Concurrent Transurethral Resection of The Prostate (TURP) and Inguinal Hernioplasty

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Huang, Allen W. Chiu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4071598/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Aug, 2024 Read the published version in BMC Urology → Version 1 posted 11 You are reading this latest preprint version Abstract Background Benign prostatic hyperplasia (BPH) is a prevalent condition in aging males, leading to bladder outlet obstruction (BOO) and associated urinary symptoms. With increasing life expectancy, the incidence of BPH and its co-morbidities, like inguinal hernia, has risen. This study explores the efficacy of combining transurethral resection of the prostate (TURP) and inguinal hernioplasty in a single surgical session to address both conditions, potentially reducing the need for multiple hospitalizations and surgical interventions. Methods This retrospective study at Chi Mei Medical Center included patients from 2014 to 2023 who underwent concurrent TURP and inguinal hernioplasty. A total of 85 patients met the criteria defined for this study. Preoperative, intraoperative, and postoperative characteristics were meticulously documented. Outcomes evaluated included the duration of the surgery, incidence of intraoperative and postoperative complications, duration of Foley catheterization, length of hospital stay, and treatment efficacy. Additionally, we conducted a comparative assessment of the surgical outcomes between two distinct techniques for inguinal hernia repair: open hernioplasty and laparoscopic hernioplasty (LH). Results In 85 patients who met the criteria, the mean age was 71.1 ± 7.8 years. The study reported no significant intraoperative complications, and postoperative care was focused on monitoring for blood loss, infection, and managing pain. The average postoperative hospital stay was 2.9 ± 1.0 days and the mean duration of catheterization was 51.6 ± 16.7 hours, with a minimal complication rate observed during the one-year follow-up. A significant reduction in both operative duration and catheterization interval was observed in patients undergoing LH as opposed to those receiving open hernioplasty. Conclusion Concurrent TURP and inguinal hernioplasty effectively manage BOO due to BPH and inguinal hernias with minimal complications, suggesting a viable approach to reducing hospital stays and surgical interventions. Laparoscopic techniques, in particular, offer benefits in operative efficiency and recovery time, making combined surgery a feasible option for selected patients. Benign prostatic hyperplasia (BPH) inguinal hernia transurethral resection of the prostate (TURP) inguinal hernioplasty Background Benign prostatic hyperplasia (BPH) is a common condition among males, especially in the elderly population. [ 1 ] The volume of prostate increases with age, and clinically, an enlarged prostate can lead to bladder outlet obstruction (BOO), resulting in urinary symptoms. With the global increase in life expectancy over the past few decades, the prevalence of BPH has risen, as well as its complications. [ 2 ] Studies indicate that 50% of males above 60 years old are affected by BPH, and over 80% of males aged 80 and above experience BPH-related issues. [ 1 , 3 , 4 ] Considering this high prevalence, there is a growing need to focus on BPH treatments in various scenarios and their potential comorbidities. One of the most common comorbidities is inguinal hernia. Co-occurrence of inguinal hernia and BPH is frequently observed. Research reports a comorbidity rate of approximately 15–25% between inguinal hernia and BPH. [ 5 , 6 ] Clinically, many males with enlarged prostates face difficulties in urination, leading to the need for intra-abdominal pressure to assist in voiding, which may contribute to the development of hernias over time. Considering such comorbidities, concurrently addressing inguinal hernia repair and benign prostatic hyperplasia in a single treatment may be a viable option, anticipating a reduction in hospitalizations and surgical interventions. [ 7 ] However, concerns arise as Transurethral Resection of the Prostate (TURP) itself often requires intra-abdominal pressure for postoperative voiding, while hernia repair surgery causes surgical site discomfort, making it challenging for patients to transition early from catheterization, potentially necessitating considerations for catheter reinsertion. [ 8 ] This study aims to evaluate the outcomes of performing TURP and inguinal hernia repair in a single treatment. Methods Selection criteria In this retrospective study, cases from Chi Mei Medical Center between 2014 ~ 2023 that concurrently underwent TURP and inguinal hernioplasty were included. The inclusion criteria for patient enrollment in this study were concurrent receipt of TURP and inguinal hernia repair, ASA score beneath 4, and follow-up duration exceeding 1 year. Exclusion criteria comprised complicated inguinal hernias, coagulative disorders, previous history of TURP, malignant pathology finding of the prostate specimen, and other conditions that could potentially impact the evaluation. Within these parameters, a total of 85 patients were included in this study. Study protocol and surgical procedure Preoperative assessments In the protocol, preoperative patient conditions (Age, ASA score, comorbidity, ect) were recorded. For the assessment of BPH, we utilize transrectal ultrasound (TRUS), MRI or CT scan results to estimate the prostate volume in patients. Serum PSA levels are also recorded, although they may not necessarily have a direct correlation with BPH. For hernias, we document their location and confirm whether they are of the direct or indirect type through imaging or intraoperative assessment. We typically administer intravenous cefazolin as preoperative prophylactic antibiotics. For patients admitted with moderate to severe pyuria based on urinary analysis, we initiate appropriate therapeutic antibiotics. Additional cefazolin is not administered preemptively before the surgery in such cases. The surgical duration was defined from anesthesia induction to the conclusion of the procedure. Surgical procedure In the technique of open hernioplasty, the procedure begins with the incision of the external oblique aponeurosis (as known as Scarpa's fascia), the elevation of the spermatic cord and the identification and classification of the hernial sac. In cases of indirect hernias, meticulous dissection is carried out from the internal ring, followed by exploration of the sac to ensure its complete reduction into the posterior wall defect. For direct hernias, the protrusion is directly repositioned into the posterior wall defect and the inguinal ligament is sutured to the conjoined tendon. Subsequent steps involve ascertaining an adequate closure without undue tension and approximating Scarpa's fascia and the cutaneous layer. In laparoscopic hernioplasty, the procedure commences with the strategic placement of the laparoscope, forceps, and scissors via a single or tri-trocar port and the establishment of a CO 2 pneumoperitoneum at 12mmHg. This setup facilitates the meticulous examination and identification of the internal ring sites. Utilizing forceps, the peritoneum at the internal ring is elevated and incised, allowing for the dissection and mobilization of the internal spermatic vessels. The hernia type is