Postoperative urinary leakage after bilateral totally extraperitoneal herniorrhaphy in a patient with a healed cystostomy and appendectomy: A case report

Abstract

We report a case of postoperative urinary leakage after bilateral laparoscopic totally extraperitoneal (TEP) herniorrhaphy. A man in his upper 80s with a healed cystostomy and appendectomy underwent bilateral TEP herniorrhaphy. Urinary leakage was noted by ultrasound examination 4 days after bilateral TEP. Cystography and computed tomography conclusively confirmed a 6-mm extraperitoneal fistula at the site of the previous cystostomy. The fistula involved the anterior bladder wall and was associated with an extended urinoma. The patient was treated by indwelling catheterization using a Foley catheter and repeated ultrasound-guided puncture and aspiration of the inguinal effusion at the bedside. The patient was completely healed 69 days after the operation with no mesh infection or bladder dysfunction. We believe that urinary leakage is possible after TEP herniorrhaphy in patients with a healed suprapubic cystostomy. Therefore, indwelling catheterization using a Foley catheter should be implemented before surgery, and the Foley catheter can be removed within 1 week after surgery if no postoperative urinary leakage is observed. A history of suprapubic cystotomy should not be regarded as a contraindication for TEP surgery. This is the first report of urinary leakage after bilateral TEP herniorrhaphy in a patient with a healed cystostomy and appendectomy.

Introduction

Laparoscopic totally extraperitoneal (TEP) herniorrhaphy has been widely used in laparoscopic repair of inguinal hernias. The complication rates associated with TEP herniorrhaphy are low, and bladder injuries during TEP repair are extremely rare^1–4; however, they are more common during endoscopic than open repair. ⁵ According to the International Endohernia Society (IEHS) guidelines, the estimated incidence of bladder injury ranges from 0.006% to 0.3%, and such injuries can be diagnosed intraoperatively and repaired endoscopically. ⁶ We herein report a case of postoperative urinary leakage after bilateral TEP herniorrhaphy in a patient with a healed cystostomy and appendectomy. We also present a review of the relevant literature.

Case report

A man in his upper 80s was admitted to our hospital for laparoscopic repair of bilateral inguinal hernias. He had undergone electroprostatectomy and cystostomy in September 2010 and appendectomy in 1987, and he had a 4-cm healed surgical scar in the right lower abdomen and a 5-mm cystostomy scare in the suprapubic region (Figure 1(a)). The patient also had a history of benign prostatic enlargement, coronary heart disease, chronic bronchitis, and old tuberculosis; however, his cardiopulmonary function was close to normal, and he could tolerate general anesthesia.

Figure 1.

Bilateral TEP repair in a patient with a healed cystostomy and appendectomy. (a) A 4-cm healed appendectomy scar in the right lower abdomen (black arrow) and a 5-mm cystostomy scar in the suprapubic region (white arrow) and (b) The adhesion of the healed cystostomy scar was incised with an electric forceps.

The operation was performed under general anesthesia with tracheal intubation. No catheter was inserted into the urinary bladder before the operation. At the beginning of the operation, a subumbilical incision was made and the rectus muscle was retracted laterally to expose the posterior rectus fascia. A 10-mm trocar was then introduced along the surface of the posterior sheath of the rectus abdominis, and carbon dioxide gas was insufflated through the trocar with a pneumoperitoneum pump to establish the preperitoneal space. Next, a laparoscope was inserted to expand the preperitoneal space and was advanced to the pubic bone under direct vision. Two 5-mm trocars were inserted into the preperitoneal space under direct laparoscopic observation. The patient was positioned at a mild Trendelenburg angle to prevent external compression of the preperitoneal space by the abdominal viscera. Blunt and sharp dissection with forceps or an electric hook was performed to clarify the anatomy of the bilateral inguinal region. Both sides of the spermatic cord and vessels were skeletonized, and the bilateral hernia sacs were dissected all the way back to the retroperitoneal space. The adhesion at the cystostomy scar was incised with an electric forceps close to the rectus abdominis muscle (Figure 1(b)). Two pieces of lightweight polypropylene mesh (PA1015; Lpmp, Wuhan, China) were rolled and inserted through the camera trocar after treatment of the hernia sac. The meshes were then unrolled and positioned to cover the bilateral hernia orifices (direct, supravesical, indirect, and femoral). Next, the meshes were fixed to Cooper’s ligament with medical glue (Compaq; Compon, Beijing, China). Bilateral herniorrhaphy and mesh repair were then performed. All procedures were eventful, and blood transfusion was not required. The total intraoperative blood loss was 20 mL. The whole operation time was 2 hours.

