The relationship between inguinal hernia and minimally-invasive surgery for prostate cancer: A systematic review of the literature | Actas Urológicas Españolas (English Edition)

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Puche-Sanz, A. Rodríguez-Martínez, M.C. Garrido-Navas, I. Robles-Fernández, F. Vázquez-Alonso, M.J. Álvarez Cubero, J.A. Lorente-Acosta, M.J. Serrano-Fernández, J.M. Cózar-Olmo" "autores" => array:9 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Puche-Sanz" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Rodríguez-Martínez" ] 2 => array:2 [ "nombre" => "M.C." "apellidos" => "Garrido-Navas" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Robles-Fernández" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Vázquez-Alonso" ] 5 => array:2 [ "nombre" => "M.J." "apellidos" => "Álvarez Cubero" ] 6 => array:2 [ "nombre" => "J.A." "apellidos" => "Lorente-Acosta" ] 7 => array:2 [ "nombre" => "M.J." "apellidos" => "Serrano-Fernández" ] 8 => array:2 [ "nombre" => "J.M." 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Bertolo, M.C. Mir Maresma, P. Bove, J. Rubio-Briones, M. Ramírez-Backhaus" "autores" => array:5 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Bertolo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "M.C." "apellidos" => "Mir Maresma" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Bove" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Rubio-Briones" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:4 [ "nombre" => "M." "apellidos" => "Ramírez-Backhaus" "email" => array:1 [ 0 => "ramirezfivo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "San Carlo di Nancy Hospital, Rome, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department de Urología, Fundación IVO, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La relación entre hernia inguinal y cirugía mínimamente invasiva para el cáncer de próstata: revisión sistemática de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 376 "Ancho" => 1250 "Tamanyo" => 74333 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Persistence of the vaginal peritoneal duct and indirect right vesico-inguinal hernia objectified during a laparoscopic radical prostatectomy with transperitoneal access. B) Bilateral direct subclinical inguinal hernia." ] ] ] "textoCompleto" => "IntroductionBoth prostate cancer (PCa) and inguinal hernia are high prevalence and incidence diseases. PCa has an incidence of 130 cases per 100,000 population per year and it is the second leading cause of cancer death in men after lung cancer.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> On the other hand, the frequency of inguinal hernia is supposed to be high but difficult to estimate. Its surrogate can be the number of surgical interventions for hernia repair. Actually, it underestimates the real prevalence. To give an idea of the numbers of the disease, 100 herniorrhaphies/plasties per 100,000 population (including women) in the United Kingdom to 280 cases per 100,000 population in the United States are yearly performed.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The high frequency of PCa and inguinal hernia implies that many patients will be affected by both the diseases either synchronously or metachronously.Indeed, Marien et al. estimated that up to 50% of patients who undergo radical prostatectomy for PCa will be diagnosed with inguinal hernia, diagnosed by either physical examination or preoperative magnetic resonance imaging.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Radical prostatectomy is the preferred treatment for localized PCa.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> During the surgical steps performed during the standard intervention (regardless of the open retropubic, laparoscopic or robotic approach), the Retzius space, a virtual cavity located between the parietal peritoneum, the posterior fascia of the transverse, and the anterior recti will be violated. This undoubtedly modifies and weakens the posterior aspect of the abdominal wall and specifically the internal inguinal orifice. As such, in a single-institutional retrospective analysis, Chang et al. found that Retzius-Sparing robot-assisted radical prostatectomy (the so called “Bocciardi approach”<a class="elsevierStyleCrossRef" href="#bib0025">5</a>) carries a lower incidence of inguinal hernia after surgery if compared to the standard transperitoneal robot-assisted approach.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>On the other hand, the only curative treatment for inguinal hernia is surgery. The available techniques are classified into two groups: the herniorrhaphies (without prosthesis) and the hernioplasties (with mesh). For hernia repair surgeries as well, the approach may be open (either anterior or posterior), posterior endoscopic or posterior laparoscopic.The matured experiences suggest that a conflict exists between the hernioplasties performed by posterior approach and radical prostatectomy. This is because the scarring and the fibrosis promoted after the mesh placement are able to compromise the feasibility and the outcomes of radical prostatectomy.The convenience and safety of combined prostatectomy and hernioplasty, the incidence of hernias after prostatectomy and the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty are clinical scenarios still debated. We therefore performed a systematic review of the literature aimed to improve the knowledge in the field. Specifically, the review was focused on the convenience and safety of combined prostatectomy and hernioplasty; the incidence of inguinal hernia after prostatectomy; and the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty.Materials and methodsEvidence acquisitionA systematic review of the literature was performed as of May 5th 2018. A specific search on PubMed and Embase databases included dedicated search strings ("Prostatic Neoplasms/surgery"[Mesh] AND "Hernia, Inguinal" [Mesh]), limited to articles in English language. All studies reporting data of interest were collected. Editorials, commentaries, abstracts, reviews, book chapters, and studies reporting experimental studies on animal or cadaver were excluded from the review.Two of the Authors (M.R.B and F.C.T) independently reviewed the literature according to the inclusion and exclusion criteria. A full text analysis was performed to confirm inclusion of screened abstracts. Additional studies of interest were included if found in the references of selected articles. All disagreement about eligibility were resolved by a discussion with R.B until a consensus was reached. This study was performed using guidelines set out by PRISMA (Preferred Reporting Items for Systematic Reviews and meta-analysis statement).<a class="elsevierStyleCrossRef" href="#bib0035">7</a> All the papers extracted were distinguished according to the 2011 Oxford Centre for Evidence-based Medicine level of evidence for therapy studies.ResultsEvidence synthesisA total of 65 papers were extracted after the systematic review of the literature. The PRISMA flow diagram is reported in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Pooled literature was grouped to respond to the three issues aim of the present study, namely 1) the convenience and safety of combined prostatectomy and hernioplasty; 2) the incidence of inguinal hernia after prostatectomy; 3) the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty.Convenience and safety of combined prostatectomy and hernioplastyTwenty-five of the included studies reported about the feasibility and the outcomes of combined surgery for PCa and hernia repair.The first available reference of combined hernioplasty and prostatectomy was described by Schegel and Walsh in 1987.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Later, we find a case series starting in 1999,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> with the first description performed by laparoscopic approach being in 2001<a class="elsevierStyleCrossRef" href="#bib0050">10</a> (Supplementary <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).In the case-control study by Celik et al., 20 patients who underwent combined laparoscopic surgery were compared to 40 controls. In the 50% of the cases, pelvic lymph-nodes dissection was performed. No significant differences were observed in operative time and complications. No lymphoceles were observed.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Unfortunately, the authors did report neither follow-up data nor extension of the lymph-nodes dissection.Gozen et al. analysed the pain within the first 7 days after laparoscopic prostatectomy combined to hernioplasty and compared the data with a control group. The mean VAS score reported by the patients with mesh was 5.65 versus 4.98 in the controls.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> The authors concluded that the differences were not statistically significant (p = 0.06) and undervalued the clinical interest of 0.67 points of mean VAS score difference. Moreover, the same group had previously reported that the use of morphine derivatives was significantly higher in patients receiving hernioplasty with mesh (26.8 mg versus 17.5 mg, p = 0.026).