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Combined Retropubic Prostatectomy and Preperitoneal Inguinal Herniorrhaphy
0022-534 7/88/1406-1442$02.00 /0
Vol. 140, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1988 by The Williams & Wilkins Co.
COMBINED RETROPUBIC PROSTATECTOMY AND PREPERITONEAL INGUINAL HERNIORRHAPHY JOSEPH ABARBANEL
AND
DAVID KIMCHE
From the Department of Urology, Golda Medical Center, Hasharon Hospital, Petah Tiqva, Israel
ABSTRACT
Inguinal hernia and an enlarged prostate causing urinary obstruction are 2 disorders with a higher frequency among elderly patients. The anatomical proximity of an inguinal hernia to the enlarged prostate raises the possibility of joint, concurrent surgical treatment of both disorders. We report on the successful preperitoneal repair via a Pfannenstiel incision of 131 inguinal hernias in 97 patients who had undergone retropubic prostatectomy owing to benign enlargement of the prostate. Followup averaged 7 years and included 91 patients with 122 direct and indirect, unilateral or bilateral hernias. Summation of our results shows a low recurrence rate (4.9 per cent) and no complications in the wake of the combined operation. In our opinion prostatectomy combined concurrently with inguinal hernia repair via a preperitoneal retropubic approach should be applied routinely in urological practice. (J. Ural., 140: 1442-1444, 1988) nstances of patients suffering concomitantly from an inguinal hernia and obstructed voiding due to an enlarged prostate are a common occurrence familiar to the general surgeon and urologist. The accepted procedure is first to perform the prostatectomy and only afterwards to treat the inguinal hernia. 1 Many urologists, therefore, refrain from any concomitant prostatectomy and repair of an inguinal hernia for various reasons, including the danger of contamination, risk of prolongation of the operation and anesthesia, lack of expertise in the technique of hernia repair and, occasionally, a reticence to perform concurrently 2 operations that usually are done separately. Such a combined surgical approach was published first in 1949 by McDonald and Huggins, who performed suprapubic prostatectomy and inguinal hernia repair by the technique of Halsted in 2 separate incisions. 2 For the last 17 years we have performed routinely preperitoneal hernia repair via a Pfannenstiel incision in all patients suffering from inguinal hernia and benign enlargement of the prostate who had undergone retropubic prostatectomy. Encouraged by the results with these patients we also have performed inguinal hernia repair in combination with other operations on the bladder (for example cystolithotomy or diverticulectomy) and lower ureter (ureterolithotomy). Our experience with this surgical approach reveals it to be efficient, beneficial to the patient and not significantly prolonging the duration of the procedure or increasing the rate of subsequent complications. Since reports in the medical literature regarding the same approach are scarce, we deem it worthwhile to report our experience and results with this technique, thereby alerting other urologists to its applicability. MATERIALS AND METHODS
Between 1970 and 1984, a total of 1,431 patients had undergone prostatectomy in our department. Of these patients 132 (9.2 per cent) were diagnosed as also suffering from an inguinal hernia. Surgical treatment included open prostatectomy in 806 patients and transurethral resection of the prostate in 625. All 35 patients with inguinal hernia and an enlarged prostate excisable transurethrally underwent a general operation for subsequent hernioplastic treatment and were excluded from the survey. However, 97 patients scheduled originally for open prostatectomy underwent simultaneous retropubic prostatectomy and inguinal hernia repair, and these comprised our study group. Patient age ranged from 47 to 83 years, with a mean age Accepted for publication March 23, 1988.
