International Journal of Urology (2018) 25, 644--648
13717
Review Article
Inseparable interaction of the prostate and inguinal hernia
Akira Miyajima
Department of Urology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
Abbreviations & Acronyms
BMI = body mass index
BPH = benign prostatic
hyperplasia
IH = inguinal hernia
IPSS = International Prostate
Symptom Score
LRP = laparoscopic radical
prostatectomy
LUTS = lower urinary tract
symptoms
RARP = robot-assisted
radical prostatectomy
RP = radical prostatectomy
TAP = transabdominal
preperitoneal
TEP = total extraperitoneal
repair
Correspondence: Akira
Miyajima M.D., Department of
Urology, Tokai University
School of Medicine,
143 Shimokasuya,
Isehara, Kanagawa 259-1193,
Japan. Email: akiram@tokai.ac.jp
Received 9 April 2018; accepted
22 May 2018.
Online publication 19 June 2018
644
doi: 10.1111/iju.
Abstract: With an increase in their prevalence, it has become apparent that both
benign prostatic hyperplasia and radical prostatectomy for cancer can induce inguinal
hernia development. An inguinal hernia is a common late complication following radical
prostatectomy, with an occurrence rate of 12–25%. Following radical prostatectomy, the
space of Retzius can develop adhesions to surrounding tissue, often causing difficulty
during inguinal hernia repair. Conversely, inguinal hernia repair before radical
prostatectomy also induces severe adhesions around the space of Retzius and causes
difficulty during radical prostatectomy. The association between radical prostatectomy
and inguinal hernia development is complex and unclear. Both urologists and surgeons
are challenged by this interaction. The surgical approaches for prostate cancer have
undergone a major transition from open surgery to robotic surgery, and the treatment
of inguinal hernia is also changing. Based on historical trends, several preventive and
treatment measures have been proposed, although there is no direct evidence for risk
factors that lead to inguinal hernia development. This article focuses on the complex
interaction between the prostate and inguinal hernia, and considers preventive measures
against inguinal hernia development.
Key words: inguinal hernia, prostate, surgery.
Etiology and risk factors for IH
IH accounts for 75% of abdominal wall hernias and 97% of groin hernias.1 IH repair is one
of the most common procedures performed in the United States.2 Risk factors for IH develop-
ment can be divided into patient risk factors and external risk factors. Patient-dependent risk
factors include male sex, older age, a patent processus vaginalis, chronic cough, systemic con-
nective tissue disorders, and a low BMI.3 While low BMI is a known risk factor for IH, high
BMI increases intra-abdominal pressure, and also seems to increase the risk of IH recurrence.
BPH and constipation are also patient-dependent risk factors. Conversely, external risk factors
include increasing cumulative occupational mechanical exposure,3 smoking, sports,4 or lower
midline incision surgery.5,6
BPH is common in the aging male population. The prevalence of BPH increases after the
age of 40 years, and BPH prevalence has increased rapidly with the aging of society.7 Pros-
tate cancer prevalence has also increased. As the prevalence of these prostatic diseases has
increased, it is apparent that BPH or RP for prostate cancer may also induce IH development.
IH is a common late complication after RP, with an occurrence rate of 12–25%. Reported risk
factors for IH after RP include previous IH surgery, age, low BMI, length of lower abdominal
incision, previous abdominal surgery, extraperitoneal-approach LRP, urethral stricture, and
clinical tumor stage.8,9
Following RP, the space of Retzius, also known as the retropubic space, develops adhe-
sions with the surrounding tissue, causing difficulty during IH repair. Conversely, IH repair
for a previous IH before RP also induces severe adhesions around the space of Retzius and
results in some difficulty during RP procedures. The association between RP and IH develop-
ment is complex and unclear. Both urologists and surgeons are challenged by this interaction.
Based on historical trends, several preventive and treatment measures have been proposed,
although there is no direct evidence supporting risk factors that lead to IH development. This
article focuses on the complex interaction between the prostate and IH and considers preven-
tive measures against the development of IH.
