Case Report
Stress Urinary Incontinence Following Inguinal Herniorrhaphy after Radical Prostatectomy
Yujiro Nagata1*, Atsushi Fukuda1, Hisae Nishii2, Mineo Takei3 and Naohiro Fujimoto1
1Department of Urology, University of Occupational and Environmental Health, Japan
2Department of Urology, National Center for Geriatrics and Gerontology, Japan
3Department of Urology, Harasanshin Hospital, Japan
*Corresponding author: Yujiro Nagata, Department of Urology, University of Occupational and Environmental Health, Kitakyushu, Japan
Published: 10 Sep 2018
Cite this article as: Nagata Y, Fukuda A, Nishii H, Takei M,
Fujimoto N. Stress Urinary Incontinence
Following Inguinal Herniorrhaphy after
Radical Prostatectomy. Ann Clin Case
Rep. 2018; 3: 1543.
Abstract
Case: A 66-year-old man underwent open radical prostatectomy and subsequently developed left
inguinal hernia. Herniorrhaphy was performed, following which he complained of severe Stress
Urinary Incontinence (SUI). To the best of our knowledge, this is the first reported case of SUI
development following inguinal herniorrhaphy in a man who had undergone radical prostatectomy.
Outcome: SUI was successfully treated with artificial urethral sphincter implantation
Conclusion: We should be aware of this extremely rare, but possible, complication of inguinal
herniorrhaphy in a patient who has undergone radical prostatectomy.
Keywords: Urinary Incontinence; Inguinal Herniorrhaphy; Radical Prostatectomy
Introduction
Inguinal hernia and Stress Urinary Incontinence (SUI) are well-known complications of radical prostatectomy [1,2]. However, SUI development following inguinal herniorrhaphy is extremely rare. We report the case of a patient who developed SUI following inguinal herniorrhaphy after open radical prostatectomy. To the best of our knowledge, this is the first reported case of SUI development following inguinal herniorrhaphy in a man who had undergone radical prostatectomy.
Case Presentation
A 66-year-old man was diagnosed with localized prostate cancer cT2cN0M0. His past medical history was unremarkable. He underwent open radical prostatectomy in 2008 after a 9-month neoadjuvant hormone therapy. Following the prostatectomy, he developed mild SUI that gradually improved. Thereafter, he did not need a pad after 15 months of prostatectomy. Four years later, he underwent salvage radiation therapy (66 Gy) for biochemical recurrence. Subsequently, the prostate-specific antigenserum levels decreased from 0.64 ng/mL to 0.1 ng/mL. After radiation, he did not experience the difficulty in voiding and his Qmax was 21.0 ml/second and urinary incontinence did not develop. During the follow-up period, he developed left inguinal hernia, for which he underwent synthetic mesh repair (inguinal herniorrhaphy) in 2014. After removal of the urethral catheter 12 French in size, he developed severe SUI. He then needed more than three pads a day for his total incontinence while standing. Cystourethrography and cystourethroscopy detected only a mild urethral stricture, and a urodynamic study showed no detrusor over activity. Conservative therapies along with pelvic exercise and use of several agents, such as anticholinergics and β2-stimulants, were ineffective in treating SUI. Two year later, an artificial urinary sphincter implantation was performed, and SUI disappeared. Patient’s clinical course is shown in Figure 1.
Discussion
The patient had moderate SUI for a few months after prostatectomy. Thereafter, SUI improved
gradually, and he rarely needed pads. SUI recurred after inguinal herniorrhaphy. Imaging as well
as endoscopic and urodynamic studies were negative for urinary in continence. The underlying
mechanisms for SUI recurrence after inguinal herniorrhaphy were unclear. Radiation to the
prostatic fossa might have slightly affected the urethral sphincter; however, this was not the main
cause for the development of SUI because he did not develop SUI after radiation therapy. It may be
suspected that this patient with post-operative sphincter damage had developed urethral stenosis
according to radical prostatectomy and/or post-operative radiation therapy which contributed to improvement of urinary incontinence. However, placement of
urethral catheter during surgery for inguinal hernia dilated the stenosis, and after removal manifested stress urinary incontinence
which had been once hidden by the urethral stenosis. This story is,
however, unlikely, because of the following reasons; 1) his SUI after
prostatectomy disappeared 15 months surgery and he did not need a
pad even after radiation, 2) he did not have the difficulty of voiding
suggesting urethral stricture that could mask SUI, 3) it is hard to
dilate urethral stricture with 12 French urethral catheter. Thus, we
believe that herniorrhaphy was the main cause of SUI.
Abdominal pressure to the bladder might have been reduced by
the dilated inguinal canal before inguinal hernia repair. However,
after the herniorrhaphy, the abdominal pressure to the inguinal
canal was blocked, resulting in increased abdominal pressure to
the bladder; this in turn might be the main cause of SUI recurrence
after the herniorrhaphy (Figure 2). To the best of our knowledge,
this is the first reported case of SUI development following inguinal
herniorrhaphy in a man who had undergone radical prostatectomy.
Although rare in occurrence, we need to be aware of SUI after hernia
repair in patients with a weak or damaged urethral sphincter.
Figure 1
Figure 1
Clinical course and urinary incontinence after prostatectomy. SUI:
Stress Urinary Incontinence, PRx: Prostatectomy, EBRT: External Beam
Radiation Therapy.
Figure 2
Figure 2
The putative mechanism of SUI recurrence after inguinal
herniorrhaphy. (a) Abdominal pressure to the bladder might be reduced by
the dilated inguinal canal. (b) Abdominal pressure to the inguinal canal was
blocked by the inguinal herniorrhaphy, resulting in SUI due to increased
abdominal pressure to the bladder.
References
- Regan TC, Mordkin RM, Constantinople NL, Spence IJ, Dejter SW Jr. Incidence of inguinal hernias following radical retropubic prostatectomy. Urology. 1996;47(4):536-7.
- Zhu S, Zhang H, Xie L, Chen J, Niu Y. Risk factors and prevention of inguinal hernia after radical prostatectomy: A systematic review and metaanalysis. J Urol. 2013;189(3):884-90.