Endourological management of multiple large bladder calculi over eroded mesh in an adult with augmented bladder and catheterisable continent appendicovesicostomy

Abstract

Migration of abdominal wall mesh in an augmented bladder is a rarely encountered complication leading to formation of bladder stones causing recurrent urinary tract symptoms. The usual management of this condition involves either open surgical or a percutaneous approach for removal of the stone and migrated portion of mesh. Diagnosis of a migrated mesh is usually made intraoperatively during cystolitholapaxy. Appropriate management results in symptomatic improvement. Endoscopic management through catheterisable continent appendicovesicostomy has not been described to manage this challenging condition. To the best of our knowledge, we describe herewith the first report of endoscopic management of a large bladder stone formed over migrated mesh which involved removal of migrated mesh with holmium laser via a Mitrafanoff.

Background

Traditionally, surgical mesh or suture erosion into the bladder has been managed with open cystotomy.¹ Multiple endoscopic modalities including holmium laser, transurethral resection and laparoscopic excision have been described for management of eroded mesh or suture material in the bladder which offers a less invasive treatment option than open surgery.^{2 3} Holmium laser is used for many endoscopic urological procedures and has been described in case reports and retrospective studies to have favourable outcomes and low morbidity in endoscopic ablation of eroded foreign bodies.^{2 4–7} Here, we report a case of endourological management of large calculi secondary to migrated mesh in an augmented bladder with appendicovesicostomy for continent self-catheterisation of bladder.

Neurogenic bladder occurs as a consequence of several conditions and is characterised by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (augmentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterisable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy).⁸ The main complications of these catheterisable channels include stomal prolapse, stomal incontinence and difficulty catheterising, typically due to channel stricture/stenosis, channel redundancy, false passages and diverticuli.⁹

Case presentation

We report a case of a 32-year-old woman born with cloacal extropy who underwent reconstructive surgery at the age of 3 years in Austria. She later underwent surgery for bladder augmentation with a catheterisable continent appendicovesicostomy, and hernia repair at age of 18 years in Switzerland. The details of surgical procedures were not available. Thereafter she was suffering from recurrent urinary tract infections (UTIs) over the last decade and was found to have bladder stones inspite of performing timely self-catheterisation. During cystolitholapaxy performed via flexible ureteroscope through the appendicovesicostomy, the nidus for the stone formation was found to be mesh eroded into the bladder wall. This was successfully ablated using holmium laser.

Investigations if relevant

Serum creatinine was 1.7 mg/dL. Her CT scan revealed a lobulated and trabeculated urinary bladder with circumferential thickening of its wall and multiple bladder calculi, the largest being 5×4.5 and 3.5×3 cm (figure 1A). The kidneys were normal appearing on CT scan.

Figure 1.

Pretreatment and post-treatment CT scans. (A) Preoperative CT scans. (B) Postoperative (first stage) CT scan.

Differential diagnosis

Our differential diagnosis for the recurrent UTIs included the presence of residual urine leading to colonisation and subsequent contamination, usage of contaminated catheters leading to re-infections and niduses of infection such as calculi.

Treatment if relevant

The patient was consented for endoscopic management with trans-appendicovesicostomal or percutaneous approach. She was given culture-specific antibiotics for 1 week prior to her surgery. The procedure began under general anaesthesia with a cystogram through the continent catheterisable stoma (figure 2A). We were not able to introduce a flexible cystoscope through the conduit. With the assistance of a glide wire, we were able to first advance a 5-French open-ended ureteral catheter into the bladder (figure 2B). The glide wire was then replaced with a sensor wire under fluoroscopy guidance. Then a 12/14 French, 36 cm long access sheath was introduced into augmented bladder over the sensor wire (figure 2C). A digital flexible ureteroscope was then introduced into the augmented bladder through the access sheath.

Figure 2.

Intraoperative fluoroscopy images demonstrating access to stone. (A) Cystogram showing appendicovesicostomy and augmented bladder. (B) Glide wire negotiated in the augmented bladder. (C) Ureteral access sheath in place.