<a class="elsevierStyleCrossRef" href="#bib0065">13</a>A consistent series was described by Do et al.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> They selected 93 patients who received laparoscopic prostatectomy associated with the correction of inguinal hernia. They reported an operative time averaging 150 min. A retroperitoneal hematoma treated in a conservative fashion and 3 symptomatic lymphoceles requiring percutaneous drainage were reported. No infections were observed. No differences were found in the need for transfusions and conversions to open surgery.All authors agreed that combined surgery is feasible and the increase in the complications rate is negligible.Similarly, in a recent non-systematic review, authors reported that the repair of inguinal hernias at the time of robotic radical prostatectomy is safe, feasible, and associated with low recurrence rates.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>However, we have some concerns regarding the combination of lymph-nodes dissection and the placement of a mesh in the same surgical space. Guidelines recommend an extended lymph-nodes dissection when lymph-nodes dissection is indicated. In recent years, due to the increasing number of patients with low-risk PCa counselled to active surveillance,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> together with the growing interest in focal therapy for PCa, the majority of prostatectomies are performed in patients with intermediate-high risk PCa. Such patients should receive prostatectomy combined with an extended lymph-nodes dissection. The incidence of lymphoceles at follow-up exceeds the 50% of the cases,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> even if the majority remains asymptomatic. The occurrence of infections is consistent, particularly when the urethro-vesical anastomosis is not watertight. The management consists of laparoscopic marsupialization or puncture. The presence of a mesh placed after hernioplasty concomitant to extended lymph-nodes dissection will not increase the occurrence of lymphocele. On the other side, when lymphocele is developed, the presence of a mesh will undoubtedly increase the troubles in the management.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Such issue was raised by Mourmouris et al. who postulated the possibility of correcting the hernia without using a mesh. At a median follow-up of 32 months, no recurrences were observed in their series of 29 patients who underwent hernia repair without mesh.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> In our experience, we consider the inguinal hernia repair at the time of prostatectomy when an extra-peritoneal approach is chosen and when lymph-nodes dissection is not indicated. In any case, the patient has to be accurately informed of the benefits and the risks of a combined surgery.Incidence of inguinal hernia after prostatectomyEighteen studies addressing the incidence of inguinal hernia after radical prostatectomy were analysed. Articles by the same groups were excluded.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a>Finally, a review,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> a meta-analysis,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> an epidemiological study<a class="elsevierStyleCrossRef" href="#bib0110">22</a> and 13 original articles were considered. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> reported the comparative studies available on the topic.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Regal et al. first reported in 1996 the potentially increased occurrence of inguinal hernias after prostatectomy. In their case-series 11 out of 92 patients (12%) who underwent radical prostatectomy had an inguinal hernia. Most of the hernias were indirect. The median time to diagnosis was 6 months.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Sun and colleagues compared 5478 patients who underwent prostatectomies with a control group of patients who did not. They observed that the 5-years and 10-years cumulative incidence of hernioplasty among patients who underwent prostatectomy was 11.7% and 17.1%, respectively. According to their data, radical prostatectomy doubles up the risk of receiving a hernioplasty in the follow-up.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>Lughezzani et al. evaluated a cohort of 11,107 PCa patients who underwent prostatectomy or radiotherapy. The risk of developing post-treatment hernia was 2.26 folds higher after prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Stranne and co-workers published several studies.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19,26–28</a> In their latest work they compared extra-peritoneal open vs transperitoneal robotic approach to prostatectomy vs a control group.The 4-years cumulative incidence of postoperative hernia was 12.2% after open (95% CI 9.0–16.4%), 5.8% (95% CI 4.0–8.3%) after robotics and 2.6% (95% CI 1.3–5.1%) in controls. The risk of developing postoperative hernia was 1.7 folds higher in patients who underwent open surgery.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>In the field of laparoscopy, the comparison between extra-peritoneal and transperitoneal approach is thought provoking.Lin et al. reported a lower risk of hernia development after transperitoneal approach, even if the difference was not statistically significant (HR 0.63, 95% CI 0.19–2.05, p = 0.44).<a class="elsevierStyleCrossRef" href="#bib0145">29</a> By contrast, Yoshimine et al. found the extraperitoneal approach sponsoring the occurrence of postoperative inguinal hernias (HR = 3.12, 95% CI 1.04–9.42).<a class="elsevierStyleCrossRef" href="#bib0150">30</a>With the advent of robotics, in a single-institutional retrospective analysis, Chang and co-workers found Retzius-sparing robotic prostatectomy lowering the incidence of inguinal hernia after surgery compared to the standard transperitoneal robotic approach.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Yamada et al. published a series of 307 consecutive men who underwent robotic prostatectomy. Incidence of inguinal hernia was 11.3, 14.0, and 15.4% at 1, 2, and 3 years after surgery, respectively. The occurrence of postoperative inguinal hernia was significantly associated with low surgeon experience and post-prostatectomy incontinence.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>In a recent meta-analysis, Zhu et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> evaluated >12,000 patients with PCa. They calculated a 15.9% (95% CI 13.1–18.7) and 6.7% (95% CI 4.8–8.6) overall probability of hernia occurrence after retropubic and laparoscopic prostatectomy, respectively. The authors underlined that the majority of the data was pooled from retrospective series. Moreover, concerns were raised about a mixed data collection from patients’ surveys, cross-check from operative room records or review of clinical histories. On the other hand, the median follow-up in the studies included in the review ranged from 17 to 120 months.Some authors investigated which circumstances are associated with the occurrence of postoperative hernia. Namely they have been reported to be a previous hernioplasty<a class="elsevierStyleCrossRefs" href="#bib0160">32,33</a> or abdominal surgery,<a class="elsevierStyleCrossRefs" href="#bib0135">27,34</a> the increased age<a class="elsevierStyleCrossRefs" href="#bib0135">27,32,33,35</a> and the low body mass index.<a class="elsevierStyleCrossRefs" href="#bib0130">26,33,35,36</a> The stenosis of the urethro-vesical anastomosis and the consequent increased intra-abdominal pressure generated for micturition has also been related to the eventual appearance of postoperative hernias.<a class="elsevierStyleCrossRefs" href="#bib0090">18,32,33,36</a>In our experience, factors particularly associated with the development of inguinal hernias requiring surgical correction after radical prostatectomy are an extra-peritoneal approach (either open or laparoscopic) and the persistence of the vaginal peritoneal duct (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A, B), confirming previous findings.<a class="elsevierStyleCrossRefs" href="#bib0070">14,33,34</a> In a series of 205 patients treated by robotic surgery, Lee et al. reported an increased risk of developing post-prostatectomy hernia in patients with persistence of the vaginal peritoneal duct.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> On the other hand, in a multivariable analysis Yoshimine and colleagues reported that the extra-peritoneoscopic approach was the only predictor (HR = 3.12; C.I 95% 1.04–9.42, p = 0.04).<a class="elsevierStyleCrossRef" href="#bib0150">30</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Koie et al. proposed a retro-pubic, mini-laparotomic surgery assisted by a laparoscopic endoscope to reduce the occurrence of hernias.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Another group indicated the preservation of the space of Retzius able to significantly reduce the incidence of hernias.