of 71 years. Over-all, 131 hernias were repaired (69 direct and 62 indirect). The hernias were bilateral in 27 patients, double (direct and indirect) on the same side in 7 and recurrent in 8 (see table). Furthermore, in addition to this combined operation 9 patients underwent resection of enlarged diverticula from the bladder and 1 underwent ureterolithotomy in the lower third of the ureter. Surgical technique. The operation is performed . via a Pfannenstiel incision. First, the anterior and lateral perivesical and periprostatic fat is retracted upward together with the pelvic peritoneum. This preparatory step facilitates approach to the pelvic floor and enables easy identification of the defects in the fascia responsible for the inguinal hernia. The direct inguinal hernia is repaired (fig. 1) by reduction of the hernial sac-a manipulation usually and easily attainable by merely pulling but occasionally requiring slight dissection. The content of the hernial sac is restored to the peritoneal cavity and usually there is no need to excise the sac. The defect in the transversalis fascia is repaired by drawing the upper borders of the transverse abdominis aponeurosis toward Cooper's ligament. The juxtaposition of these tissues is facile and does not usually require relaxing incisions in the fascia. Repair of an indirect inguinal hernia (fig. 2) necessitates separation of the hernial sac from the spermatic cord or even leaving behind the distal portion in cases of large inguinoscrotal hernias. After resection of the inguinal sac the repair is effected by moving the spermatic cord medially, and ligating the medial and lateral crura of the internal inguinal ring laterally to the cord to ensure closure of the defect. The suturing is done with nonabsorbable 1 and 2zero sutures, mostly of the nylon variety. The prostatectomy is performed next by the retropubic approach, care being taken to ensure tight sealing of the prostatic capsule. All patients in our department who have undergone prostatectomy routinely receive antibiotics, mostly cephalosporins. Types of inguinal hernias encountered in 97 patients who had undergone inguinal hernia repair combined with prostatectomy Unilat. direct inguinal hernia Unilat. indirect inguinal hernia Unilat. direct and indirect inguinal hernia Bilat. direct inguinal hernia Bilat. indirect inguinal hernia Bilat. direct and indirect inguinal hernia Totals
1442
No. Pts.
No. Hernias
33 30 7
33 30 14
12 10
24 20
5
10
97
131
COMBINED Pi:10STATECTOMY AND INGUINAL HERNIORRHAPHY
1443
Fm. 1. a, repair of direct inguinal defect (A). B, transversalis fascia. C, iliopubic tract. D, Cooper's ligament. E, Spermatic cmd. b, preperitoneal closure of direct inguinal hernia. B, transversalis fascia. C, iliopubic tract. D, Cooper's ligament.
Fm. 2. a, repair of indirect inguinal hernia (A). B, transversalis fascia. C, iliopubic tract. b, preperitoneal closure of indirect inguinal hernia. B, transversalis fascia. C, iliopubic tract. D, closure of indirect defect. RESULTS
Of the 97 patients operated on 8 (8.5 per cent) had bacterial infection of the surgical wound that yielded gram-positive microorganisms (Staphylococcus aureus) upon culture. Urine cultures from the same patients all were negative for this microorganism. One patient died 3 days postoperatively of acute myocardial infarction. Followup of the patients averaged 7 years (maximum 10 and minimum 3 years) and encompassed 91 patients who had undergone repair of 122 hernias. Another 5 patients were lost to followup and 1, as mentioned previously, died shortly postoperatively. In 6 patients the hernia recurred and considering that 122 hernias were repaired the recurrence rate was 4.9 per cent; 3 of these patients were reoperated upon by the general surgeon.
