Radical Cystectomy (RC) with urinary diversion is a standard management for Bladder cancer. Parastomal Hernia (PH) is a well-known complication following the Ileal Conduit (IC). Prophylactic mesh placement is done to prevent the occurrence of PH. Various techniques have been described for this. We aim to illustrate the technique we use for the placement of mesh to prevent the occurrence of parastomal hernia following RC.

We describe our steps for prophylactic mesh to prevent a PH in patients undergoing RC with an IC. A composite mesh is preferred due to the resorbable surface of the cruciate flaps that are in contact with the stoma.

Step 1: Cruciate incision on mesh
A custom mesh of approximately 8 x 8 cm is used, and a 2 x 2 cm cruciate incision is made in the centre of the mesh. The cruciate incision, along with the flaps created, allow greater conformity of the mesh to the diameter of the stoma when it is passed through.

Step 2: Mesh placement
A preperitoneal space between the posterior rectus sheath and the peritoneum is developed and the mesh is placed in this preperitoneal plane. This has been referred to as the sublay-preperitoneal technique. The advantage of developing this plane for mesh placement is the reduced vascularity compared to the space between the rectus muscle and the posterior rectus sheath.

Step 3: Externalization of IC
The mesh is placed with the cruciate opening lined up for the stoma to be brought through. No sutures are used to anchor the mesh. Following this, the ileal conduit is brought through the peritoneum, pre-peritoneal mesh, rectus muscle, subcutaneous tissue, and skin to form the standard stoma. (Figure)

The advantages of our technique: 
1) Measurement of exact dimensions for the creation of the opening in the mesh is not needed as the cruciate incision allows greater conformity. 
2) Placement of mesh in the less vascular preperitoneal plane.
3) Lack of need for sutures to anchor the mesh.

The available limited literature shows a prophylactic mesh reduces the prevalence of PH and is safe with minimal mesh-related complications. We present our surgical technique detailing the specific steps for a sublay pre-peritoneal mesh placement at the time of the ileal conduit creation.