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Sakai et al. and the group of Kanda et al. suggested that a blunt dissection of the parietal peritoneum of the internal inguinal orifice would reduce the likelihood of hernias.<a class="elsevierStyleCrossRefs" href="#bib0190">38,39</a> Fujii et al. proposed the ligation of the peritoneal-vaginal duct<a class="elsevierStyleCrossRef" href="#bib0200">40</a> and Stranne et al. the closure by suture of the internal inguinal orifice.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>In summary, minimizing the dissection between the parietal peritoneum and the transverse muscle fascia, between the parietal peritoneum and the spermatic cord and consequently the peritoneum and the internal inguinal orifice might reduce the occurrence of hernias. The occurrence of inguinal hernia after prostatectomy has a multifactorial, complex aetiology. To suggest a universal strategy able to minimize the risk of postoperative hernia is unrealistic. The use of prophylactic meshes at the time of prostatectomy in all patients is not justified and considered to be an overtreatment. On the other hand, in an interesting work, Marien et al. published a series of 178 patients with a 52% rate of inguinal hernia after prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The authors underlined how the use of accurate physical examination, ultrasound with abdominal press, and magnetic resonance imaging allows to reduce the misdiagnosis.Impact of previous laparoscopic or open posterior hernioplasty during radical prostatectomyLaparoscopic or open posterior approach to hernia repair is an anatomical, intuitive, elegant and attractive procedure for most surgeons. Regardless the approach, the creation of a virtual space is necessary, namely the separation of the parietal peritoneum from the fascia of the anterior rectus muscle and the transverse muscle, in addition to the cord itself and the iliac vessels. In the most medial portion, the bladder will be separated from the pubic symphysis and the anterior rectus muscle. The reduction of the sac is continued with the placement of the mesh, aimed to obliterate the defect and to prevent the recurrence of direct or indirect hernia. However, regardless of the material used, local scar adhesion and subsequent fibrosis of the tissues will occur. The parietal peritoneum and the anterior aspect of the bladder will be fixed to the posterior fascia of the obliques and the bladder will adhere to the pubic symphysis and the anterior rectus muscle. In addition, the most lateral portions of the external iliac vessels (both the artery and the vein) will be involved in such fibrosis. In summary, after violation of the Retzius space, a secondary access to the prostate will be more challenging.We found a total of 13 original articles and 1 meta-analysis about the topic. Borchers et al. in 2001 described and recommended the perineal approach for prostatectomy in patients who previously received bilateral inguinal mesh (Supplementary Table 1).<a class="elsevierStyleCrossRef" href="#bib0205">41</a>One year later, Katz and colleagues published two “aborted” retropubic prostatectomies in patients with mesh. This article generated an intense debate regarding the troubles with prostatectomy in patients who underwent previous laparoscopic hernioplasty. Many of the authors stated that, in such cases, prostatectomy should be proscribed, favouring radiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0210">42–44</a> The first two cases described in which radical prostatectomy could be completed in patients who previously underwent laparoscopic hernioplasty were published by Brown and Dahl.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> A transperitoneal laparoscopic approach was used.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>Stolzenburg et al. published a comparative study including 9 patients who underwent previous laparoscopic hernioplasty. Operative time was longer and they did not perform lymph-nodes dissection in such patients.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> Immediately after, the Heidelberg group published 20 cases demonstrating the feasibility of prostatectomy even after hernioplasty, although longer operative time and more consistent use of analgesics were reported.<a class="elsevierStyleCrossRef" href="#bib0235">47</a>In a recent meta-analysis of 11 studies comparing a total of 462 patients after laparoscopic mesh hernioplasty who underwent radical prostatectomy versus a control group of 1540 cases (5 studies about open radical prostatectomy, 3 about laparoscopy and 3 about robotic surgery), no differences were found in operative time and blood losses. On the other hand, patients with mesh were less likely to receive lymph-nodes dissection. Finally, a subgroup analysis found a prolonged catheterization time in the patients who had mesh.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> No data regarding differences in cancer control are available, even if it is reasonable to expect no differences.A currently FDA approved single-port purpose-built robotic platform has been tested in the pre-clinical setting, showing the possibility to widen the access routes to the prostate.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> Interestingly, trans-perineal radical prostatectomies, radical cystectomies with pelvic lymph-nodes dissection and trans-vesical radical/partial prostatectomies have been performed on cadaver models by using this novel device.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> The advantages of trans-perineal or trans-vesical access to both cystectomy and prostatectomy are potentially promising in the subset of patients who previously received hernioplasty with mesh.It is not reliable to obtain solid conclusions from the studies addressing the feasibility of prostate surgery in patients with subsequent corrections of inguinal hernias. The results are heterogeneous. The learning curve counts in this issue. As such, the first experiences were proscribing prostatectomy,<a class="elsevierStyleCrossRefs" href="#bib0255">51–53</a> whilst the later series considered it feasible, even including a lymphadenectomy.<a class="elsevierStyleCrossRef" href="#bib0270">54</a> The reader should note that the authors who published the feasibility of prostatectomy in patients with mesh had consistent experience.<a class="elsevierStyleCrossRefs" href="#bib0230">46,47</a> Moreover, the risk of a tendency to publish only when the surgical outcomes are satisfactory is unmeasurable.There is consensus that prostatectomy after previous hernioplasty with mesh is a challenging procedure, with longer operative time and higher risk of complications, including peritoneal perforations, bladder injuries, prolonged bladder atony, troubles in the anastomosis and limitations in lymph-nodes dissection. In addition, in the case of muscle-invasive bladder cancer with indication to radical cystectomy, the presence of meshes in the Retzius space could itself influences the oncological safety of the procedure.In our unpublished experience, the data from previous studies are corroborated. In patients who received mesh for hernioplasty, radical prostatectomy is feasible, but the access to the prostate is complex, with longer operative time, limited space and the need for reconstruction of the Retzius space after prostatectomy aimed to avoid contact of the polypropylene mesh with the bowel loops. In case of mesh and indication to lymph-nodes dissection, the authors of the present review avoid the ipsilateral lymph-nodes dissection. The risk of vascular injury in case of a mesh adhered to the external iliac artery does not justify, in our opinion, the actual oncological benefit of lymph-nodes dissection. We believe that the literature supports the one-stage combined intervention for patients suffering from both inguinal hernia and PCa amenable of radical prostatectomy. Based on the few available literature evidences, the combined treatment should not be recommended when lymph-nodes dissection for PCa is indicated and in cases of positive hydro-distress test of the urethro-vesical anastomosis. In any case, accurate patient’s counselling and dedicated consent forms are mandatory, in the setting of an experienced multidisciplinary team. Approximately 15% of the patients undergoing standard retro-pubic radical prostatectomy will develop inguinal hernia. It is possible that the incidence is lower for laparoscopic prostatectomies and much lower after transperitoneal approach. The median time to the appearance of the hernia is 6 months. It is possible that limiting the dissection of the parietal peritoneum of the transverse muscles reduces the risk of hernia development. However, this could be detrimental during a challenging procedure such as radical prostatectomy and should not compromise the oncological goal of the intervention. Previous laparoscopic or open posterior hernioplasty does not preclude further pelvic surgery but could increase the difficulty of the procedure. As such, screening for pelvic cancers (both prostate and bladder cancer), particularly in patients at higher risk, would be recommended prior to