“Mesh on the Move” Transabdominal Preperitoneal Mesh Erosion into the Urinary Bladder after Laparoscopic Inguinal Hernia Repair

Abstract

Mesh erosion into the urinary bladder is an uncommon but potentially serious late complication of laparoscopic inguinal hernia repair, particularly following transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches. Proposed mechanisms include inadequate peritoneal coverage, excessive mesh fixation, postoperative infection, and chronic inflammatory responses. Clinical presentation is often delayed and nonspecific, leading to diagnostic challenges and prolonged morbidity. We report the case of a 60-year-old male with recently diagnosed hypertension and diabetes mellitus who had undergone laparoscopic mesh repair for left inguinal hernia (details unavailable). He presented with a 9-month history of recurrent burning micturition, lower abdominal pain, and intermittent hematuria. His history was notable for recurrent urinary tract infections over 5 years. Initial evaluation at another centre revealed vesical calculus, left staghorn calculus, and grade 1 prostatomegaly; he underwent transurethral resection of the prostate with cyst lithotripsy. One month later, his urinary symptoms recurred. Investigations at our center showed, on cystoscopy, polypropylene mesh eroding into the anterior bladder wall. Computed tomography (CT) revealed a heterogeneously enhancing lesion in the right anterolateral bladder wall with contrast extravasation. Definitive surgical management involved laparotomy with excision of the involved bladder wall segment containing the mesh, followed by two-layer bladder repair and suprapubic catheter placement. The patient had an uneventful recovery. Intravesical mesh migration should be considered in any patient with persistent urinary symptoms following laparoscopic inguinal hernia repair. A high index of suspicion, combined with early use of CT urography and cystoscopy, facilitates timely diagnosis. Surgical removal of the mesh with bladder wall repair is curative in most cases. This case underscores the importance of meticulous mesh placement and secure peritoneal closure during laparoscopic hernia repairs to minimize such rare but significant complications.

INTRODUCTION

Hernia repair with synthetic mesh has become the gold standard for both open and laparoscopic approaches, owing to its low recurrence rates and durable outcomes. However, mesh-related complications, though uncommon, are increasingly recognized in clinical practice. These include chronic pain, infection, migration, and erosion into adjacent viscera. Among these, erosion into the urinary bladder is particularly rare but potentially serious, often leading to recurrent urinary tract infections, hematuria, urinary retention, or fistula formation.

Since the first description of mesh erosion into the bladder in 1994, approximately 23 cases have been reported in the literature. The majority have followed inguinal hernia repair using laparoscopic techniques such as transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair. Reported time intervals from surgery to presentation vary widely – from as early as 3 months to as late as 20 years – reflecting both delayed onset and diagnostic challenges. Notably, nearly half of documented cases (43.5%) present within 1–5 years postoperatively.

Given the potential for delayed recognition and the morbidity associated with intravesical mesh migration, awareness among surgeons and urologists is essential. This report describes a rare case of mesh erosion into the urinary bladder following laparoscopic TEP inguinal hernia repair, complicated by a vesicocutaneous fistula, and reviews relevant literature to highlight diagnostic and surgical considerations.

CASE REPORT

A 60-year-old male with newly detected hypertension and diabetes mellitus and a history of laparoscopic TAPP mesh repair for left inguinal hernia presented with a history of episodic burning micturition associated with lower abdomen pain and occasionally noticing blood at the urethral meatus after passing urine for 9 months.

To begin with, he had a history of recurrent urinary tract infection for 5 years and was taking native medication. Then, he presented to a tertiary care hospital due to unresolved symptoms and was evaluated. He was diagnosed with vesical calculus and left staghorn calculus with grade 1 prostatomegaly, underwent TURP + cystolithotripsy a year.

He was apparently normal for 1 month postsurgery, and then he again developed features of UTI, persistent in nature and now associated with complaints of noticing blood at the urethral meatus occasionally. Hence, he presented to our hospital and was evaluated. Cystoscopy study showed Prolene mesh erosion into the anterior wall of bladder [Figure 1].

