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Prostate Cancer: Radical Prostatectomy

Previous LaparoscopicInguinal Hernia Repair Does NotAdversely Affect the Functional orOncological Outcomes of EndoscopicExtraperitoneal Radical ProstatectomyHoang Minh Do, Kevin Turner, Anja Dietel, Andrew Wedderburn, Evangelos Liatsikos,and Jens-Uwe Stolzenburg

OBJECTIVE To investigate whether previous laparoscopic inguinal hernia repair (LIHR) affected adverselykey outcome measures in radical prostatectomy, including perioperative data, pathologic data,complications, potency, continence, and prostate-specific antigen (PSA). We have shownpreviously that LIHR does not preclude safe endoscopic extraperitoneal radical prostatectomy(EERPE).

METHODS EERPE is the standard approach to radical prostatectomy in our unit. Between 2001 and June2009 we encountered 92 patients who had previously undergone LIHR who underwent ourstandard technique of EERPE other than modification of port placement and development of theextraperitoneal space. We recorded our standard perioperative/postoperative dataset. Twelve-month follow-up data were available from 75 of 92 patients with 6-month follow-up of theremaining 17.

RESULTS Fifty-nine patients had undergone previous unilateral total extraperitoneal hernioplasty (TEP):16 bilateral TEP, 15 unilateral transabdominal extraperitoneal hernioplasty (TAPP), and 2bilateral TAPP. Although we needed to modify our technique, there was no increase in ouroperative time (153 minutes). Where indicated, we were able to perform bilateral nerve sparingand pelvic lymphadenectomy on the contralateral side to the LIHR. There were no majorcomplications and no blood transfusions. Our positive margin rate, continence, and potency ratesdid not differ from our series of 2000 consecutive EERPEs. Ninety-four-point-seven percent ofmen had an undetectable PSA at 12 months.

CONCLUSIONS LIHR does not adversely affect perioperative and key outcome measures in EERPE. UROLOGY

77: 963–968, 2011. © 2011 Elsevier Inc.

Inguinal hernia repair and radical prostatectomy (RP)are frequently performed operations in the agingmale. There is a growing tendency for both opera-

tions to be performed by minimally invasive techniques.Minimally invasive inguinal hernia repair may be by totalextraperitoneal hernioplasty (TEP) or by transabdominalextraperitoneal hernioplasty (TAPP). Various tech-niques for minimally invasive prostatectomy have beendescribed,1-3 of which endoscopic extraperitoneal radicalrostatectomy (EERPE) is one. More than 2000 EERPEsave now been performed in our institution.4

From the Department of Urology, University of Leipzig, Leipzig, Germany; Departmentof Urology, Royal Bournemouth Hospital, Bournemouth, UK; and Department ofUrology, University of Patras, Greece

Reprint requests: Hoang Minh Do MD, University of Leipzig, Department of Urology,�e 20, 04103 Leipzig, Germany. E-mail: minh@medizin.uni-leipzig.de

Liebigstra

Submitted: June 16, 2009, accepted (with revisions): June 19, 2010

© 2011 Elsevier Inc.All Rights Reserved

Synchronous LIHR and minimally invasive radicalprostatectomy is performed frequently.5 However, previ-ous LIHR with mesh placement can complicate subse-quent radical prostatectomy. The extensive adhesionsbetween the abdominal wall and the peritoneum causedby prosthetic mesh placement hinder the dissection nec-essary for RP. This is particularly the case with open RP(causing some experienced surgeons to consider previousTEP/TAPP as an absolute contraindication to openRP6). We and others have previously demonstrated thatprevious TEP/TAPP present certain problems in laparo-scopic prostatectomy as well. In our initial report of 14cases of EERPE after previous TEP/TAPP, we demon-strated that minor modifications in technique are re-quired but that there was no associated increase in meanoperative time or in perioperative/immediate postopera-

tive complications.7 Here we present functional and on-

0090-4295/11/$36.00 963doi:10.1016/j.urology.2010.06.068

ors.

cological results (with a minimum of 6 months follow-up)for 92 patients who had undergone previous TEP/TAPP.