© 2018 The Japanese Urological Association

IH development and LUTS
Sanchez-Ortiz et al. performed an analysis of 693 consecutive
patients who underwent RARP.10 Patients with a preoperative
IPSS of 15 or greater had a 22.4% chance of requiring IH repair
compared to 5% of patients with lower scores. The authors
concluded that regardless of prostate size, men with preopera-
tive LUTS and an IPSS of 15 or greater should be counseled
on the potential need for IH repair using RARP. This suggests
the need for increased caution in patients with LUTS as mesh
material may be required for fixation when RARP is performed
in these patients.
Kaiho et al. noted that responses to question 6 of the IPSS
(i.e. “Over the past month, how often have you had to push
or strain to begin urination?”) were associated with postoper-
ative urinary straining and history of previous hernia repair,
both of which were significant risk factors for postoperative
IH development.11 A possible mechanism remains the fact
that patients with LUTS may need to strain to void, and this
effort over time may have a direct impact on the abdominal
wall contributing to the development of IH. Moreover,
repeated urinary straining tends to push the small intestine
into the processus vaginalis. In particular, urinary straining is
associated with IH development after RP, and LUTS with
urinary straining can clearly induce IH development. Such
complaints from patients in addition to physical findings
should be evaluated before prostatectomy.
IH development after RP
It is important to consider the results of a Scandinavian study
regarding IH after RP.12 The Kaplan–Meier cumulative
occurrence of IH development after 48 months was 12.2%,
5.8%, and 2.6% in patients who underwent open RP, patients
who underwent RARP, and controls, respectively. Nissen
et al. concluded that open RP for prostate cancer leads to an
increased risk of IH development, and that RARP may lower
this risk when compared to open surgery. They also reported
an almost fourfold increase in IH repair after open RP com-
pared with controls, and men who underwent radiation ther-
apy had an almost twofold increase in IH incidence. In
addition to postoperative changes in the abdominal wall, there
is an increased incidence of IH after RP or radiation therapy
for prostate cancer.13
Zhu et al. performed a meta-analysis of 29 trials, and
reported that postoperative IH developed in 15.9% of patients
who underwent open RP and 6.7% (4.8–8.6) of those who
underwent laparoscopic RP. Most cases of IH occurred within
the first 2 years after surgery, and right-side and indirect-type
IH predominated. Moreover, the incidence of IH after retrop-
ubic RP was significantly higher than that in patients who
had no operation, laparoscopic surgery, radical perineal
prostatectomy, minilaparotomy radical retropubic prostatec-
tomy, or pelvic lymph node dissection, but was not signifi-
cantly higher than that in patients who underwent simple
open prostatectomy or cystectomy. Several reports also
demonstrated that IH occurrence rate after retropubic RP
(12.2–38.7%) was significantly higher than that in controls
(2.6–2.9%).5,12,14,15
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Interaction of the prostate and IH
In addition, increasing age, low BMI, subclinical IH, previ-
ous IH repair, and anastomotic stricture increased the risk of
IH after RP. The authors also suggested that damage to the
posterior layer of the rectus sheath might be involved in the
development of IH after RP. Prophylactic surgery for high-
risk subjects is recommended before RP to minimize the inci-
dence of IH.16
Preventive measures from open
surgery to robotic surgery
In 1987, Schlegel and Walsh described routine surgery for
preperitoneal IH repair in patients with symptomatic or inci-
dentally discovered IH who were undergoing open RP or
radial cystoprostatectomy (Table 1).17 The transversus arch
was approximated to the iliopubic tract and Cooper’s liga-
ment, and interrupted sutures were then applied to direct the
hernia. Indirect hernias were repaired by mobilizing the sper-
matic cord and dissecting any excess tissue. If the hernia sac
was identified, it was dissected free from the spermatic cord
and reduced. Finally, the transversus arch was approximated
to the iliopubic tract with interrupted sutures. Using this clas-
sic approach, they identified 41 cases of IH and were able to
repair 32 among the 369 patients in the study. In addition,
Choi et al. improved the technique by prosthetic mesh place-
ment for hernia repair during RP in 1999.18 This was the first
report of simultaneous hernioplasty using mesh during RP to
reduce the development of IH.