indiscriminately proceed to surgery for hernia repair.Conflict of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1330669" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Background" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1226032" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1330668" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Contexto" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1226033" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Evidence acquisition" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Evidence synthesis" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Convenience and safety of combined prostatectomy and hernioplasty" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Incidence of inguinal hernia after prostatectomy" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Impact of previous laparoscopic or open posterior hernioplasty during radical prostatectomy" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-28" "fechaAceptado" => "2019-10-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1226032" "palabras" => array:6 [ 0 => "Inguinal hernia" 1 => "Prostate cancer" 2 => "Radical prostatectomy" 3 => "Laparoscopy" 4 => "Hernioplasty" 5 => "Surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1226033" "palabras" => array:6 [ 0 => "Hernia inguinal" 1 => "Cáncer de próstata" 2 => "Prostatectomía radical" 3 => "Laparoscopia" 4 => "Hernioplastia" 5 => "Cirugía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveWe aimed to perform a systematic review about the relationship between inguinal hernia and surgery for prostate cancer. BackgroundDiagnosis of abdominal wall defects and prostate cancer may be either synchronous or metachronous. The convenience and safety of combined prostatectomy and hernioplasty, the incidence of hernias after prostatectomy and the feasibility of prostatectomy in patients with previous laparoscopic hernioplasty are still debated. MethodsPubMed and Embase were queried by dedicated search strings. Two researchers independently reviewed the pooled references and selected the articles of interest, including reviews. ResultsSixty-five studies were evaluated. 22 studies analysed the feasibility and the outcomes of a combined surgery, namely one-stage radical prostatectomy and herniorrhaphy or hernioplasty. Literature evidences support the combined intervention to patients suffering from an inguinal hernia and a prostate cancer amenable of radical prostatectomy. 16 studies addressing the potential increase in the occurrence of inguinal hernia after radical prostatectomy were evaluated. Approximately 15% of patients who undergo retro-pubic radical prostatectomy will develop inguinal hernia. It is suggested that the incidence might be lower in laparoscopic prostatectomy series, particularly in case of transperitoneal approach. The median time to the appearance of the hernia is around 6 months. After evaluation of 14 studies, it is concluded that laparoscopic hernioplasty does not preclude prostatectomy but hinders further pelvic surgery. ConclusionsOne-stage combined hernioplasty and radical prostatectomy may be accepted except in cases of lymph-nodes dissection and/or positive hydro-distress test of the urethro-vesical anastomosis. Accurate patient’s counselling and dedicated consent form are mandatory, in the setting of an experienced multidisciplinary team." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Background" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoHemos realizado una revisión sistemática sobre la relación entre la hernia inguinal yla cirugía para el cáncer de próstata. ContextoEl diagnóstico de defectos de la pared abdominal y el cáncer de próstata puedesuceder de manera sincrónica o metacrónica. La utilidad y seguridad de la cirugía combinada, laincidencia de hernias tras la cirugía prostática y la viabilidad de la prostatectomía en pacientescon hernioplastia laparoscópica previa siguen siendo debatidas hoy en día. MétodosSe consultaron PubMed y Embase con los textos de búsqueda correspondientes. Demanera independiente, 2 investigadores revisaron las referencias bibliográficas y seleccionaronlos artículos de interés, incluyendo revisiones. ResultadosSe evaluaron 65 estudios, 22 de los cuales analizan la viabilidad y los resultadosde una cirugía combinada (prostatectomía radical y herniorrafia o hernioplastia en un mismoacto quirúrgico). La bibliografía respalda la intervención combinada en pacientes que padecenuna hernia inguinal y un cáncer de próstata subsidiario de prostatectomía radical. Se evaluaron16 estudios que abordan el potencial incremento de las hernias inguinales tras una prostatec-tomía radical. Aproximadamente un 15% de los pacientes que reciben prostatectomía radicalretropúbica clásica desarrollarán hernias inguinales. Es posible que esta incidencia se vea redu-cida en la prostatectomía laparoscópica, y probablemente sea menor aún con el abordajetransperitoneal. El tiempo medio hasta la aparición de la hernia es de alrededor de 6 meses.Tras la evaluación de 14 estudios, se concluye que la hernioplastia laparoscópica no imposibilitala prostatectomía, pero dificulta la cirugía pélvica ulterior. ConclusionesLa hernioplastia y la prostatectomía radical combinadas en un mismo acto quirúr-gico son aceptables, excepto en el caso de estar indicada la linfadenectomía o si la anastomosisuretrovesical no queda estanca a la hidrodistensión intraoperatoria. El asesoramiento adecuado del paciente y el formulario de consentimiento informado son obligatorios en el marco de unequipo multidisciplinario experimentado." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Contexto" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bertolo R, Mir Maresma MC, Bove P, Rubio-Briones J, Ramírez-Backhaus M. La relación entre hernia inguinal y cirugía mínimamente invasiva para el cáncer de próstata: revisión sistemática de la literatura. Actas Urol Esp. 2020;44:131–138." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1529 "Ancho" => 2083 "Tamanyo" => 198012 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "PRISMA flow diagram." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 376 "Ancho" => 1250 "Tamanyo" => 74333 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Persistence of the vaginal peritoneal duct and indirect right vesico-inguinal hernia objectified during a laparoscopic radical prostatectomy with transperitoneal access. B) Bilateral direct subclinical inguinal hernia." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Lap, Laparoscopic; n.s, not significant; HR, Hazard Ratio; RRP, retropubic radical prostatectomy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comparison between surgical approaches \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Higher incidence with \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Differences \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lin et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lap extraperitoneal vs Lap transperitoneal</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lap transperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yoshimine et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lap extraperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HR = 3,1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abe et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RRP vs Lap transperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open extraperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n.s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stranne et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RRP vs Robotic transperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open extraperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HR = 1,86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Matsubara et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RRP vs Perineal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open extraperitoneal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HR = 5,56 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2280553.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Available studies comparing different surgical approaches to radical prostatectomy and the incidence of inguinal hernia." ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 78493 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:54 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The impact of underreported Veterans Affairs data on national cancer statistics: analysis using population-based SEER registries" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N. 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The relationship between inguinal hernia and minimally-invasive surgery for prostate cancer: A systematic review of the literature

La relación entre hernia inguinal y cirugía mínimamente invasiva para el cáncer de próstata: revisión sistemática de la literatura

R. Bertoloa, M.C. Mir Maresmab, P. Bovea, J. Rubio-Brionesb, M. Ramírez-Backhausb,

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ramirezfivo@gmail.com

Corresponding author.

