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Radical retropubic prostatectomy and inguinal hernia repair.

We read with interest the recent Controversial Topics in Surgery debate regarding inguinal hernia – laparoscopic versus open repair.1,2 The benefits of both methods were eloquently presented; however, as urologists, we feel that an important consideration has been ignored in this debate. Increasing numbers of younger men are now being diagnosed with early prostate cancer. Though optimal management of this patient group has yet to be established, it is likely that many men will continue to opt for ablative surgery of the prostate. Our personal experience of attempted radical retropubic prostatectomy being near impossible following laparoscopic hernia repair is confirmed by others who substantiate it to be incredibly difficult, if not impossible.3,4 Regardless of whether the laparoscopic repair is via the transperitoneal or extraperitoneal approach, dissection of the obliterated retro pubic space, to allow mobilisation of the prostate is difficult because of the secondary fibrotic reaction caused by the mesh repair. Fibrosis around the anterior surface of the bladder and the prostate, often extending laterally to the endopelvic fascia, obliterates the tissue planes compromising oncological cancer principles and, most probably, outcomes. The same problems will face the laparoscopic radical prostatectomist and also those who favour the perineal approach. We feel that general surgeons who regularly perform laparoscopic inguinal hernia repairs should be aware of the consequences of this approach, as decision making in patients who are subsequently diagnosed with early prostate cancer will be influenced by their actions. Indeed, perhaps there is a case for more careful prostate assessment or ‘screening’ of patients undergoing laparoscopic hernia repair.