Endoscopic holmium laser fragmentation and retrieval of migrated intravesical prolene mesh

Abstract

A 52-year-old man presented with lower urinary tract symptoms and intermittent haematuria for the last 6 months. He had undergone totally extraperitoneal right inguinal hernia repair a decade ago. The ultrasonography and an X-ray of the pelvis suggested a large radio-opaque shadow in the bladder. However, CT revealed an encrusted intravesical extension of the migrated mesh along the right anterolateral wall. The entire intravesical part of the migrated mesh with encrustations was successfully retrieved by endourological approach using holmium laser. The patient symptomatically improved and at follow-up, cystoscopy showed a complete re-epithelisation of the bladder mucosa. The intravesical extension of migrated mesh is a rare but challenging complication following mesh hernioplasty and can be successfully managed with a complete endoscopic approach.

Background

The introduction of prostheses in the management of hernia and stress urinary incontinence has shown promising success rates and is considered as the standard surgical care.¹ The increasing application of such prostheses also increased the appearance of new yet challenging complications. Of particular interest, the intraurethral or intravesical erosion of prostheses is considered one of the most difficult conundrums for the urologists. The incidence of such erosion after mid-urethral sling is reported to be 1%–6%, however, the intravesical erosion of migrated mesh following laparoscopic mesh hernioplasty for inguinal hernia is extremely rare.^2–4 The literature is even more scarce in the endoscopic management of such intravesical erosions and none of them were reported following a totally extraperitoneal (TEP) repair. In the present report, we would like to highlight the feasibility of endoscopic management of encrusted intravesical extension of the migrated mesh following laparoscopic TEP repair.

Case presentation

A 52-year-old man presented with storage lower urinary tract symptoms (LUTS) and intermittent haematuria of 6 months’ duration. The patient denied any history of flank pain, lithuria or obstructive LUTS. The patient had undergone laparoscopic TEP repair for right inguinal hernia 10 years ago. His general and systemic examination did not reveal any abnormality. The prostate felt normal on digital rectal examination (DRE).

Investigations

The routine blood investigations including complete blood counts, renal and liver function tests and coagulation profile were within normal limits. Serum prostate specific antigen was 1.2 ng/dL. Urine routine and microscopy showed abundant red blood cells and few pus cells, however culture was sterile. The pelvis X-ray showed a large calcified lesion in the true pelvis and a ring-like foreign body in the right hemipelvis (figure 1A). Ultrasonography (USG) of the urinary tract showed hyperechogenic contents within the urinary bladder immobile to posture change and bilateral normal kidneys (figure 1B). Further, a non-contrast CT scan of the abdomen revealed the calcified crumpled migrated mesh inside the urinary bladder eroding through the right anterolateral wall (figure 1C).

Figure 1.

(A) Pelvis X-ray showing radio-opaque shadow in the region of urinary bladder (arrow). (B) Ultrasound showing hyperechoic contents with post-acoustic shadow within the urinary bladder. The contents were immobile on posture change. (C) Plain CT scan of urinary bladder revealing encrusted migrated mesh eroding the right anterolateral wall of the bladder (arrow head).

Differential diagnosis

In an elderly man with intermittent haematuria and storage LUTS, the initial differentials were benign enlargement of the prostate (BEP), bladder stone and carcinoma bladder. However, the absence of obstructive LUTS and a normal prostate on DRE excluded BEP to some extent. Investigations showed calcified material in urinary bladder which may have many differentials. First and foremost, differential would be vesical calculus which can be diagnosed accurately using pelvic X-ray, urinary bladder ultrasound and plain CT scan of pelvis. Vesical calculus is usually mobile and moves as when patient changes position, and may be detected on USG or plain CT.

Foreign body in urinary bladder (mesh, intrauterine contraceptive device) can also present in this manner. Long-standing foreign bodies in urinary tract often are associated with deposition of calcium and other minerals making it look like a calculus. It is well known that the urothelial malignancy may be associated with calcification and may present with intermittent haematuria with storage LUTS. Patient usually gives history of smoking. Correct diagnosis can be made via urine cytology, CT urography and transurethral resection.

Schistosomiasis is an endemic parasitic infection caused by various trematodes of the genus Schistosoma and commonly involves urinary bladder. Patient usually presents with intermittent haematuria and history of travel to endemic area. Radiologically linear calcifications can be seen in bladder mucosa and diagnosis can be made by cystoscopic biopsy.