DISCUSSION
Inguinal hernia and an enlarged prostate causing urinary obstruction are 2 disorders of greater prevalence among patients of an advanced age group. 3 • 4 The effort involved in micturition, which is accompanied by significant increase of the intra-abdominal pressure, as well as weakness of the inguinal canal tissues that occurs with advanced age are among the main reasons for the more frequent occurrence of inguinal hernia. 5 The anatomical proximity of an inguinal hernia to the enlarged prostate raises the possibility of a joint concomitant surgical treatment of both disorders. Not surprising, then, in 1949 McDonald and Huggins performed such concomitant prostatectomy and inguinal hernia repair. 2 However, this was done by 2 separate incisions with the hernia repair effected by
an inguinal approach using the Halsted technique. Subsequently, Maluf and Tauber6 described a technique for combined prostatectomy and herniorrhaphy via a Pfannenstiel incision. Similarly, Weinberg and associates used a Pfannenstiel incision but with a rounded extension upward along the line of the inguinal canal, with separate incisions of the fascia and with an inguinal approach to the hernia repair. 7 Recently, Schlegel and Walsh described a technique for inguinal hernia repair via a preperitoneal approach through a median longitudinal incision, which was done in prostate cancer patients in combination with cystoprostatectomy or radical retropubic prostatectomy. 4 We perform routinely such a combined operation in every patient suffering concurrently from benign enlargement of the prostate and an inguinal hernia in which there is a favorable indication for open prostatectomy. The operation uses a single incision (Pfannenstiel) via a preperitoneal retropubic approach. Our experience shows that the hernial repair lasts a few minutes at the most and does not significantly prolong the duration of anesthesia. The postoperative outcome fails to show any increase in mortality or morbidity, and in the few instances when infection develops in the surgical wound the responsible bacteria are not encountered in the urine cultures. Taking precautions to seal the prostatic capsule tightly and to eliminate any existing urinary infection by antibiotic treatment preoperatively in our opinion can obviate the risk that the area of inguinal hernia repair will become infected through contaminated urine. During a mean 7-year followup of our patients we found a recurrence rate of 4.9 per cent. Schlegel and Walsh reported no recurrence of the hernia in any of their patients but their followup was much shorter (average 11.4 months).4 In a review of the results of various studies on inguinal hernia repair alone performed by the ordinary inguinal approach, we found a recurrence rate of 2 to 33 per cent. 8 Theoretically, one
1444
ABARBANEL AND KIMCHE
would expect repair of inguinal hernia alone, which is done in 2 or 3 layers, to yield lower recurrence rates than a preperitoneal retropubic repair, which is done in a single layer. Not so, according to our results. The reason for this discrepancy resides in our opinion in the finding of Martin and Stone that the most important cause for recurrence of the hernia is an increase in the intra-abdominal pressure stemming from obstruction of the lower urinary tract. 5 It is clear, then, that prostatectomy combined with inguinal hernia repair actually reduces the likelihood of hernia recurrence. On the other hand, in some elderly patients undergoing only inguinal hernia repair there still remains an obstructive disturbance in the lower urinary passageways and, consequently, a higher recurrence rate of the hernia is to be expected. The preperitoneal retropubic approach to inguinal hernia repair has further advantages. For example it enables one to discover (and correct) additional hernias not detected on the preoperative physical examination. Again, sliding hernias as well as adjacent organs, such as the large blood vessels, intestines and bladder, are most easily identified in the course of this approach. Finally, in cases of recurrent hernia the area is at least free of the typical adhesions encountered by the surgeon upon repeat of the inguinal approach. For all these reasons we believe that the described joint surgical technique to repair concurrently an inguinal hernia (via a preperitoneal retropubic
approach) and enlargement of the prostate has great merit and deserves to be applied routinely in urological practice. REFERENCES
1. Cramer, S. 0., Malangoni, M. A., Sculte, W. J. and Condon, R. E.: Inguinal hernia repair before and after prostatic resection. Surgery, 94: 627, 1983. 2. McDonald, D. F. and Huggins, C.: Simultaneous prostatectomy and inguinal herniorrhaphy. Surg., Gynec. & Obst., 89: 621, 1949. 3. Jasper, W. S., Sr.: Combined open prostatectomy and herniorrhaphy. J. Urol., 111: 370, 1974. 4. Schlegel, P. N. and Walsh, P. C.: Simultaneous preperitoneal hernia repair during radical pelvic surgery. J. Urol., 137: 1180, 1987. 5. Martin, J. D., Jr. and Stone, H. H.: Recurrent inguinal hernia. Ann. Surg., 156: 713, 1962. 6. Maluf, N. S. and Tauber, A. S.: Combined prostatectomy and herniorrhaphy through the Pfannenstiel incision. Urol. Int., 11: 51, 1961. 7. Weinberg, S. R., Kovetz, A. and Lazarus, S. M.: Technique of herniorrhaphy. In: Simultaneous Prostatectomy and Inguinal Herniorrhaphy. Springfield: Charles C Thomas Publishers, chapt. V, pp. 41-44, 1971. 8. Zimmerman, I. M. and Anson, B. J.: The Anatomy and Surgery of Hernia. Baltimore: The Williams & Wilkins Co., pp. 218-220, 1953.