MATERIAL AND METHODS

We have described previously in detail both the standard tech-nique of EERPE1 and the modifications required to facilitateEERPE after previous TEP/TAPP.7 Briefly, our standard tech-

Table 1. Patient demographics, perioperative, pathologic,

First 2000 EERPE

Demographics andperioperative data

Number of cases 2000Age, y 63.2 (range, 40-77)PSA 10.2 ng/mL (range, 0.64-82)Operative time 156 min (range, 50-320)Blood loss 255 mL (range, 20-1200)Transfusion rate 0.6%Prostate size, g 47.1 (range, 14-208)Lymphadenectomy

performed937 (46.85%)

Nerve sparing performed 730 (36.5%)Duration of

catheterization, d6.3 (range, 3-38)

PathologyGleason sum

StagingpT2a 221 (11.1%)pT2b 117 (5.9%)pT2c 966 (48.3%)pT3a 492 (24.6%)pT3b 197 (9.9%)Positive marginsOverall 364/2002 (18%)

pT2 127/1304 (9.7%)pT2a 4/221 (1.8%)pT2b 22/117 (18.8%)pT2c 101/966 (10.5%)

pT3 237/698 (33.9%)pT3a 147/492 (29.9%)pT3b 90/197 (45.7%)

Follow-up dataPSA

�0.1 ng/mL at 6 mo 94.5%�0.1 ng/mL at 12 mo 93.8%

3-mo continuance0 pads 68%1-2 pads 26%�2 pads 6%

6-mo continuance0 pads 85%1-2 pads 12%�2 pads 3%

12-mo continuance(n � 75)

0 pads 92%1-2 pads 7%�2 pads 1%

Potency*6 mo 59.5%12 mo (n � 75) 67.7% (bilateral nerve sparing

* Erections adequate for intercourse with or without PDE5 inhibit

nique includes insertion of a 12-mm camera port just to the

964

right of the midline, superficial to the posterior rectus fascia. Todo this, the extraperitoneal space is first developed by insuffla-tion of a caudally directed balloon. Further blunt dissectionwith the lens is used to free the peritoneum from the abdominalwall. Two 5-mm ports are then inserted on the right side, anda 5- and 12-mm port are inserted on the left. In the case ofprevious left LIHR, the initial insertion of the camera port anddevelopment of the extraperitoneal space are the same as the

follow-up data

EERPE with previous LIHR Significance (P)

9264.36 (range, 46-77)

0.2 ng/mL (range, 10.6-52.4)52.95 min (range, 100-240) .35 (M-W U)

260 mL (range, 20-800) .73 (M-W U)0% .73 (�2)

43.71 (range, 11-100)(50%) (39 unilateral, 7 bilateral)

32 (35%)5.9 (range, 4-20) .4 (�2)

4-640.5%726.2%

8-10 (33.3%)

8 (8.8%)4 (4.3%)

61 (66.3%)14 (15.2%)5 (5.4%)

9/92 (9.8%) .47 (Fisher’s exact test)4/73 (5%)0/8 (0%)1/4 (25%)

3/61 (4.9%)5/19 (26.3%)4/14 (28.6%)1/5 (20%)

95% .26 (Fisher’s exact test)94.7% .48 (Fisher’s exact test)

.44 (�2 test)74.7%16.5%

8.8%.07 (�2 test)

84.3%15.7%

0%.08 (�2 test)

91.6%8.4%0%

63% .47 (�2 test)73% .33 (�2 test)

and

11

46

)

standard technique, but the positions of the other ports are

UROLOGY 77 (4), 2011

modified. Where there has been a previous right-sided LIHR,the first (camera) port is inserted on the left-hand side of theumbilicus. The positions of the other ports are also adjustedslightly.

Pelvic lymphadenectomy (PLND) was performed when pre-operative PSA was �10 and/or when Gleason sum was �7.

We recorded our standard perioperative and postoperativedataset. Twelve-month follow-up was available for 75 patients,and 6-month follow-up for the remaining 17.

Statistical analysis was performed using appropriate tests,including the Mann-Whitney U, Fisher’s exact, and chi-squaretests. In all tests, P �.05 was taken to be significant.