Stranne et al. also followed the prophylactic procedure first
described by Schlegel and Walsh,17 and analyzed the effects
of this simple surgical intervention. Of 254 patients, 127 had
the prophylactic procedure on the right side and 127 on the
left. The cumulative IH incidence was 3.5% for the interven-
tion side and 9.1% for the controls. Following this trial, sev-
eral groups challenged the preventive studies.
Sakai et al. proposed that a simple procedure able to dis-
sect the internal ring and the spermatic cord from the sur-
rounding tissue was effective.19 They reported that this
procedure resulted in only a 1.6% recurrence rate during a
median follow-up period of 41 months. The authors specu-
lated that adhesions involving the internal ring following the
procedure might have had a beneficial effect on preventing
IH after open RP. Fujii et al. introduced another method to
transect the processus vaginalis free from the spermatic cord
in addition to the dissection of the spermatic cord itself.20
Based on these studies, Kanda et al. compared these two
methods using the same surgical team.21 Their results showed
that the processus vaginalis transection procedure was supe-
rior to the simpler prophylactic procedure for the prevention
of IH after RP. Recent trends in surgery for prostate cancer
including robotic-assisted surgery have been reported to
reduce IH occurrence rates.13 In the future, we will need to
focus on robotic surgery-associated IH.
Several studies have described IH repair during RARP.
Joshi et al. reported the effectiveness of concurrent robotic
TAP hernioplasty using mesh placement during RARP.22
Upon completing RARP, the peritoneum overlying the myo-
pectineal orifice is opened, the orifice is dissected free, and
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A MIYAJIMA

Table 1 Preventive measures for IH development during RP

IH recurrence rate
Reported year Authors Operation method to prostate Preventive procedure prevention vs controls Added operation time (min)
1987 Schlegel & Walsh Open RP, cystectomy Narrowing internal ring 0% (prevention group) –
1999 Choi et al. Open RP Mesh placement 0% (prevention group) –
2010 Stranne et al. Open RP Narrowing internal ring 3.5% vs 9.1% 5–10
2010 Joshi et al. RARP TAP 0% (prevention group) 24
2016 Ludwig et al. RARP or LRP TEP 0% (prevention group) 31–32
2016 Kanda et al. Open RP Processus vaginalis transection 0% vs 24.8% –
2017 Rogers et al. RARP TAP – 12–15
2017 Chang et al. Retzius-sparing RARP – 3.7% vs 7.8% –

the hernia is reduced. The mesh is then affixed over the ori-
fice with titanium tacks, and the peritoneum is closed over
the mesh. The mean operative time for TAP hernioplasty pro-
cedure is 24 min. Moreover, Rogers et al. reported that
although TAP hernioplasty during RARP increased surgical
time, there was no increase in postoperative complications,
suggesting that concomitant performance of both procedures
is feasible and safe.23
Conversely, Ludwig et al. compared concomitant laparo-
scopic TEP and RARP with similar combined IH repair with
LRP. Following standard extraperitoneal RARP with pelvic
lymph node dissection, surgeons performed TEP using the
same ports. On the side with the hernia, the contents were
reduced and the space was cleared for prosthetic mesh. The
hernia sac was reduced, and the synthetic mesh was used to
reinforce the myopectineal orifice. When compared to stan-
dard LRP or RARP, unilateral TEP prolonged operative time
by approximately 30 min.24 Since IH recurrence was not
observed, the authors concluded that RARP with concomitant
TEP is safe, effective, and comparable to the laparoscopic
approach. Thus, simultaneous IH repair during RARP may be
justified in patients with IH or subclinical IH.
