Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Inguinal hernia after radical retropubic prostatectomy: risk factors and prevention

Nature Reviews Urology volume 8, pages 267–273 (2011)Cite this article

Subjects

Abstract

The two most frequently occurring and well-described complications of radical retropubic prostatectomy (RRP) for prostate cancer are incontinence and impotence. Inguinal hernia (IH) has, over the last decade, emerged as an additional complication, with an estimated incidence of 15–20% after RRP. IH is a common lesion in men aged between 50 and 70 years with or without prostate cancer, and the literature indicates that annual incidence is somewhere between 0.5% and 1% in the general male population. Important risk factors for the development of post-RRP IH are previous IH surgery, increasing age, and low BMI. However, subclinical IH at the time of RRP and a lower midline incision seem to be the most important causative factors. Prophylactic procedures and, in the case of clinically detectable IH lesions, concurrent repair during RRP are advocated. Reports on alternative approaches to RRP, such as minilaparotomy RRP, laparoscopic radical prostatectomy (including robot-assisted procedures) and radical perineal prostatectomy have indicated low rates of postoperative IH. The risk of developing IH after prostatectomy should be part of the preoperative risk assessment when making treatment decisions for patients with prostate cancer.

Key Points

  • Inguinal hernia (IH) is an established postoperative complication of radical retropubic prostatectomy (RRP) with an estimated incidence of 15–20%

  • Subclinical or clinically detectable IH at the time of surgery and use of a lower midline incision are associated with a higher risk of developing postoperative IH

  • Other constitutional factors such as increasing age and low BMI might also contribute to IH development

  • In patients with clinically detectable IH before surgery, concurrent repair of IH at the time of RRP and a prophylactic procedure on the contralateral side should be considered

  • Prophylactic procedures should be performed on both sides in patients without detectable IH before surgery

  • The risk of IH after laparoscopic radical prostatectomy procedures seems to be lower than after RRP

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Walsh, P. C., Lepor, H. & Eggleston, J. C. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate 4, 473–485 (1983).

    Article  CAS  PubMed  Google Scholar 

  2. Pirtskhalaishvili, G., Hrebinko, R. L. & Nelson, J. B. The treatment of prostate cancer: an overview of current options. Cancer Pract. 9, 295–306 (2001).

    Article  CAS  PubMed  Google Scholar 

  3. Heidenreich, A. et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease. Eur. Urol. 59, 61–71 (2010).

    Article  PubMed  Google Scholar 

  4. Walsh, P. C. Anatomic radical prostatectomy: evolution of the surgical technique. J. Urol. 160, 2418–2424 (1998).

    Article  CAS  PubMed  Google Scholar 

  5. Salomon, L. et al. Combined reporting of cancer control and functional results of radical prostatectomy. Eur. Urol. 44, 656–660 (2003).

    Article  PubMed  Google Scholar 

  6. Walsh, P. C. in Campbell's Urology 8th edn (eds Walsh, P. C. et al.) 3107–3129 (Saunders, Philadelphia, 2002).

    Google Scholar 

  7. Bianco, F. J. Jr, Scardino, P. T. & Eastham, J. A. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”). Urology 66 (Suppl. 5), 83–94 (2005).

    Article  Google Scholar 

  8. Regan, T. C., Mordkin, R. M., Constantinople, N. L., Spence, I. J. & Dejter, S. W. Jr . Incidence of inguinal hernias following radical retropubic prostatectomy. Urology 47, 536–537 (1996).

    Article  CAS  PubMed  Google Scholar 

  9. Ichioka, K. et al. High incidence of inguinal hernia after radical retropubic prostatectomy. Urology 63, 278–281 (2004).

    Article  PubMed  Google Scholar 

  10. Stranne, J., Hugosson, J. & Lodding, P. Inguinal hernia is a common complication in lower midline incision surgery. Hernia 11, 247–252 (2007).

    Article  CAS  PubMed  Google Scholar 

  11. Sekita, N. et al. Incidence of inguinal hernia after prostate surgery: open radical retropubic prostatectomy versus open simple prostatectomy versus transurethral resection of the prostate. Int. J. Urol. 16, 110–113 (2009).