Vol. 140, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1988 by The Williams & Wilkins Co.
COMBINED RETROPUBIC PROSTATECTOMY AND PREPERITONEAL INGUINAL HERNIORRHAPHY JOSEPH ABARBANEL
AND
DAVID KIMCHE
From the Department of Urology, Golda Medical Center, Hasharon Hospital, Petah Tiqva, Israel
ABSTRACT
Inguinal hernia and an enlarged prostate causing urinary obstruction are 2 disorders with a higher frequency among elderly patients. The anatomical proximity of an inguinal hernia to the enlarged prostate raises the possibility of joint, concurrent surgical treatment of both disorders. We report on the successful preperitoneal repair via a Pfannenstiel incision of 131 inguinal hernias in 97 patients who had undergone retropubic prostatectomy owing to benign enlargement of the prostate. Followup averaged 7 years and included 91 patients with 122 direct and indirect, unilateral or bilateral hernias. Summation of our results shows a low recurrence rate (4.9 per cent) and no complications in the wake of the combined operation. In our opinion prostatectomy combined concurrently with inguinal hernia repair via a preperitoneal retropubic approach should be applied routinely in urological practice. (J. Ural., 140: 1442-1444, 1988) nstances of patients suffering concomitantly from an inguinal hernia and obstructed voiding due to an enlarged prostate are a common occurrence familiar to the general surgeon and urologist. The accepted procedure is first to perform the prostatectomy and only afterwards to treat the inguinal hernia. 1 Many urologists, therefore, refrain from any concomitant prostatectomy and repair of an inguinal hernia for various reasons, including the danger of contamination, risk of prolongation of the operation and anesthesia, lack of expertise in the technique of hernia repair and, occasionally, a reticence to perform concurrently 2 operations that usually are done separately. Such a combined surgical approach was published first in 1949 by McDonald and Huggins, who performed suprapubic prostatectomy and inguinal hernia repair by the technique of Halsted in 2 separate incisions. 2 For the last 17 years we have performed routinely preperitoneal hernia repair via a Pfannenstiel incision in all patients suffering from inguinal hernia and benign enlargement of the prostate who had undergone retropubic prostatectomy. Encouraged by the results with these patients we also have performed inguinal hernia repair in combination with other operations on the bladder (for example cystolithotomy or diverticulectomy) and lower ureter (ureterolithotomy). Our experience with this surgical approach reveals it to be efficient, beneficial to the patient and not significantly prolonging the duration of the procedure or increasing the rate of subsequent complications. Since reports in the medical literature regarding the same approach are scarce, we deem it worthwhile to report our experience and results with this technique, thereby alerting other urologists to its applicability. MATERIALS AND METHODS
Between 1970 and 1984, a total of 1,431 patients had undergone prostatectomy in our department. Of these patients 132 (9.2 per cent) were diagnosed as also suffering from an inguinal hernia. Surgical treatment included open prostatectomy in 806 patients and transurethral resection of the prostate in 625. All 35 patients with inguinal hernia and an enlarged prostate excisable transurethrally underwent a general operation for subsequent hernioplastic treatment and were excluded from the survey. However, 97 patients scheduled originally for open prostatectomy underwent simultaneous retropubic prostatectomy and inguinal hernia repair, and these comprised our study group. Patient age ranged from 47 to 83 years, with a mean age Accepted for publication March 23, 1988.