Mechanism of IH development after RP
The precise mechanism of IH development after standard RP
remains unclear, but several hypotheses have been proposed
(Fig. 1). Shimbo et al. postulated that the peritoneum and vas
deferens were stretched during urethrovesical anastomosis,
resulting in a medial shifting of the internal ring, with subse-
quent widening leading to IH development.25 Moreover, Lee
et al. reported that a patent processus vaginalis, which is a
peritoneal protrusion toward the deep inguinal ring, is an
important risk factor for IH after RARP.26 As discussed
above, Kaiho et al. proposed that repeated straining for urina-
tion pushes the small intestine into the funnel-shaped proces-
sus vaginalis, which can easily occur following release of the
vas deferens from the prostate during RP. They postulated
that the release of the vas deferens and the increased abdomi-
nal pressure after RP can induce development of IH in
patients with urinary straining.
Chang et al. found that Retzius space preservation with
RARP lowered IH incidence compared with standard
RARP.27 They hypothesized that lower IH incidence might be
due to the maximum preservation of anatomical structures of
the anterior component including the space of Retzius, mainte-
nance of the anatomical attachment of the entire bladder to the
anterior abdominal wall fascia, and an undisturbed external
prostate-vesicular angle.28,29 In addition, the preservation of
these anatomical structures may also preserve the myopecti-
neal orifice and its components by avoiding medial stretching
of the internal ring. Indeed, perineal RP resulted in a lower
incidence of IH, compared with standard open RP.30 In sum-
mary, Retzius space preservation may play a role in the

(a) Peritoneum (b) Peritoneum

Internal iliac ring

Internal iliac ring
Bladder Bladder

Prostate

Fig. 1 Proposed hypotheses regarding mechanisms of inguinal hernia development after radical prostatectomy. (a) Before prostatectomy; (b) after prostatec-
tomy.

646 © 2018 The Japanese Urological Association


pathogenesis of IH development. Although these hypotheses
may explain the exact mechanism in part, they are still merely
speculation.
Impact of prior IH repair on
subsequent RP
Katz et al. experienced a case in which bilateral laparoscopic
IH repair complicated a subsequent RP (Table 2).31 This case
report drew attention from many urologists and led to some dis-
cussion. Subsequently, several publications have described the
severe fibrotic reaction that obliterates the retropubic space,
making the operation very difficult.32–34 Foley and Kirby sug-
gested that this situation might be encountered more frequently
in urological practice because of the increasing number of RPs
being performed. Conversely, Kennedy-Smith successfully
performed RP in a similar situation and suggested that a previ-
ous IH surgery contributed only minimally to the technical dif-
ficulty of the RP, while such patients need to be warned of the
potential for additional morbidity.
Siddiqui et al. evaluated the experience with RARP in the
setting of previous inguinal or abdominal surgery.35 From a
prospective cohort of 2950 consecutive patients who under-
went transperitoneal RARP, they identified 1049 (27%) with
a history of abdominal or inguinal surgery. Adhesiolysis at
the time of surgery was graded and the grade was based on
time required to take down adhesions, density of adhesions,
and area of coverage of adhesions. Any adhesiolysis taking
more than 30 min or involving a minilaparotomy incision
was considered extensive. They found that patients with pre-
vious surgery required adhesiolysis compared with patients
with no previous surgery, and especially noted that patients
with a history of bilateral hernias with mesh frequently
required extensive adhesiolysis. Nevertheless, they concluded
that previous inguinal surgery is not a contraindication to
RARP because accessing the prostate through the peritoneum
with the precision of robotic instruments allows for successful
completion of RARP, regardless of the type or extent of
mesh hernia repairs.
