Clinical – anatomical justification of the one-stage retropubic prostatectomy and simultaneous preperitoneal hernioplasty in patients with benign prostatic hyperplasia and inguinal hernia

Abstract

Introduction. Among the complex and unresolved issues of urology and herniology, simultaneous operations for benign prostatic hyperplasia and inguinal hernia occupy a significant place. Inguinal hernias are often found in patients undergoing surgery for benign prostatic hyperplasia, inguinal hernias also often occur after prostatectomy. The presence of an inguinal hernia impairs the quality of life of patients suffering from benign prostatic hyperplasia and carries a potential threat of entrapment. Hernioplasty in a patient with benign prostatic hyperplasia can be complicated by urinary retention in the postoperative period. Therefore, the possibility of one-time simultaneous hernioplasty during prostatectomy for benign prostatic hyperplasia is an urgent issue in both urology and abdominal surgery. The aim of the work: To substantiate the feasibility of using one-moment retropubic prostatectomy and simultaneous pre-peritoneal inguinal hernioplasty from the standpoint of the clinical and anatomical structure of the retropubic space and the back wall of the inguinal canal, as well as to study the factors that affect the occurrence of inguinal hernias after prostatectomy. Research methodology and methods. To substantiate the expediency of retropubic prostatectomy and simultaneous pre-peritoneal hernioplasty, the distance from the middle of the cystic-prostatic junction to the middle of the opening of the direct and indirect inguinal hernias was determined during the operation after removal of the hernia sac from the right and left sides. All simultaneous retropubic prostatectomies and simultaneous hernioplasty were performed from a transverse suprapubic approach, its length varied from 15 to 20 cm depending on the patient's constitution. 36 simultaneous hernioplasty operations were performed on 32 patients (hernioplasty was performed on both sides in 4 cases): an inguinal hernia was detected on the right side in 20 cases, and on the left side in 16 cases. Research results and discussions. The average distance from the middle of the cystic-prostatic junction to the middle of the direct hernia opening was 7.7 ± 1.2 cm on the right side and 7.9 ± 1.1 cm on the left side; the average distance from the middle of the cystic-prostatic junction to the middle of the indirect hernia opening was 11.8 ± 1.4 cm on the right side and 11.6 ± 1.6 cm on the left side. It was established that the operative zones of retropubic prostatectomy and simultaneous pre-peritoneal inguinal hernioplasty are located next to each other, and the maximum distance between them does not exceed 12 cm. The analysis of the literature and our own clinical and anatomical studies made it possible to identify the following anatomical factors of the occurrence of inguinal hernia after prostatectomy: dissection and stretching of the transverse fascia with mirrors, trauma to the muscles of the anterior-lateral wall of the abdomen and a decrease in their tone and sphincter function around the inguinal canal, cicatricial changes in the cystic-prostatic segment with tension in the abdominal part of the vas deferens and expansion of the internal inguinal ring and vaginal process of the peritoneum, straining during urination with an increase intra-abdominal pressure and weakening of the transverse fascia and muscle-aponeurotic structures of the inguinal area, age-related hormonal deficiency. Conclusions. A significant percentage of the formation of inguinal hernias after prostatectomy is associated with anatomical changes that occur after prostatectomy in this area. The close location of the intraoperative zone of prostatectomy to the zone of hernioplasty requires simultaneous pre-peritoneal hernioplasty of not only obvious, but also hidden (occult) inguinal hernias, as well as inguinal hernias in the initial stages of their formation during prostatectomy in patients with benign prostatic hyperplasia and inguinal hernia.