Ho, SHB

Lai, TCT

Ma, WK

Ng, ATL

Tsang, CF

Tsu, HLJ

Wong, JKW

Yiu, MK

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Asian Journal of Urology (2017) 4, 253e255Available online at www.sciencedirect.comScienceDirectjournal homepage: www.elsevier .com/locate/ajurCase ReportAnterior perineal hernia after anteriorexenterationKa Wing Wong*, Terence Chun-ting Lai, Ada Tsui-lin Ng,Brian Sze-ho Ho, James Hok-leung Tsu, Chiu Fung Tsang,W.K. Ma, Ming Kwong YiuDivision of Urology, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong,ChinaReceived 20 March 2016; received in revised form 25 May 2016; accepted 14 September 2016Available online 14 March 2017KEYWORDSPerineal hernia;Anteriorexenteration;Bladder cancer;Mesh repair* Corresponding author.Peer review under responsibilityUniversity.http://dx.doi.org/10.1016/j.ajur.20172214-3882/ª 2017 Editorial Office of Athe CC BY-NC-ND license (http://creaAbstract Perineal hernia is a rare complication of anterior exenteration. We reported thiscomplication after an anterior exenteration for bladder cancer with bleeding complicationrequiring packing and second-look laparotomy. Perineal approach is a simple and effectivemethod for repair of perineal hernia.ª 2017 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. Thisis an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. IntroductionPerineal hernia is a rare complication of anterior exenter-ation [1e4]. Diagnosis requires careful history taking andphysical examination with high level of suspicion. Imagingsuch as ultrasonography or computed tomogrphy (CT) helpsto confirm the diagnosis [2,5]. Different surgical ap-proaches have been adopted to the repair of perinealhernia [3,6]. We reported the management of this compli-cation after an anterior exenteration for bladder cancerof Second Military Medical.03.002sian Journal of Urology. Productitivecommons.org/licenses/by-nc-with bleeding complication requiring packing and second-look laparotomy.2. Case presentationWe report a case of a 63-year-old female who sufferedfrom anterior perineal hernia after anterior exenterationfor bladder cancer. She had history of diabetes mellitus,hypertension, bronchiectasis and transabdominal hys-terectomy with bilateral salpingo-oophorectomy in 1990sfor a benign pathology. She first presented with mucus inher urine in 2013. Subsequent flexible cystoscopyrevealed a 2 cm sessile mass at the trigone. Transurethralresection of the bladder tumor was performed and his-topathology showed adenocarcinoma with detrusor mus-cle invasion. CT scan showed no upper tract lesions oron and hosting by Elsevier B.V. This is an open access article undernd/4.0/).Figure 2 CT pelvis with Valsalva maneuver. Left, sagittalview; Right, coronal view. Arrows showed the anterior perinealhernia.254 K.W. Wong et al.lymph node metastases. Colonoscopy was performed torule out a primary colonic tumor and the result wasnormal.Anterior exenteration was performed in May 2013. Un-expectedly dense adhesions were found between theanterior rectal wall and posterior bladder wall during theoperation. The surgeons decided to resect the bladder andurethra en-bloc with the proximal rectum and distal sig-moid colon. However, there was profuse venous bleedingfrom pre-sacral venous plexus after colorectal dissection. Itwas partially controlled with pins and tacker screws. Thepre-sacral area was further packed with gauze roll. Bothureters were brought out through the inferior part of themain wound.Second-look laparotomy was performed 2 days later.Hemostasis was achieved. An ileal conduit was fashioned.Colorectal anastomosis was performed 6 cm above the analverge with Covidien EEA 28 mm stapler. A defunctioningtransverse colostomy was fashioned which was eventuallyclosed 6 months later. Final histopathology of the specimenwas pT2a adenocarcinoma of the bladder with clearresection margin.She complained of a labial mass since the early post-operative period. Serial CT scans however showed no evi-dence of recurrence until she was found to have a sus-pected perineal hernia during physical examination in May2015 (Fig. 1). CT pelvis with Valsalva