Picozzi et al. performed a meta-analysis and systematic
review of 7497 patients to evaluate the feasibility and out-
comes of open, laparoscopic, and robotic strategies for RP in
patients with previous synthetic mesh IH repair.36 They con-
cluded that prior IH repair with mesh placement might com-
plicate subsequent RP in terms of perioperative parameters
Table 2 Unfavorable impact of preceding surgery to the following
surgery
IH repair Need to dissect adhesions and prolong operation
before RP (Siddiqui et al.)35
Becomes very difficult RP (Katz et al.)31
Complicates future pelvic surgery (Hsia et al.)34
Decrease numbers of resected lymph node, prolong hospital
stay and catheterization in open RP while marginally
affecting LRP (Picozzi et al.)36
RP before Safe, but prolong operative time of IH repair
IH repair (Le Page et al.)38
© 2018 The Japanese Urological Association
14422042, 2018, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iju.13717 by Cochrane Philippines, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Interaction of the prostate and IH
including blood loss, catheterization duration, and extent of
lymph node dissection. This suggested that a transperitoneal
robotic approach may be technically easier than an open
approach for these patients. However, patient provision of
adequate informed consent still may be required for these
multiple aspects, which may be influenced by mesh place-
ment.
Should patients be informed of the risk
of IH following prostatectomy?
How many urologists have noticed the increase in IH devel-
opment after RP? Were prostate cancer patients aware of the
potential risk of IH before undergoing RP? The mean occur-
rence rate of IH after RP is approximately 15%, and urolo-
gists have observed that patients are at risk of IH
development. Nevertheless, the potential of IH occurrence is
unpredictable as definite risk is difficult to determine in the
absence of subclinical IH. The IH occurrence rate for the lat-
ter is not low and may be comparable to the urinary inconti-
nence rate observed in patients following RP. Since RP may
increase the risk of IH development regardless of the
approach used, this complication should be discussed with
patients who are scheduled for RP.37
Are urologists aware of how a surgeon
approaches IH repair after
prostatectomy?
Urologists tend to focus on how to manage RP with periop-
erative IH development. It is obvious that RP induces IH
development, while IH repair complicates RP. Understand-
ably, most urologists face difficulties in such cases, albeit to
different degrees. It would be interesting to know how sur-
geons approach IH repair in patients with prior RP. Le Page
et al. reported the modest impression that TEP and IH
repair in experienced hands required a slightly longer opera-
tive time for patients who had previously undergone RP
than in those who had not undergone RP, while other out-
comes were equivalent in both groups.38 Nevertheless, they
mentioned that the most difficult and adherent area is supe-
rior to the iliac vessels, especially when a Hem-o-lokâ clip
had previously been applied to the vas deferens during RP.
They also stated that other operative repair approaches
should always be considered for these difficult cases, even
for experienced and skilled surgeons, while open approaches
to IH repair are still recommended for a less experienced
surgeon.
Conclusions
Although RP is currently performed with robotic surgery, the
development of IH remains an ongoing concern. We need to
inform patients undergoing RP of the potential risk of devel-
oping IH, regardless of the surgical method chosen. A patient
who is at risk of a subclinical hernia requires consultation
with a specialist surgeon before RP, and simultaneous mesh
placement may be recommended during RP. Conversely, it
may also be useful for the surgeon to determine the patient’s
647

A MIYAJIMA
prostate-specific antigen level prior to IH repair. Furthermore,
surgeons need to be aware that dissection of the space of Ret-
zius during RP may lead to adhesions, and this may have a
significant impact on the development of IH, although the
exact mechanism remains speculative.
Conflict of interest
None declared.
References
1 Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Nationwide
prevalence of groin hernia repair. PLoS ONE 2013; 8: e54367.
2 Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ.
Open or endoscopic total extraperitoneal inguinal hernia repair?: a systematic
review. Surg. Endosc. 2007; 21: 161–6.
3 Oberg S, Andresen K, Rosenberg J. Etiology of inguinal hernias: a compre-
hensive review. Front. Surg. 2017; 4: 52.
