Prevention of Parastomal Hernia by Mesh Placement

Overview

Concurrent placement of a mesh during formation of ileal conduit will decrease the incidence of parastomal hernia and associated complications.

Full Title of Study: “A Randomized Study of the Utility of Composite Mesh Placement to Prevent Parastomal Hernia in Patients Undergoing Urinary Diversion With Ileal Conduit”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Prevention
    • Masking: None (Open Label)
  • Study Primary Completion Date: August 2016

Detailed Description

Subject to inclusion and exclusion criteria, patients will be randomized 1:1 to the control and intervention groups: Randomization groups: – Group 1 (control): Ileal Conduit – Group 2 (intervention): Ileal conduit with concurrent mesh placement. Ethicon PHYSIOMESH composite mesh will be utilized for this study. This is a composite mesh with a reduced polypropylene content. It is a widely used, commercially available hernia mesh, and its use and placement are simple and well described. The mesh will be placed at the time of radical cystectomy and ileal conduit. A small circle of mesh, the diameter of the ileal conduit, will be excised to allow for fitment around the ileal conduit. The mesh will be placed so that it encompasses the ileal conduit in a non-constricting manner, and will be sutured to the anterior abdominal wall. Product will be stored in a secure, sterile manner at the UMH operating room sterile supply room, and in accordance with institutional policies. Patients from both groups will be followed up in a standard fashion. Follow up visits and clinical assessment will be at 6 weeks after surgery, 3 monthly during the first year, then every 6 months for at least 5 years. During each visit, patients will be clinically evaluated for the presence or absence of parastomal hernia, and any routine surveillance radiology imaging will be reviewed. Parastomal hernia is clinically defined as an incisional hernia at the site of the ileal conduit stoma. This may be clinically apparent by examining the patient during performance of abdominal straining or Valsalva maneuver, or may be evident on radiology imaging.

Interventions

  • Device: Ethicon Physiomesh
    • Ethicon Physiomesh will be paced at the time of radical cystectomy and ileal conduit.

Arms, Groups and Cohorts

  • No Intervention: Group 1 – Ideal Conduit No Mesh
    • No mesh will be placed at the time of radical cystectomy and ileal conduit.
  • Active Comparator: Group 2 – Ileal Conduit with Mesh
    • Ethicon Physiomesh will be placed at the time of radical cystectomy and ileal conduit.

Clinical Trial Outcome Measures

Primary Measures

  • Rate of Reduction of the Incidence of Parastomal Hernia
    • Time Frame: 18 months
    • Rate of reduction of the incidence of parastomal hernia in study participants, as assessed by physical examination

Secondary Measures

  • Number of Participants Who Develop Mesh Related Complications
    • Time Frame: 60 months
    • Assessed by physical examination including: Mesh erosion and infection Stomal stenosis and necrosis Frequency of stoma pouch appliance changes. Record by physical exam the incidence of parastomal hernia at 5 years.

Participating in This Clinical Trial

Inclusion Criteria

1. Patients eligible to undergo urinary diversion with ileal conduit. 2. Patients with the ability to understand and willingness to sign a written informed consent document. 3. Men and Women aged 18 to 80 years. Exclusion Criteria:

1. Patients unable or unwilling to consent to the proposed surgery 2. Pregnant women 3. Patients with prior ileal conduit surgery undergoing revision.

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: 80 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • University of Miami
  • Collaborator
    • Ethicon, Inc.
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Murugesan Manoharan, MD, Principal Investigator, University of Miami

Citations Reporting on Results

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Israelsson LA. Preventing and treating parastomal hernia. World J Surg. 2005 Aug;29(8):1086-9. doi: 10.1007/s00268-005-7973-z.

Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. Incidence and risk factors of stomal complications in patients undergoing cystectomy with ileal conduit urinary diversion for bladder cancer. J Urol. 2007 Sep;178(3 Pt 1):950-4. doi: 10.1016/j.juro.2007.05.028. Epub 2007 Jul 16.

Pearl RK. Parastomal hernias. World J Surg. 1989 Sep-Oct;13(5):569-72. doi: 10.1007/BF01658872.

Israelsson LA. Parastomal hernias. Surg Clin North Am. 2008 Feb;88(1):113-25, ix. doi: 10.1016/j.suc.2007.10.003.

Martin L, Foster G. Parastomal hernia. Ann R Coll Surg Engl. 1996 Mar;78(2):81-4.

Marimuthu K, Vijayasekar C, Ghosh D, Mathew G. Prevention of parastomal hernia using preperitoneal mesh: a prospective observational study. Colorectal Dis. 2006 Oct;8(8):672-5. doi: 10.1111/j.1463-1318.2006.00996.x.

Etherington RJ, Williams JG, Hayward MW, Hughes LE. Demonstration of para-ileostomy herniation using computed tomography. Clin Radiol. 1990 May;41(5):333-6. doi: 10.1016/s0009-9260(05)81696-4.

Cheung MT, Chia NH, Chiu WY. Surgical treatment of parastomal hernia complicating sigmoid colostomies. Dis Colon Rectum. 2001 Feb;44(2):266-70. doi: 10.1007/BF02234303.

Pastor DM, Pauli EM, Koltun WA, Haluck RS, Shope TR, Poritz LS. Parastomal hernia repair: a single center experience. JSLS. 2009 Apr-Jun;13(2):170-5.

Rubin MS, Schoetz DJ Jr, Matthews JB. Parastomal hernia. Is stoma relocation superior to fascial repair? Arch Surg. 1994 Apr;129(4):413-8; discussion 418-9. doi: 10.1001/archsurg.1994.01420280091011.

Stephenson BM, Phillips RK. Parastomal hernia: local resiting and mesh repair. Br J Surg. 1995 Oct;82(10):1395-6. doi: 10.1002/bjs.1800821033. No abstract available.

Hammond TM, Huang A, Prosser K, Frye JN, Williams NS. Parastomal hernia prevention using a novel collagen implant: a randomised controlled phase 1 study. Hernia. 2008 Oct;12(5):475-81. doi: 10.1007/s10029-008-0383-z. Epub 2008 May 17.

Serra-Aracil X, Bombardo-Junca J, Moreno-Matias J, Darnell A, Mora-Lopez L, Alcantara-Moral M, Ayguavives-Garnica I, Navarro-Soto S. Randomized, controlled, prospective trial of the use of a mesh to prevent parastomal hernia. Ann Surg. 2009 Apr;249(4):583-7. doi: 10.1097/SLA.0b013e31819ec809.

Janes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study. World J Surg. 2009 Jan;33(1):118-21; discussion 122-3. doi: 10.1007/s00268-008-9785-4.

Shabbir J, Chaudhary BN, Dawson R. A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation. Colorectal Dis. 2012 Aug;14(8):931-6. doi: 10.1111/j.1463-1318.2011.02835.x.

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