prostate cancer ( pca ) is a major health threat for men , being the second greatest cause of cancer deaths among men in europe and in our country . the incidence of pca has a tendency to increase and to be more common in men aged more than 50 years . the lifetime prevalence rate of inguinal hernia ( ih ) in men aged more than 45 years ranges between 28.0 and 39.7% . with this high prevalence rate , it is reasonable to assume that men who have localized pca and are candidates for radical prostatectomy ( rp ) have the same risk of ih as age - matched men in the general population at the time of operation . this operation can be performed in an open or laparoscopic fashion , with or without the application of mesh . either biodegradable or synthetic mesh is preferred in ihr techniques that include placement of mesh . there are 2 recognized methods of laparoscopic ihr ( lihr ) : total extraperitoneal repair ( tep ) and transabdominal preperitoneal repair ( tapp ) . laparoscopic radical prostatectomy ( lrp ) has gained importance in the treatment of localized pca after guillonneau et al published their technique . over time , extraperitoneal lrp ( e - lrp ) has been shown to be an effective and safe method for the management of pca , with some advantages over the transperitoneal approach . although both transperitoneal and extraperitoneal techniques can be combined with lihr , e - lrp is more advantageous , as it avoids the contact of the mesh with the bowel , thus markedly reducing the risk of adhesions . we regard the tep+e - lrp combination as preferable in patients with an ih and localized pca . we used a matched - pairs design to compare results in patients who underwent simultaneous e - lrp and lihr ( e - lrp+lihr ) with those in a control group who underwent only e - lrp . from march 2004 through november 2013 , 340 patients underwent lrp by the same surgeon ( t.e . ) . of these patients , 85 had transperitoneal lrp ( t - lrp ) and 255 had e - lrp . after excluding the first 40 cases of e - lrp as constituting the learning curve , we evaluated 215 patients who underwent the procedure . a further 20 patients who underwent e - lrp+lihr were evaluated and compared with 40 who underwent only e - lrp , in a matched - pairs analysis . in the preoperative evaluation , the inguinal canals were examined by the same surgeon ( t.e . ) in patients maintained in the upright position during a valsalva maneuver . for the patients with reducible ihs , regardless of defect size , tep hernia repair was performed after rp was completed . the technique used for e - lrp has been published . after a transverse incision 1 cm below the umbilicus and a sharp incision of the rectus fascia , the retzius space was accessed with blunt digital dissection between the rectus muscle and the posterior sheath of its fascia . located 10 cm lateral to the infraumbilical incision , both medial 10-mm trocars were inserted into the preperitoneal space under digital control . after a 12-mm trocar was inserted into the infraumbilical incision , all trocars were fixed , and the wounds were closed with interrupted sutures . the lateral fusion of the fascia transversalis was incised below the epigastric arteries to reach borgros ' space , and 2 additional 5-mm trocars were inserted laterally under laparoscopic control . after high transection of the urachus and division of both lateral umbilical ligaments , the sixth trocar was placed in the right lower abdomen after the retzius space was dissected completely . when indicated , a bilateral lymphadenectomy consisting of the obturator and internal and external iliac lymph nodes was performed . after the endopelvic fascia was incised on both sides , the deep dorsal vein complex was controlled with sutures and divided . the prostatic apex was dissected meticulously , and the neurovascular bundles were preserved in the patients , as indicated . the division of the urethra was followed by the posterior dissection of the prostate and the seminal vesicles and vas deferens . the prostate was completely freed by division of the cranial pedicles and inserted into an organ bag . the hernia sac was mobilized and dissected from the spermatic cord structures ( figure 1 ) . the defect in the ih area was measured with a flexible plastic tape , a portion of polypropylene mesh with approximate dimensions of 810  1012 cm was prepared , and a 6-cm vertical cut was made in the mesh extracorporeally to accommodate the spermatic cord ( figure 2 ) . to facilitate placement , the mesh the unfolded mesh was positioned around the spermatic structures to cover the visible defect and anchored to the abdominal wall with 4 sutures on each corner ( figure 3 and 4 ) . operation time , duration of catheterization , length of hospital stay , preoperative and postoperative hemoglobin values , estimated blood loss ( ebl ) , time to perform the anastomosis and its quality , percentage of patients who underwent bilateral lymphadenectomy , and duration of analgesic treatment were recorded . the soundness of the anastomosis was evaluated by infusing 200 ml saline into the bladder through a urethral catheter after the vesicourethral anastomosis was completed and was classified into 4 groups : no leak , mild leak , moderate leak , and severe leak . postoperative parameters were evaluated , including pathologic stage and gleason score , specimen volume , follow - up duration , and biochemical recurrence rates . all patients had given written informed consent before the surgery for the use of the collected data at any time . the principles of the declaration of helsinki for research involving human subjects were followed during the study , and the confidentiality of the patients ' data was guaranteed . numeric data were compared by independent t test , and the  test was used for the comparison of the nonnumeric outcomes . all statistical analyses were performed with the ibm statistical package for social sciences ( spss ) software , version 22 ( armonk , new york , usa ) . the patients ' demographics and the operative and