determined, and the sac is subsequently retracted and corrected with the placement of a mesh securely affixed to the abdominal wall for reinforcement. The procedure concludes with the careful closure of all trocar entry points at the fascial level and the subsequent suturing of the skin. During TURP, urethral calibration and dilatation precede the introduction of the resectoscope into the bladder under direct visualization. Utilizing a panendoscopic lens, the procedure involves delineating the distance from the urethral orifices to the bladder neck and retracting the lens to the verumontanum to assess the prostatic lobes' positioning. Resection commences at one lobe, employing techniques such as bipolar electrosurgery, greenlight photoselective vaporization, or Thulium, Vela, and Multipulse laser applications ranging from 20 to 120 watts for precise tissue removal, vaporization, coagulation, or enucleation. The procedure meticulously avoids the penetration of the prostatic capsule, halting resection upon visualization of bladder neck and capsule fibers. The contralateral lobe undergoes a similar procedure. Post-resection, a Toomey evacuator facilitates the removal of excised tissue. The operation concludes with the withdrawal of the resectoscope, insertion of a tri-lumen Foley catheter for bladder irrigation, ensuring the integrity and functionality of the urinary tract. Postoperative hospitalization During the postoperative hospitalization period, we monitor blood loss and infection status through blood tests including white blood cell count and hemoglobin, as well as urine routine analysis and culture. We also document the administration of intravenous analgesics and the time from surgery completion to catheter removal. If the retention issue persists after removing Foley, re-catheterization is considered. Finally, we record the postoperative length of hospital stay and monitor for the presence of urinary tract infections or surgical wound infections during the hospitalization, and record the Visual Analog Scale (VAS) score at the time of discharge. Subsequent outpatient follow-up includes recording changes in voiding symptoms and alterations in urinary medications. Statistical Methods Quantitative variables were presented as mean ± standard deviation. Qualitative variables were reported as frequency and percentage. For quantitative independent variables, a comparison between groups one and two was conducted using the independent sample t-test. Non-parametric quantitative variables were assessed with the Mann-Whitney U test. Qualitative variables underwent comparison using the Chi-square test. A p-value of less than 0.05 was considered statistically significant. Results During the specified time period and within the inclusion criteria, a total of 110 patients were collected. After applying exclusion criteria, 85 patients remained (including 6 who had undergone previous prostate surgery, 1 with severe and complex hernia, 1 with an excessively large prostate, 1 with a high PSA level, and 16 with malignant pathology findings in the prostate specimen). The mean age was 71.1 ± 7.8 years, and preoperative basic data were documented in Table 1 . All patients had ASA scores between 2 and 4, and if there was a history of cancer, the ECOG score was 0. Regarding inguinal hernia types, 30 patients had a direct type, 40 had an indirect type, and 15 had both types of hernia simultaneously. Concerning inguinal hernia location, 62 were unilateral and 23 having bilateral hernias. Among the 85 patients, 12 had undergone hernia repair surgery in the past, with 6 having hernias on different sides and 6 having hernias on the same side, indicating recurrent hernias. Table 1 N(%) Total number of patients 85 Age 71.1 ± 7.8 (year) Co-morbidities CAD 9 Hypertension 36 Diabetes Mellitus 10 Asthma / COPD 5 CKD 5 Anticoagulant use 14 Abdominal Surgical History 17 Hernioplasty (Same Side / Contralateral Side) 6/6 Others 4 Type of Hernia Direct 30 (35.3%) Indirect 40 (47.1%) Mixed 15 (17.6%) Position of Hernia Unilateral(left/right) 24/38 (72.9%) Bilateral 23 (27.1%) Status of Hernia (primary/recurrent) 79/6 (92.9%/7.1%) Prostate volume 60.3 ± 26.5 (g) PSA level 4.0 ± 4.4 (µg/dL) Regarding BPH, the average prostate volume for the 85 patients was 60.3 ± 26.5 mL. For each patient, a prostate specimen was obtained intraoperatively and sent for pathological examination to confirm the absence of malignancy. Patients with elevated PSA levels underwent transrectal ultrasound-guided prostate biopsy (TRUSP) and/or MRI. Details related to the surgery were documented in Table 2 . The average surgical time was 3 hours and 31minutes ± 65 minutes. For hernioplasty, 61 patients chose open hernioplasty, and among the 24 who underwent laparoscopic surgery. Regarding prostate surgery, 12 patients underwent traditional Bipolar TURP, and among the remaining 74 undergoing different laser surgery. The average weight of the resected prostate was 19.5 ± 16.2 g. No patient experienced significant bleeding, major vessel injury, spermatic cord injury, or bladder injury during surgery. Table 2 N(%) Total number of patients 85 Operation for Hernia Open Hernioplasty 61 Laparoscopic Hernioplasty (3-port / 1-port) 11/13 Operation for TURP Traditional Bipolar TURP 12 Greenlight vaporization 2 Laser Prostatectomy 45 Laser Enucleation 25 Operation Time 3hr 31min ± 65min TURP Resection Volume 19.5 ± 16.2 (g) Intraoperative Complications Significant Hemorrhage 0 Major Vascular Injury 0 Spermatic Cord Injury 0 Urinary Bladder Injury 0 No patient received a blood transfusion during surgery, and the average change in hemoglobin before and after surgery was a decrease of 1.6 ± 0.8 g/dL, with a WBC increase of 5.0 ± 2.5 x10^3/µL. However, there were no occurrences of postoperative fever, wound infection, or gross hematuria during hospitalization. The average catheter retention time during hospitalization was 51.6 ± 16.7 hours, excluding 10 patients who underwent catheter reinsertion or had the catheter brought back. During hospitalization, intravenous or intramuscular form analgesics were used to assess severe pain, with 28 patients receiving injectable pain medication postoperatively. The average postoperative length of stay was 2.9 ± 1.0 days, and each patient's VAS upon discharge was beneath 2, with bladder irrigation already discontinued. Postoperative details were recorded in Table 3 . Table 3 N(%) Total number of patients 85 ΔHb -1.6 ± 0.8 (g/dL) ΔWBC 5.0 ± 2.5 (10^3/µL) Duration of Foley Catheter 51.6 ± 16.7 (hr) Manual Bladder Irrigation 3 Re-catheterization 7 Discharge with Foley 7 Duration of Hospital Stay 2.9 ± 1.0 (day) Use of IV/IM form analgesics 28 Discharge VAS < 2 (points) Complication During Postoperative Stay Fever 0 Wound Infection 0 Gross Hematuria 0 Follow-up will continue for one year after discharge and the details were established in Table 4 . One patient developed urinary tract infection and epididymitis two weeks after discharge, another patient developed hyponatremia two weeks after discharge, and three patients experienced urethral stricture within a year, undergoing transurethral incision of the bladder neck (TUIBN). We conducted a follow-up study on the usage of oral alpha-blockers (such as Tamsulosin, Doxazosin, and Silodosin) in different stage of the treatment to infer the severity of BOO induced by BPH and thereby to evaluate the efficacy of the surgical