    Article  PubMed  Google Scholar 

  12. Lodding, P. et al. Inguinal hernia after radical retropubic prostatectomy for prostate cancer: a study of incidence and risk factors in comparison to no operation and lymphadenectomy. J. Urol. 166, 964–967 (2001).

    Article  CAS  PubMed  Google Scholar 

  13. Sun, M. et al. Comparative study of inguinal hernia repair after radical prostatectomy, prostate biopsy, transurethral resection of the prostate or pelvic lymph node dissection. J. Urol. 183, 970–975 (2010).

    Article  PubMed  Google Scholar 

  14. Skandalakis, J. E., Colborn, G. L., Skandalakis, L. J. & McClusky, D. A. III . in Nyhus and Condon's Hernia 5th edn (eds Fitzgibbons, R. J. J. & Greenburg, A. G.) 29–43 (Lippincott Williams & Wilkins, Philadelphia, 2002).

    Google Scholar 

  15. Tsai, P. J., Yu, C. C., Lee, Y. H. & Huang, J. K. Inguinal hernia after radical retropubic prostatectomy-experience of Kaohsiung Veterans General Hospital. J. Chin. Med. Assoc. 67, 141–144 (2004).

    PubMed  Google Scholar 

  16. Nomura, T. et al. Lower incidence of inguinal hernia: minilaparotomy radical retropubic prostatectomy compared with conventional technique. A preliminary report. Urol. Int. 74, 32–37 (2005).

    Article  PubMed  Google Scholar 

  17. Twu, C. M., Ou, Y. C., Yang, C. R., Cheng, C. L. & Ho, H. C. Predicting risk factors for inguinal hernia after radical retropubic prostatectomy. Urology 66, 814–818 (2005).

    Article  PubMed  Google Scholar 

  18. Fukuta, F. et al. Preoperative computed tomography finding predicts for postoperative inguinal hernia: new perspective for radical prostatectomy-related inguinal hernia. Urology 68, 267–271 (2006).

    Article  PubMed  Google Scholar 

  19. Stranne, J., Hugosson, J. & Lodding, P. Post-radical retropubic prostatectomy inguinal hernia: an analysis of risk factors with special reference to preoperative inguinal hernia morbidity and pelvic lymph node dissection. J. Urol. 176, 2072–2076 (2006).

    Article  PubMed  Google Scholar 

  20. Abe, T. et al. Postoperative inguinal hernia after radical prostatectomy for prostate cancer. Urology 69, 326–329 (2007).

    Article  PubMed  Google Scholar 

  21. Matsubara, A. et al. Inguinal hernia after radical perineal prostatectomy: comparison with the retropubic approach. Urology 70, 1152–1156 (2007).

    Article  PubMed  Google Scholar 

  22. Koie, T. et al. Frequency of postoperative inguinal hernia after endoscope-assisted mini-laparotomy and conventional retropubic radical prostatectomies. Int. J. Urol. 15, 226–229 (2008).

    Article  PubMed  Google Scholar 

  23. Lepor, H. & Robbins, D. Inguinal hernias in men undergoing open radical retropubic prostatectomy. Urology 70, 961–964 (2007).

    Article  PubMed  Google Scholar 

  24. Stranne, J. et al. Inguinal hernia after radical prostatectomy for prostate cancer: results from a randomized setting and a nonrandomized setting. Eur. Urol. 58, 719–726 (2010).

    Article  PubMed  Google Scholar 

  25. Abramson, J. H., Gofin, J., Hopp, C., Makler, A. & Epstein, L. M. The epidemiology of inguinal hernia. A survey in western Jerusalem. J. Epidemiol. Community Health 32, 59–67 (1978).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Rubenstein, R. S. et al. Conceptualization and measurement of physiologic health for adults Vol. 15 Surgical Conditions (RAND, Santa Monica, 1983).