pathology results are presented in table 1 . no statistically significant difference was determined for age , body mass index ( bmi ) , preoperative prostate - specific antigen ( psa ) level , transrectal ultrasonography determined prostate weight , and clinical stage between the 2 groups . regarding the pathology findings ( table 1 ) , gleason score sums of the preoperative prostate biopsy and the specimen after prostatectomy , pathological stage , and specimen weights were not significantly different among the groups . operation time , preoperative and postoperative hemoglobin values , ebl , duration of catheterization , hospital length of stay , time to perform the anastomosis and its quality classification , percentage of patients with bilateral lymphadenectomy , and duration of analgesic treatment were also similar between the 2 groups . demographic , operative , and pathologic results of e - lrp and e - lrp+lihr data are expressed as the mean  sd or n ( % ) . delta hb : decrease in hemoglobin ; gs , gleason score ; psa , prostate - specific antigen ; trus , transrectal ultrasonography . perioperative complications according to the clavien - dindo classification ( minor : grades 1 and 2 ; major : grades 3 , 4 , and 5 ) are shown in table 2 . all patients in both groups had similar follow - up duration and biochemical recurrence rate during this period . none of the patients in the e - lrp+lihr group had a recurrence of ih during the follow - up time . perioperative complications according to the clavien - dindo classification data were collected at the follow - up of patients in the e - lrp and e - lrp+lihr groups and are expressed as the mean  sd or n ( % ) . the patients ' demographics and the operative and pathology results are presented in table 1 . no statistically significant difference was determined for age , body mass index ( bmi ) , preoperative prostate - specific antigen ( psa ) level , transrectal ultrasonography determined prostate weight , and clinical stage between the 2 groups . regarding the pathology findings ( table 1 ) , gleason score sums of the preoperative prostate biopsy and the specimen after prostatectomy , pathological stage , and specimen weights were not significantly different among the groups . operation time , preoperative and postoperative hemoglobin values , ebl , duration of catheterization , hospital length of stay , time to perform the anastomosis and its quality classification , percentage of patients with bilateral lymphadenectomy , and duration of analgesic treatment were also similar between the 2 groups . demographic , operative , and pathologic results of e - lrp and e - lrp+lihr data are expressed as the mean  sd or n ( % ) . delta hb : decrease in hemoglobin ; gs , gleason score ; psa , prostate - specific antigen ; trus , transrectal ultrasonography . perioperative complications according to the clavien - dindo classification ( minor : grades 1 and 2 ; major : grades 3 , 4 , and 5 ) are shown in table 2 . all patients in both groups had similar follow - up duration and biochemical recurrence rate during this period . none of the patients in the e - lrp+lihr group had a recurrence of ih during the follow - up time . perioperative complications according to the clavien - dindo classification data were collected at the follow - up of patients in the e - lrp and e - lrp+lihr groups and are expressed as the mean  sd or n ( % ) . rp is the treatment of choice with curative intent in pca , and the use of lrp has gradually risen after guillonneau et al standardized the technique . although the laparoscopic procedure carries a steep learning curve and a large number of operations is necessary to gain enough experience , experienced surgeons have reported promising results , with oncological and functional outcomes that are comparable with those of open surgery . although e - lrp is somewhat disadvantageous because of its narrower working space , it has gained acceptance among some surgeons , as it involves no contact with the bowel . e - lrp can be performed efficaciously and safely without a significant difference noted in the oncological results when compared with those of t - lrp . ih is a common problem in men aged more than 50 years , and ihr is the most frequently performed operation in general surgery . the incidence of subclinical ih was reported between 10 and 33% , whereas it was found to be 20% in autopsy studies . the chance that a man will undergo an ihr during his life is 27% . in a recent study evaluating 5870 men in rotterdam , when the probability of coexistence of these 2 common conditions is combined with the common observation that rp becomes more difficult after ihr , some surgeons recommend screening for pca in all men who must undergo an ihr and vice versa . the potential risk factors including older age , lower bmi , bladder neck contracture , and a history of ih have been reported to be associated with ih after rp . several studies have shown that the incidence of ih increases in men who have undergone rp . sekita et al found that the incidence of ih is higher after open simple prostatectomy and retropubic rp ( rrp ) when compared with that occurring after transurethral resection of the prostate ( turp ) . although some researchers have stated that there is no difference in the incidence of ih between rrp and lrp , in a recent study , nilsson et al reported that the incidence is increased in rrp versus that in minimally invasive rp ( traditional lrp and robot - assisted lrp ) . yoshimine et al concluded that the incidence of ih is higher in e - lrp than in t - lrp . although there are conflicting conclusions about the feasibility of performing rrp and lrp after ihr , katz et al and erdogru et al showed that both operations can be performed successfully but pose increased complexity . peeters et al observed that rrp after preperitoneal ihr is more difficult to perform and is associated with a longer duration of hospitalization and less adequate lymphadenectomy for intermediate- and high - risk pca . in their recent meta - analysis of 7497 patients from 11 studies , picozzi et al concluded that previous lihr with mesh placement can complicate subsequent rp , regardless of the technique ( open vs laparoscopic vs robotic ) , in terms of bleeding , catheterization time , and extent of pelvic lymphadenectomy . on the contrary , spernat et al reported that rp ( open , laparoscopic , or robotic ) is not contraindicated and can be performed safely after lihr ; however , lymph node dissection can not be performed in 50% of patients because of adhesions , and this possibility may lead to inadequate staging and treatment . there are several studies in the literature emphasizing that simultaneous repair of ihs detected during lrp is easy , and therefore , an hr should not be postponed . in their series consisting of 93 cases of preperitoneal ihrs performed during endoscopic extraperitoneal rp , do et al concluded that neither the complication rates nor the oncological and functional outcomes were influenced by the simultaneous performance of the procedures . teber et al established that a simultaneous lihr with prosthetic mesh during lrp results in a statistically significant increase in the duration of the operation and the need for analgesics , although no significant differences were recorded in complication rates and positive surgical margins . on the other hand , gzen et al found that simultaneous lihr does not affect the duration of the operation or complication rates and pain levels after e - lrp . in the present study , we recorded a mean operative time of 195 and 176 minutes for groups with and without a simultaneous lihr , respectively , although this 19-minute increase in favor of the repair group was not statistically significant . we can conclude that simultaneous lihrs can be performed by an experienced surgeon without a significant increase in operation time . on the other hand , these results may be due to the small sample size . no statistically significant difference was observed in any of the other parameters between the 2 groups , which appears to be consistent with data reported in the literature . our results for complication rates and duration of the operation were similar to those of gzen et al . although lymphadenectomy during e - lrp has a tendency to cause more lymphoceles than the transperitoneal approach , we did not observe this complication in either study group . development of a lymphocele can also affect the rate of other complications ( eg , mesh - related infection ) . performing an lihr with prosthetic mesh during lihr has a significantly lower incidence of infection and inguinal hematoma when compared to open surgery . the incidence of mesh - associated infection in lihr is very low ( range , 00.17% ) , perhaps because the contact of mesh with the skin is prevented when the mesh passes through the trocar . our mesh - related infection incidence of 0% is consistent with that reported in the literature . first , a relatively small number of patients was evaluated in each group , which may affect the reliability of the statistical analysis . we think that using a matched - pairs analysis compensated for this deficit to some degree . second , a retrospective study instead of a prospective randomized one provides a lower level of evidence . a prospective randomized study with a high case volume would prevent selection bias and provide much more accurate results . third , no information was available on the dose of the analgesic medications ( narcotic or nonnarcotic ) used in each group . as the study was retrospective , only data about the duration of analgesic treatment could be gathered from the progress notes . although a slightly increased analgesic dose was observed in the e - lrp+lihr group ( data not shown ) , it was not clear why nor was the information suitable for statistical analysis , as data were missing in some patients ' charts . it was not possible to make a comparison between the groups , as the data were not reported for every patient . the lack of centralized evaluation by a single pathologist may have contributed to this problem . evaluating patients with pca who will undergo e - lrp is important , as an ih can be efficiently and safely treated by simultaneous lihr . thus , the need for an extra operation with an additional financial burden on the health system can be avoided .
background and objectives : prostate cancer and inguinal hernia are common health issues in men aged more than 50 years . recently , 
 more data are accumulating that laparoscopic radical prostatectomy ( lrp ) and laparoscopic inguinal hernia repair ( lihr ) can be performed in the same operation . 
 the purpose of this study was to compare patients who underwent simultaneous extraperitoneal lrp ( e - lrp ) and lihr with control patients who underwent only e - lrp in a matched - pairs design.methods:medical records of 215 patients were evaluated , and 20 patients who underwent e - lrp+lihr were compared with 40 patients who underwent only e - lrp in a matched - pairs analysis . 
 preoperative clinical parameters ( age , body mass index , prostate - specific antigen , clinical stage , gleason score of the prostate biopsy , and prostate volume ) and operative data ( operation time , duration of catheterization , length of hospital stay , estimated blood loss , time to perform the anastomosis and its quality , and the percentage of patients with bilateral lymphadenectomy ) were evaluated , as well as postoperative parameters ( pathological stage , gleason score , specimen weight , follow - up duration , biochemical recurrence , complication rates , and duration of postoperative analgesic treatment).results : no statistically significant differences were found in the preoperative and operative parameters between the 2 study groups . 
 pathological parameters and the follow - up period and complication rates were similar between the 2 groups.conclusion:performing lihr and e - lrp during the same operation is safe and feasible in the treatment of patients with prostate cancer and inguinal hernia .