a San Carlo di Nancy Hospital, Rome, Italy

b Department de Urología, Fundación IVO, Valencia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Both prostate cancer &#40;PCa&#41; and inguinal hernia are high prevalence and incidence diseases&#46; PCa has an incidence of 130 cases per 100&#44;000 population per year and it is the second leading cause of cancer death in men after lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the other hand&#44; the frequency of inguinal hernia is supposed to be high but difficult to estimate&#46; Its surrogate can be the number of surgical interventions for hernia repair&#46; Actually&#44; it underestimates the real prevalence&#46; To give an idea of the numbers of the disease&#44; 100 herniorrhaphies&#47;plasties per 100&#44;000 population &#40;including women&#41; in the United Kingdom to 280 cases per 100&#44;000 population in the United States are yearly performed&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The high frequency of PCa and inguinal hernia implies that many patients will be affected by both the diseases either synchronously or metachronously&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Indeed&#44; Marien et al&#46; estimated that up to 50&#37; of patients who undergo radical prostatectomy for PCa will be diagnosed with inguinal hernia&#44; diagnosed by either physical examination or preoperative magnetic resonance imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Radical prostatectomy is the preferred treatment for localized PCa&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> During the surgical steps performed during the standard intervention &#40;regardless of the open retropubic&#44; laparoscopic or robotic approach&#41;&#44; the Retzius space&#44; a virtual cavity located between the parietal peritoneum&#44; the posterior fascia of the transverse&#44; and the anterior recti will be violated&#46; This undoubtedly modifies and weakens the posterior aspect of the abdominal wall and specifically the internal inguinal orifice&#46; As such&#44; in a single-institutional retrospective analysis&#44; Chang et al&#46; found that Retzius-Sparing robot-assisted radical prostatectomy &#40;the so called &#8220;Bocciardi approach&#8221;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41; carries a lower incidence of inguinal hernia after surgery if compared to the standard transperitoneal robot-assisted approach&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; the only curative treatment for inguinal hernia is surgery&#46; The available techniques are classified into two groups&#58; the herniorrhaphies &#40;without prosthesis&#41; and the hernioplasties &#40;with mesh&#41;&#46; For hernia repair surgeries as well&#44; the approach may be open &#40;either anterior or posterior&#41;&#44; posterior endoscopic or posterior laparoscopic&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The matured experiences suggest that a conflict exists between the hernioplasties performed by posterior approach and radical prostatectomy&#46; This is because the scarring and the fibrosis promoted after the mesh placement are able to compromise the feasibility and the outcomes of radical prostatectomy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The convenience and safety of combined prostatectomy and hernioplasty&#44; the incidence of hernias after prostatectomy and the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty are clinical scenarios still debated&#46; We therefore performed a systematic review of the literature aimed to improve the knowledge in the field&#46; Specifically&#44; the review was focused on the convenience and safety of combined prostatectomy and hernioplasty&#59; the incidence of inguinal hernia after prostatectomy&#59; and the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evidence acquisition</span><p id="par0040" class="elsevierStylePara elsevierViewall">A systematic review of the literature was performed as of May 5th 2018&#46; A specific search on PubMed and Embase databases included dedicated search strings &#40;&#34;Prostatic Neoplasms&#47;surgery&#34;&#91;Mesh&#93; AND &#34;Hernia&#44; Inguinal&#34; &#91;Mesh&#93;&#41;&#44; limited to articles in English language&#46; All studies reporting data of interest were collected&#46; Editorials&#44; commentaries&#44; abstracts&#44; reviews&#44; book chapters&#44; and studies reporting experimental studies on animal or cadaver were excluded from the review&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Two of the Authors &#40;M&#46;R&#46;B and F&#46;C&#46;T&#41; independently reviewed the literature according to the inclusion and exclusion criteria&#46; A full text analysis was performed to confirm inclusion of screened abstracts&#46; Additional studies of interest were included if found in the references of selected articles&#46; All disagreement about eligibility were resolved by a discussion with R&#46;B until a consensus was reached&#46; This study was performed using guidelines set out by PRISMA &#40;Preferred Reporting Items for Systematic Reviews and meta-analysis statement&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> All the papers extracted were distinguished according to the 2011 Oxford Centre for Evidence-based Medicine level of evidence for therapy studies&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evidence synthesis</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 65 papers were extracted after the systematic review of the literature&#46; The PRISMA flow diagram is reported in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Pooled literature was grouped to respond to the three issues aim of the present study&#44; namely 1&#41; the convenience and safety of combined prostatectomy and hernioplasty&#59; 2&#41; the incidence of inguinal hernia after prostatectomy&#59; 3&#41; the feasibility of prostatectomy in patients who previously underwent laparoscopic hernioplasty&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Convenience and safety of combined prostatectomy and hernioplasty</span><p id="par0060" class="elsevierStylePara elsevierViewall">Twenty-five of the included studies reported about the feasibility and the outcomes of combined surgery for PCa and hernia repair&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The first available reference of combined hernioplasty and prostatectomy was described by Schegel and Walsh in 1987&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Later&#44; we find a case series starting in 1999&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> with the first description performed by laparoscopic approach being in 2001<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> &#40;Supplementary <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the case-control study by Celik et al&#46;&#44; 20 patients who underwent combined laparoscopic surgery were compared to 40 controls&#46; In the 50&#37; of the cases&#44; pelvic lymph-nodes dissection was performed&#46; No significant differences were observed in operative time and complications&#46; No lymphoceles were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Unfortunately&#44; the authors did report neither follow-up data nor extension of the lymph-nodes dissection&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Gozen et al&#46; analysed the pain within the first 7 days after laparoscopic prostatectomy combined to hernioplasty and compared the data with a control group&#46; The mean VAS score reported by the patients with mesh was 5&#46;65 versus 4&#46;98 in the controls&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The authors concluded that the differences were not statistically significant &#40;p&#8239;&#61;&#8239;0&#46;06&#41; and undervalued the clinical interest of 0&#46;67 points of mean VAS score difference&#46; Moreover&#44; the same group had previously reported that the use of morphine derivatives was significantly higher in patients receiving hernioplasty with mesh &#40;26&#46;8&#8239;mg versus 17&#46;5&#8239;mg&#44; p&#8239;&#61;&#8239;0&#46;026&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">A consistent series was described by Do et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> They selected 93 patients who received laparoscopic prostatectomy associated with the correction of inguinal hernia&#46; They reported an operative time averaging 150&#8239;min&#46; A retroperitoneal hematoma treated in a conservative fashion and 3 symptomatic lymphoceles requiring percutaneous drainage were reported&#46; No infections were observed&#46; No differences were found in the need for transfusions and conversions to open surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All authors agreed that combined surgery is feasible and the increase in the complications rate is negligible&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Similarly&#44; in a recent non-systematic review&#44; authors reported that the repair of inguinal hernias at the time of robotic radical prostatectomy is safe&#44; feasible&#44; and associated with low recurrence rates&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">However&#44; we have some concerns regarding the combination of lymph-nodes dissection and the placement of a mesh in the same surgical space&#46; Guidelines recommend an extended lymph-nodes dissection when lymph-nodes dissection is indicated&#46; In recent years&#44; due to the increasing number of patients with low-risk PCa counselled to active surveillance&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> together with the growing interest in focal therapy for PCa&#44; the majority of prostatectomies are performed in patients with intermediate-high risk PCa&#46; Such patients should receive prostatectomy combined with an extended lymph-nodes dissection&#46; The incidence of lymphoceles at follow-up exceeds the 50&#37; of the cases&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> even if the majority remains asymptomatic&#46; The occurrence of infections is consistent&#44; particularly when the urethro-vesical anastomosis is not watertight&#46; The management consists of laparoscopic marsupialization or puncture&#46; The presence of a mesh placed after hernioplasty concomitant to extended lymph-nodes dissection will not increase the occurrence of lymphocele&#46; On the other side&#44; when lymphocele is developed&#44; the presence of a mesh will undoubtedly increase the troubles in the management&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Such issue was raised by Mourmouris et al&#46; who postulated the possibility of correcting the hernia without using a mesh&#46; At a median follow-up of 32 months&#44; no recurrences were observed in their series of 29 patients who underwent hernia repair without mesh&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In our experience&#44; we consider the inguinal hernia repair at the time of prostatectomy when an extra-peritoneal approach is chosen and when lymph-nodes dissection is not indicated&#46; In any case&#44; the patient has to be accurately informed of the benefits and the risks of a combined surgery&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Incidence of inguinal hernia after prostatectomy</span><p id="par0100" class="elsevierStylePara elsevierViewall">Eighteen studies addressing the incidence of inguinal hernia after radical prostatectomy were analysed&#46; Articles by the same groups were excluded&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Finally&#44; a review&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> a meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> an epidemiological study<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and 13 original articles were considered&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> reported the comparative studies available on the topic&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Regal et al&#46; first reported in 1996 the potentially increased occurrence of inguinal hernias after prostatectomy&#46; In their case-series 11 out of 92 patients &#40;12&#37;&#41; who underwent radical prostatectomy had an inguinal hernia&#46; Most of the hernias were indirect&#46; The median time to diagnosis was 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Sun and colleagues compared 5478 patients who underwent prostatectomies with a control group of patients who did not&#46; They observed that the 5-years and 10-years cumulative incidence of hernioplasty among patients who underwent prostatectomy was 11&#46;7&#37; and 17&#46;1&#37;&#44; respectively&#46; According to their data&#44; radical prostatectomy doubles up the risk of receiving a hernioplasty in the follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Lughezzani et al&#46; evaluated a cohort of 11&#44;107 PCa patients who underwent prostatectomy or radiotherapy&#46; The risk of developing post-treatment hernia was 2&#46;26 folds higher after prostatectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Stranne and co-workers published several studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19&#44;26&#8211;28</span></a> In their latest work they compared extra-peritoneal open vs transperitoneal robotic approach to prostatectomy vs a control group&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The 4-years cumulative incidence of postoperative hernia was 12&#46;2&#37; after open &#40;95&#37; CI 9&#46;0&#8211;16&#46;4&#37;&#41;&#44; 5&#46;8&#37; &#40;95&#37; CI 4&#46;0&#8211;8&#46;3&#37;&#41; after robotics and 2&#46;6&#37; &#40;95&#37; CI 1&#46;3&#8211;5&#46;1&#37;&#41; in controls&#46; The risk of developing postoperative hernia was 1&#46;7 folds higher in patients who underwent open surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In the field of laparoscopy&#44; the comparison between extra-peritoneal and transperitoneal approach is thought provoking&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Lin et al&#46; reported a lower risk of hernia development after transperitoneal approach&#44; even if the difference was not statistically significant &#40;HR 0&#46;63&#44; 95&#37; CI 0&#46;19&#8211;2&#46;05&#44; p&#8239;&#61;&#8239;0&#46;44&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> By contrast&#44; Yoshimine et al&#46; found the extraperitoneal approach sponsoring the occurrence of postoperative inguinal hernias &#40;HR&#8239;&#61;&#8239;3&#46;12&#44; 95&#37; CI 1&#46;04&#8211;9&#46;42&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">With the advent of robotics&#44; in a single-institutional retrospective analysis&#44; Chang and co-workers found Retzius-sparing robotic prostatectomy lowering the incidence of inguinal hernia after surgery compared to the standard transperitoneal robotic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Yamada et al&#46; published a series of 307 consecutive men who underwent robotic prostatectomy&#46; Incidence of inguinal hernia was 11&#46;3&#44; 14&#46;0&#44; and 15&#46;4&#37; at 1&#44; 2&#44; and 3 years after surgery&#44; respectively&#46; The occurrence of postoperative inguinal hernia was significantly associated with low surgeon experience and post-prostatectomy incontinence&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In a recent meta-analysis&#44; Zhu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> evaluated &#62;12&#44;000 patients with PCa&#46; They calculated a 15&#46;9&#37; &#40;95&#37; CI 13&#46;1&#8211;18&#46;7&#41; and 6&#46;7&#37; &#40;95&#37; CI 4&#46;8&#8211;8&#46;6&#41; overall probability of hernia occurrence after retropubic and laparoscopic prostatectomy&#44; respectively&#46; The authors underlined that the majority of the data was pooled from retrospective series&#46; Moreover&#44; concerns were raised about a mixed data collection from patients&#8217; surveys&#44; cross-check from operative room records or review of clinical histories&#46; On the other hand&#44; the median follow-up in the studies included in the review ranged from 17 to 120 months&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Some authors investigated which circumstances are associated with the occurrence of postoperative hernia&#46; Namely they have been reported to be a previous hernioplasty<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> or abdominal surgery&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;34</span></a> the increased age<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;32&#44;33&#44;35</span></a> and the low body mass index&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;33&#44;35&#44;36</span></a> The stenosis of the urethro-vesical anastomosis and the consequent increased intra-abdominal pressure generated for micturition has also been related to the eventual appearance of postoperative hernias&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;32&#44;33&#44;36</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our experience&#44; factors particularly associated with the development of inguinal hernias requiring surgical correction after radical prostatectomy are an extra-peritoneal approach &#40;either open or laparoscopic&#41; and the persistence of the vaginal peritoneal duct &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#44; B&#41;&#44; confirming previous findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;33&#44;34</span></a> In a series of 205 patients treated by robotic surgery&#44; Lee et al&#46; reported an increased risk of developing post-prostatectomy hernia in patients with persistence of the vaginal peritoneal duct&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> On the other hand&#44; in a multivariable analysis Yoshimine and colleagues reported that the extra-peritoneoscopic approach was the only predictor &#40;HR&#8239;&#61;&#8239;3&#46;12&#59; C&#46;I 95&#37; 1&#46;04&#8211;9&#46;42&#44; p&#8239;&#61;&#8239;0&#46;04&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Koie et al&#46; proposed a retro-pubic&#44; mini-laparotomic surgery assisted by a laparoscopic endoscope to reduce the occurrence of hernias&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Another group indicated the preservation of the space of Retzius able to significantly reduce the incidence of hernias&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Sakai et al&#46; and the group of Kanda et al&#46; suggested that a blunt dissection of the parietal peritoneum of the internal inguinal orifice would reduce the likelihood of hernias&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a> Fujii et al&#46; proposed the ligation of the peritoneal-vaginal duct<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> and Stranne et al&#46; the closure by suture of the internal inguinal orifice&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In summary&#44; minimizing the dissection between the parietal peritoneum and the transverse muscle fascia&#44; between the parietal peritoneum and the spermatic cord and consequently the peritoneum and the internal inguinal orifice might reduce the occurrence of hernias&#46; The occurrence of inguinal hernia after prostatectomy has a multifactorial&#44; complex aetiology&#46; To suggest a universal strategy able to minimize the risk of postoperative hernia is unrealistic&#46; The use of prophylactic meshes at the time of prostatectomy in all patients is not justified and considered to be an overtreatment&#46; On the other hand&#44; in an interesting work&#44; Marien et al&#46; published a series of 178 patients with a 52&#37; rate of inguinal hernia after prostatectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The authors underlined how the use of accurate physical examination&#44; ultrasound with abdominal press&#44; and magnetic resonance imaging allows to reduce the misdiagnosis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Impact of previous laparoscopic or open posterior hernioplasty during radical prostatectomy</span><p id="par0180" class="elsevierStylePara elsevierViewall">Laparoscopic or open posterior approach to hernia repair is an anatomical&#44; intuitive&#44; elegant and attractive procedure for most surgeons&#46; Regardless the approach&#44; the creation of a virtual space is necessary&#44; namely the separation of the parietal peritoneum from the fascia of the anterior rectus muscle and the transverse muscle&#44; in addition to the cord itself and the iliac vessels&#46; In the most medial portion&#44; the bladder will be separated from the pubic symphysis and the anterior rectus muscle&#46; The reduction of the sac is continued with the placement of the mesh&#44; aimed to obliterate the defect and to prevent the recurrence of direct or indirect hernia&#46; However&#44; regardless of the material used&#44; local scar adhesion and subsequent fibrosis of the tissues will occur&#46; The parietal peritoneum and the anterior aspect of the bladder will be fixed to the posterior fascia of the obliques and the bladder will adhere to the pubic symphysis and the anterior rectus muscle&#46; In addition&#44; the most lateral portions of the external iliac vessels &#40;both the artery and the vein&#41; will be involved in such fibrosis&#46; In summary&#44; after violation of the Retzius space&#44; a secondary access to the prostate will be more challenging&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">We found a total of 13 original articles and 1 meta-analysis about the topic&#46; Borchers et al&#46; in 2001 described and recommended the perineal approach for prostatectomy in patients who previously received bilateral inguinal mesh &#40;Supplementary Table 1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">One year later&#44; Katz and colleagues published two &#8220;aborted&#8221; retropubic prostatectomies in patients with mesh&#46; This article generated an intense debate regarding the troubles with prostatectomy in patients who underwent previous laparoscopic hernioplasty&#46; Many of the authors stated that&#44; in such cases&#44; prostatectomy should be proscribed&#44; favouring radiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;44</span></a> The first two cases described in which radical prostatectomy could be completed in patients who previously underwent laparoscopic hernioplasty were published by Brown and Dahl&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> A transperitoneal laparoscopic approach was used&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Stolzenburg et al&#46; published a comparative study including 9 patients who underwent previous laparoscopic hernioplasty&#46; Operative time was longer and they did not perform lymph-nodes dissection in such patients&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Immediately after&#44; the Heidelberg group published 20 cases demonstrating the feasibility of prostatectomy even after hernioplasty&#44; although longer operative time and more consistent use of analgesics were reported&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In a recent meta-analysis of 11 studies comparing a total of 462 patients after laparoscopic mesh hernioplasty who underwent radical prostatectomy versus a control group of 1540 cases &#40;5 studies about open radical prostatectomy&#44; 3 about laparoscopy and 3 about robotic surgery&#41;&#44; no differences were found in operative time and blood losses&#46; On the other hand&#44; patients with mesh were less likely to receive lymph-nodes dissection&#46; Finally&#44; a subgroup analysis found a prolonged catheterization time in the patients who had mesh&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> No data regarding differences in cancer control are available&#44; even if it is reasonable to expect no differences&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">A currently FDA approved single-port purpose-built robotic platform has been tested in the pre-clinical setting&#44; showing the possibility to widen the access routes to the prostate&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Interestingly&#44; trans-perineal radical prostatectomies&#44; radical cystectomies with pelvic lymph-nodes dissection and trans-vesical radical&#47;partial prostatectomies have been performed on cadaver models by using this novel device&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> The advantages of trans-perineal or trans-vesical access to both cystectomy and prostatectomy are potentially promising in the subset of patients who previously received hernioplasty with mesh&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">It is not reliable to obtain solid conclusions from the studies addressing the feasibility of prostate surgery in patients with subsequent corrections of inguinal hernias&#46; The results are heterogeneous&#46; The learning curve counts in this issue&#46; As such&#44; the first experiences were proscribing prostatectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;53</span></a> whilst the later series considered it feasible&#44; even including a lymphadenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> The reader should note that the authors who published the feasibility of prostatectomy in patients with mesh had consistent experience&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">46&#44;47</span></a> Moreover&#44; the risk of a tendency to publish only when the surgical outcomes are satisfactory is unmeasurable&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">There is consensus that prostatectomy after previous hernioplasty with mesh is a challenging procedure&#44; with longer operative time and higher risk of complications&#44; including peritoneal perforations&#44; bladder injuries&#44; prolonged bladder atony&#44; troubles in the anastomosis and limitations in lymph-nodes dissection&#46; In addition&#44; in the case of muscle-invasive bladder cancer with indication to radical cystectomy&#44; the presence of meshes in the Retzius space could itself influences the oncological safety of the procedure&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In our unpublished experience&#44; the data from previous studies are corroborated&#46; In patients who received mesh for hernioplasty&#44; radical prostatectomy is feasible&#44; but the access to the prostate is complex&#44; with longer operative time&#44; limited space and the need for reconstruction of the Retzius space after prostatectomy aimed to avoid contact of the polypropylene mesh with the bowel loops&#46; In case of mesh and indication to lymph-nodes dissection&#44; the authors of the present review avoid the ipsilateral lymph-nodes dissection&#46; The risk of vascular injury in case of a mesh adhered to the external iliac artery does not justify&#44; in our opinion&#44; the actual oncological benefit of lymph-nodes dissection&#46; We believe that the literature supports the one-stage combined intervention for patients suffering from both inguinal hernia and PCa amenable of radical prostatectomy&#46; Based on the few available literature evidences&#44; the combined treatment should not be recommended when lymph-nodes dissection for PCa is indicated and in cases of positive hydro-distress test of the urethro-vesical anastomosis&#46; In any case&#44; accurate patient&#8217;s counselling and dedicated consent forms are mandatory&#44; in the setting of an experienced multidisciplinary team&#46; Approximately 15&#37; of the patients undergoing standard retro-pubic radical prostatectomy will develop inguinal hernia&#46; It is possible that the incidence is lower for laparoscopic prostatectomies and much lower after transperitoneal approach&#46; The median time to the appearance of the hernia is 6 months&#46; It is possible that limiting the dissection of the parietal peritoneum of the transverse muscles reduces the risk of hernia development&#46; However&#44; this could be detrimental during a challenging procedure such as radical prostatectomy and should not compromise the oncological goal of the intervention&#46; Previous laparoscopic or open posterior hernioplasty does not preclude further pelvic surgery but could increase the difficulty of the procedure&#46; As such&#44; screening for pelvic cancers &#40;both prostate and bladder cancer&#41;&#44; particularly in patients at higher risk&#44; would be recommended prior to indiscriminately proceed to surgery for hernia repair&#46;</p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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                  "titulo" => "Convenience and safety of combined prostatectomy and hernioplasty"
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                  "identificador" => "sec0035"
                  "titulo" => "Incidence of inguinal hernia after prostatectomy"
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                  "titulo" => "Impact of previous laparoscopic or open posterior hernioplasty during radical prostatectomy"
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    "fechaRecibido" => "2019-06-28"
    "fechaAceptado" => "2019-10-28"
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            0 => "Inguinal hernia"
            1 => "Prostate cancer"
            2 => "Radical prostatectomy"
            3 => "Laparoscopy"
            4 => "Hernioplasty"
            5 => "Surgery"
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            0 => "Hernia inguinal"
            1 => "C&#225;ncer de pr&#243;stata"
            2 => "Prostatectom&#237;a radical"
            3 => "Laparoscopia"
