In a healthy middle‑aged male with an inguinal hernia and benign prostatic hyperplasia, can laparoscopic inguinal hernioplasty and transurethral resection of the prostate be performed in the same operative session?

Combined Laparoscopic Inguinal Hernioplasty and TURP: Feasibility and Safety

Yes, laparoscopic inguinal hernioplasty and TURP can be safely performed in the same operative session in appropriately selected healthy patients, with evidence demonstrating no increase in morbidity compared to staged procedures. 1, 2

Evidence Supporting Combined Surgery

Safety and Efficacy Data

Multiple studies demonstrate that combining these procedures is both practical and safe:

• A retrospective series of 44 patients undergoing combined TURP and inguinal herniorrhaphy showed no significant differences in postoperative complications compared to either procedure performed alone, with no mesh infections detected. 2

• A study of 31 patients demonstrated good outcomes in 86% of cases with a morbidity rate of only 10.7%, no hernia recurrences, and mean hospital stay of 3.6 days. 1

• Larger series of 55 and 92 patients showed wound infection rates of 5.4% and hernia recurrence rates of 6-7.6%, which compare favorably to results when procedures are performed separately. 3, 4

Advantages of Combined Approach

The simultaneous approach offers several benefits:

• Reduces the number of anesthetic exposures, which is particularly important in elderly patients with cardiovascular comorbidities. 1, 4

• Decreases total hospital stay and direct healthcare costs compared to staged procedures. 1

• Prevents hernia recurrence that can occur when hernia repair is performed first without addressing bladder outlet obstruction, as straining from dysuria increases recurrence risk. 4

Critical Patient Selection Criteria

Appropriate Candidates

Select patients who meet these criteria:

• Healthy middle-aged to elderly males without significant cardiopulmonary compromise who can tolerate extended operative time (mean 126 minutes vs 61 minutes for TURP alone). 2

• Patients with moderate-to-severe LUTS from BPH requiring surgical intervention per AUA guidelines, including those with acute urinary retention, recurrent retention, or severe dysuria. 5, 1

• Prostate size appropriate for TURP (typically 30-80 ml), as larger glands may require alternative approaches. 5

Important Caveats and Contraindications

Infection Risk Considerations

Elevated PSA levels may indicate chronic prostatic inflammation and should raise concern about increased infection risk when combining procedures with mesh placement. 6

• A case report documented mesh rejection and bilateral inguinal abscess 3 months post-operatively in a patient with elevated PSA and atypical adenomatous hyperplasia with chronic inflammation. 6

• Consider obtaining prostate biopsy if PSA is significantly elevated to rule out chronic infection or malignancy before proceeding with combined surgery. 6

Technical Considerations

Use bipolar TURP when available for combined procedures, as it reduces TUR syndrome risk and allows longer resection times without hyponatremia complications. 5

• Limit total operative time and maintain meticulous hemostasis throughout both procedures. 7, 8

• Most series utilized spinal anesthesia (96.8% in one study), which is appropriate for both procedures. 4

• Administer appropriate perioperative antibiotics given the combination of urologic and mesh-based procedures. 6

Surgical Approach Selection

Hernia Repair Technique

Historical series predominantly used open techniques (Bassini in 82.6% of cases), but laparoscopic totally extraperitoneal (TEP) repair is feasible and has been successfully combined with TURP. 6, 4

• The laparoscopic approach offers advantages of reduced postoperative pain and faster recovery for the hernia component. 6

• Be aware that bladder erosion from mesh is a theoretical risk when combining procedures, though rare in reported series. 6

Common Pitfalls to Avoid

• Do not perform hernia repair first without addressing bladder outlet obstruction, as this leads to high hernia recurrence rates from persistent straining. 4

• Avoid combining procedures in patients with active urinary tract infection or significantly elevated PSA without further workup. 6

• Do not attempt combined surgery if prostate size exceeds 80 grams, as this may require open prostatectomy rather than TURP. 5

• Ensure adequate surgical expertise in both procedures, as operative time is significantly longer (approximately double) compared to either procedure alone. 2