Utility of prophylactic mesh in the prevention of parastomal hernia after ileal conduit: assessing the current evidence

Parastomal hernia (PSH) is one of the most frequent complications following radical cystectomy with ileal conduit urinary diversion. It is defined as an abnormal protrusion of intrabdominal contents through the rectus fascia around the ileal conduit. The incidence of PSH varies widely amongst cystectomy patients from 17% to 68% (1,2). This variation is primarily due to differences in PSH characterization (radiographic PSH vs. clinical PSH) and duration of follow-up after surgery. While most patients with PSH are asymptomatic, those with symptoms can have reduced quality of life from pain and discomfort, or problems with the stoma appliance itself (e.g., poor fit, leakage, skin ulceration) (3). Less common, but more significant complications such as life-threatening urinary or bowel obstruction can also occur. In addition, the rate of re-operation for symptomatic PSH has been estimated to be as high as 30% in some populations (1). Due to the high incidence of PSH and its associated patient morbidity, a variety of techniques have been evaluated for PSH prevention including prophylactic mesh placement around the ileal conduit at the time of urinary diversion.

Djaladat and colleagues recently published a 2024 article in The Journal of Urology entitled “Prophylactic use of biologic mesh in ileal conduit (PUBMIC): a randomized clinical trial”. In this paper, the authors investigated the efficacy of prophylactic mesh in preventing PSH in patients undergoing radical cystectomy. Over 140 patients were randomized 1:1 to receive either intraperitoneal biologic mesh or control (no mesh). Interestingly, at 2 years follow-up, the authors found no difference in radiologic or clinical PSH between the two groups, suggesting that prophylactic mesh placement may not be helpful in preventing PSH. The authors did acknowledge that certain subgroups of patients (i.e., previous abdominal radiation, higher pathologic stage) were at higher risk for development of PSH overall (4).

This recently published study joins only one other urologic-focused randomized controlled trial (RCT) investigating the utility of prophylactic mesh placement in preventing PSH. In 2020, Liedberg and colleagues out of Sweden evaluated a synthetic polypropylene mesh deployed via a retro-rectus approach. At 2 years follow-up, 23% and 11% of patients in the control and intervention arms, respectively, developed a clinical PSH (P=0.06). At 3 years follow-up, patients in the intervention arm were significantly less likely to have developed a clinical PSH (P=0.02). Additional findings between both studies demonstrated that prophylactic mesh can be placed regardless of surgical approach (i.e., robotic vs. open) and safely without an increased rate of post-operative complications (5). However, it is important to note that one key difference between the Liedberg and Djaladat RCTs was the approach to mesh placement. Unlike the intraperitoneal onlay technique used by Djaladat and colleagues, the Swedish trial employed a retro-rectus approach to mesh insertion. Prior research has demonstrated that a retro-rectus or “sublay” technique is associated with a lower risk of hernia occurrence and recurrence. It is hypothesized that the major factors to minimize hernia recurrence are mesh-tissue integration and avoidance of surrounding tissue devascularization and infection. The sublay technique, while more technically challenging, allows for optimal tissue integration from two tissues—the rectus muscle itself and the posterior rectus sheath. These interactions also protect the mesh from superficial wound complications and does not require the creation of tissue flaps that risk devascularization. On the other hand, while protected from superficial wound complications, intraperitoneal mesh is exposed to intra-abdominal contents and lacks the robust tissue integration of the sublay technique (6). It appears that the sublay technique is the most common among urologists—a meta-analysis of PSH after radical cystectomy identified 5 studies using prophylactic mesh, all of which utilized the sublay technique (7). Thus, failure to detect a difference between the intervention and control arms in the PUBMIC trial may partially be explained a less effective technique to mesh placement in a population at high-risk for hernia development.

Results from the PUBMIC trial should also be interpreted in the context of the existing literature surrounding PSH prevention overall. Problematic PSH development is not unique to urology. Numerous meta-analyses have been published demonstrating that prophylactic mesh placement at the time of end colostomy creation significantly reduces the incidence of PSH among colorectal surgery patients (8,9). In fact, the European Hernia Society guidelines recommend the use of synthetic mesh in the construction of end colostomy to prevent PSH formation (10). Unlike the colorectal surgery literature, the evidence for placement of prophylactic mesh at the time of ileal conduit urinary diversion is still in its infancy.

There are also other risk factors for PSH development independent of mesh placement. Both the urologic and colorectal literature have demonstrated that elevated body mass index is a risk factor for PSH (11,12). A recent paper from Lone et al. specifically found that high fat mass and low muscle mass and serum albumin are associated with PSH after radical cystectomy (13). Therefore, one hypothesis is that an increased fat mass leads to a higher risk of PSH by increasing the tension of the abdominal wall on the stoma (14). To extrapolate from these data, it is reasonable to assume that optimizing patient nutrition and body composition would be other beneficial interventions in the prevention of PSH and should be recommended when feasible. Unfortunately, optimizing these factors may not always be realistic in this patient population and will undeniably lead to treatment delay.

It is important to note that Djaladat and colleagues followed patients for only 2 years. While most PSHs occur in the first 2 years after surgery, it cannot be ignored that the natural history of PSHs involves progression and enlargement of fascial defects in patients over time. Donahue and colleagues radiographically followed PSH after cystectomy and found that patients can progress from type 2 to type 3 PSH (hernia with bowel contents and not just abdominal fat or omentum) up to 5 years after surgery. Therefore, as the authors note in their study, 2 years may not be a sufficient length of time to find an appreciable difference in the effect of prophylactic mesh placement. As such, the authors suggest that patients with a longer life expectancy may benefit from prophylactic mesh. However, with 5-year survival after radical cystectomy reaching over 50% (15) and increasing with better chemo/immunotherapy, it is feasible that the majority of patients could benefit from prophylactic mesh particularly if the effects are most critical a few years after surgery.

Djaladat and colleagues should be commended for completing a well thought out study to better understand the role of prophylactic mesh in the prevention of PSH in the urologic population. It is clear that PSH is a multifactorial event. When possible, optimizing body composition and nutrition could be helpful. It is still not clear if mesh placement is useful in preventing PSH. To better understand its efficacy, further studies investigating long-term rates of PSH are needed. There are currently two RCTs that are attempting to better understand this problem. Groups out of Memorial Sloan Kettering and the Czech Republic each have active trials measuring the incidence of PSH up to 2 years following radical cystectomy with prophylactic mesh (16,17). While these trials may not have long-term follow-up, they will add to the body of evidence to help determine if prophylactic mesh is useful to prevent short-term incidence of PSH and we look forward to the results of these trials.

Acknowledgments

None.

Footnote

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