Influence of previous laparo-endoscopic inguinal hernia repair on performing radical prostatectomy: a nationwide survey among urological surgeons.

BACKGROUND: There is considerable demographic overlap of inguinal hernia patients and prostate cancer patients. Previous laparo-endoscopic inguinal hernia mesh repairs can complicate subsequent radical prostatectomies due to adhesions and distortion of anatomic planes. This study aims to assess the experience of urological surgeons on the safety and feasibility of performing radical prostatectomies after laparo-endoscopic inguinal hernia mesh repair. METHODS: For this cross-sectional study, an online 24 question survey was developed regarding the experience in performing a radical prostatectomy and pelvic lymph node dissection (PLND) with a prior preperitoneal inguinal hernia mesh repair. Between June 2016 and December 2017, the questionnaire was sent to all 68 urological surgeons performing radical prostatectomy in the Netherlands. RESULTS: The response rate of urological surgeons was 69% (n = 47). The majority (77%) of urological surgeons perform robot-assisted laparoscopic prostatectomies. A previous preperitoneal inguinal hernia repair was reported by 40% of urological surgeons in 10-30% of patients undergoing radical prostatectomy. Radical prostatectomy with prior preperitoneal inguinal hernia mesh repair is considered more difficult by 49%, predominantly because of (occasionally to always) experienced longer operating times (88.4%), increased blood loss (46.5%), difficult dissection of Retzius space (88.4%), nerve-sparing difficulties (32.6%), less adequate PLND (69.8%), and bladder- (16.3%) or peritoneal perforations (27.9%). Additionally, 11.6% had performed mesh explantation, 16.3% had aborted radical prostatectomies, and 35.7% experienced increased inguinal hernia recurrences after radical prostatectomies with prior preperitoneal inguinal hernia mesh repair. More experienced urological surgeons reported an increased difficulty for all outcomes. CONCLUSIONS: Laparo-endoscopic inguinal hernia mesh repair has a significant impact on performing a radical prostatectomy and PLND. Surgeons should postpone the inguinal hernia repair of patients in the workup for a radical prostatectomy, with the preferable option of performing the radical prostatectomy and inguinal hernia repair in the same procedure. Alternatively, a Lichtenstein repair can be performed.

Quantifying the Mitigating Effects of Whole-Breast Radiotherapy and Systemic Treatments on Regional Recurrence Incidence Among Breast Cancer Patients.

BACKGROUND: Despite the potential for residual lymph node metastases after a negative or positive sentinel lymph node biopsy (SLNB), breast cancer patients rarely experience regional recurrences (RRs). This study aimed to quantify the effects of nonsurgical treatments on RR incidence among SLNB-negative (SLNB N0) breast cancer patients. METHODS: All primary SLNB N0-staged breast cancer patients with a diagnosis between 2005 and 2008 and 5-year follow-up data on recurrences were selected from the Netherlands Cancer Registry. The cumulative incidence function (CIF) for RR was calculated as the first event at 5 years, taking into account any other first-event (local or distant recurrence, contralateral breast cancer, or death) as competing risk. Cox regression analysis was used to model the cause-specific hazard of RR developing as the first event to quantify the effect of adjuvant systemic therapy and whole-breast radiotherapy (RT) on RR incidence at 5 years. RESULTS: The study included 13,512 patients. Of these patients, 162 experienced an RR. The CIF of RR at 5 years was 1.3% (95% confidence interval [CI], 1.1-1.5%), whereas the CIFs for death and other events were 4.4% and 9.5%, respectively. Cox regression analysis showed hazard ratios (HRs) of 0.46 (95% CI 0.33-0.64), 0.31 (95% CI 0.18-0.55), and 0.40 (95% CI 0.24-0.67) respectively for patients treated by RT as a routine part of breast-conserving therapy (BCT), chemotherapy, and hormonal therapy. CONCLUSION: RT as routine part of BCT, chemotherapy, and hormonal therapy independently exerted a mitigating effect on the risk for the development of RR. The three methods at least halved the risk.