intervention. Preoperatively, alpha-blockers were prescribed to 68 out of 85 patients (80%). This number decreased to 47 patients (55.3%) one month after the surgery, and further declined to 15 patients (17.6%) by the twelve-month postoperative mark. These findings suggest that TURP, as part of concurrent surgery, achieves the anticipated therapeutic outcomes. Additionally, within the one-year follow-up, no patients experienced a recurrence of hernia on the operated side, further substantiating the effectiveness of hernioplasty within the concurrent surgery. Table 4 Open Hernioplasty N(%) Laparoscopic Hernioplasty N(%) P value Total number of patients 61 24 Age 71.1 ± 8.4 (year) 70.9 ± 6.2 (year) 0.886 Prostate volume 57.9 ± 27.5 (g) 66.4 ± 23.3(g) 0.183 Operation time 3hr 45min ± 67min 2hr 55min ± 45min 0.0011 Use of IV/IM form analgesics 23 (38%) 5 (21%) 0.6246 Duration of Foley Catheter* 54.5 ± 17.9 (hr) 44.7 ± 11 (hr) 0.0492 Re-catheterization 6 (10%) 1 (4%) 0.6762 Duration of Hospital Stay 3.15 ± 1.09 (Days) 2.73 ± 0.65 (Days) 0.2219 *Duration of Foley Catheter: 75 patients were involved in this analysis, 53 underwent open hernioplasty and 22 underwent laparoscopic hernioplasty. 10 patients who underwent catheter reinsertion or had the catheter brought back were excluded. Regarding hernioplasty, the differences between open and laparoscopic approaches were compared in concurrent surgery. A significant difference was noted in operative times between open hernioplasty (3hr 45 min ± 67min) and LH (2hr 55min ± 45min), p = 0.0011. Analysis of patients who successfully had their Foley catheters removed prior to discharge revealed average durations of 54.5 ± 17.9 hours for open hernioplasty and 44.7 ± 11 hours for laparoscopic hernioplasty (p = 0.0492). No significant statistical difference was noted in catheter reinsertion rates. Details comparing open and laparoscopic hernioplasty are documented in Table 4 . Discussion The comorbidity rate of BPH and inguinal hernia is notably high, with incidences of inguinal hernia in ”post-prostatectomy cases” ranging between 15–25%, in contrast to a general prevalence of approximately 5%. [ 8 ] This elevation in prevalence has been hypothesized to stem from increased intra-abdominal pressure during micturition. [ 9 , 10 ] Given this prevalence, the feasibility of simultaneous surgical interventions has been postulated to potentially reduce overall costs, operative and anesthesia durations, and hospitalization lengths, a concept supported by existing literature. [ 7 , 8 ] Considerations for combined procedures include potential additional complications and the potential difficulty in catheter removal post-operation. Therefore, a case series analysis was conducted on patients electing for combined surgery within our institution. Some researches indicate that concurrent TURP and hernioplasty do not elevate postoperative complication rates, a finding corroborated by ours. [ 11 , 12 ] In previous research, it has been noted that resection of a large volume prostate gland can result in micro-injuries and micro-perforations to the prostatic capsule at the bladder neck. Such damage facilitates the extravasation of fluid into the pre-peritoneal space, theoretically posing a significant risk of infection, particularly concerning when considering the pre-peritoneally placed mesh in concurrent surgeries of TURP and hernioplasty. [ 13 , 14 , 15 , 16 ] Despite these concerns, our study did not observe any incidents of pre-peritoneal infection postoperatively among the patients, suggesting that with appropriate surgical techniques and perioperative management, the risk of such complications may be mitigated. In our study, concurrent surgeries were effective in managing both inguinal hernia and BOO secondary to BPH. Among 85 patients undergoing concurrent surgery, all presented with inguinal masses and micturition difficulties preoperatively, with postoperative follow-ups indicating complete resolution of inguinal hernia and the majority achieving successful catheter removal and spontaneous urination during hospitalization. Only a minority required catheter reinsertion. At outpatient follow-ups, most patients reported satisfactory urination, with those discharged with catheters having them removed at the first follow-up, without subsequent complications and expressing satisfaction with their postoperative quality of life. Moreover, upon assessing the 12-month postoperative use of alpha-blockers, initially, 68 patients (80%) were prescribed alpha-blockers before surgery. By the 12-month postoperative mark, only 15 patients (17.6%) remained on such medications. This significant reduction indicates that the TURP component of the concurrent surgery is effective in achieving the desired therapeutic outcomes. Among all participants, only one encountered a urinary tract infection within two weeks post-surgery, and another developed hyponatremia. Within a year, none reported recurrent hernia, and only three patients underwent TUIBN surgery for urethral stricture, indicating a similar complication rate compared to previous studies. [ 17 ] The significant difference in operative times and duration of Foley catheterization between open hernioplasty and LH suggests that, LH is the preferable choice in concurrent surgeries, effectively shortening operative time and duration of catheterization. As previously mentioned, existing literature suggests that TURP requires the use of intra-abdominal pressure for postoperative voiding, while hernia repair surgeries contribute to surgical site discomfort. Notably, open surgical approaches are associated with more significant discomfort, potentially resulting in slower wound healing and, consequently, a prolonged need for catheterization. This extended catheterization period may inherently elevate the risk of urinary tract infections. This study, encompassing 85 patients undergoing concurrent surgery and meticulously documenting preoperative, intraoperative, and postoperative patient conditions, presents the largest case series to date on simultaneous surgery for hernia and BPH-induced BOO. However, caution should be exercised when interpreting these findings due to several limitations. The study's external validity is constrained by its single-center design, stringent inclusion and exclusion criteria, and the potential insufficiency of a one-year follow-up duration. Additionally, the absence of a control group precludes direct statistical analysis of certain variables. Future research should aim to address these aspects. In an era of advancing anesthetic and surgical techniques, efforts should be made to reduce the frequency and costs associated with the management of highly comorbid conditions, as each hospitalization and anesthetic procedure carries its own set of risks. Our study demonstrates the low complication rates of combined surgeries and their efficacy in treating both conditions. Conclusion Our study results demonstrate that a concurrent TURP and inguinal hernioplasty is effective for managing BPH-induced BOO and inguinal hernia over a one-year follow-up period, with a minimal complication rate. Crucially, this approach is expected to reduce the number of hospital stays and surgical interventions, thereby lowering associated risks and costs. Moreover, within the context of combined surgery, laparoscopic techniques offer the advantage of shorter operative times and potentially reduced