    Google Scholar 

  27. Rutkow, I. M. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg. Clin. North Am. 78, 941–951 (1998).

    Article  CAS  PubMed  Google Scholar 

  28. Lughezzani, G. et al. Comparative study of inguinal hernia repair rates after radical prostatectomy or external beam radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 78, 1307–1313 (2010).

    Article  PubMed  Google Scholar 

  29. Stranne, J., Hugosson, J., Iversen, P., Morris, T. & Lodding, P. Inguinal hernia in stage M0 prostate cancer: a comparison of incidence in men treated with and without radical retropubic prostatectomy-an analysis of 1105 patients. Urology 65, 847–851 (2005).

    Article  PubMed  Google Scholar 

  30. Nielsen, M. E. & Walsh, P. C. Systematic detection and repair of subclinical inguinal hernias at radical retropubic prostatectomy. Urology 66, 1034–1037 (2005).

    Article  PubMed  Google Scholar 

  31. Matthews, R. D. & Neumayer, L. Inguinal hernia in the 21st century: an evidence-based review. Curr. Probl. Surg. 45, 261–312 (2008).

    Article  PubMed  Google Scholar 

  32. Lau, H., Fang, C., Yuen, W. K. & Patil, N. G. Risk factors for inguinal hernia in adult males: a case-control study. Surgery 141, 262–266 (2007).

    Article  PubMed  Google Scholar 

  33. Ichioka, K., Kohei, N., Yoshimura, K., Arai, Y. & Terai, A. Impact of retraction of vas deferens in postradical prostatectomy inguinal hernia. Urology 70, 511–514 (2007).

    Article  PubMed  Google Scholar 

  34. Marien, T., Taouli, B., Telegrafi, S., Babb, J. & Lepor, H. Optimizing the detection of subclinical inguinal hernias in men undergoing open radical retropubic prostatectomy. BJU Int. 106, 1468–1472 (2010).

    Article  PubMed  Google Scholar 

  35. Rosemar, A., Angerås, U. & Rosengren, A. Body mass index and groin hernia: a 34-year follow-up study in Swedish men. Ann. Surg. 247, 1064–1068 (2008).

    Article  PubMed  Google Scholar 

  36. Rabbani, F., Yunis, L. H., Touijer, K. & Brady, M. S. Predictors of inguinal hernia after radical prostatectomy. Urology 77, 391–395 (2010).

    Article  PubMed  Google Scholar 

  37. Yoshimine, S. et al. Extraperitoneal approach induces postoperative inguinal hernia compared with transperitoneal approach after laparoscopic radical prostatectomy. Jpn J. Clin. Oncol. 40, 349–352 (2010).

    Article  PubMed  Google Scholar 

  38. Allaf, M. E., Hsu, T. H., Sullivan, W. & Su, L. M. Simultaneous laparoscopic prosthetic mesh inguinal herniorrhaphy during transperitoneal laparoscopic radical prostatectomy. Urology 62, 1121 (2003).

    Article  PubMed  Google Scholar 

  39. Ghavamian, R., Knoll, A. & Teixeira, J. A. Simultaneous extraperitoneal laparoscopic radical prostatectomy and intraperitoneal inguinal hernia repair with mesh. JSLS 9, 231–234 (2005).

    PubMed  PubMed Central  Google Scholar 

  40. Teber, D., Erdogru, T., Zukosky, D., Frede, T. & Rassweiler, J. Prosthetic mesh hernioplasty during laparoscopic radical prostatectomy. Urology 65, 1173–1178 (2005).

    Article  PubMed  Google Scholar 

  41. Finley, D. S., Rodriguez, E. Jr & Ahlering, T. E. Combined inguinal hernia repair with prosthetic mesh during transperitoneal robot assisted laparoscopic radical prostatectomy: a 4-year experience. J. Urol. 178, 1296–1299 (2007).

    Article  PubMed  Google Scholar 

  42. Lee, B. C., Rodin, D. M., Shah, K. K. & Dahl, D. M. Laparoscopic inguinal hernia repair during laparoscopic radical prostatectomy. BJU Int. 99, 637–639 (2007).