Cystolithopaxy was performed using a 200-micron laser fibre at the settings of 0.3 J and 40 Hz with the aim of dusting the stone using a 120 W Holmium laser machine (Lumenis, Israel). During the terminal part of stone dusting, the nidus of stone formation was found to be the mesh eroding into the bladder (figure 3A). After fragmenting the stone, the mesh was further dissected. We then increased the energy to setting of 2 J and reduced the frequency to 20 Hz and resected the visible mesh and separated it into multiple small pieces (figure 3B). With extreme caution to avoid perforation, the intramural portion of the mesh was carefully resected to the depth of the bladder serosa. Once complete, multiple attempts were made to irrigate the stone fragments out through ureteral access sheath. However, some residual dust and small stone particles remained in the bladder. Therefore, we placed a 14-French Foley catheter via the appendicovesicostomy to maximally drain residual dust and mesh fragments. There were no intraoperative complications with the procedure, and the patient was discharged the next day after an uneventful hospitalisation. The stone was composed of triple phosphate.

Figure 3.

Intraoperative images of mesh eroded into bladder. (A) Mesh as the nidus of bladder stone. (B) Mesh embedded in bladder wall.

The foley catheter was kept for 1 week, and CT scan was performed at 1 month after the procedure and revealed several residual bladder stones (figure 1B). She then underwent a second stage cystoscopy via her appendicovesicostomy with a digital ureteroscope. Several small residual stones <5 mm were found and basketed. Complete stone clearance was confirmed endoscopically. The site of mesh ablation on the bladder was well-healed and scarred over. She had a postoperative CT scan at 6 weeks after her second stage procedure and she was completely stone free.

Outcome and follow-up

At 1-year follow-up, she has remained asymptomatic and free of any symptomatic UTIs. The sonogram of her bladder does not reveal any recurrence of stone.

Discussion

Several less-invasive modalities have been explored for excision of mesh which has eroded into the bladder. Solely laparoscopic or laparoscopic-assisted endoscopic resection of mesh in the bladder has been described in a single-centre study in the context of complications secondary to intravesical mesh erosion following placement of tension-free vaginal tape. They reported no major complications.¹⁰

In a study of 14 patients, transurethral resection of mesh with high-voltage electric current Oh and Ryu reported that mesh could be completely removed in 13 patients with only 1 patient developing a recurrent stone at a mean follow-up of 18 months. However, complications included three vesicovaginal fistulas.¹¹

Transurethral endoscopic excision using Holmium laser has been described as an alternative to electric current at a setting ranging from 2.5 W to 10 W.³ Of the nine patients described since 2005, six developed recurrence over a short follow-up of slightly above 1 year.^{12 13}

This case is unique as it describes the use of mesh ablation through a mitrofanoff into an augmented bladder through a flexible ureteroscope which had its own difficulties. A flexible ureteroscope had to be used due to the inability to introduce a larger calibre, flexible cystoscope through the tortuous mitrofanoff. It is important to emphasise the ability of a flexible ureteroscope through a mitrofanoff as this may be the only viable, accessible and versatile minimally invasive option in such patients and can potentially replace the open surgery and its associated complications.

Although a second stage was required in our patient for basketing of the remaining small stone fragment, she has since then remained stone-free and without recurrence in symptoms for 1 year. Further follow-up is necessary to determine the long-term efficacy of endoscopic management for this rare pathology.

Patient’s perspective.

I had been dealing with frequent urinary infections since childhood and was quite scared when I was told that I had a stone in my bladder with erosion of the mesh into my bladder. I was extremely happy that I was able to avoid open surgery to treat the stones. I am relieved that my recurrent episodes of urinary tract infection have resolved and I am back to my regular activities.

Learning points.

• Surgical mesh erosion into the bladder is a known phenomenon and it often acts as a nidus for stone formation.

• Both lithotripsy and mesh excision can be effectively and safely performed with holmium laser.

• Holmium laser is a versatile tool as it can be used via flexible ureteroscope through an appendicovesicostomy which may often be the only accessible route for stone fragmentation in patients with continent catheterisable pouches.