The patient was discharged from the hospital without pain or discomfort 1 day after surgery. Urination was normal during the first 2 days after surgery. However, the patient thereafter developed incision pain and was hospitalized again 4 days after surgery. Physical examination revealed massive edema of the bilateral inguinal region and genital region. An ultrasound scan revealed a perivesical fluid collection and small amount of ascites without hydronephrosis.

Indwelling catheterization using a Foley catheter and repeated ultrasound-guided puncture and aspiration of the inguinal effusion were immediately performed at the bedside, resulting in the collection of 400 mL of soy sauce-like, watery liquid. The creatinine level of the liquid was 9137 µmol/L and the adenosine deaminase level was 5.0 U/L, confirming urine. Routine blood examination findings were normal; the serum creatinine level was 339 µmol/L, serum urea level was 18.9 mmol/L, serum uric acid level was 485 µmol/L, serum CRP level was 34.38 mg/L, and procalcitonin level was 0.20 ng/mL. The patient received antimicrobial therapy for 5 days, after which his serum uric acid level was 448 µmol/L and serum creatinine and urea levels were both normal. The patient developed a low fever with a maximum body temperature of 37.6°C during hospitalization. After physical cooling, his body temperature decreased to normal. The patient also developed small amounts of discontinuous urethral hematuria. His serum CRP level decreased to 5.52 mg/L. Routine urinalysis showed occult blood +2 and full-field red blood cells. Considering the possibilities of prostatic hyperplasia and bleeding, treatment was initiated with finasteride tablets (5 mg orally once a day), tamsulosin sustained-release capsules (0.2 mg orally once a night), and solifenacin succinate (5 mg once a day) to relieve bladder spasms. Cystography and unenhanced lower abdominal computed tomography (CT) (Figure 2(a), (b)) definitively confirmed a 6-mm extraperitoneal fistula at the site of the previous cystostomy. The fistula involved the anterior bladder wall and was associated with an extended urinoma.

Figure 2.

Healing process of the bladder fistula as shown by cystography and CT. (a), (b) A 6-mm fistula in the anterior bladder wall (arrows) with a perivesical fluid collection. (c) A drainage tube was punctured through the abdominal wall into the bladder. (d), (e) A 2-mm urinary fistula in the anterior bladder wall (arrows) without fluid collection and (f) Cystography and CT revealed no urinary fistula in the bladder wall.

Ultrasonography-guided puncture and aspiration of the inguinal incision effusion was performed four times. The amount of liquid extracted each time was 40 to 60 mL. Culture results revealed no bacteria. Because of the recurrence of effusion, a tube was placed for continuous drainage and was confirmed to enter the bladder by CT (Figure 2(c)). The puncture drainage tube and Foley catheter were left in place to drain urine, producing drainage of about 2000 mL of urine a day. The drainage tube spontaneously detached after 18 days. Cystography and unenhanced lower abdominal CT (Figure 2(d), (e)) showed a 2-mm urinary fistula at the site of the previous cystostomy. The fistula involved the anterior bladder wall, and no fluid collection was present. The hematuria did not recur. Cystography and CT examination before removal of the Foley catheter revealed no urinary fistula in the bladder wall. The patient was discharged on the 69th postoperative day. He was subsequently followed up as an outpatient and remained symptom-free. No mesh infection or bladder dysfunction was noted. No recurrent inguinal hernia or perivesical fluid collection was found by ultrasonography during the 6-month follow-up period. The patient was satisfied with the treatment.

The patient provided consent for treatment, and written consent for publication of his case has been obtained. The reporting of this study conforms to the CARE guidelines. ⁷ All patient details have been de-identified. This paper was approved for publication by the ethics committee of The 991st Hospital of Joint Logistic Support Force of People’s Liberation Army.