    Article  PubMed  Google Scholar 

  43. Joshi, A. R., Spivak, J., Rubach, E., Goldberg, G. & DeNoto, G. Concurrent robotic trans-abdominal pre-peritoneal (TAP) herniorrhaphy during robotic-assisted radical prostatectomy. Int. J. Med. Robot. 6, 311–314 (2010).

    Article  PubMed  Google Scholar 

  44. Stranne, J. Inguinal Hernia after Urologic Surgery in Males with Special Reference to Radical Retropubic Prostatectomy—A Clinical, Epidemiological and Methodological Study [online]. Thesis, Göteborg University http://gupea.ub.gu.se/handle/2077/706 (2006).

  45. Stranne, J. Inguinal hernia as a complication to urological lower midline incision surgery. Review Series Urology 12, 2–8 (2008).

    Google Scholar 

  46. Schlegel, P. N. & Walsh, P. C. The use of the preperitoneal approach for the simultaneous repair of inguinal hernia during surgery on the bladder and prostate. World J. Surg. 13, 555–559 (1989).

    Article  CAS  PubMed  Google Scholar 

  47. Choi, B. B., Steckel, J., Denoto, G., Vaughan, E. D. & Schlegel, P. N. Preperitoneal prosthetic mesh hernioplasty during radical retropubic prostatectomy. J. Urol. 161, 840–843 (1999).

    Article  CAS  PubMed  Google Scholar 

  48. Savetsky, I. L., Rabbani, F., Singh, K. & Brady, M. S. Preperitoneal repair of inguinal hernia at open radical prostatectomy. Hernia 13, 517–522 (2009).

    Article  CAS  PubMed  Google Scholar 

  49. Antunes, A. A., Dall'oglio, M., Crippa, A. & Srougi, M. Inguinal hernia repair with polypropylene mesh during radical retropubic prostatectomy: an easy and practical approach. BJU Int. 96, 330–333 (2005).

    Article  PubMed  Google Scholar 

  50. Drachenberg, D. E. & Bell, D. G. Preperitoneal mesh-plug herniorraphy during radical retropubic prostatectomy. Can. J. Urol. 9, 1602–1606 (2002).

    PubMed  Google Scholar 

  51. Manoharan, M., Vyas, S., Araki, M., Nieder, A. M. & Soloway, M. S. Concurrent radical retropubic prostatectomy and Lichtenstein inguinal hernia repair through a single modified Pfannenstiel incision: a 3-year experience. BJU Int. 98, 341–344 (2006).

    Article  PubMed  Google Scholar 

  52. Sakai, Y. et al. Simple prophylactic procedure of inguinal hernia after radical retropubic prostatectomy: isolation of the spermatic cord. Int. J. Urol. 16, 848–851 (2009).

    Article  PubMed  Google Scholar 

  53. Fujii, Y. et al. A novel technique to prevent postradical retropubic prostatectomy inguinal hernia: the processus vaginalis transection method. Urology 75, 713–717 (2009).

    Article  PubMed  Google Scholar 

  54. Taguchi, K. et al. Simple method of preventing postoperative inguinal hernia after radical retropubic prostatectomy. Urology 76, 1083–1087 (2010).

    Article  PubMed  Google Scholar 

  55. Stranne, J. et al. Post-radical prostatectomy inguinal hernia: a simple surgical intervention can substantially reduce the incidence-results from a prospective randomized trial. J. Urol. 184, 984–989 (2010).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Sahlgrenska University Hospital and The Sahlgrenska Academy, University of Gothenburg, Gothenburg, SE-413 45, Sweden

    Johan Stranne & Pär Lodding

Authors
  1. Johan Stranne
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pär Lodding
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

J. Stranne and P. Lodding contributed equally to researching the article, discussion of content and editing the manuscript before subscription. J. Stranne wrote the article.

Corresponding author

Correspondence to Johan Stranne.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stranne, J., Lodding, P. Inguinal hernia after radical retropubic prostatectomy: risk factors and prevention. Nat Rev Urol 8, 267–273 (2011). https://doi.org/10.1038/nrurol.2011.40

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2011.40

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing