Radical retropubic prostatectomy frustrated by prior laparoscopic mesh herniorrhaphy

Case report Radical retropubic prostatectomy frustrated by prior laparoscopic mesh herniorrhaphy Matthew R. Cooperberg, MD, MPH, Tracy M. Downs, MD, and Peter R. Carroll, MD, San Francisco, Calif From the Department of Urology, Program in Urologic Oncology, Urologic Outcomes Research Group, UCSF/Mt Zion Comprehensive Cancer Center, University of California, San Francisco, Calif A 57- YEAR OLD MAN was found on routine screening to have a serum prostate specific antigen (PSA) level of 4.1 ng/mL, and was referred for evaluation. He had bilateral induration at the base of the prostate. A transrectal ultrasonography and pros- tate needle biopsy were performed based on the elevated PSA. The ultrasonography revealed no abnormalities, but 3 of 10 core biopsies obtained under ultrasonographic guidance revealed pros- tatic adenocarcinoma. There were 2 positive bi- opsies on the left and 1 on the right; the Gleason score in each core was 3 + 3. The patient had a history of laparoscopic bilateral hernia repair with the use of mesh approximately 6 months before his referral. His past medical history was otherwise significant only for hypertension. Based on his serum PSA ( < 10 ng/mL), Gleason score (no pattern 4 or 5 disease), and clinical stage (T2c based on the 2002 American Joint Committee on Cancer and the International Union Against Cancer classification), the patient was felt to have low-risk prostate cancer. After considering the various treatment options available, the patient elected to undergo radical retropubic prostatec- tomy with a bilateral nerve-sparing approach. At the time of exploration of the retropubic space, very dense adhesions involving the bladder, Accepted for publication October 17, 2003. Reprint requests: Peter R. Carroll, MD, UCSF/M. Zion Cancer Center, 1600 Divisadero St, 3rd Floor, San Francisco, CA 94115- Surgery 2004;135:452-3. 0039-6060/$ - see front matter O 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2003.10.014 prostate, and pelvic sidewall were found. The endopelvic fascia was also indurated. These changes were attributed to the previous laparoscopic bilateral mesh herniorrhaphy. Despite midline in- cision of the mesh, it became apparent that extensive adhesions extended between the mesh and the bladder and prostate. The patient had expressed a strong desire for bilateral nerve sparing, but due to the extent of the adhesions, neither nerve sparing nor complete removal of the prostate could be assured. Therefore, after an intra- operative discussion with the patient’s family, the decision was made not to proceed with retropubic prostatectomy. The patient’s postoperative recovery was un- eventful. He was referred to a radiation oncologist, and, 6 weeks after the operation, underwent transperineal permanent seed implantation for prostate interstitial radiotherapy. His first PSA after brachytherapy (3 months after implantation) was 1.5 ng/mL; to date he has maintained his potency. DISCUSSION Inguinal hernia and prostate cancer are both highly prevalent diseases. More than 750,000 hernia repairs are performed annually in the United States alone, 90% of them in men and 80% involving a mesh prosthesis. 1 The estimated US incidence of prostate cancer in 2003 is 220,900—the highest of any noncutaneous human malignancy. 2 Radical prostatectomy, usually per- formed from a retropubic approach, is the most common treatment for localized prostate cancer, particularly among younger men and those with favorable risk disease. The procedure offers excel- lent long-term oncologic outcomes. Postoperative SURGERY 452