|Year : 2017 | Volume
| Issue : 2 | Page : 139-142
Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair
Arjun Singh Sandhu1, Ameet Kumar2, Bharath N Kumar1
1 Department of Urology, Army Hospital Research and Referral, New Delhi, India
2 Department of Surgery, Command Hospital Air Force, Bangalore, Karnataka, India
|Date of Submission||27-May-2016|
|Date of Acceptance||15-Aug-2016|
|Date of Web Publication||9-Mar-2017|
Department of Surgery, Command Hospital Air Force, Bangalore - 560 007, Karnataka
Source of Support: None, Conflict of Interest: None
Along with advantages, evolving surgical techniques bring unique complications. A young male developed urinary symptoms a few months after undergoing laparoscopic inguinal hernia repair. On evaluation, mesh erosion into the urinary bladder was found. Removal of mesh with repair of bladder was done. A vesico-cutaneous fistula resulted which was managed with repeat surgery. We review all such cases reported in literature; discuss the etiopathogenesis, presentation, management and possible preventive measures. To the best of our knowledge, this is only the 12th case being reported.
Keywords: Complications, laparoscopic inguinal hernia repair, mesh erosion, urinary bladder, vesico-cutaneous fistula
|How to cite this article:|
Sandhu AS, Kumar A, Kumar BN. Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair. J Min Access Surg 2017;13:139-42
| ¤ Introduction|| |
Along with advantages, evolving surgical techniques bring unique complications. The posterior approach to inguinal hernia (IH) repair, especially the laparoscopic approach has its own set of complications, one of them being mesh erosion into viscera. While mesh erosion into bowel has been reported, erosion of mesh into the urinary bladder (UB) has only infrequently been reported. We report a case of a young male who underwent totally extraperitoneal (TEP) mesh repair for IH and ended up with a delayed complication of mesh erosion into the UB.
| ¤ Case Report|| |
A 32-year-old male underwent TEP for left IH at another centre. Six months later, he reported to that centre with urinary retention for which he was catheterised. A cystopanendoscopy (CPE) was done, findings of which were not available. Thereafter, he was put on alpha-blockers and discharged after he was voiding well. A year later, he again reported to that centre with terminal haematuria and dysuria on and off. CPE was done with findings of a passable stricture of bulbomembranous urethra and irregular thickening in the left anterolateral wall of UB. He was managed as a case of urinary tract infection (UTI) and discharged. A few months later, he reported back with same complaints and was investigated. Urine microscopy/culture, renal function tests, ultrasound kidney UB (KUB), retrograde cystourethrogram and micturating cystourethrogram were normal. A computed tomography (CT) urography demonstrated mesh migration into the left anterolateral wall of UB [Figure 1]. CPE confirmed the findings of CT urography. Removal of mesh with repair of the bladder in two layers was done via an extraperitoneal approach. A suprapubic catheter (SPC) was done in addition to per urethral catheter (PUC) and a drain placed. The drain and SPC were removed on POD-5 and PUC on POD-10. Following this, he developed a urinary leak from the wound. A CPE found a rent in the dome of UB. The rent was closed in two layers over SPC. Post-operative, the patient again developed urinary leak from the wound.
|Figure 1: Computed tomography urography revealing mesh erosion into the left anterolateral wall of urinary bladder|
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Then, he reported to our centre with complaints of a persistent urinary leak from the wound and minimal urinary output per urethra. He had a 10 cm × 4 cm wound with a vesico-cutaneous fistula [Figure 2]. He was initially managed conservatively with the placement of SPC and PUC, culture-specific antibiotics and daily dressings. The wound healed gradually, and the SPC was removed. He had a tiny fistulous opening in the lower midline scar. CT fistulogram revealed a vesico-cutaneous fistula arising from the left anterolateral wall of UB [Figure 3]. He finally underwent excision of the veisco-cutaneous fistula and repair of the bladder, 3½ years after the initial surgery (TEP). Post-operative recovery was uneventful. Histopathology of the fistula revealed chronic inflammation with foreign body type giant cell reaction. Six months following discharge, he is doing well [Figure 4].
|Figure 2: At presentation to our centre; vesico-cutaneous fistula following the surgery for mesh removal|
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|Figure 3: Computed tomography fistulogram showing the vesico-cutaneous fistula|
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| ¤ Discussion|| |
Mesh-related complications inherent to a laparoscopic IH repair wherein the mesh is placed in a preperitoneal space are mesh migration and mesh erosion into viscera with consequent fistulisation. The only cases of such complication reported with anterior repairs are those in which a mesh plug was inserted and had migrated. Mesh migration may occur consequent to non-fixation/improper fixation of mesh and have been noticed more frequently with the transabdominal preperitoneal approach than TEP. The hypotheses put forwards to explain mesh erosion are (a) mesh infection with subsequent fistulisation, (b) partial injury to the adjacent visceral wall and (c) direct erosion of the mesh into the viscera due to its proximity. Our case had undergone TEP and tacks were used that could be seen in the CT scan.
Mesh erosion into UB can present as recurrent UTI, haematuria, vesico-cutaneous fistula or mimic an intravesical stone. It is prudent to have a high degree of suspicion in patients with previous laparoscopic IH surgery who present with these symptoms. This is more relevant when the patient is young as was our case. The initial CPE findings of UB wall thickening was ignored leading to increased morbidity to the patient. Agrawal and Avill reported one such case wherein similar findings were present, and repeated cystoscopy clinched the diagnosis.
Initial investigations for such cases would be a urine microscopy/culture which would show evidence of UTI and the offending organism; X-ray KUB may show a focal opacity in the region of UB depending on the extent of calcareous deposit on the eroded mesh. Vital to clinching a diagnosis would be a CT urography and cystoscopy, both of which are complementary to each other. CT scan would reveal a fistula and thickening of the bladder wall whereas the cystoscopy would directly visualise the eroded mesh, often buried under calcareous deposits.
The optimal management of such cases would be mesh explantation through an extraperitoneal approach, identification of the rent in UB, trimming it to healthy margins and repair in two layers with the placement of both SPC and PUC along with drainage of the space of Retzius. This case was managed on similar lines at the previous centre. Why the repair failed is a matter of speculation. The possible causes may have been tension at the suture line or infection. Furthermore, has been reported a case of successful cystoscopic removal of the mesh. However, in our opinion, this approach could be hazardous for two reasons. One, dense adhesions may prevent the retrieval of mesh and in the process, the rent could be worsened and two, the rent is not addressed and could lead to a persistent fistula.
We did an extensive literature search and identified 11 reported cases of mesh erosion into UB following laparoscopic IH repair. The details of these cases are given in [Table 1]. Thus, ours is only the 12th case to be reported since the first report that was published in 1994.
|Table 1: Summary of cases of mesh erosion into the urinary bladder following laparoscopic repair of inguinal hernia reported in literature|
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The mesh erosion can possibly be prevented by meticulous dissection with avoidance of bleeding. This would help in good vision and prevention of injury to viscera. Furthermore, creating optimal space so that the mesh can be properly spread out, avoiding wrinkling (small space) or migration (larger than necessary space). At this time, it would be incorrect to advocate mesh fixation as a preventive method as the worldwide; surgeons are moving away from using tackers due to its complications like inguinodynia. Further, these tackers themselves may cause direct injury to viscera when placed inappropriately. A safe method to fix may be using fibrin glue.
| ¤ Conclusion|| |
Mesh erosion into UB is increasingly being reported. A high index of suspicion is warranted when patients with a history of laparoscopic IH repair report with urinary complaints. An early intervention may reduce the morbidity. And as is often said, prevention is better than cure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest. 
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]