RESULTSBetween December 2001 and November 2008, we per-formed EERPE on 2125 consecutive patients with clini-cally localized prostate cancer (cT1-cT2c). Of these 2125patients, 92 had undergone LIHR previously, 59 (2.8%)had previously undergone unilateral TEP, 16 (0.8%) bi-lateral TEP, 15 (0.7%) unilateral TAPP, and 2 (0.09%)bilateral TAPP). Patient demographics, preoperativedata, pathologic data, and outcome data are summarizedin Table 1. Complications are summarized in Table 2.The impact of unilateral (or no) PLND in cases where itwas indicated (by our criteria) is examined in Tables 3and 4 by comparison with our main series of EERPE.

In one case with previous bilateral TEP, the extraperi-toneal space could not be developed adequately and theprocedure was performed by transperitoneal access usingthe same descending technique. Fifty-one patients ful-filled our criteria for PLND. In 39/51, only unilateralPLND was performed. This was because PLND could notbe safely performed on the side ipsilateral to the previoushernia repair: in these patients, the mesh obscured theobturator fossa and the risk of neurovascular injury be-cause of PLND on this side was judged to be unacceptablyhigh. In 7/51 patients who had undergone unilateralLIHR, bilateral PLND was possible. Five of 51 patientshad previously undergone bilateral LIHR, and PLND wasnot performed. In all cases where PLND was possible, itwas to the level of the bifurcation of the common iliac

Table 2. Complications

First 200

PerioperativeRectal injury 7 (0Ureteric injury 1 (0

Early postoperative (�1 mo postoperatively)Anastomotic leak 37 (1Bleeding/hematoma 13 (0Deep vein thrombosis 11 (0Urinary tract infection 9 (0Symptomatic lymphocele 36 (3

Late complications (�1 mo postoperatively)Cerebrovascular accidentAnastomotic stricture 3 (0

Sum of all complications 117 (5

artery.

UROLOGY 77 (4), 2011

COMMENTUndoubtedly, previous LIHR increases the difficulty ofEERPE. We have commented previously on how thetechnique should be modified in these circumstances. It isour recommendation that surgeons should be experi-enced in EERPE before they embark on EERPE withprevious LIHR. With this proviso, we were keen toascertain whether the increased difficulty of the surgeryadversely affected the key preoperative and postoperativeparameters of a radical prostatectomy. With regard to theoperation itself, there was no increase in operative time,transfusion rate, blood loss, or our ability to performnerve sparing. Regarding complications, the incidence ofcomplications was apparently higher overall in patientswho underwent EERPE after previous LIHR than in ourseries of 2000 EERPEs as a whole (12% vs 5.85%). Thisdifference was of borderline significance (P � .06). Theincidence of individual complications was too low toallow statistical comparison between groups. Unfortu-nately, our standard dataset does not include detailedrecording of validated measures of all outcomes afterprostate cancer treatment, such as the Expanded ProstateCancer Index Composite or the UCLA Prostate CancerIndex. We recognize this as a limitation of our series as a

RPE EERPE With Previous LIHR Significance (P)

) 0%) 0

) 3 (3.3%)) 3 (3.3%)) 0) 2 (2.2%)) 2 (2.2%)

1 (1.1%)%) 0%) 11 (12%) 0.06 (�2 test)

Table 3. Pathologic data from patients in whom only uni-lateral pelvic lymphadenectomy was possible (n � 39)

n � 39unilat PLND

n � 7bilat PLND

n � 5No PLND

Gleason sum4-6 44.1% 60% 33.3%7 26.5% 40% 33.4%8-10 29.4% 33.3%

StagingpT2a 5.1% 20%pT2b 5.1% 80% 14.3%pT2c 53.8% 57.1%pT3a 25.6% 14.3%pT3b 10.4% 14.3%

Positive marginsOverall 17.9% 0% 14.3%

0 EE

.4%

.05

.9%

.7%

.6%

.5%

.8%

.15

.85

whole.

