Efficacy of prophylactic use of biologic mesh in ileal conduit: insights from the PUBMIC trial

Parastomal hernia (PSH) has been reported as a common complication after ileal conduit (IC) urinary diversion that impairs quality of life and results in a clinically significant problem for many patients. The rate of PSH has been reported to range from 30% to 65%, including asymptomatic patients (1). Although serious complications such as strangulation and obstruction requiring emergent interventions are rare, PSH repair is considered a challenging surgery with a high recurrence rate (2). In addition, re-surgery itself significantly impairs quality of life and increases other complications besides PSH (3). According to the need for PSH prevention, the randomized controlled trials (RCTs) have been performed on prophylactic mesh use during radical cystectomy with IC, which did not change the radiological PSH rate, while reducing the frequency of clinical hernia (4). Djaladat et al. conducted a RCT including 146 patients who received cystectomy with IC to evaluate the efficacy and safety of the FlexHD prophylactic biological mesh using the sublay intraperitoneal technique (5).

At a median follow-up of 2 years, a significant preventive effect of the prophylactic mesh was not observed in clinical or radiological PSH development. However, careful interpretation is required due to the limitations of the study. Firstly, the follow-up period is only 2 years, which may need more observation to see the long-term preventive effect. Notably, Kaplan-Meier analysis in the present study showed a tendency to reduce long-term PSH similar to the previous study (4). Secondly, this study may have included patients with a relatively low risk of PSH. As their previous study reported independent predictors for radiological PSH, such as female gender, higher body mass index (BMI), diabetes, and chronic obstructive pulmonary disease (6), optimal stratification using those risk factors might reveal the pronounced preventive effect of prophylactic mesh placement. Thirdly, surgical techniques to prevent PSH without using mesh have not been fully elucidated. The stoma construction through the rectus abdominis muscle (7), stoma placement via extraperitoneal route (8), and fixing the stoma to the fascia (9) have been proposed to reduce PSH, although these techniques have not yet been supported by sufficient evidence. Further studies are warranted to establish effective prevention techniques.

Regardless of the limitations mentioned above, we would like to thank the authors for carrying out the RCT of the significant topic. Especially, the confirmation of safe placement of prophylactic biological mesh with short additional operative time and no significant intraoperative complications is a significant finding from this study. Mature data with a longer follow-up period, as well as data from other trials on this topic, are required. Selective use of prophylactic biologic mesh in patients with high-risk of PSH can be considered until mature data are available.

Acknowledgments

None.

Footnote

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