4 Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a sys-
tematic literature review. Br. J. Sports Med. 2008; 42: 954–64.
5 Stranne J, Hugosson J, Lodding P. Inguinal hernia is a common complication
in lower midline incision surgery. Hernia 2007; 11: 247–52.
6 Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the
US population. Am. J. Epidemiol. 2007; 165: 1154–61.
7 Lim KB. Epidemiology of clinical benign prostatic hyperplasia. Asian J.
Urol. 2017; 4: 148–51.
8 Stranne J, Lodding P. Inguinal hernia after radical retropubic prostatectomy:
risk factors and prevention. Nat. Rev. Urol. 2011; 8: 267–73.
9 Yoshimine S, Miyajima A, Nakagawa K, Ide H, Kikuchi E, Oya M.
Extraperitoneal approach induces postoperative inguinal hernia compared with
transperitoneal approach after laparoscopic radical prostatectomy. Jpn. J.
Clin. Oncol. 2010; 40: 349–52.
10 Sanchez-Ortiz RF, Andrade-Geigel C, Lopez-Huertas H, Cadillo-Chavez R,
Soto-Aviles O. Preoperative international prostate symptom score predictive
of inguinal hernia in patients undergoing robotic prostatectomy. J. Urol.
2016; 195: 1744–7.
11 Kaiho Y, Mitsuzuka K, Yamada S et al. Urinary straining contributes to
inguinal hernia after radical retropubic prostatectomy. Int. J. Urol. 2016; 23:
478–83.
12 Stranne J, Johansson E, Nilsson A et al. Inguinal hernia after radical prostate-
ctomy for prostate cancer: results from a randomized setting and a nonran-
domized setting. Eur. Urol. 2010; 58: 719–26.
13 Nilsson H, Stranne J, Stattin P, Nordin P. Incidence of groin hernia repair
after radical prostatectomy: a population-based nationwide study. Ann. Surg.
2014; 259: 1223–7.
14 Koie T, Yoneyama T, Kamimura N, Imai A, Okamoto A, Ohyama C. Fre-
quency of postoperative inguinal hernia after endoscope-assisted mini-laparot-
omy and conventional retropubic radical prostatectomies. Int. J. Urol. 2008;
15: 226–9.
15 Nomura T, Mimata H, Kitamura H et al. Lower incidence of inguinal hernia:
mini-laparotomy radical retropubic prostatectomy compared with conventional
technique. A preliminary report. Urol. Int. 2005; 74: 32–7.
16 Zhu S, Zhang H, Xie L, Chen J, Niu Y. Risk factors and prevention of ingu-
inal hernia after radical prostatectomy: a systematic review and meta-analysis.
J. Urol. 2013; 189: 884–90.
17 Schlegel PN, Walsh PC. Simultaneous preperitoneal hernia repair during radi-
cal pelvic surgery. J. Urol. 1987; 137: 1180–3.
18 Choi BB, Steckel J, Denoto G, Vaughan ED, Schlegel PN. Preperitoneal
prosthetic mesh hernioplasty during radical retropubic prostatectomy. J. Urol.
1999; 161: 840–3.
648
14422042, 2018, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iju.13717 by Cochrane Philippines, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
19 Sakai Y, Okuno T, Kijima T et al. Simple prophylactic procedure of inguinal
hernia after radical retropubic prostatectomy: isolation of the spermatic cord.
Int. J. Urol. 2009; 16: 848–51.
20 Fujii Y, Yamamoto S, Yonese J et al. The processus vaginalis transection
method to prevent postradical prostatectomy inguinal hernia: long-term
results. Urology 2014; 83: 247–52.
21 Kanda T, Fukuda S, Kohno Y, Fukui N, Kageyama Y. The processus vagi-
nalis transection method is superior to the simple prophylactic procedure for
prevention of inguinal hernia after radical prostatectomy. Int. J. Clin. Oncol.
2016; 21: 384–8.