Treatment

At the time of cystoscopy, heavily encrusted mesh was seen eroding through the right anterolateral wall of the bladder away from the ureteric orifices (figure 2A). The 120 W holmium laser was used to fragment the encrustations and the mesh into smaller pieces using the power initially of 20 W and gradually increasing it up to 60 W. The intravesical extension of the mesh was completely removed and the point of entry was fulgurated (figure 2B). In the immediate perioperative period, bladder irrigation with normal saline was applied via 22Fr Foley’s catheter for a short period of time.

Figure 2.

(A) Cystoscopic view showing the intravesical erosion of the migrated mesh with encrustations. (B) Fragments of mesh retrieved after holmium laser fragmentation. C) Follow-up cystoscopy showing complete re-epithelisation of the bladder mucosa.

Outcome and follow-up

The postoperative period was uneventful and the patient was discharged on second postoperative day after catheter removal. In the follow-up, the patient remained asymptomatic and cystoscopy done at 3 and 12 months showed a completely re-epithelised bladder mucosa in the region of erosion (figure 2C).

Discussion

Mesh migration after inguinal hernia repair is rare and only few reports of intravesical erosions of migrated mesh are available following laparoscopic inguinal hernia repair.^5–8 A study was conducted by Frenkl et al on 22 cases of iatrogenic foreign bodies in the bladder and urethra after pelvic floor surgery, they recommended cystorrhaphy or urethroplasty for mesh erosion of the lower urinary tract and reported difficulty in endoscopic retrieval of mesh.⁹ Clearly open surgery has its own complications increasing the morbidity and hospital stay of the patient. More positive outcomes are seen with endoscopic mesh removal especially after advancements in laser technology. In a retrospective review done by Jo et al, 23 female patients with migrated intravesical or intraurethral mesh were managed by endoscopic approach, and authors concluded transurethral route was well tolerated and had high success rates in terms of mesh clearance. They also concluded that patients who were managed with holmium laser had significantly less complications and short hospital stay.¹⁰

Among the laparoscopic repair, transabdominal pre-peritoneal (TAPP) repair has been associated with mesh migration more commonly than the TEP repair.¹¹ The presentation varied between cases ranged from asymptomatic to overt symptoms like haematuria, recurrent urinary tract infections to more complex conditions like bladder stone formation and colovesical fistula.¹¹ Our patient presented with intermittent haematuria and irritative LUTS almost a decade later the initial mesh repair suggesting the time taken for the mesh migration before eroding the bladder to become symptomatic.

The displacement along the pathway of least resistance by inadequate mesh fixation or external displacing forces is proposed as the primary mechanism, while the displacement with erosion of different anatomical planes by foreign body reaction is considered as the secondary mechanism of mesh migration.⁵ The mesh fixation is one of the most debatable topics in the literature on laparoscopic inguinal hernia repair. The presence of a single metallic tack in the region of Cooper’s ligament retrospectively revealed in the pelvis X-ray of our case, suggests a possible inadequate fixation of the mesh. However, the final erosion of the bladder wall signifies the trans-anatomical plane migration induced by the foreign body reaction as well.

The type of mesh used, mesh fixation technique intraoperatively, mesh infection and inadequate rest postoperatively are contributing factors for mesh migration and erosion. Restriction of strenuous activity and bending in the immediate postoperative period were proposed to prevent mesh and staples being dislodged.¹² Earlier reports on the management of intravesical erosion of the migrated mesh were mainly by open approach including partial cystectomy.⁶

In the very first attempt of endoscopic management of such eroded mesh, the mesh was simply pulled out via cystoscopy. The presence of soft stone around the mesh enabled the retrieval by simple manipulation.⁵ Another report mentioned the use of pneumatic lithotrite to fragment the stone and low-watt holmium laser to break the intravesical extension of the migrated mesh following TAPP repair.⁸ In contrast to the previous reports, we completely used a high-power holmium laser to remove the entire intravesical part of the migrated mesh with heavy encrustations following TEP repair. We did not encounter any perioperative complications.

With the rarity of the condition and absence of specific guidelines, the management of intravesical extension of the migrated mesh relies on the few anecdotal reports or individual surgeon preference. However, a complete endoscopic management of such case is feasible and clearly associated with less morbidity and early recovery compared with open surgery. Further large series or multi-institutional data analyses can give further insight of the management of such cases.

Learning points.

• Intravesical erosion of the migrated mesh following laparoscopic inguinal hernia repair is rare.

• A high index of suspicion, detailed review of the surgical history and sequential appropriate investigations help in arriving at the diagnosis.

• Endoscopic management using holmium laser for intravesical erosion of the migrated mesh is a feasible option.