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ups wND [

Our positive margin rates for EERPE after LIHR didnot differ from those of our series of EERPE as a whole.This result probably reflects the fact that although devel-opment of the extraperitoneal space is more difficult,once the space is developed, the dissection of the prostateis not compromised and our ability to achieve clearmargins was not reduced.

In the only other similar series in the literature, Erdo-gru et al reported their experience of transperitoneallaparoscopic radical prostatectomy (the Heilbronn tech-nique) after transperitoneal LIHR in a small series ofpatients.8 In agreement with our study, they found nodverse impact on perioperative parameters. They didnd a significantly increased rate of administration ofoth narcotic and non-narcotic analgesia in patients whoad undergone previous LIHR. Although we did notpecifically evaluate analgesic usage, we did not noteubjectively that previous LIHR made a difference in oureries.

It seems that the intense fibrotic reaction that resultsrom insertion of a prosthetic mesh presents more of aroblem to open RP than laparoscopic prostatectomy.everal experienced surgeons have had to abandon openP in patients with a history of LIHR and have stated

ubsequently that previous LIHR is a contraindication topen RP.6,9 Though not all surgeons who perform open

RP share this view,10-12 all comment that open RP isore difficult in the context of previous LIHR. Given

hat we and others8 have found laparoscopic prostatec-tomy to be relatively straightforward in the context ofprevious LIHR, we suggest that laparoscopic prostatec-tomy is the procedure of choice for patients undergoingradical surgery for prostate cancer who have previouslyundergone LIHR.

Although LRP itself may not be compromised, animportant question is whether previous LIHR affectsPLND. In our series, only ipsilateral PLND was compro-mised. The role of lymphadenectomy in prostate canceris controversial. Our standard lymphadenectomy in-volves complete clearance of the obturator fossa and theexternal and internal iliac vessels up to the bifurcation.The consequences of omitting the lymphadenectomy inpatients where it is currently indicated by our criteria areuncertain. Although accurate staging may be affected,prognosis may not.13 Furthermore, even where nodes areound to be involved, subsequent management may de-

Table 4. PSA follow-up data for patients with previous LIHRwith patients without previous LIHR and bilateral PLND

Previous LIHR andunilateral PLND

(n � 39)

Previous Lbilateral

n �

PSA�0.1 ng/mL at 6 mo 85.7% 100%�0.1 ng/mL at 12 mo 83.3%% 94.

* Meaningful statistical comparison is not possible between grocolumns 1 and 4 were used (i.e., previous LIHR and unilateral PL

end more on other parameters (margin status, seminal

966

esicle involvement, pre-op PSA, postop PSA trajectory,leason score) than on lymph node status alone. Our

ositive margin rate was no higher in patients in whome performed unilateral PLND, bilateral PLND, or noLND (17.9%, 0%, and 14.3%, respectively) than in ourain series of EERPE/bilateral PLND without previousIHR (18% overall) (Table 3). Similarly, there was noifference in the percentage of patients with undetect-ble PSA at 6 and 12 months between these groupsTable 4). Therefore, although we acknowledge thatonger follow-up is required before the true impact ofmitting PLND is realized, there is no reason currently toonclude that the outcome of EERPE will be compro-ised in these patients.It is debatable whether use of, or conversion to, an

lternative approach for RP would have facilitated PLNDn the cases where bilateral lymphadenectomy was indi-ated but could not be performed. Experienced openurgeons have also reported difficulty with lymphadenec-omy after previous LIHR. For example, Vijan et aleviewed 9 patients with previous LIHR out of a series of2,735 patients who underwent open radical prostatec-omy.10 They found that in 6 of 9 patients, PLND had toe abandoned on one or both sides for fear of iatrogenicliac vessel injury. Conversely, Erdogru et al reported noifficulty with pelvic lymphadenectomy in their series of0 patients with previous LIHR who underwent trans-eritoneal LRP.8 We acknowledge that conversion to aransperitoneal approach might have facilitated PLNDut judged the risk of iatrogenic injury to be too high.

CONCLUSIONSIn this paper, we demonstrate that not only is EERPEfeasible after previous LIHR, but that there is no differ-ence in the perioperative parameters, pathologic data,risk of complications, or key short-term outcomes.

