Vesicocutaneous fistula after sliding hernia repair.

Sliding inguinal hernias are usually direct inguinal hernias containing various abdominal viscera. The incidence of bladder forming a part of an inguinal hernia, called as "scrotal cystocele," is 1-4%. The risk of bladder injury is as high as 12% when repairing this type of hernia. This case report emphasizes this aspect in a 65-year-old man who presented with urinary leak through the scrotal wound following right inguinal hernia repair.

INTRODUCTION

The incidence of bladder forming a part of an inguinal hernia is 1–4%.[1] With correct knowledge of anatomy and careful dissection, injuries to the bladder during hernia repair can be prevented, but it can especially happen in very large sacs. We hereby report a case where the patient first presented with a scrotal abscess and vesicocutaneous fistula after surgical repair of sliding hernia.

CASE REPORT

A 65-year-old morbidly obese man underwent mesh hernioplasty for large right inguinal hernia. After removing the urethral catheter, he developed gradually increasing right scrotal swelling with fever. Ultrasound scrotum revealed a septate fluid collection for which incision and drainage was performed. Thereafter, he developed continuous urine leakage from the site of incision and drainage, Figure 1. The patient was referred to our institute. We carried out a cystogram via the urethral catheter that revealed a fistulous communication between bladder and scrotal skin, Figure 1. He was kept on urethral catheter drainage for 3 weeks. At 3 weeks, cystoscopy revealed normal anterior and posterior urethra, non-obstructing prostatic lobes and a defect in the anterior bladder wall with no evidence of mesh erosion. Bilateral ureteric openings were normally present and were away from the fistula site. A guidewire was passed through the defect that exited via the scrotal wound. Exploration was performed through a right groin incision extending into the right scrotum. Almost the whole of the bladder was lying in the right scrotum and densely adherent to the right testis and cord structures and mesh. There was a fistulous opening at the dome of the bladder wall well away from the mesh. The bladder was dissected carefully from all around. Our main concerns were inguinal hernia repair and creation of extraperitoneal space to reposition the bladder in the normal position, which was not possible without performing right high inguinal orchiectomy. Hence, we performed right high inguinal orchiectomy and removal of mesh and extraperitoneal space was made to reposition the urinary bladder to its normal position. Fistula opening was repaired in two layers and the bladder was put on continuous drainage via 20 french urethral catheter, Figure 2. The right inguinal canal was closed in three layers. Scrotoplasty was also performed. An 18 french suction drain was kept in the scrotum. Post-operatively at 2 weeks, there was no urinary leak on cystogram and the urethral catheter was removed and normal voiding was restored.

Figure 1

Scars of previous surgery with vesicocutaneous fistula and cystogram showing contrast in the left hemiscrotum

Figure 2

The entire urinary bladder lying in the scrotum, with the bladder re-positioned into the normal position

DISCUSSION

The incidence of bladder forming a part of an inguinal hernia is 1–4%.[1] Levine coined the term “scrotal cystocoele” in 1951 for inguinoscrotal herniation of the bladder.[1] Urinary bladder herniations are usually diagnosed at the time of inguinal herniorraphy and are commonly repaired through the same incision. Careful inguinal dissection is required because of a high risk of iatrogenic bladder injury.[2] They are sometimes found incidentally during the evaluation of a patient with lower urinary tract symptoms and associated inguinal hernias. Two-stage micturition is the classical symptom, with the second stage facilitated by some form of external pressure on the bladder. Bladder hernias can be para-peritoneal, extra-peritoneal or intraperitoneal.[3] The para-peritoneal type is the most common type and the extra-peritoneal type is the least common. Because imaging all patients with large hernias may not be cost-effective, imaging studies are performed only when bladder herniation is suspected. The diagnostic triad of lateral displacement of the distal one-third of the ureter, small asymmetric bladder and incomplete visualization of the bladder base on an intravenous urogram has been described by Reardon and Lowman.[4] Voiding cystourethrography offers the best imaging modality. Iatrogenic injury to the bladder during hernia repair can be due to multiple factors, such as an inexperienced surgeon in the early part of the learning curve or an obese patient with large hernial sac with unrecognized bladder component. In our patient, there could have been an injury to the bladder that was not recognized at the time of hernia repair, which led to subsequent scrotal abscess formation resulting in a vesicocutaneous fistula. Most urinary bladder herniations are diagnosed at the time of herniorrhaphy.[5] If unrecognized, these usually present immediately after catheter removal, but presentation can sometimes be delayed in case the fistula is very small and there is no infravesical obstruction. Management includes immediate repair in case it is recognized intraoperatively. In case of unrecognized injury and with delayed presentation, the first step is to put a wide caliber per urethral catheter followed by thorough evaluation with urine culture examination and cystogram. A small fistula can be healed with only continuous bladder drainage with per urethral catheter or preferably suprapubic cystostomy, provided lower tract infravesical obstruction has been ruled out. A larger fistula needs open surgical management. Careful dissection is needed in the extraperitoneal space while separating the sac from cord structures as the bladder forms a part of the posterior wall of the sac. After completing bladder dissection, the fistula is repaired in two to three layers and an adequate space is created in the extraperitoneal plane to reposition the bladder. Sometimes, large hernias could be treated by resection of the herniated bladder as described by Thomas and Gomella.[25] In our case, the whole bladder was lying in the scrotum and extensive adhesions were present between the cord structures and the bladder. High inguinal orchiectomy was performed to create space for the bladder and for proper closure of the inguinal canal. Non-obstructive voiding has to be ensured after removing the catheter.

CONCLUSION

Urinary bladder rarely forms a part of an inguinal hernia and, with the correct knowledge of anatomy and careful dissection injuries to the bladder during hernia repair, surgery can be prevented. Surgically creation of an extraperitoneal space for bladder repositioning is of paramount importance, sometimes needing inguinal orchiectomy in the elderly. Infravesical obstruction has to be taken care of for better outcome.