Invited commentary: “radical retropubic prostatectomy frustrated by laparoscopic mesh herniorrhaphy”

Given the high incidence of both inguinal hernias and prostate cancer in middle-aged men, the scenario described by Cooperberg et al in their article, “Radical retropubic prostatectomy frustrated by laparoscopic mesh herniorrhaphy,” is bound to occur with increasing frequency. Laparoscopic herniorrhaphy has been shown to cause less pain and to result in a faster resumption of physical activities than open hernia repairs. ^{,  ,}  When laparoscopic herniorrhaphy is offered as an option, many educated consumers with an active lifestyle chose the laparoscopic approach. This group of patients is the same group that would be likely to opt for nerve-sparing radical prostatectomy (NSRP) if they had early-stage prostate cancer. Hence, the dilemma posed in this article is real. We can assume from past experience that open hernia repairs that place mesh into the preperitoneal space (the so called “plug and patch” repairs) do not interfere with performance of NSRP. In these repairs, however, the preperitoneal portion of the mesh does not impinge on the midline, nor should it lie much deeper than Cooper's ligament. In the case reported by Cooperberg et al, a large sheet of mesh had been used to repair bilateral hernias. This is a technique that would be used by only a minority of surgeons, rather most surgeons would use 2 separate pieces of mesh, thus leaving the midline free. In my own hospital's experience, laparoscopic hernia repairs have not prevented the performance of NSRP, open or laparoscopically. There is no question, however, that the previous laparoscopic herniorrhaphy makes the prostatectomy more difficult. In their article, Cooperberg et al properly suggest several key technical details regarding mesh placement that may mitigate the problems that are caused by scarring in the preperitoneal space. Their suggestions should be followed carefully. Most importantly, the issue of informed consent should include the potential for limiting a patient's options for treating prostate cancer in the future when they opt for a laparoscopic hernia repair. I believe that as experience is gained with laparoscopic prostatectomy, the benefits of higher magnification and meticulous hemostasis may lead to peaceful coexistence of NSRP and laparoscopic hernia repairs.