Risk for hernia after first-line treatment for prostate cancer

The risk for an inguinal hernia after a radical prostatectomy for the treatment of localized prostate cancer is well known to most urologic surgeons, and patients are commonly advised to be cautious about heavy lifting too soon after their surgery in order to be able to minimize this risk.

A new article by Nilsson et al. in the Annals of Surgery has now documented the frequency of such hernias after first-line treatment for prostate cancer in Sweden, and compared this risk to the risk for such hernias in the rest of the male population of Sweden. The findings are also discussed in an article on the Reuters web site.

Nilsson and her colleagues used data from the Prostate Cancer Database Sweden (PCBaSe) and the Swedish Hernia Register for events occurring between 1998 and 2010. They were able to calculate and compare the incidence of inguinal hernia for four different groups of men:

  • Men treated for localized prostate cancer by open radical prostatectomy.
  • Men treated for localized prostate cancer by minimally invasive prostatectomy (i.e., laparoscopic surgery)
  • Men treated for localized prostate cancer with radiation therapy
  • A control cohort of men not treated for prostate cancer, matched for age and county of residence.

Here are their findings:

  • The study included a total of 28,608 cases and 105,422 controls.
  • Men who received any one of the three treatments for localized prostate cancer had a higher incidence of hernia that the control cohort.
    • For men treated by open radical prostatectomy, the hazard ratio (HR) = 3.95.
    • For men treated by minimally invasive prostatectomy, HR = 3.37
    • For men treated by radiation therapy, HR = 1.84

In other words, men who had had an open radical prostatectomy were at nearly four times the risk of a hernia compared to the controls; men who had minimally invasive surgery were at about three times the risk compared to controls; and (unexpectedly) men who had radiation therapy were at nearly twice the risk.

The increased risk for hernia among the surgical patients is not entirely surprising — although one does tend to wonder whether patients are being adequately advised of this risk when they are discharged after surgery. By comparison, the increased risk for radiation therapy patients is surprising. We had certainly never heard previously that this was a potential risk for patients receiving radiation therapy.

The Reuter’s article already mentioned above does also raise the question of how many of these operations for hernia repair are really necessary. This is unclear. There is a potential risk for over-treatment of minimally symptomatic hernias, and elective surgery is no longer recommended for this type of hernia. On the other hand, it is not clear from this Swedish study just how many of the hernias seen in patients treated initially for prostate cancer meet the “minimally symptomatic” criteria … and in any case, prostate cancer patients do need to be clearly advised what they should and should not be doing so that they can avoid this risk entirely for a significant period of time after their initial treatment for prostate cancer.

9 Responses

  1. The Reuters article makes reference to the hernia operations being performed within 6 years after treatment. It would be interesting to know more details about the time factor. Exactly when were these operations performed, and specifically when after each of the 3 different treatments? (My guess would be that the hernia operations after radiation were performed later compared to those after surgery). Surely the data are available.

    I assume that the study did not include data on when these patients re-started heavy physical activities. The question remains: exactly how long do patients have to restrain themselves regarding heavy lifting and other strenuous activities.

  2. As noted above “one does tend to wonder whether patients are being adequately advised of this risk when they are discharged after surgery.”

    Perhaps a more relevant question is “Are patients being advised of this risk when they are electing primary treatment?” After surgery may be a bit too late in the game.

  3. Richard, I think the answer to your first question is no.

    As pointed out by Sitemaster, “patients are commonly advised to be cautious about heavy lifting too soon”, but not about the consequences. The advice usually is for a few weeks or 2 months, which may not be long enough, but we don’t know.

    Either way, patients oftentimes do not adhere to that, hanging pictures or playing golf while they are still off work after surgery. I am not aware of any survivor who was advised of the risk after EBRT.

  4. Well, I was treated here in Sweden by EBRT and HDR brachytherapy, and do not remember being advised about this.

  5. George:

    I am not surprised. This is the first time I have ever heard it suggested in the prostate cancer literature — going back 20-odd years.

  6. Well now I will be “aware” of this happening … received radiation and was not informed to modify my work during or after treatment — apartment complexes, trashing units out and moving paint or appliances … but at least I know now — 5 months post-treatment.

  7. I have just been told I have developed a hernia 2.5 years after surgery and a second ultrasound (the first one being approx 1 year after surgery with a conclusion I had not).

    As I reflect back on the lack of post-operative information received related to this risk existing and then the response to the symptoms presenting 1.5 years ago (less than 1 year after surgery; a radical prostatectomy), I find the concerns regarding post-op care information presented in your article ringing true for me.

    I still remember clearly feeling a popping session in my mid left side of the abdomen during a regular yoga class and then subsequently seeing a distinct bulge that has fluctuated in size/appearance ever since.

    Now, with a diagnosis confirmed, I am back to my GP for further referrals to decide what to do.

    Thank you

  8. THE HERNIAS ARE CAUSED BY THE DRUG LUPRON, which is prescribed to men with prostate cancer! The hernias are not directly related to prostate surgery or radiation. Abdominal fascia is androgen-dependent like bones (see here).

  9. Dear Ms Preston:

    (1) The article referred to above is based on data from men who would never have received a drug like Lupron because this drug (and other drugs of the same class) is not given to men prior to surgery except in very rare cases.

    (2) The article that you refer to is based on data from mouse models of advanced prostate cancer.

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