Figure 1.

Cystoscopy image demonstrating Prolene mesh erosion into the anterior wall of the urinary bladder. The circled area highlights the eroded polypropylene mesh protruding into the bladder lumen

Computed tomography (CT) study showed a heterogeneously enhancing area with central hypodensity in the right anterolateral aspect of the bladder abutting the bladder wall, with bladder contrast seen extravasating to the collection m/s 1.9 cm × 1.2 cm [Figure 2].

Figure 2.

Contrast-enhanced computed tomography images showing a heterogeneously enhancing lesion with central hypodensity in the right anterolateral aspect of the urinary bladder abutting the bladder wall, with extravasation of bladder contrast into the adjacent collection. The blue arrows indicate the site of mesh-related inflammatory collection and bladder wall defect associated with mesh erosion.

He underwent laparotomy + excision of right anterolateral wall of the bladder with proline mesh on August 7, 2025, with intraoperative findings of mesh eroding to the right anterolateral wall of the urinary bladder. Laparotomy was done, and the above findings were confirmed. We proceeded with excision of the right anterolateral portion of the bladder wall with mesh, and the defect was closed in two layers with absorbable sutures after insertion of an SPC [Figure 3].

Figure 3.

(a) Mesh with lateral wall infiltration of the urinary bladder (blue arrows indicate the site of mesh infiltration and bladder involvement), (b) infiltration to the bladder point of invasion, (c) separation from the lateral pelvic wall, (d) bladder infiltration by mesh at the dome, (e) mesh excised and defect closed (blue arrow indicates the repaired bladder site), (f) excised mesh with bladder wall

Postoperatively, the patient recovered well with expected outcome.

DISCUSSION

Mesh erosion into the urinary bladder is a rare but serious complication following laparoscopic inguinal hernia repair, particularly with TAPP and TEP approaches. The first such case was reported in 1994, and since then, approximately two dozen cases have been described in the literature. However, the true incidence is likely underreported due to misdiagnosis or late presentation.[1,2]

Multiple mechanisms have been proposed. Mechanical migration may occur when fixation is inadequate or when excessive dissection of the preperitoneal space disrupts supporting structures, allowing gradual mesh displacement toward the bladder wall.[3] Chronic inflammatory response to the synthetic material can lead to progressive fibrosis and tissue erosion.[4] Secondary infection may accelerate the process by weakening the bladder wall through persistent inflammation.[5]

Presentation varies widely – from lower urinary tract symptoms (frequency, urgency, and dysuria) to recurrent urinary tract infections and hematuria. Because of this no specificity, diagnosis is often delayed, with reported latency from hernia repair to symptom onset ranging from 3 months to over 20 years.[6,7]

Cystoscopy is considered the gold standard for confirming intravesical mesh, allowing direct visualization and biopsy if needed.[8] CT urography provides superior delineation of the mesh–bladder relationship, surrounding inflammatory changes, and any associated fistulae.[9] MRI has also been used in selected cases for soft-tissue characterization.[10]

Definitive treatment requires complete mesh removal, thorough bladder wall debridement, and watertight two-layer closure.[11] The choice of surgical approach – open, laparoscopic, or robotic – should be individualized based on the surgeon’s expertise, extent of adhesion, and complication profile.[12] Conservative management is generally discouraged, as retained mesh increases the risk of recurrent infection or fistula formation.[13]

Preventive strategies include meticulous dissection during TAPP/TEP, avoiding unnecessary lateral dissection near the bladder dome, secure but minimal fixation, and careful patient selection for laparoscopic repair in recurrent or complex hernias.[14,15] Prognosis is generally good following timely surgery, though delayed diagnosis can lead to persistent bladder dysfunction or recurrent fistulae.[16]

CONCLUSION

Persistent urinary symptoms after laparoscopic hernia repair should raise suspicion for mesh erosion. Early imaging and cystoscopy enable prompt diagnosis. Multidisciplinary surgical management yields good outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.