Editorial Comment to Patent processus vaginalis in adults who underwent robot‐assisted laparoscopic radical prostatectomy: Predictive signs of postoperative inguinal hernia in the internal inguinal floor

摘要

The article addresses the issue of a patent processus vaginalis (PPV) as a risk factor for inguinal hernia (IH) development after transperitoneal robot-assisted laparoscopic radical prostatectomy (RALP).1 The authors use a retrospective approach of identifying PPV from the video recordings of the RALP procedures carried out at their institution. All patients were questioned and examined for IH every 3–4 months during follow up. The approach is sound and provides interesting results. However, a few points should be made to put the results into perspective. First, although IH is an established complication of open radical retropubic prostatectomy (RRP), data on IH after RALP is, according to a PubMed search on 28 July 2012, limited to just two studies. In our study from 2010, we found postoperative IH in 5.8% of RALP patients compared with 2.6% in a control group.2 This difference, however, was not statistically significant. As there is no control group in the present study, we cannot establish that the IH incidence after RALP really is higher than in the general population. The figures presented do, nevertheless, indicate that a slightly increased risk is likely, as the expected annual incidence in men of this age is approximately 0.5–1%.3 However, regardless of whether the risk of IH is increased by the procedure or not, it seems beneficial if a future IH could be prevented during the prostatectomy procedure, as the authors suggest. Second, a number of studies have described preoperative subclinical IH as a risk factor for postoperative IH development after RRP. These subclinical IH has been detected by clinical examination,4 intraoperatively,5 computed tomography (CT),6 magnetic resonance imaging (MRI) and/or ultrasonography.7 It might well be that what is described as PPV in this study and the previously described subclinical IH, especially those detected by CT and/or MRI/ultrasonography, are the same. Studies investigating if this is the case are therefore warranted. As preoperative MRI of the prostatic region is becoming more and more common, for staging of the tumor and planning of the procedure, it would be interesting to focus on the inguinal region to plan a prophylactic procedure for patients with a visible lesion, especially where an extraperitoneal approach, open or laparoscopic, is planned. Third, the authors suggest that an intraoperative hernia repair should be carried out on patients with PPV. Hernia repair today includes placing of foreign material in the inguinal region and this would be carried out in 73.5% of groins unnecessarily, as just 26.5% of patients with PPV developed IH. The increased risk of postoperative complications as a result of the hernia repair must therefore be taken in to account. A number of prophylactic procedures with good results have been suggested for RRP, all less intrusive and without the placing of foreign material.8-10 It seems to me that one of these prophylactic procedures should be adapted to RALP, and should be carried out on patients with PPV in order to minimize the risk of postoperative complications. Hernia repair with placing of foreign material should be carried out only if the patients have a clinically manifest IH. None declared.