durations of catheterization. Overall, combined surgery appears to be a feasible surgical option for appropriately selected patients. Abbreviations BPH benign prostatic hyperplasia BOO bladder outlet obstruction TURP transurethral resection of the prostate LH laparoscopic hernioplasty PSA prostate specific antigen TRUS transrectal ultrasound ASA American Society of Anesthesiologists CT computerized tomography MRI magnetic resonance imaging VAS visual analog scale TRUSP transrectal ultrasound-guided prostate biopsy Declarations Ethics approval and consent to participate The study was approved by our institutional ethical committee (Chi Mei Medical Center, Taiwan). Due to the retrospective nature of the study, an Informed Consent Statement was not used. The need for informed consent was waived by the ethics committee of Chi Mei Medical Center. Consent for publication Not applicable. Availability of data and materials All datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding No funding. Authors' Contributions T.W.H: data collection and management, data analysis, manuscript writing/editing; W.H.T: protocol/project development, data collection or management, data analysis, manuscript editing; S.K.H: protocol/project development, manuscript writing/editing; A.W.C: protocol/project development, manuscript writing/editing; C.F.L: protocol/project development, manuscript writing/editing; Y.L.S: protocol/project development, manuscript writing/editing. Acknowledgements We extend our sincere appreciation to the patients who participated in this study, contributing invaluable insights to the advancement of concurrent TURP and inguinal hernioplasty. Our gratitude also goes to the medical staff involved in the care and management of these patients. Additionally, we acknowledge the support and resources provided by Chi Mei Medical Center that facilitated the successful execution of this research. Conflict of Interest Statement The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript. References Egan KB. The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. Urol Clin North Am. 2016;43(3):289 – 97. 10.1016/j.ucl.2016.04.001 . PMID: 27476122. GBD 2019 Benign Prostatic Hyperplasia Collaborators. The global, regional, and national burden of benign prostatic hyperplasia. Lancet Healthy Longev. 2022;3(11):e754–76. 10.1016/S2666-7568(22)00213-6 . Epub 2022 Oct 20. PMID: 36273485; PMCID: PMC9640930. in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Miernik A, Gratzke C. Current Treatment for Benign Prostatic Hyperplasia. Dtsch Arztebl Int. 2020;117(49):843–54. 10.3238/arztebl.2020.0843 . 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Cite Share Download PDF Status: Published Journal Publication published 31 Aug, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 25 Jun, 2024 Reviews received at journal 24 Jun, 2024 Reviewers agreed at journal 28 May, 2024 Reviews received at journal 30 Mar, 2024 Reviewers agreed at journal 27 Mar, 2024 Reviewers agreed at journal 27 Mar, 2024 Reviewers invited by journal 27 Mar, 2024 Editor invited by journal 15 Mar, 2024 Submission checks completed at journal 15 Mar, 2024 Editor assigned by journal 15 Mar, 2024 First submitted to journal 11 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4071598","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280910815,"identity":"75c7a3a4-4e50-4f23-84ba-811094ce078d","order_by":0,"name":"Ting-Wei Hsu","email":"","orcid":"","institution":"Chi Mei Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ting-Wei","middleName":"","lastName":"Hsu","suffix":""},{"id":280910816,"identity":"9332a948-4ec7-48aa-8bbd-8514f1bfabe7","order_by":1,"name":"Wen-Hsin Tseng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYNCCCgYGA6IV84DJM0haeIjSwthGihZ7Bh7Dx4XzDsubszcfYPhRsY3BXiKBkC08xsYztx023NlzLIGx58xtBh7CWni3SfNuO8y44UaOATNjG1CLNGEt23/zzjlsT5KWbcy8DYcTSdBymP+zNM+x9OQNZ44lHAT6hYfn/gP8Wtjb2xI/89RY22443nzwwY+K23LsPQfwa2FgBpPNYPIAAxHRAgN1xCocBaNgFIyCkQgAW3A+PPpokAkAAAAASUVORK5CYII=","orcid":"","institution":"Chi Mei Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Wen-Hsin","middleName":"","lastName":"Tseng","suffix":""},{"id":280910817,"identity":"6ebced29-67df-4948-a3d5-215a134016b1","order_by":2,"name":"Steven K. Huang","email":"","orcid":"","institution":"Chi Mei Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"K.","lastName":"Huang","suffix":""},{"id":280910818,"identity":"3abf7b36-9ebf-46fa-904e-6a08a7fe13c0","order_by":3,"name":"Allen W. Chiu","email":"","orcid":"","institution":"Shin Kong WHS Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Allen","middleName":"W.","lastName":"Chiu","suffix":""},{"id":280910819,"identity":"93db129a-5b07-49c6-b38c-7db35d830324","order_by":4,"name":"Chien-Feng Li","email":"","orcid":"","institution":"Chi Mei Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Chien-Feng","middleName":"","lastName":"Li","suffix":""},{"id":280910820,"identity":"54195a6d-4701-42f2-a3f4-98ee39f03bf0","order_by":5,"name":"Yow-Ling Shiue","email":"","orcid":"","institution":"National Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Yow-Ling","middleName":"","lastName":"Shiue","suffix":""}],"badges":[],"createdAt":"2024-03-11 08:19:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4071598/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4071598/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01571-z","type":"published","date":"2024-08-31T15:58:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63821553,"identity":"b8df5180-7c88-40e2-afca-c1de96a7e769","added_by":"auto","created_at":"2024-09-02 16:14:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":474121,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4071598/v1/412fcb09-d213-4dbd-bfe7-c9730acd6b28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Concurrent Transurethral Resection of The Prostate (TURP) and Inguinal Hernioplasty","fulltext":[{"header":"Background","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH) is a common condition among males, especially in the elderly population.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e The volume of prostate increases with age, and clinically, an enlarged prostate can lead to bladder outlet obstruction (BOO), resulting in urinary symptoms. With the global increase in life expectancy over the past few decades, the prevalence of BPH has risen, as well as its complications.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e Studies indicate that 50% of males above 60 years old are affected by BPH, and over 80% of males aged 80 and above experience BPH-related issues.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e Considering this high prevalence, there is a growing need to focus on BPH treatments in various scenarios and their potential comorbidities.\u003c/p\u003e \u003cp\u003eOne of the most common comorbidities is inguinal hernia. Co-occurrence of inguinal hernia and BPH is frequently observed. Research reports a comorbidity rate of approximately 15\u0026ndash;25% between inguinal hernia and BPH.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Clinically, many males with enlarged prostates face difficulties in urination, leading to the need for intra-abdominal pressure to assist in voiding, which may contribute to the development of hernias over time. Considering such comorbidities, concurrently addressing inguinal hernia repair and benign prostatic hyperplasia in a single treatment may be a viable option, anticipating a reduction in hospitalizations and surgical interventions.