22 Joshi AR, 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. 2010; 6: 311–4.
23 Rogers T, Parra-Davila E, Malcher F et al. Robotic radical prostatectomy
with concomitant repair of inguinal hernia: is it safe? J. Robot. Surg. 2018;
12: 325–30.
24 Ludwig WW, Sopko NA, Azoury SC et al. Inguinal hernia repair during
extraperitoneal robot-assisted laparoscopic radical prostatectomy. J. Endourol.
2016; 30: 208–11.
25 Shimbo M, Endo F, Matsushita K et al. Incidence, risk factors and a novel
prevention technique for inguinal hernia after robot-assisted radical prostatec-
tomy. Urol. Int. 2017; 98: 54–60.
26 Lee DH, Jung HB, Chung MS, Lee SH, Chung BH. Patent processus vagi-
nalis in adults who underwent robot-assisted laparoscopic radical prostatec-
tomy: predictive signs of postoperative inguinal hernia in the internal inguinal
floor. Int. J. Urol. 2013; 20: 177–82.
27 Chang KD, Abdel Raheem A, Santok GDR et al. Anatomical Retzius-space
preservation is associated with lower incidence of postoperative inguinal her-
nia development after robot-assisted radical prostatectomy. Hernia 2017; 21:
555–61.
28 Asimakopoulos AD, Miano R, Galfano A et al. Retzius-sparing robot-assisted
laparoscopic radical prostatectomy: critical appraisal of the anatomic land-
marks for a complete intrafascial approach. Clin. Anat. 2015; 28: 896–902.
29 Galfano A, Di Trapani D, Sozzi F et al. Beyond the learning curve of the
Retzius-sparing approach for robot-assisted laparoscopic radical prostatec-
tomy: oncologic and functional results of the first 200 patients with >/=
1 year of follow-up. Eur. Urol. 2013; 64: 974–80.
30 Matsubara A, Yoneda T, Nakamoto T et al. Inguinal hernia after radical per-
ineal prostatectomy: comparison with the retropubic approach. Urology 2007;
70: 1152–6.
31 Katz EE, Patel RV, Sokoloff MH, Vargish T, Brendler CB. Bilateral laparo-
scopic inguinal hernia repair can complicate subsequent radical retropubic
prostatectomy. J. Urol. 2002; 167: 637–8.
32 Cook H, Afzal N, Cornaby AJ. Laparoscopic hernia repairs may make subse-
quent radical retropubic prostatectomy more hazardous. BJU Int. 2003; 91:
729.
33 Cooperberg MR, Downs TM, Carroll PR. Radical retropubic prostatectomy
frustrated by prior laparoscopic mesh herniorrhaphy. Surgery 2004; 135:
452–3.
34 Hsia M, Ponsky L, Rosenblatt S, Jones JS. Laparoscopic inguinal hernia repair
complicates future pelvic oncologic surgery. Ann. Surg. 2004; 240: 922.
35 Siddiqui SA, Krane LS, Bhandari A et al. The impact of previous inguinal or
abdominal surgery on outcomes after robotic radical prostatectomy. Urology
2010; 75: 1079–82.
36 Picozzi SC, Ricci C, Bonavina L et al. Feasibility and outcomes regarding
open and laparoscopic radical prostatectomy in patients with previous syn-
thetic mesh inguinal hernia repair: meta-analysis and systematic review of
7,497 patients. World J. Urol. 2015; 33: 59–67.
37 Hakimi AA, Rabbani F. Prostate cancer: postprostatectomy inguinal hernia:
does surgical method matter? Nat. Rev. Urol. 2011; 8: 11–3.
38 Le Page P, Smialkowski A, Morton J, Fenton-Lee D. Totally extraperitoneal
inguinal hernia repair in patients previously having prostatectomy is feasible,
safe, and effective. Surg. Endosc. 2013; 27: 4485–90.
© 2018 The Japanese Urological Association