of 71 years. Over-all, 131 hernias were repaired (69 direct and 62 indirect). The hernias were bilateral in 27 patients, double (direct and indirect) on the same side in 7 and recurrent in 8 (see table). Furthermore, in addition to this combined operation 9 patients underwent resection of enlarged diverticula from the bladder and 1 underwent ureterolithotomy in the lower third of the ureter. Surgical technique. The operation is performed . via a Pfannenstiel incision. First, the anterior and lateral perivesical and periprostatic fat is retracted upward together with the pelvic peritoneum. This preparatory step facilitates approach to the pelvic floor and enables easy identification of the defects in the fascia responsible for the inguinal hernia. The direct inguinal hernia is repaired (fig. 1) by reduction of the hernial sac-a manipulation usually and easily attainable by merely pulling but occasionally requiring slight dissection. The content of the hernial sac is restored to the peritoneal cavity and usually there is no need to excise the sac. The defect in the transversalis fascia is repaired by drawing the upper borders of the transverse abdominis aponeurosis toward Cooper's ligament. The juxtaposition of these tissues is facile and does not usually require relaxing incisions in the fascia. Repair of an indirect inguinal hernia (fig. 2) necessitates separation of the hernial sac from the spermatic cord or even leaving behind the distal portion in cases of large inguinoscrotal hernias. After resection of the inguinal sac the repair is effected by moving the spermatic cord medially, and ligating the medial and lateral crura of the internal inguinal ring laterally to the cord to ensure closure of the defect. The suturing is done with nonabsorbable 1 and 2zero sutures, mostly of the nylon variety. The prostatectomy is performed next by the retropubic approach, care being taken to ensure tight sealing of the prostatic capsule. All patients in our department who have undergone prostatectomy routinely receive antibiotics, mostly cephalosporins. Types of inguinal hernias encountered in 97 patients who had undergone inguinal hernia repair combined with prostatectomy Unilat. direct inguinal hernia Unilat. indirect inguinal hernia Unilat. direct and indirect inguinal hernia Bilat. direct inguinal hernia Bilat. indirect inguinal hernia Bilat. direct and indirect inguinal hernia Totals
1442
No. Pts.
No. Hernias
33 30 7
33 30 14
12 10
24 20
5
10
97
131
COMBINED Pi:10STATECTOMY AND INGUINAL HERNIORRHAPHY
1443
Fm. 1. a, repair of direct inguinal defect (A). B, transversalis fascia. C, iliopubic tract. D, Cooper's ligament. E, Spermatic cmd. b, preperitoneal closure of direct inguinal hernia. B, transversalis fascia. C, iliopubic tract. D, Cooper's ligament.
Fm. 2. a, repair of indirect inguinal hernia (A). B, transversalis fascia. C, iliopubic tract. b, preperitoneal closure of indirect inguinal hernia. B, transversalis fascia. C, iliopubic tract. D, closure of indirect defect. RESULTS
Of the 97 patients operated on 8 (8.5 per cent) had bacterial infection of the surgical wound that yielded gram-positive microorganisms (Staphylococcus aureus) upon culture. Urine cultures from the same patients all were negative for this microorganism. One patient died 3 days postoperatively of acute myocardial infarction. Followup of the patients averaged 7 years (maximum 10 and minimum 3 years) and encompassed 91 patients who had undergone repair of 122 hernias. Another 5 patients were lost to followup and 1, as mentioned previously, died shortly postoperatively. In 6 patients the hernia recurred and considering that 122 hernias were repaired the recurrence rate was 4.9 per cent; 3 of these patients were reoperated upon by the general surgeon.