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e However, concerns arise as Transurethral Resection of the Prostate (TURP) itself often requires intra-abdominal pressure for postoperative voiding, while hernia repair surgery causes surgical site discomfort, making it challenging for patients to transition early from catheterization, potentially necessitating considerations for catheter reinsertion.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the outcomes of performing TURP and inguinal hernia repair in a single treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSelection criteria\u003c/h2\u003e \u003cp\u003eIn this retrospective study, cases from Chi Mei Medical Center between 2014\u0026thinsp;~\u0026thinsp;2023 that concurrently underwent TURP and inguinal hernioplasty were included.\u003c/p\u003e \u003cp\u003e The inclusion criteria for patient enrollment in this study were concurrent receipt of TURP and inguinal hernia repair, ASA score beneath 4, and follow-up duration exceeding 1 year.\u003c/p\u003e \u003cp\u003eExclusion criteria comprised complicated inguinal hernias, coagulative disorders, previous history of TURP, malignant pathology finding of the prostate specimen, and other conditions that could potentially impact the evaluation.\u003c/p\u003e \u003cp\u003eWithin these parameters, a total of 85 patients were included in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy protocol and surgical procedure\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003ePreoperative assessments\u003c/h2\u003e \u003cp\u003eIn the protocol, preoperative patient conditions (Age, ASA score, comorbidity, ect) were recorded. For the assessment of BPH, we utilize transrectal ultrasound (TRUS), MRI or CT scan results to estimate the prostate volume in patients. Serum PSA levels are also recorded, although they may not necessarily have a direct correlation with BPH. For hernias, we document their location and confirm whether they are of the direct or indirect type through imaging or intraoperative assessment.\u003c/p\u003e \u003cp\u003eWe typically administer intravenous cefazolin as preoperative prophylactic antibiotics. For patients admitted with moderate to severe pyuria based on urinary analysis, we initiate appropriate therapeutic antibiotics. Additional cefazolin is not administered preemptively before the surgery in such cases. The surgical duration was defined from anesthesia induction to the conclusion of the procedure.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eIn the technique of open hernioplasty, the procedure begins with the incision of the external oblique aponeurosis (as known as Scarpa's fascia), the elevation of the spermatic cord and the identification and classification of the hernial sac. In cases of indirect hernias, meticulous dissection is carried out from the internal ring, followed by exploration of the sac to ensure its complete reduction into the posterior wall defect. For direct hernias, the protrusion is directly repositioned into the posterior wall defect and the inguinal ligament is sutured to the conjoined tendon. Subsequent steps involve ascertaining an adequate closure without undue tension and approximating Scarpa's fascia and the cutaneous layer.\u003c/p\u003e \u003cp\u003eIn laparoscopic hernioplasty, the procedure commences with the strategic placement of the laparoscope, forceps, and scissors via a single or tri-trocar port and the establishment of a CO\u003csub\u003e2\u003c/sub\u003e pneumoperitoneum at 12mmHg. This setup facilitates the meticulous examination and identification of the internal ring sites. Utilizing forceps, the peritoneum at the internal ring is elevated and incised, allowing for the dissection and mobilization of the internal spermatic vessels. The hernia type is determined, and the sac is subsequently retracted and corrected with the placement of a mesh securely affixed to the abdominal wall for reinforcement. The procedure concludes with the careful closure of all trocar entry points at the fascial level and the subsequent suturing of the skin.\u003c/p\u003e \u003cp\u003eDuring TURP, urethral calibration and dilatation precede the introduction of the resectoscope into the bladder under direct visualization. Utilizing a panendoscopic lens, the procedure involves delineating the distance from the urethral orifices to the bladder neck and retracting the lens to the verumontanum to assess the prostatic lobes' positioning. Resection commences at one lobe, employing techniques such as bipolar electrosurgery, greenlight photoselective vaporization, or Thulium, Vela, and Multipulse laser applications ranging from 20 to 120 watts for precise tissue removal, vaporization, coagulation, or enucleation. The procedure meticulously avoids the penetration of the prostatic capsule, halting resection upon visualization of bladder neck and capsule fibers. The contralateral lobe undergoes a similar procedure. Post-resection, a Toomey evacuator facilitates the removal of excised tissue. The operation concludes with the withdrawal of the resectoscope, insertion of a tri-lumen Foley catheter for bladder irrigation, ensuring the integrity and functionality of the urinary tract.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003ePostoperative hospitalization\u003c/h2\u003e \u003cp\u003eDuring the postoperative hospitalization period, we monitor blood loss and infection status through blood tests including white blood cell count and hemoglobin, as well as urine routine analysis and culture. We also document the administration of intravenous analgesics and the time from surgery completion to catheter removal. If the retention issue persists after removing Foley, re-catheterization is considered. Finally, we record the postoperative length of hospital stay and monitor for the presence of urinary tract infections or surgical wound infections during the hospitalization, and record the Visual Analog Scale (VAS) score at the time of discharge. Subsequent outpatient follow-up includes recording changes in voiding symptoms and alterations in urinary medications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eStatistical Methods\u003c/h2\u003e \u003cp\u003eQuantitative variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Qualitative variables were reported as frequency and percentage. For quantitative independent variables, a comparison between groups one and two was conducted using the independent sample t-test. Non-parametric quantitative variables were assessed with the Mann-Whitney U test. Qualitative variables underwent comparison using the Chi-square test. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the specified time period and within the inclusion criteria, a total of 110 patients were collected. After applying exclusion criteria, 85 patients remained (including 6 who had undergone previous prostate surgery, 1 with severe and complex hernia, 1 with an excessively large prostate, 1 with a high PSA level, and 16 with malignant pathology findings in the prostate specimen).\u003c/p\u003e \u003cp\u003eThe mean age was 71.