Regional Recurrence Risk Following a Negative Sentinel Node Procedure Does Not Approximate the False-Negative Rate of the Sentinel Node Procedure in Breast Cancer Patients Not Receiving Radiotherapy or Systemic Treatment.

BACKGROUND: Although the false-negative rate of the sentinel lymph node biopsy (SLNB) in breast cancer patients is 5-7%, reported regional recurrence (RR) rates after negative SLNB are much lower. Adjuvant treatment modalities probably contribute to this discrepancy. This study assessed the 5-year RR risk after a negative SLNB in the subset of patients who underwent breast amputation without radiotherapy or any adjuvant treatment. METHODS: All patients operated for primary unilateral invasive breast cancer between 2005 and 2008 were identified in the Netherlands Cancer Registry. Patients with a negative SLNB who underwent breast amputation and who were not treated with axillary lymph node dissection, radiotherapy, or any adjuvant systemic treatment were selected. The cumulative 5-year RR rate was estimated by Kaplan-Meier analysis. RESULTS: A total of 13,452 patients were surgically treated for primary breast cancer and had a negative SLNB, and 2012 patients fulfilled the selection criteria. Thirty-eight RRs occurred during follow-up. Multifocal disease was associated with a higher risk of developing RR (P = 0.04). The median time to RR was 27 months and was significantly shorter in patients with estrogen receptor-negative (ER-) breast cancer (9.5 months; P = 0.003). The 5-year RR rate was 2.4% in the study population compared with 1.1% in the remainder of 11,440 SLNB-negative patients (P = 0.0002). CONCLUSIONS: Excluding the effect of radiotherapy and systemic treatment resulted in a twofold 5-year RR risk in breast cancer patients with a tumor-free SLNB. This 5-year RR rate was still much lower than the reported false-negative rate of the SLNB procedure.

Effectiveness of endoscopic totally extraperitoneal (TEP) hernia correction for clinically occult inguinal hernia (EFFECT): study protocol for a randomized controlled trial.

BACKGROUND: Groin pain is a frequent complaint in surgical practice with an inguinal hernia being at the top of the differential diagnosis. The majority of inguinal hernias can be diagnosed clinically. However, patients with groin pain without signs of an inguinal hernia on anamnesis or physical examination provide a diagnostic challenge. If ultrasonography shows a hernia that could not be detected clinically, this entity is called a clinically occult hernia. It is debatable if this radiological hernia is the cause of complaints in all patients with inguinal pain. The objective of this study is to assess whether watchful waiting is non-inferior to endoscopic totally extraperitoneal (TEP) inguinal repair in patients with a clinically occult inguinal hernia. METHODS: The EFFECT study is a multicenter non-blinded randomized controlled non-inferiority trial. Adult patients with unilateral groin pain and a clinically occult inguinal hernia are eligible to participate in this study. A total of 160 participants will be included and randomized to TEP inguinal hernia repair or a watchful waiting approach. The primary outcome of this study is pain reduction 3 months after treatment, measured by the Numeric Rating Scale (NRS). Secondary outcomes are quality of life, cost-effectiveness, patient satisfaction and crossover rate. Eight surgical centers will take part in the study. Participants will be followed-up for 1 year. DISCUSSION: This is the first large randomized controlled trial comparing treatments for patients with groin pain and a clinically occult inguinal hernia. To date, there are no interventional studies on the effect of surgery or a watchful waiting approach in terms of pain or quality of life in this subset of patients. A trial comparing the outcomes of the two approaches in patients with a clinically occult inguinal hernia is urgently needed to provide data facilitating the choice between the two treatment options. If watchful waiting is not inferior to surgical repair, costs of surgical repair may be saved. TRIAL REGISTRATION: The study protocol (NL61730.100.17) is approved by the Medical Ethics Committee (MEC-U) of the Diakonessenhuis, Utrecht, The Netherlands. The study was registered at the Netherlands Trial Registry ( NTR6835 ) registered on November 13, 2017.

