Background <p>Parastomal hernia (PSH) is the most common long-term complication after abdominoperineal resection (APR) with permanent end colostomy. Although prophylactic mesh placement has been suggested to reduce the rate of PSH, the optimal mesh type and surgical technique remain unclear. Recently, three-dimensional funnel-shaped meshes have been introduced to stabilize the bowel loop and minimize stoma-related mechanical stress, potentially reducing the incidence of PSH.</p> Methods <p>This retrospective cohort study, reported in accordance with STROBE guidelines, included consecutive patients who underwent elective laparoscopic permanent end colostomy (PEC) between 2011 and 2019 at a single institution. Patients were assigned to either a group without mesh or a group that received prophylactic intraperitoneal funnel-shaped mesh. The primary endpoint was radiologically confirmed PSH incidence. Kaplan-Meier analysis and Cox regression were used to assess differences in cumulative PSH risk over time.</p> Results <p>Seventy-five patients were included (mesh group: 37; no-mesh group: 38), with a median follow-up of 46 and 43 months, respectively. The mesh group had a lower, but not statistically significant, absolute incidence of PSH (21.6% vs. 39.5%, p = 0.094). Importantly, the Kaplan-Meier analysis revealed a significantly lower cumulative incidence of PSH in the mesh group over time (p= 0.033). Postoperative complication rates were comparable between the groups.</p> Conusions <p>Prophylactic placement of a funnel-shaped mesh during PEC was associated with a reduced cumulative incidence of PSH over long-term followup without increasing surgical morbidity. These results underline the potential benefit of funnel-shaped meshes in PSH prevention and highlight the need for prospective randomized studies.</p>