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years, and preoperative basic data were documented in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All patients had ASA scores between 2 and 4, and if there was a history of cancer, the ECOG score was 0. Regarding inguinal hernia types, 30 patients had a direct type, 40 had an indirect type, and 15 had both types of hernia simultaneously. Concerning inguinal hernia location, 62 were unilateral and 23 having bilateral hernias. Among the 85 patients, 12 had undergone hernia repair surgery in the past, with 6 having hernias on different sides and 6 having hernias on the same side, indicating recurrent hernias.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 (year)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-morbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma / COPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal Surgical History\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHernioplasty (Same Side / Contralateral Side)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosition of Hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral(left/right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/38 (72.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatus of Hernia (primary/recurrent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79/6 (92.9%/7.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.3\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 (g)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSA level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 (\u0026micro;g/dL)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding BPH, the average prostate volume for the 85 patients was 60.3\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 mL. For each patient, a prostate specimen was obtained intraoperatively and sent for pathological examination to confirm the absence of malignancy. Patients with elevated PSA levels underwent transrectal ultrasound-guided prostate biopsy (TRUSP) and/or MRI.\u003c/p\u003e \u003cp\u003eDetails related to the surgery were documented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The average surgical time was 3 hours and 31minutes\u0026thinsp;\u0026plusmn;\u0026thinsp;65 minutes. For hernioplasty, 61 patients chose open hernioplasty, and among the 24 who underwent laparoscopic surgery. Regarding prostate surgery, 12 patients underwent traditional Bipolar TURP, and among the remaining 74 undergoing different laser surgery. The average weight of the resected prostate was 19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 g. No patient experienced significant bleeding, major vessel injury, spermatic cord injury, or bladder injury during surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation for Hernia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen Hernioplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic Hernioplasty (3-port / 1-port)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation for TURP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional Bipolar TURP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreenlight vaporization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaser Prostatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaser Enucleation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation Time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3hr 31min\u0026thinsp;\u0026plusmn;\u0026thinsp;65min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTURP Resection Volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 (g)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative Complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant Hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor Vascular Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpermatic Cord Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary Bladder Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo patient received a blood transfusion during surgery, and the average change in hemoglobin before and after surgery was a decrease of 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 g/dL, with a WBC increase of 5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 x10^3/\u0026micro;L. However, there were no occurrences of postoperative fever, wound infection, or gross hematuria during hospitalization. The average catheter retention time during hospitalization was 51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 hours, excluding 10 patients who underwent catheter reinsertion or had the catheter brought back. During hospitalization, intravenous or intramuscular form analgesics were used to assess severe pain, with 28 patients receiving injectable pain medication postoperatively. The average postoperative length of stay was 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 days, and each patient's VAS upon discharge was beneath 2, with bladder irrigation already discontinued. Postoperative details were recorded in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔHb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 (g/dL)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔWBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 (10^3/\u0026micro;L)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Foley Catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 (hr)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManual Bladder Irrigation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-catheterization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge with Foley\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Hospital Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 (day)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of IV/IM form analgesics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 (points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication During Postoperative Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGross Hematuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFollow-up will continue for one year after discharge and the details were established in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. One patient developed urinary tract infection and epididymitis two weeks after discharge, another patient developed hyponatremia two weeks after discharge, and three patients experienced urethral stricture within a year, undergoing transurethral incision of the bladder neck (TUIBN). We conducted a follow-up study on the usage of oral alpha-blockers (such as Tamsulosin, Doxazosin, and Silodosin) in different stage of the treatment to infer the severity of BOO induced by BPH and thereby to evaluate the efficacy of the surgical intervention. Preoperatively, alpha-blockers were prescribed to 68 out of 85 patients (80%). This number decreased to 47 patients (55.3%) one month after the surgery, and further declined to 15 patients (17.6%) by the twelve-month postoperative mark. These findings suggest that TURP, as part of concurrent surgery, achieves the anticipated therapeutic outcomes. Additionally, within the one-year follow-up, no patients experienced a recurrence of hernia on the operated side, further substantiating the effectiveness of hernioplasty within the concurrent surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen Hernioplasty N(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopic Hernioplasty N(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;27.5 (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.4\u0026thinsp;\u0026plusmn;\u0026thinsp;23.3(g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3hr 45min\u0026thinsp;\u0026plusmn;\u0026thinsp;67min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2hr 55min\u0026thinsp;\u0026plusmn;\u0026thinsp;45min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse of IV/IM form analgesics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Foley Catheter*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.5\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9 (hr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11 (hr)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRe-catheterization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Hospital Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09 (Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65 (Days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Duration of Foley Catheter: 75 patients were involved in this analysis, 53 underwent open hernioplasty and 22 underwent laparoscopic hernioplasty. 