maneuver revealed awide-necked anterior perineal hernia containing ileum sit-uated anterior to the superficial transverse perineal mus-cles (Fig. 2).Transperineal repair of the hernia was performed in thelithotomy position. The incision was made lateral to theleft labia majora. Further dissection deeper downrevealed a 4 cm defect lateral to the left side of the vaginaand anterior to the superficial transverse perineal muscle.The defect was covered with a tailored polypropyleneProlene mesh and anchored with 2-0 non-absorbablepolyester Ethibond suture. It was sutured anteriorly tothe pelvic floor and inferior pubic rami, posteriolaterallyto the sacrospinous ligament and posteriorly to the peri-neal body.Postoperatively the wound was complicated with su-perficial wound abscess which was managed with incisionand drainage. The mesh was not involved. There was noFigure 1 Clinical photos of perineum of the patient.recurrence of the perineal hernia at last follow-up visit inthe outpatient clinic 8 months after surgery.3. DiscussionPerineal hernia is the protrusion of intraperitoneal orextraperitoneal contents through a congenital or acquireddefect of the pelvic diaphragm. The first case was reportedin 1743 [7]. Anatomically, perineal hernia can be classifiedinto anterior or posterior form based on their positionrelative to the superficial transverse perineal muscle(Fig. 1). Primary perineal hernia is rare [1e4]. Perinealhernia is usually secondary to complications of pelvic op-erations. The prevalence of secondary perineal hernia wasreported up to 7% after pelvic exenteration but less than 1%after abdominoperineal resection [8,9]. The actual preva-lence is however believed to be higher as the patients arecommonly asymptomatic [5]. Predisposing factors includefemale gender, extensive pelvic resection especially pelvicexenteration, previous hysterectomy, radiotherapy andpresence of infections [6,8]. The reported patient hadmultiple predisposing factors for perineal hernia includingfemale gender, history of hysterectomy and anterior pelvicexenteration. Extensive dissection of the pelvis may disruptthe anatomy of the pelvis, leading to subsequent perinealhernia formation.Perineal hernia usually occurs within the first year afterthe pelvic operations [6,10]. Patients can manifest clini-cally as a unilateral bulge in the area of the labia or glutealor perineal region. Careful physical examination usuallyreveals a perineal swelling with a positive cough impulse.The diagnosis can be supported by sonography or CT scanwith Valsalva maneuver as illustrated in this patient [2,5].Surgical repair of perineal hernia is indicated for symp-tomatic control as well as prevention of complications suchas small bowel obstruction and strangulation [6]. There is nosingle best treatment approach. Perineal hernias can berepaired through transabdominal, perineal, or combinedabdomino-perineal approaches [3,6]. The advantages anddisadvantages of different approaches are summarized inTable 1. Limited data suggested perineal approach is asso-ciated with higher recurrence rate [6,10]. This may beexplained by poor fixation ofmesh due to limited exposure inperineal approaches. But the results were largely limited byTable 1 Advantages and disadvantages of different approaches to perineal hernia (Summarized from Stamatiou et al. [4]).Approaches Advantages DisadvantagesTrans-abdominal Optimal exposure for dissection and reductionof hernia sac;Need for more pelvic dissection;Possible for simultaneous trans-abdominal procedure;More morbidityBetter mesh fixation;Feasible for minimally-invasive approachesPerineal Simplest; Suboptimal exposure for dissectionand reduction of hernia sac;Less morbidityDifficult mesh fixationCombined abdomino-perineal Best for complex cases; Increased magnitude of operations;Best exposure More morbidityAnterior perineal hernia after anterior exenteration 255the small number of patients and the retrospective nature ofthe studies. In our patient, a major pelvic operation withradical cystectomy and ileal conduit was performed initially.Severe adhesion and difficult dissection were