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Preventing Parastomal Hernia After Ileal Conduit by the Use of a Prophylactic Mesh: A Randomised Study
Fredrik Liedberg1, Petter Kollberg2, Marie Allerbo3
1Institution of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden.
Insights
Prophylactic mesh implantation significantly reduces parastomal hernia (PSH) risk after ileal conduit surgery. This approach lowers PSH incidence without increasing mesh-related complications, though it slightly prolongs operating time.
Area of Science:
- Urology
- Surgical Oncology
- Medical Engineering
Background:
- Parastomal hernia (PSH) is a common complication following urinary diversion with ileal conduit.
- Effective prevention strategies for PSH are clinically significant.
Purpose of the Study:
- To evaluate the efficacy of prophylactic lightweight mesh in the sublay position for reducing PSH incidence after open cystectomy with ileal conduit construction.
Main Methods:
- A randomized controlled trial involving 242 patients undergoing open cystectomy with ileal conduit.
- Patients were randomized 1:1 to conventional stoma construction or prophylactic mesh implantation in the sublay position.
- Primary endpoint was clinical PSH; secondary endpoints included radiological PSH and mesh-related complications.
Main Results:
- A significant reduction in clinical PSH was observed in the prophylactic mesh group (11%) compared to the control group (23%) within 24 months (HR 0.45, p=0.02).
- No significant difference in radiological PSH rates was found between groups.
- Surgical operating time was marginally increased in the mesh group, but no increase in mesh-related complications or short-term postoperative complications was noted.
Conclusions:
- Prophylactic sublay mesh implantation effectively decreases the cumulative incidence of parastomal hernia after ileal conduit urinary diversion.
- This preventive strategy does not elevate the risk of mesh-related complications, despite a slight increase in median surgical time.
Background:
Parastomal hernia (PSH) after urinary diversion with ileal conduit is frequently a clinical problem.
Objective:
To investigate whether a prophylactic lightweight mesh in the sublay position can reduce the cumulative incidence of PSH after open cystectomy with ileal conduit.
Design, Setting, And Participants:
From 2012 to 2017, we randomised 242 patients 1:1 to conventional stoma construction (n = 124) or prophylactic mesh (n = 118) at three Swedish hospitals (ISRCTN 95093825).
Outcome Measurements And Statistical Analysis:
The primary endpoint was clinical PSH, and secondary endpoints were radiological PSH assessed in prone position with the stoma in the centre of a ring, parastomal bulging, and complications from the mesh.
Results And Limitations:
Within 24 mo, 20/89 (23%) patients in the control arm and 10/92 (11%) in the intervention arm had developed a clinical PSH (p = 0.06) after a median follow-up of 3 yr, corresponding to a hazard ratio of 0.45 (confidence interval 0.24-0.86, p = 0.02) in the intervention arm. The proportions of radiological PSHs within 24 mo were 22/89 (25%) and 17/92 (19%) in the two study arms. During follow-up, five patients in the control arm and two in the intervention arm were operated for PSH. The median operating time was 50 min longer in patients receiving a mesh. No differences were noted in proportions of Clavien-Dindo complications at 90 d postoperatively or in complications related to the mesh during follow-up.
Conclusions:
Prophylactic implantation of a lightweight mesh in the sublay position decreases the risk of PSH when constructing an ileal conduit without increasing the risk of complications related to the mesh. The median surgical time is prolonged by mesh implantation.
Patient Summary:
In this randomised report, we looked at the risk of parastomal hernia after cystectomy and urinary diversion with ileal conduit with or without the use of a prophylactic mesh. We conclude that such a prophylactic measure decreased the occurrence of parastomal hernias, with only a slight increase in operating time and no added risk of complications related to the mesh.
