Parastomal hernias after cystectomy and ileal conduit urinary diversion: surgical treatment and the use of prophylactic mesh: a systematic review

Laparoscopic Sugarbaker repair of parastomal hernia following radical cystectomy and ileal conduit: a single-center experience

PURPOSE

Parastomal hernia (PH) is a frequent complication following radical cystectomy and ileal conduit. The purpose of this study was to summarize the clinical experience and technical characteristics of laparoscopic Sugarbaker repair of PH following radical cystectomy and ileal conduit.

METHODS

We retrospectively evaluated all patients who underwent laparoscopic treatment of PH following radical cystectomy and ileal conduit at Huashan Hospital, Fudan University from May 2013 to December 2022.

RESULTS

Thirty-five patients were included in the study. Median follow up was 32months (IQR, 25-38 months). Three patients presented with a recurrence (8.6%), with a median time to recurrence of 14 months. Out of the 35 patients, Thirty-two underwent totally laparoscopic repair using the Sugarbaker technique, Three patients required open surgery to repair the intestinal injury after laparoscopic exploration. One patient died 9 months post-surgery due to COVID-19. During the follow-up period, two patients developed a peristomal abscess, and one patient experienced partial intestinal obstruction 10 days after surgery.

CONCLUSION

Surgical management of PH following radical cystectomy and ileal conduit is challenging. The laparoscopic Sugarbaker technique for repairing PH following radical cystectomy and ileal conduit has low complication and recurrence rate.

Perioperative and extended outcomes of patients undergoing parastomal hernia repair following cystectomy and ileal conduit

PURPOSE

To report perioperative and long-term postoperative outcomes of cystectomy patients with ileal conduit (IC) urinary diversion undergoing parastomal hernia (PSH) repair.

METHOD

We reviewed patients who underwent cystectomy and IC diversion between 2003 and 2022 in our center. Baseline variables, including surgical approach of PSH repair and repair technique, were captured. Multivariable Cox regressionanalysis was performed to test for the associations between different variables and PSH recurrence.

RESULTS

Thirty-six patients with a median (IQR) age of 79 (73-82) years were included. The median time between cystectomy and PSH repair was 30 (14-49) months. Most PSH repairs (32/36, 89%) were performed electively, while 4 were due to small bowel obstruction. Hernia repairs were performed through open (n=25), robotic (10), and laparoscopic approaches (1). Surgical techniques included direct repair with mesh (20), direct repair without mesh (4), stoma relocation with mesh (5), and stomarelocation without mesh (7). The 90-day complication rate was 28%. In a median follow-up of 24 (7-47) months, 17 patients (47%) had a recurrence. The median time to recurrence was 9 (7-24) months. On multivariable analysis, 90-day complication following PSH repair was associated with an increased risk of recurrence.

CONCLUSIONS

In this report of one of the largest series of PSH repair in the Urology literature, 47% of patients had a recurrence following hernia repair with a median follow-up time of 2 years. There was no significant difference in recurrence rates when comparing repair technique or the use of open or minimally invasive approaches.

Repair of parastomal hernia after Bricker procedure: retrospective consecutive experience of a tertiary center

BACKGROUND

Ileal conduit parastomal hernias (ICPHs) are frequent after radical cystectomy with ileal conduit urinary diversion, but their management is debated. This study aimed to review the results of ICPH repair according to Sugarbaker or Sandwich techniques, with special interest in ICPH recurrence and urological complications.

METHODS

The authors reviewed a consecutive series of patients undergoing ICPH repair between January 2014 and December 2020. Primary endpoints were ICPH recurrences at clinical exam and cross-sectional abdominal computed tomography (CT) scans. Secondary endpoints were any other complications possibly related to the ICPH repair.

RESULTS

Twenty-three patients underwent ICPH repair surgery (16 Sugarbaker and 7 Sandwich techniques) during the study period. Sixteen patients underwent a primary laparoscopic approach. All but one patient underwent at least one abdominal CT during the follow-up. Median clinical and CT scan follow-up times were 57 and 50.5 months, respectively. Clinical and CT ICPH recurrence rates were 4.5% and 13% at 5 years, respectively. Eighteen patients (78%) suffered no urological complications during the follow-up period, but three patients (13%) needed redo surgery on the urinary ileal conduit.

CONCLUSION

The modified Sugarbaker or Sandwich techniques might be considered as promising techniques for ICPH repair with a low rate of recurrence. The urological complications, and particularly the ileal conduit-related issues, need to be evaluated in further studies. Controlled and prospective data are required to compare the Sugarbaker and Sandwich techniques to the Keyhole approach for ICPH repairs.

Systematic review and meta-analysis of the incidence of incisional hernia in urological surgery

PURPOSE

To evaluate the incidence of incisional hernia in patients undergoing direct access to the abdominal cavity in urological surgery.

METHODS

We conducted a systematic review in Pubmed, Embase, and Cochrane Central from 1980 to the present according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Eighty-four studies were selected for inclusion in this analysis, and meta-analysis and meta-regression were performed.

RESULTS

The total incidence in the 84 studies was 4.8% (95% CI 3.7% - 6.2%) I2 93.84%. Depending on the type of incision, it was higher in the open medial approach: 7.1% (95% CI 4.3%-11.8%) I2 92.45% and lower in laparoscopic surgery: 1.9% (95% CI 1%-3.4%) I2 71, 85% According to access, it was lower in retroperitoneal: 0.9% (95% CI 0.2%-4.8%) I2 76.96% and off-midline: 4.7% (95% CI 3.5%-6.4%) I2 91.59%. Regarding the location of the hernia, parastomal hernias were more frequent: 15.1% (95% CI 9.6% - 23%) I2 77.39%. Meta-regression shows a significant effect in reducing the proportion of hernias in open lateral, laparoscopic and hand-assisted compared to medial open access.

CONCLUSION

The present review finds the access through the midline and stomas as the ones with the highest incidence of incisional hernia. The use of the lateral approach or minimally invasive techniques is preferable. More prospective studies are warranted to obtain the real incidence of incisional hernias and evaluate the role of better techniques to close the abdomen.

Evidence-Based Analysis of the Critical Steps of Radical Cystectomy for Bladder Cancer

Radical cystectomy (RC) is an integral part of the management of patients with advanced-stage bladder cancer. This major oncologic operation is prone to complications resulting in morbidity and mortality. We analyzed the critical steps of open RC, performed an evidence-based review of these steps, and discussed our experience and approach. We conducted a literature review of the open RC technique, identified the critical steps that consistently appeared across different sources, and organized these steps into a framework. PubMed was queried with the critical steps as keywords for relevant articles published from 1 January 2013 to 1 August 2023. We utilized this query to conduct a systematic review of the literature using the outcomes of overall survival and 90-day complication rate. We developed the "Summary for the 10 Critical Operative Steps of Radical Cystectomy", a concise guide to the approach to open RC. When available, an evidence-based analysis of each critical step was performed. We also included additional components of cystectomy optimization such as pre-habilitation in the preoperative phase, standard versus extended lymphadenectomy, the vaginal-sparing approach to female radical cystectomy, patient-reported outcomes following urinary diversion, the use of a mesh for stoma formation, and the use of the ERAS protocol for postoperative care. An evidence-based assessment of RC may help provide valuable information to optimize surgical techniques and patient outcomes.