References1. Stolzenburg JU, Truss MC, Do M, et al. Evolution of endoscopic

extraperitoneal radical prostatectomy (EERPE)—technical im-provements and development of a nerve-sparing, potency-preserv-ing approach. World J Urol. 2003;21:147-152.

2. Rassweiler J, Seemann O, Hatzinger M, et al. Technical evolutionof laparoscopic radical prostatectomy after 450 cases. J Endourol.2003;17:143-154.

3. Guillonneau B, Cathelineau X, Barret E, et al. Vallancien G.Laparoscopic radical prostatectomy: technical and early oncologi-

unilateral PLND, bilateral PLND, and no PLND, compared

andD

Previous bilateralLIHR and noPLND n � 5

No previous LIHRand bilateral

PLND (n � 937)Significance

(P)

100% 90% .61*80% 86.9% .81*

ith only 5 to 7 patients. Therefore, for statistical analysis, onlyn � 39] vs no previous LIHR and bilateral PLND [n � 937]).

and

IHRPLN7

3%

cal assessment of 40 operations. Eur Urol. 1999;36:14-20.

UROLOGY 77 (4), 2011

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4. Stolzenburg JU, Rabenalt R, Do M, et al. Endoscopic extraperito-neal radical prostatectomy: the University of Leipzig experience of2000 cases. J Endourol. 2008;22:2319-2325.

5. Stolzenburg JU, Rabenalt R, Dietel A, et al. Hernia repair duringendoscopic (laparoscopic) radical prostatectomy. J LaparoendoscAdv Surg Tech A. 2003;13:27-31.

6. Katz EE, Patel RV, Sokoloff MH, et al. Bilateral laparoscopicinguinal hernia repair can complicate subsequent radical retropubicprostatectomy. J Urol. 2002;167:637-638.

7. Stolzenburg JU, Anderson C, Rabenalt R, et al. Endoscopic extra-peritoneal radical prostatectomy in patients with prostate cancerand previous laparoscopic inguinal mesh placement for herniarepair. World J Urol. 2005;23:295-299.

8. Erdogru T, Teber D, Frede T, et al. The effect of previous trans-peritoneal laparoscopic inguinal herniorrhaphy on transperitoneallaparoscopic radical prostatectomy. J Urol. 2005;173:769-772.

9. Foley CL, Kirby RS. Re: bilateral laparoscopic inguinal herniarepair can complicate subsequent radical retropubic prostatectomy.J Urol. 2003;169:1475.

10. Vijan SS, Wall JC, Greenlee SM, et al. Consequences of endo-scopic inguinal hernioplasty with mesh on subsequent open radicalprostatectomy. Hernia. 2008;12:415-419.

11. Kennedy-Smith A. Re: bilateral laparoscopic inguinal hernia repaircan complicate subsequent radical retropubic prostatectomy. J Urol.2003;169:1475-1476.

12. Liedberg F. Re: bilateral laparoscopic inguinal hernia repair cancomplicate subsequent radical retropubic prostatecomy. J Urol.2002;168:661; [Author reply:661-662].

3. DiMarco DS, Zincke H, Sebo TJ, et al. The extent of lymphadenec-tomy for pTXNO prostate cancer does not affect prostate cancer out-come in the prostate specific antigen era. J Urol. 2005;173:1121-1125.

EDITORIAL COMMENTIt is estimated that 25% of hernia repairs are performed lapa-roscopically. Given the demographic overlap (age, gender) ofpatients with inguinal hernia and those with prostate cancer,and the frequency of both conditions, one can expect a signif-icant portion of patients with prostate cancer to have had alaparoscopic inguinal hernia repair (LIHR). This can be via anumber of approaches that include laparoscopic extraperitonealor transabdominal extraperitoneal mesh herniorrhaphy. Thejuxtaposition of surgical trauma, combined with mesh-inducedinflammation results in significant scar formation in the alreadyconfined space of Retzius. The scarring can complicate subse-quent pelvic surgery, making dissection of the bladder, prostate,and pelvic vessels more tedious and difficult.

