The mean operative time was 67.57 min, suggesting that the procedure was technically feasible in this selected population. Among the 64 patients, 18 underwent general anesthesia and 46 underwent neuraxial anesthesia, reflecting the individualized perioperative management used in this cohort. Selective drain placement was used in 14.06% of patients, mainly in cases with relatively extensive dissection, larger dead space, or concern about postoperative fluid collection, with the intention of reducing the risk of seroma, hematoma, and related wound complications. The median postoperative length of stay was 4 days. This should be interpreted not only in light of the relatively advanced age and comorbidity burden of our cohort, but also in the context of local perioperative care pathways. In China, home-based postoperative wound care and community medical support are not always sufficiently developed, and some patients prefer a somewhat longer hospital stay to ensure more adequate wound care and observation. Prolonged in-hospital monitoring may also facilitate earlier detection and management of wound-related complications. In our cohort, this practice did not appear to result in an excessive increase in treatment costs.
In terms of postoperative chronic pain and foreign body sensation, although reported rates of chronic inguinal pain after hernia repair vary widely in the literature, Lichtenstein repairs have reported chronic pain rates as high as 21.5% in some studies [8–10]. Iftikhar et al. further found that chronic post-herniorrhaphy groin pain primarily affects physical function, which in turn negatively impacts mental and social well-being [11]. In our study, two patients reported chronic postoperative groin pain accompanied by foreign body sensation during follow-up. Both returned for outpatient reassessment, and pain severity was graded as mild using the Numeric Rating Scale and the Visual Analogue Scale. One patient described a more noticeable foreign body sensation; however, because the pain remained mild and there was no substantial impact on daily functioning, continued clinical observation rather than specific intervention was considered appropriate, and the symptoms subsequently improved during follow-up. Nevertheless, these findings should be interpreted cautiously. No hernia-specific assessment instrument was available in our clinical setting during the study period, and pain-related outcomes were therefore evaluated using general pain scales and routine clinical follow-up rather than disease-specific tools. Accordingly, our data do not allow strong conclusions regarding chronic postoperative inguinal pain or quality of life.
Postoperative hematoma and seroma formation are among the most common complications following IH repair [12]. Factors such as the method of mesh fixation, larger hernia size, and direct (medial) hernias have been identified as independent risk factors for developing hematomas or seromas [13]. Some authors have suggested that using minimally invasive techniques (laparoscopic/endoscopic repair) can reduce postoperative seroma or hematoma rates [14]. However, other studies report no significant difference in the incidence of these complications between open and laparoscopic hernia repair [15–18]. Postoperative wound-related complications were uncommon in our series. Only one patient (1.56%) developed postoperative incisional hematoma and seroma. Ecchymosis, localized swelling, and bulging at the operative site were observed during postoperative ward rounds, and the diagnosis of hematoma was subsequently confirmed by computed tomography and ultrasonography. Ultrasound-guided puncture and catheter drainage were then performed, after which the patient’s condition improved. On review of this case, the patient had a BMI of 26.1 kg/m2 and a history of hypertension, which may have contributed to postoperative fluid accumulation. We also noted that no drain had been placed intraoperatively in this patient, raising the possibility that selective prophylactic drainage might have reduced the risk of this complication.
Age > 50 years, history of smoking, and BMI > 30 kg/m2 are independent risk factors for hernia recurrence [19, 20]. Our single patient with a suspected recurrence was an older gentleman (nearly 80 years old) who, by his own report during a follow-up call, did not adhere to postoperative instructions — he resumed physical labor and missed scheduled follow-up visits. These factors likely contributed to his suspected recurrence. However, as the patient refused further examinations, this situation could not be confirmed in clinical practice. Therefore, although the recurrence signals observed in our series of studies were relatively low, the actual recurrence rate might still be underestimated, especially for asymptomatic cases.
During the same study period, 25 additional patients with inguinal hernia after radical prostatectomy underwent other repair methods, including Lichtenstein repair and TEP. However, these subgroups were relatively small, and treatment allocation was based on clinical judgment rather than randomization. Therefore, meaningful comparative analysis between surgical approaches was not feasible in the present retrospective study. This should be acknowledged when interpreting our findings, as the study was designed as a case series of patients treated with open partial preperitoneal tension-free repair rather than as a comparative evaluation of different techniques.
This study has several limitations. First, this was a retrospective single-center study with a relatively small sample size, and selection bias could not be fully avoided. Second, although other repair methods were used in some post-RP patients during the same period, the number of these patients was small and treatment allocation was based on clinical judgment rather than randomization; therefore, no comparative analysis between surgical approaches was performed. Third, because the original database focused on post-RP inguinal hernia cases, detailed procedure-level information for patients excluded from the analytic cohort was not systematically extracted. Finally, recurrence and chronic discomfort were assessed mainly through routine outpatient visits and telephone follow-up rather than a fully standardized follow-up protocol. Therefore, the present findings should be interpreted as a surgeon-specific, center-related retrospective experience, and further multicenter comparative studies are needed to confirm the role of this technique.
In conclusion, open partial preperitoneal tension-free repair may be a feasible option for selected patients with inguinal hernia after radical prostatectomy when performed by surgeons familiar with this technique. However, given the retrospective design, limited sample size, absence of a comparative group, and surgeon-specific, center-related nature of the present experience, the findings should be interpreted cautiously. Further multicenter and comparative studies are needed before broader conclusions can be drawn regarding the role of this technique relative to Lichtenstein repair, TEP, TAPP, or robotic-assisted posterior repair.
Supplementary Information
Acknowledgements
We would like to express our gratitude to the First Affiliated Hospital of Ningbo University for providing the patient data.
Abbreviations
- RP
Radical prostatectomy
- IH
Inguinal hernia
- ASIS
Anterior superior iliac spine
- SD
Standard deviation
- NRS
Numeric rating scale
- VAS
Visual Analogue Scale
Authors’ contributions
All authors contributed to the conception and design of the study. Z. Ye provided guidance and design for the manuscript. The literature search and data analysis were conducted by M. Huang and S. Wang The initial draft of the manuscript was written by Y.Du, with further revisions and review done by Y. Lin and W. Yu. The formatting and preparation of the figures were completed by Y. Du. All authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript.
Funding
This study received no funding.
Data availability
All data generated or analysed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
This retrospective study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 098RS). The requirement for informed consent to participate was waived by the Institutional Ethics Committee of the First Affiliated Hospital of Ningbo University because of the retrospective design of the study and the use of anonymized patient data. The study protocol was registered at Medicalresearch.org (Registration No. ChiCTR2500101225).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Supplementary Materials
Data Availability Statement
All data generated or analysed during this study are included in this published article.