10 patients who underwent catheter reinsertion or had the catheter brought back were excluded.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding hernioplasty, the differences between open and laparoscopic approaches were compared in concurrent surgery. A significant difference was noted in operative times between open hernioplasty (3hr 45 min\u0026thinsp;\u0026plusmn;\u0026thinsp;67min) and LH (2hr 55min\u0026thinsp;\u0026plusmn;\u0026thinsp;45min), p\u0026thinsp;=\u0026thinsp;0.0011. Analysis of patients who successfully had their Foley catheters removed prior to discharge revealed average durations of 54.5\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9 hours for open hernioplasty and 44.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11 hours for laparoscopic hernioplasty (p\u0026thinsp;=\u0026thinsp;0.0492). No significant statistical difference was noted in catheter reinsertion rates. Details comparing open and laparoscopic hernioplasty are documented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe comorbidity rate of BPH and inguinal hernia is notably high, with incidences of inguinal hernia in \u0026rdquo;post-prostatectomy cases\u0026rdquo; ranging between 15\u0026ndash;25%, in contrast to a general prevalence of approximately 5%.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e This elevation in prevalence has been hypothesized to stem from increased intra-abdominal pressure during micturition.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e Given this prevalence, the feasibility of simultaneous surgical interventions has been postulated to potentially reduce overall costs, operative and anesthesia durations, and hospitalization lengths, a concept supported by existing literature.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eConsiderations for combined procedures include potential additional complications and the potential difficulty in catheter removal post-operation. Therefore, a case series analysis was conducted on patients electing for combined surgery within our institution. Some researches indicate that concurrent TURP and hernioplasty do not elevate postoperative complication rates, a finding corroborated by ours. \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e In previous research, it has been noted that resection of a large volume prostate gland can result in micro-injuries and micro-perforations to the prostatic capsule at the bladder neck. Such damage facilitates the extravasation of fluid into the pre-peritoneal space, theoretically posing a significant risk of infection, particularly concerning when considering the pre-peritoneally placed mesh in concurrent surgeries of TURP and hernioplasty.\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e Despite these concerns, our study did not observe any incidents of pre-peritoneal infection postoperatively among the patients, suggesting that with appropriate surgical techniques and perioperative management, the risk of such complications may be mitigated.\u003c/p\u003e \u003cp\u003eIn our study, concurrent surgeries were effective in managing both inguinal hernia and BOO secondary to BPH. Among 85 patients undergoing concurrent surgery, all presented with inguinal masses and micturition difficulties preoperatively, with postoperative follow-ups indicating complete resolution of inguinal hernia and the majority achieving successful catheter removal and spontaneous urination during hospitalization. Only a minority required catheter reinsertion. At outpatient follow-ups, most patients reported satisfactory urination, with those discharged with catheters having them removed at the first follow-up, without subsequent complications and expressing satisfaction with their postoperative quality of life. Moreover, upon assessing the 12-month postoperative use of alpha-blockers, initially, 68 patients (80%) were prescribed alpha-blockers before surgery. By the 12-month postoperative mark, only 15 patients (17.6%) remained on such medications. This significant reduction indicates that the TURP component of the concurrent surgery is effective in achieving the desired therapeutic outcomes. Among all participants, only one encountered a urinary tract infection within two weeks post-surgery, and another developed hyponatremia. Within a year, none reported recurrent hernia, and only three patients underwent TUIBN surgery for urethral stricture, indicating a similar complication rate compared to previous studies.\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e The significant difference in operative times and duration of Foley catheterization between open hernioplasty and LH suggests that, LH is the preferable choice in concurrent surgeries, effectively shortening operative time and duration of catheterization. As previously mentioned, existing literature suggests that TURP requires the use of intra-abdominal pressure for postoperative voiding, while hernia repair surgeries contribute to surgical site discomfort. Notably, open surgical approaches are associated with more significant discomfort, potentially resulting in slower wound healing and, consequently, a prolonged need for catheterization. This extended catheterization period may inherently elevate the risk of urinary tract infections.\u003c/p\u003e \u003cp\u003eThis study, encompassing 85 patients undergoing concurrent surgery and meticulously documenting preoperative, intraoperative, and postoperative patient conditions, presents the largest case series to date on simultaneous surgery for hernia and BPH-induced BOO. However, caution should be exercised when interpreting these findings due to several limitations. The study's external validity is constrained by its single-center design, stringent inclusion and exclusion criteria, and the potential insufficiency of a one-year follow-up duration. Additionally, the absence of a control group precludes direct statistical analysis of certain variables. Future research should aim to address these aspects.