The impact of previous LIHR on the performance and out-come of radical prostatectomy vary widely. Initial reports sug-gested it was a relative contraindication to the open approach.Several case reports documented an inability to proceed withthe planned open surgery in the face of intense, mesh-associatedscarring, which effectively obliterated the space of Retzius.1-3

Rassweiler et al also reported converting to open a case oftransperitoneal laparoscopic radical prostatectomy (LRP) forthe same reason in their early series.4 Further efforts to over-ome this led to reports of LRP after mesh inguinal hernior-haphy via both the transperitoneal5-7 and extraperitoneal

route,8 in which prostate removal and reconstruction of theanastomosis was successful. However, reports of the extent ofpelvic lymph node dissection (PLND) status vary, with somerecommending PLND only on the side not affected by themesh, to prevent vascular and nerve injury.8

The authors investigated the impact of previous LIHR, not

just on feasibility but also on outcomes after radical prostatec-

UROLOGY 77 (4), 2011

tomy. Ninety-two patients with previous LIHR were comparedwith the rest of their overall cohort of 2000 patients treatedwith extraperitoneal radical prostatectomy. No statistical dif-ference was found in any of the parameters evaluated. It shouldbe noted that lymphadenectomy on the side of mesh incorpo-ration was abandoned in approximately 76.5% patients (39/51)that fulfilled the author’s criteria for PLND, of which a vastmajority were stages T2(c) (53.8%) and T3a (25.6%). Asacknowledged by the authors, these patients were not appro-priately staged because of the associated risks. Although nobiochemical recurrence is seen at 12-month follow up, thepotential negative effect of omitting the lymph node dissection,if any, will only be known with long-term data in this group ofpatients with locally advanced disease. The hurdle in perform-ing PLND after mesh herniorrhaphy is not unique to thelaparoscopic approach. Recent reports of retropubic radicalprostatectomy (RRP) also experienced similar fates for PLND.An extended PLND was abandoned as a result of severe pelvicscarring in 6 of 15 cases.9 Similarly, Neff and See10 retrospec-ively compared 38 patients that underwent RRP without pre-ious LIHR with 18 with previous LIHR. Both groups hadimilar statistical outcomes except for a single failure of PLNDn the laparoscopic mesh hernia group caused by dense scarringncompassing the external iliac vessels and the obturator fossa.

In light of the literature available, the nonabsorbable meshnduces intense inflammatory reaction in the surrounding tis-ues, which may hinder removal of the prostate. It, however,ompromises the quality of associated staging PLND, irrespec-ive of a transperitoneal or extraperitoneal approach.

We are advocates of the extraperitoneal route to performobot-assisted radical prostatectomy. The extraperitoneal ap-roach duplicates the open radical prostatectomy techniqueith all its implications, including direct access to the extra-eritoneal space of Retzius, which is most useful in patients withrevious abdominal surgeries, where adhesiolysis is avoided.he peritoneum serves as a natural barrier in keeping theowels out of the surgical field while restricting urine or bloodrom flowing into the extraperitoneal space, and it potentiallyecreases the risk of bowel injury or port site hernias. Anxtended PLND can be carried out with the extraperitonealpproach. A 30° angled down-scope facilitates the cephaladspect of the dissection. Meticulous clipping, however, is nec-ssary to lessen the risk of lymphocele. In patients with previousxtraperitoneal LIHR, where an extended PLND is indicated,he transabdominal route is preferred. The latter is easier in thatetting, and also mitigates the risk of lymphocele. This report oflarge number of patients with previous LIHR treated using thextraperitoneal approach addresses the perceived limitations ofhis minimally invasive approach to radical prostatectomy.

hmed Ghazi, M.D., University of Rochester Medicalenter, Rochester, New York and Strong Memorialospital, Urology Department, Rochester, New York

References1. Katz EE, Patel RV, Sokoloff MH, et al. Bilateral laparoscopic

inguinal hernia repair can complicate subsequent radical retropubicprostatectomy. J Urol. 2002;167(2 Pt. 1):637-638.

2. Cook H, Afzal N, Cornaby AJ. Laparoscopic hernia repairs maymake subsequent radical retropubic prostatectomy more hazardous.

BJU Int. 2003;91:729.

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