            4 => "Hernioplastia"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We aimed to perform a systematic review about the relationship between inguinal hernia and surgery for prostate cancer&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of abdominal wall defects and prostate cancer may be either synchronous or metachronous&#46; The convenience and safety of combined prostatectomy and hernioplasty&#44; the incidence of hernias after prostatectomy and the feasibility of prostatectomy in patients with previous laparoscopic hernioplasty are still debated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">PubMed and Embase were queried by dedicated search strings&#46; Two researchers independently reviewed the pooled references and selected the articles of interest&#44; including reviews&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Sixty-five studies were evaluated&#46; 22 studies analysed the feasibility and the outcomes of a combined surgery&#44; namely one-stage radical prostatectomy and herniorrhaphy or hernioplasty&#46; Literature evidences support the combined intervention to patients suffering from an inguinal hernia and a prostate cancer amenable of radical prostatectomy&#46; 16 studies addressing the potential increase in the occurrence of inguinal hernia after radical prostatectomy were evaluated&#46; Approximately 15&#37; of patients who undergo retro-pubic radical prostatectomy will develop inguinal hernia&#46; It is suggested that the incidence might be lower in laparoscopic prostatectomy series&#44; particularly in case of transperitoneal approach&#46; The median time to the appearance of the hernia is around 6 months&#46; After evaluation of 14 studies&#44; it is concluded that laparoscopic hernioplasty does not preclude prostatectomy but hinders further pelvic surgery&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">One-stage combined hernioplasty and radical prostatectomy may be accepted except in cases of lymph-nodes dissection and&#47;or positive hydro-distress test of the urethro-vesical anastomosis&#46; Accurate patient&#8217;s counselling and dedicated consent form are mandatory&#44; in the setting of an experienced multidisciplinary team&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Hemos realizado una revisi&#243;n sistem&#225;tica sobre la relaci&#243;n entre la hernia inguinal yla cirug&#237;a para el c&#225;ncer de pr&#243;stata&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Contexto</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de defectos de la pared abdominal y el c&#225;ncer de pr&#243;stata puedesuceder de manera sincr&#243;nica o metacr&#243;nica&#46; La utilidad y seguridad de la cirug&#237;a combinada&#44; laincidencia de hernias tras la cirug&#237;a prost&#225;tica y la viabilidad de la prostatectom&#237;a en pacientescon hernioplastia laparosc&#243;pica previa siguen siendo debatidas hoy en d&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se consultaron PubMed y Embase con los textos de b&#250;squeda correspondientes&#46; Demanera independiente&#44; 2 investigadores revisaron las referencias bibliogr&#225;ficas y seleccionaronlos art&#237;culos de inter&#233;s&#44; incluyendo revisiones&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron 65 estudios&#44; 22 de los cuales analizan la viabilidad y los resultadosde una cirug&#237;a combinada &#40;prostatectom&#237;a radical y herniorrafia o hernioplastia en un mismoacto quir&#250;rgico&#41;&#46; La bibliograf&#237;a respalda la intervenci&#243;n combinada en pacientes que padecenuna hernia inguinal y un c&#225;ncer de pr&#243;stata subsidiario de prostatectom&#237;a radical&#46; Se evaluaron16 estudios que abordan el potencial incremento de las hernias inguinales tras una prostatec-tom&#237;a radical&#46; Aproximadamente un 15&#37; de los pacientes que reciben prostatectom&#237;a radicalretrop&#250;bica cl&#225;sica desarrollar&#225;n hernias inguinales&#46; Es posible que esta incidencia se vea redu-cida en la prostatectom&#237;a laparosc&#243;pica&#44; y probablemente sea menor a&#250;n con el abordajetransperitoneal&#46; El tiempo medio hasta la aparici&#243;n de la hernia es de alrededor de 6 meses&#46;Tras la evaluaci&#243;n de 14 estudios&#44; se concluye que la hernioplastia laparosc&#243;pica no imposibilitala prostatectom&#237;a&#44; pero dificulta la cirug&#237;a p&#233;lvica ulterior&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La hernioplastia y la prostatectom&#237;a radical combinadas en un mismo acto quir&#250;r-gico son aceptables&#44; excepto en el caso de estar indicada la linfadenectom&#237;a o si la anastomosisuretrovesical no queda estanca a la hidrodistensi&#243;n intraoperatoria&#46; El asesoramiento adecuado del paciente y el formulario de consentimiento informado son obligatorios en el marco de unequipo multidisciplinario experimentado&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
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            "identificador" => "abst0035"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
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        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bertolo R&#44; Mir Maresma MC&#44; Bove P&#44; Rubio-Briones J&#44; Ram&#237;rez-Backhaus M&#46; La relaci&#243;n entre hernia inguinal y cirug&#237;a m&#237;nimamente invasiva para el c&#225;ncer de pr&#243;stata&#58; revisi&#243;n sistem&#225;tica de la literatura&#46; Actas Urol Esp&#46; 2020&#59;44&#58;131&#8211;138&#46;</p>"
      ]
    ]
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0055"
          ]
        ]
      ]
    ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">PRISMA flow diagram&#46;</p>"
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      1 => array:8 [
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; Persistence of the vaginal peritoneal duct and indirect right vesico-inguinal hernia objectified during a laparoscopic radical prostatectomy with transperitoneal access&#46; B&#41; Bilateral direct subclinical inguinal hernia&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lap&#44; Laparoscopic&#59; n&#46;s&#44; not significant&#59; HR&#44; Hazard Ratio&#59; RRP&#44; retropubic radical prostatectomy&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comparison between surgical approaches&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Higher incidence with&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Lin et al&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="\n
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                  \t\t\t\t">Lap extraperitoneal vs Lap transperitoneal</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lap transperitoneal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">n&#46;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yoshimine et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lap extraperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HR&#8239;&#61;&#8239;3&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abe et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RRP vs Lap transperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open extraperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">n&#46;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Stranne et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RRP vs Robotic transperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open extraperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">HR&#8239;&#61;&#8239;1&#44;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Matsubara et al&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">RRP vs Perineal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Open extraperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">HR&#8239;&#61;&#8239;5&#44;56&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Available studies comparing different surgical approaches to radical prostatectomy and the incidence of inguinal hernia&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:54 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "N&#46; Howlader"
                            1 => "L&#46;A&#46; Ries"
                            2 => "D&#46;G&#46; Stinchcomb"
                            3 => "B&#46;K&#46; Edwards"
                          ]
                        ]
                      ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jnci/djn517"
                      "Revista" => array:6 [
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                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiologic&#44; economic&#44; and sociologic aspects of hernia surgery in the United States in the 1990s"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "I&#46;M&#46; Rutkow"
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                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/S0039-6109(05)70363-7"
                      "Revista" => array:6 [
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                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comprehensive preoperative evaluation and repair of inguinal hernias at the time of open radical retropubic prostatectomy decreases risk of developing post-prostatectomy hernia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "T&#46; Marien"
                            1 => "B&#46; Taouli"
                            2 => "S&#46; Telegrafi"
                            3 => "J&#46;S&#46; Babb"
                            4 => "H&#46; Lepor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1464-410X.2012.11334.x"
                      "Revista" => array:6 [
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                        "volumen" => "110"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22966978"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trends in management for patients with localized prostate cancer&#44; 1990&#8211;2013"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;R&#46; Cooperberg"
                            1 => "P&#46;R&#46; Carroll"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2015.6036"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2015"
                        "volumen" => "314"
                        "paginaInicial" => "80"
                        "paginaFinal" => "82"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26151271"
                            "web" => "Medline"
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              ]
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            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy&#58; oncologic and functional results of the first 200 patients with &#8805; 1 year of follow-up"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Galfano"
                            1 => "D&#46; Di Trapani"
                            2 => "F&#46; Sozzi"
                            3 => "E&#46; Strada"
                            4 => "G&#46; Petralia"
                            5 => "M&#46; Bramerio"
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eururo.2013.06.046"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Urol"
                        "fecha" => "2013"
                        "volumen" => "64"
                        "paginaInicial" => "974"
                        "paginaFinal" => "980"
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                  "contribucion" => array:1 [
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                      "titulo" => "Anatomical Retzius-space preservation is associated with lower incidence of postoperative inguinal hernia development after robot-assisted radical prostatectomy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;D&#46; Chang"
                            1 => "A&#46; Abdel Raheem"
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