DISCUSSION
Inguinal hernia and an enlarged prostate causing urinary obstruction are 2 disorders of greater prevalence among patients of an advanced age group. 3 • 4 The effort involved in micturition, which is accompanied by significant increase of the intra-abdominal pressure, as well as weakness of the inguinal canal tissues that occurs with advanced age are among the main reasons for the more frequent occurrence of inguinal hernia. 5 The anatomical proximity of an inguinal hernia to the enlarged prostate raises the possibility of a joint concomitant surgical treatment of both disorders. Not surprising, then, in 1949 McDonald and Huggins performed such concomitant prostatectomy and inguinal hernia repair. 2 However, this was done by 2 separate incisions with the hernia repair effected by
an inguinal approach using the Halsted technique. Subsequently, Maluf and Tauber6 described a technique for combined prostatectomy and herniorrhaphy via a Pfannenstiel incision. Similarly, Weinberg and associates used a Pfannenstiel incision but with a rounded extension upward along the line of the inguinal canal, with separate incisions of the fascia and with an inguinal approach to the hernia repair. 7 Recently, Schlegel and Walsh described a technique for inguinal hernia repair via a preperitoneal approach through a median longitudinal incision, which was done in prostate cancer patients in combination with cystoprostatectomy or radical retropubic prostatectomy. 4 We perform routinely such a combined operation in every patient suffering concurrently from benign enlargement of the prostate and an inguinal hernia in which there is a favorable indication for open prostatectomy. The operation uses a single incision (Pfannenstiel) via a preperitoneal retropubic approach. Our experience shows that the hernial repair lasts a few minutes at the most and does not significantly prolong the duration of anesthesia. The postoperative outcome fails to show any increase in mortality or morbidity, and in the few instances when infection develops in the surgical wound the responsible bacteria are not encountered in the urine cultures. Taking precautions to seal the prostatic capsule tightly and to eliminate any existing urinary infection by antibiotic treatment preoperatively in our opinion can obviate the risk that the area of inguinal hernia repair will become infected through contaminated urine. During a mean 7-year followup of our patients we found a recurrence rate of 4.9 per cent. Schlegel and Walsh reported no recurrence of the hernia in any of their patients but their followup was much shorter (average 11.4 months).4 In a review of the results of various studies on inguinal hernia repair alone performed by the ordinary inguinal approach, we found a recurrence rate of 2 to 33 per cent. 8 Theoretically, one
1444
ABARBANEL AND KIMCHE
would expect repair of inguinal hernia alone, which is done in 2 or 3 layers, to yield lower recurrence rates than a preperitoneal retropubic repair, which is done in a single layer. Not so, according to our results. The reason for this discrepancy resides in our opinion in the finding of Martin and Stone that the most important cause for recurrence of the hernia is an increase in the intra-abdominal pressure stemming from obstruction of the lower urinary tract. 5 It is clear, then, that prostatectomy combined with inguinal hernia repair actually reduces the likelihood of hernia recurrence. On the other hand, in some elderly patients undergoing only inguinal hernia repair there still remains an obstructive disturbance in the lower urinary passageways and, consequently, a higher recurrence rate of the hernia is to be expected. The preperitoneal retropubic approach to inguinal hernia repair has further advantages. For example it enables one to discover (and correct) additional hernias not detected on the preoperative physical examination. Again, sliding hernias as well as adjacent organs, such as the large blood vessels, intestines and bladder, are most easily identified in the course of this approach. Finally, in cases of recurrent hernia the area is at least free of the typical adhesions encountered by the surgeon upon repeat of the inguinal approach. For all these reasons we believe that the described joint surgical technique to repair concurrently an inguinal hernia (via a preperitoneal retropubic
approach) and enlargement of the prostate has great merit and deserves to be applied routinely in urological practice. REFERENCES
1. Cramer, S. 0., Malangoni, M. A., Sculte, W. J. and Condon, R. E.: Inguinal hernia repair before and after prostatic resection. Surgery, 94: 627, 1983. 2. McDonald, D. F. and Huggins, C.: Simultaneous prostatectomy and inguinal herniorrhaphy. Surg., Gynec. & Obst., 89: 621, 1949. 3. Jasper, W. S., Sr.: Combined open prostatectomy and herniorrhaphy. J. Urol., 111: 370, 1974. 4. Schlegel, P. N. and Walsh, P. C.: Simultaneous preperitoneal hernia repair during radical pelvic surgery. J. Urol., 137: 1180, 1987. 5. Martin, J. D., Jr. and Stone, H. H.: Recurrent inguinal hernia. Ann. Surg., 156: 713, 1962. 6. Maluf, N. S. and Tauber, A. S.: Combined prostatectomy and herniorrhaphy through the Pfannenstiel incision. Urol. Int., 11: 51, 1961. 7. Weinberg, S. R., Kovetz, A. and Lazarus, S. M.: Technique of herniorrhaphy. In: Simultaneous Prostatectomy and Inguinal Herniorrhaphy. Springfield: Charles C Thomas Publishers, chapt. V, pp. 41-44, 1971. 8. Zimmerman, I. M. and Anson, B. J.: The Anatomy and Surgery of Hernia. Baltimore: The Williams & Wilkins Co., pp. 218-220, 1953.