anticipatedwith transabdominal approach. Perineal approach for thispatient resulted in a much less major operation and it wouldbe a more appropriate choice in this situation.The principles of repair are the same in different ap-proaches, which involve reduction of hernia contents,dissection and isolation of the fascial defect, and recon-struction of the pelvic floor. Tension-free primary repair isusually not possible due to the attachment of fascia to therigid pelvis. In pooled analysis [6], the recurrence was up to50% compared with 20% after mesh repair. Syntheticmeshes, grafts, flaps, or even interposition of uterus orbladder can be applied for reconstruction of the pelvicfloor. Use of composite mesh significantly reduces visceraladhesion [11] although its use was not necessary in thispatient as the closure of the peritoneal defect wascompleted with the repair of the hernia defect. Tissue flapreconstruction is more commonly used for recurrent herniasor hernias with a history of irradiation or infection. It istechnically more demanding and is associated with donorsite morbidities and devastating complications like flapnecrosis.Postoperative perineal hernia is potentially preventable.Identification of patients at risk is important. Some authorsadvocated for the prophylactic closure of perineal woundwith a muscle flap such as vertical rectus abdominis muscle[12,13] although there are no strong evidence to support itsefficacy. Prevention of postoperative wound infection andpelvic collection are equally important.The follow-up period is relatively short (8 months) tolook for any recurrence of hernia. Although majority ofrecurrence occurs within the first year, late recurrence upto 5 years after hernia repair did happen [6].4. ConclusionWe reported an uncommon complication of anterior peri-neal hernia after anterior pelvic exenteration. Perinealapproach is a simple and effective method for repair ofperineal hernia.Conflicts of interestThe authors declare no conflict of interest.References[1] De Garengeot RJC. Sur plusieurs hernies singulieres. MemAcad R Chir (Paris) 1743;1:699.[2] Nieto-Zermeno J, Godoy-Murillo JG, Cadena-Santillana JL.Posterior perineal hernia. Report of a case and review of theliterature. Bol Med Hosp Infant Mex 1993;50:741e4.[3] Salameh JR. Primary and unusual abdominal wall hernias. SurgClin North Am 2008;88:45e60.[4] Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Peri-neal hernia: surgical anatomy, embryology, and technique ofrepair. Am Surg 2010;76:474e9.[5] Steffensen TS, Opitz JM, Gilbert-Barness E. Congenital peri-neal hernia in a fetus with trisomy 18. Fetal Pediatr Pathol2009;28:95e9.[6] Morcos BB, Al-Masri M, Baker B. Perineal hernia, anotherincisional hernia? Indian J Surg 2009;71:112e6.[7] Rutledge FN, Smith JP, Wharton JT, O’Quinn AG. Pelvicexenteration: analysis of 296 patients. Am J Obstet Gynecol1977;129:881e92.[8] Penkov N, Damianov D, Asenov Y, Gerzilov P, Sedloev T.Recurrent perineal hernia-case report and review of theliterature. Chirurgia (Bucur) 2015;110:81.[9] Mjoli M, Sloothaak DAM, Buskens CJ, Bemelman WA, Tanis PJ.Perineal hernia repair after abdominoperineal resection: apooled analysis. Colorectal Dis 2012;14:e400e6.[10] So JB, Palmer MT, Shellito PC. Postoperative perineal hernia.Dis Colon Rectum 1997;40:954e7.[11] Arnaud J, Hennekinne-Mucci S, Pessaux P, Tuech J, Aube C.Ultrasound detection of visceral adhesion after intraperito-neal ventral hernia treatment: a comparative study of pro-tected versus unprotected meshes. Hernia 2003;7:85e8.[12] Howell AM, Jarral OA, Faiz O, Ziprin P, Darzi A, Zacharakis E.How should perineal wounds be closed following abdomi-noperineal resection in patients post radiotherapyeprimaryclosure or flap repair? Best evidence topic (BET). Int J Surg2013;11:514e7.[13] Johnston DB, McBrearty A, Armstrong A. Laparoscopicmobilization of a rectus abdominis myofascial flap forthe prevention of perineal hernia post-abdominoperinealresection of the rectum a feasibility study? Surg Innov 2015;22:656.

Anterior perineal hernia after anterior exenteration

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