Discussion

Compared with transabdominal preperitoneal repair, TEP repair can significantly shorten the operative time, reduce intraoperative trauma, and limit postoperative pain in the treatment of adult inguinal hernia. Numerous scientific reports, meta-analyses, prospective studies, and randomized trials have evaluated the effectiveness and safety of the TEP procedure.^1,3,4,8,9 The most common early complications after inguinal hernia repair are hematomas, seromas, urinary retention, and surgical site infection. Life-threatening complications rarely occur. TEP repair has particularly low rates of complications and recurrence; thus, it is worth popularizing. ⁹ TEP repair has been widely used in laparoscopic repair of inguinal hernias. ³ TEP repair for groin hernias is considered difficult in patients with a healed surgical scar in the lower abdomen. A history of lower abdominal surgery was once considered to be a relative contraindication for TEP repair. The feasibility of the TEP approach in patients with a history of open prostatectomy or other lower abdominal surgery such as appendectomy has recently been described in the literature.^10–12 The feasibility is stated as an expert opinion in the European Hernia Society guidelines. The success rate of TEP repair can reach 89%. ¹⁰ Watt et al. ¹² described 165 patients with a history of radical prostatectomy who underwent TEP repair. Among these patients, only three required conversion to open surgery, confirming that TEP can be safely performed in patients with a history of radical prostatectomy. However, a meta-analysis suggested that patients with a history of lower abdominal surgery who need hernia repair obtain less benefit from TEP repair than those with no history of surgery. ¹³

Bladder injury during TEP repair is very rare but must be taken seriously. Most bladder injuries are found during the TEP operation and may be the result of careless use of a Veress needle or a trocar. The most common bladder injury during inguinal hernia repair occurs when treating sliding hernias (“bladder ears”), and the degree of accidental bladder injury during inguinal hernia repair was severe in most cases reported in the literature. ¹⁴ In one study, the incidence of bladder injury during bilateral TEP repair was significantly higher than that during unilateral TEP repair (0.28% vs. 0.04%, respectively). ¹⁵

The IEHS guidelines ¹⁶ recommend that the bladder is decompressed by either having the patient void immediately preoperatively (preferred method) or using an indwelling catheter before the TEP procedure. Bladder injury recognized during laparoscopy can be repaired laparoscopically, ⁶ and this should be followed by bladder drainage for 7 to 10 days. Small defects found after surgery may be managed with postoperative decompression via an indwelling catheter for urinary drainage, whereas larger defects necessitate repair.

In our case, the bladder injury was associated with the scar of the previous cystostomy, which was separated during the operation without ligation or suturing and resulted in a postoperative urinary fistula. A 6-mm extraperitoneal fistula at the site of the previous cystostomy involving the anterior bladder wall was confirmed by cystography and unenhanced lower abdominal CT. This type of bladder injury is very rare and has not been reported in the literature. We performed a search of PubMed using the Medical Subject Headings “totally extraperitoneal,” “TEP,” or “laparoscopic hernioplasty” combined with “cystostomy” or “vesicostomy,” but no literature was found. There was no literature on the treatment of inguinal hernia by TEP herniorrhaphy after suprapubic cystostomy and appendectomy.

The findings in our case indicate that a history of suprapubic cystostomy need not be regarded as a contraindication for TEP surgery; however, dissection of all adhesions should be carefully performed, and the patient should be closely observed for bladder injury. The surgeon should pay special attention to bladder injury caused by heat damage induced by monopolar devices. An indwelling Foley catheter should be placed before surgery, and the Foley catheter can be removed within 1 week after surgery if no postoperative urinary leakage is observed.

Conclusion

Urinary leakage is possible after TEP herniorrhaphy in patients with a healed suprapubic cystostomy, and dissection of any adhesions should be carefully performed. This is the first report of urinary leakage after bilateral TEP herniorrhaphy in a patient with a healed cystostomy and appendectomy. Whether patients with an inguinal hernia and healed suprapubic cystostomy can benefit from TEP herniorrhaphy requires further investigation.