Higher Recurrence Rate After Endoscopic Totally Extraperitoneal (TEP) Inguinal Hernia Repair With Ultrapro Lightweight Mesh: 5-Year Results of a Randomized Controlled Trial (TULP-trial).

OBJECTIVE: The aim of this study was to determine inguinal hernia recurrence rates 5 years after endoscopic totally extraperitoneal (TEP) inguinal hernia repair when either lightweight or heavyweight mesh was used. BACKGROUND: Recurrence is an important complication of inguinal hernia surgery. Higher recurrence rates of Ultrapro lightweight meshes after TEP repair have been demonstrated, yet data regarding long-term follow-up are limited. METHODS: From 2010 to 2012, 950 male adult patients with primary unilateral hernias were randomized to TEP hernia repair with heavyweight (Prolene) or lightweight (Ultrapro) mesh. Five years postoperatively, the validated PINQ-PHONE telephone questionnaire was carried out. Participants with a positive questionnaire reply were scheduled for a clinical visit. A recurrence was defined as a clinically detectable bulge in the operated groin on physical examination. RESULTS: Data on development of recurrence could be obtained from 790 patients (83.2% 5-year follow-up rate). Four patients presented with a recurrence at the outpatient clinic between 2 and 5 years postoperatively. Thirty-five patients (4.6%) with a positive PINQ-PHONE reply (60.0% lightweight vs 40.0% heavyweight) were physically examined at the outpatient clinic. In 2 patients (lightweight) a recurrence was detected. The total 5-year recurrence rate after TEP hernia repair was 2.4% (3.8% lightweight, 1.1% heavyweight, P = 0.01). A significantly higher recurrence rate for lightweight mesh in primary direct hernias was found (P = 0.003). CONCLUSIONS: The overall recurrence rate 5 years after TEP repair was low. Ultrapro lightweight meshes showed higher recurrence rates than heavyweight meshes and are not recommended for endoscopic TEP inguinal hernia repair.

Assessment of Valvular Disorders in Survivors of Hodgkin's Lymphoma Treated by Mediastinal Radiotherapy ± Chemotherapy.

As the number of Hodgkin's lymphoma (HL) survivors grows, understanding long-term complications becomes more important. Mediastinal radiotherapy (MRT) seems to cause valvular disease, and the prevalence might increase during follow-up. In this cross-sectional study 82 HL survivors participated (52% men, mean age 47.8 years, 50 treated with MRT). Valvular disease was diagnosed by transthoracic echocardiography and compared between HL survivors treated with and without MRT. Univariate and multivariate logistic regression analysis was used to identify predictors for valvular disease. During a median follow-up of 13.4 years (range 2 to 39 years), ≥ mild valvular disease was present in 61.2% of HL survivors with MRT (n = 30), compared with 31.0% of HL survivors without MRT (n = 9; odds ratio [OR] 3.51, 95% CI 1.32 to 9.30, p = 0.01). In multivariate analysis, only current age remained predictive for ≥ mild valvular disease (OR 1.08 per year, 95% CI 1.01 to 1.14, p = 0.023). Aortic regurgitation (AR) was most prevalent and irradiated patients had significantly more ≥ mild AR (38.2% vs 6.8%, p = 0.007). Within the MRT subgroup, time after radiation of >15 years was associated with AR (OR 4.70, 95% CI 1.05 to 21.03, p = 0.043), after adjusting for current age and hypertension. Severe valvular disease was present in 24.5% of HL survivors with MRT compared with 3.4% without MRT (p = 0.016). Valvular surgery was performed in 9 HL survivors (18.0%) with MRT and in none without MRT. In conclusion, the prevalence of valvular disease in HL survivors treated with MRT is high and increases with time after irradiation. Long-time screening for valvular disease by transthoracic echocardiography might be worthwhile.