\u003c/p\u003e \u003cp\u003eIn an era of advancing anesthetic and surgical techniques, efforts should be made to reduce the frequency and costs associated with the management of highly comorbid conditions, as each hospitalization and anesthetic procedure carries its own set of risks. Our study demonstrates the low complication rates of combined surgeries and their efficacy in treating both conditions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study results demonstrate that a concurrent TURP and inguinal hernioplasty is effective for managing BPH-induced BOO and inguinal hernia over a one-year follow-up period, with a minimal complication rate. Crucially, this approach is expected to reduce the number of hospital stays and surgical interventions, thereby lowering associated risks and costs. Moreover, within the context of combined surgery, laparoscopic techniques offer the advantage of shorter operative times and potentially reduced durations of catheterization. Overall, combined surgery appears to be a feasible surgical option for appropriately selected patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebenign prostatic hyperplasia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBOO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebladder outlet obstruction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTURP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etransurethral resection of the prostate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elaparoscopic hernioplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprostate specific antigen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTRUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etransrectal ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputerized tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evisual analog scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTRUSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etransrectal ultrasound-guided prostate biopsy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by our institutional ethical committee (Chi Mei Medical Center, Taiwan). Due to the retrospective nature of the study, an Informed Consent Statement was not used. The need for informed consent was waived by the ethics committee of Chi Mei Medical Center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.W.H: data collection and management, data analysis, manuscript writing/editing; W.H.T: protocol/project development, data collection or management, data analysis, manuscript editing; S.K.H: protocol/project development, manuscript writing/editing; A.W.C: protocol/project development, manuscript writing/editing; C.F.L: protocol/project development, manuscript writing/editing; Y.L.S: protocol/project development, manuscript writing/editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere appreciation to the patients who participated in this study, contributing invaluable insights to the advancement of concurrent TURP and inguinal hernioplasty. Our gratitude also goes to the medical staff involved in the care and management of these patients. Additionally, we acknowledge the support and resources provided by Chi Mei Medical Center that facilitated the successful execution of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEgan KB. The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms: Prevalence and Incident Rates. 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PMID: 24972732.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Benign prostatic hyperplasia (BPH), inguinal hernia, transurethral resection of the prostate (TURP), inguinal hernioplasty","lastPublishedDoi":"10.21203/rs.3.rs-4071598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4071598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBenign prostatic hyperplasia (BPH) is a prevalent condition in aging males, leading to bladder outlet obstruction (BOO) and associated urinary symptoms. With increasing life expectancy, the incidence of BPH and its co-morbidities, like inguinal hernia, has risen. This study explores the efficacy of combining transurethral resection of the prostate (TURP) and inguinal hernioplasty in a single surgical session to address both conditions, potentially reducing the need for multiple hospitalizations and surgical interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study at Chi Mei Medical Center included patients from 2014 to 2023 who underwent concurrent TURP and inguinal hernioplasty. A total of 85 patients met the criteria defined for this study. Preoperative, intraoperative, and postoperative characteristics were meticulously documented. Outcomes evaluated included the duration of the surgery, incidence of intraoperative and postoperative complications, duration of Foley catheterization, length of hospital stay, and treatment efficacy. Additionally, we conducted a comparative assessment of the surgical outcomes between two distinct techniques for inguinal hernia repair: open hernioplasty and laparoscopic hernioplasty (LH).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn 85 patients who met the criteria, the mean age was 71.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 years. The study reported no significant intraoperative complications, and postoperative care was focused on monitoring for blood loss, infection, and managing pain. The average postoperative hospital stay was 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 days and the mean duration of catheterization was 51.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 hours, with a minimal complication rate observed during the one-year follow-up. A significant reduction in both operative duration and catheterization interval was observed in patients undergoing LH as opposed to those receiving open hernioplasty.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eConcurrent TURP and inguinal hernioplasty effectively manage BOO due to BPH and inguinal hernias with minimal complications, suggesting a viable approach to reducing hospital stays and surgical interventions. Laparoscopic techniques, in particular, offer benefits in operative efficiency and recovery time, making combined surgery a feasible option for selected patients.\u003c/p\u003e","manuscriptTitle":"Concurrent Transurethral Resection of The Prostate (TURP) and Inguinal Hernioplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 15:01:28","doi":"10.21203/rs.3.rs-4071598/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-25T14:51:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-24T15:35:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217563007636080913082169517537881151789","date":"2024-05-28T13:46:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-30T21:59:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0ba8de3e-af1d-4734-8300-755ee713b108","date":"2024-03-28T00:33:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2ed2f4ba-9de3-4c46-8e42-04f684012af5","date":"2024-03-27T17:05:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-27T17:03:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-15T08:29:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-15T08:28:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-15T08:28:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-03-11T08:05:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cfa9c466-6c72-49d0-806c-9ac95d1bcdfd","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T16:08:38+00:00","versionOfRecord":{"articleIdentity":"rs-4071598","link":"https://doi.org/10.1186/s12894-024-01571-z","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-08-31 15:58:07","publishedOnDateReadable":"August 31st, 2024"},"versionCreatedAt":"2024-03-19 15:01:28","video":"","vorDoi":"10.1186/s12894-024-01571-z","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01571-z","workflowStages":[]},"version":"v1","identity":"rs-4071598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4071598","identity":"rs-4071598","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}