A Rare Presentation of Vesicocutaneous Fistula as Groin Abscess after 8 Years of Laparoscopic Mesh Repair of Inguinal Hernia

Abstract

Laparoscopic mesh repair of inguinal hernia is common but rarely associated with vesicocutaneous fistula as a complication. The most common implications are mesh erosion and migration due to inappropriate strategies in the selection of the mesh type, size, and placement of mesh. This case study reports a 74-year-old man who suffered immense physical, mental, and cosmetic hardship due to a vesicocutaneous fistula postlaparoscopic mesh repair of an inguinal hernia performed 8 years ago. He presented with groin abscess secondary to vesicocutaneous fistula, diagnosed with high inflammatory markers and computed tomography abdomen pelvis. Groin abscess was drained and identified vesicocutaneous fistula which was managed conservatively.

INTRODUCTION

Laparoscopic mesh repair has become an established technique for repairing inguinal hernia.^[1] Laparoscopic mesh repair has the advantage of better exposure and minimal postoperative pain. However, mesh reinforcement remains the mainstay of groin hernia repair.^[1–3] Due to the proximity to the urinary bladder during the repair, mesh migration may rarely lead to urinary bladder erosion and present as vesicocutaneous fistula.^[3] Even now, vesicocutaneous fistula is underreported and warrants more awareness; therefore, we are presenting this case report of vesicocutaneous fistula as a delayed complication of totally extraperitoneal (TEP) repair of inguinal hernia presented as groin abscess. After extensive research on MEDLINE, we assert that this is the third case of vesicocutaneous fistula after laparoscopic hernia repair surgery presenting as either groin swelling or abdominal wall sinus, but this is the only case successfully managed conservatively because the previous two cases underwent surgery.^[4,5] Despite being rare, postmesh hernioplasty vesicocutaneous fistula can be recurrent, causing immense physical, psychological, and cosmetic distress to the patient.^[6,7] Hence, it is imperative to make an early diagnosis, and surgical intervention to improve outcomes and the quality of life.

CASE REPORT

A 74-year-old man presented to the accident and emergency department in September 2020 with complaints of progressively increasing right groin swelling and purulent discharge for the past few days. He was systemically well in himself. Examination revealed a right groin abscess of 7 cm × 5 cm in diameter with a pus-discharging sinus. The rest of the examination was unremarkable.

The patient has a medical history of hypertension and is on prolonged warfarin use for atrial fibrillation. He also had a laparoscopic TEP repair for the right groin inguinal hernia in 2012. It is worth noting that, post-TEP repair; he had microscopic hematuria and sterile pyuria. The cystoscopy showed a very unusual anterior right side bladder wall with extensive bullous cystitis and strange yellow discoloration and no fistula was found. His management was discussed in a multidisciplinary meeting, and he was put on surveillance and subsequently discharged.

A preliminary diagnosis of a right groin abscess was made based on clinical examination and C-reactive protein of 70 [Table 1]. Abdomen and pelvis computerized tomography with contrast (CTAP) was performed which revealed an extraperitoneal localized fluid collection in the anterior pelvis containing the mesh, several locules of gas, and the mesh was adherent to the urinary bladder. In addition, a tract extending from the bladder to the right groin was spotted which was associated with an indurated area in the subcutaneous soft tissue suggesting a cutaneous fistula, as shown in Figure 1. He was managed with intravenous antibiotics, cefuroxime, and metronidazole as per trust guidelines.

Table 1: Laboratory investigations

Figure 1: CTAP Image: Inflammation and fluid collection anterior to the urinary bladder. CTAP: Abdomen and pelvis computerized tomography with contrast

The patient underwent an emergency exploration of the right groin under general anesthesia. A groin crease incision was made to drain pus from the extraperitoneal space. At the same time, old mesh embedded into tissues was found; it was densely adherent and not easily amenable to removal. Hence, the peritoneum was not breached during the surgery.

In the postoperative period, there was copious watery discharge from the surgical wound site, which necessitated multiple dressing changes, often on an hourly basis, but there were no signs of systemic sepsis. A stoma bag was applied to the wound, which was filling up with clear fluid. All along during this period, he had good urinary output. Diagnosis of bladder fistula was considered in view of the clear watery discharge from the wound. An indwelling urinary catheter was inserted to drain the urinary bladder. Drain fluid creatinine was requested and came back as 1331 µmol/L.

This patient was discharged on oral flucloxacillin for a week as per sensitivity for Staphylococcus aureus and to be followed by general surgeon and urologist. He was seen in the clinic; his symptoms were improving, and the repeat fluid creatinine was 70 mmol/L. His latest computed tomography (CT) abdomen – Pelvis showed that the collection anterior to the bladder wall related to the mesh, measured 7.4 cm in width by 2.4 cm in depth, and has improved minimally when compared with the previous scan, as shown in Figure 2 and a fistulous tract is again identified. Surprisingly, the cystoscopy was unremarkable, and no bladder fistula was found. In view of the small opening fistula and densely adherent mesh which means major surgery involving joint care of the urologist and surgeon, the patient was managed conservatively. After 5 months the patient became asymptomatic, and the collection was resolved.

Figure 2: CTAP image showed decrease in collection postdrainage of groin abscess. CTAP: Abdomen and pelvis computerized tomography with contrast

DISCUSSION

Vesicocutaneous fistula is a rare unwanted outcome associated with the laparoscopic mesh repair of inguinal hernia.^[4–7] Additional and more common causes include pelvic fracture following extensive pelvic trauma, after radiation therapy in pelvic malignancies, postmajor pelvic surgery such as a hip arthroplasty and radical hysterectomy, and a complication of a large urinary bladder stone.^[7,8]

The timeline of vesicocutaneous fistula formation as a complication of laparoscopic mesh repair for inguinal hernia varies. Most cases reported so far occurred in the immediate aftermath, but none has been reported as a long-term complication.^[9] One case has established a relation between the tackers used in inguinal mesh repair surgeries and the formation of a vesicocutaneous fistula.^[3]

In hernioplasty, mesh migration is the leading cause of vesicocutaneous fistula and can be divided into two possible scenarios, firstly, a primarily migration of mesh due to improper mesh attachment to the surrounding tissues, leading to mesh migration along the line of least resistance, and secondarily, due to excessive granulation tissue formation causing bladder wall erosion, akin to foreign body inflammation.^[3]

Mesh fixation in laparoscopic hernia repair remains a contentious issue. In a straightforward hernia defect <3 cm, fixation is avoided, due to the surgical advantages of shorter operative time, minimal short-term postoperative pain reduced chances of urinary retention and lower cost.^[3] Lo et al. reported higher, but statistically insignificant (P = 0.28) recurrence in nonfixation cases than mesh fixation.^[10] Mesh reinforcement and fixation in hernia repair are more debatable in view of the span of reported complications ranging from 3 months to 20 years after the hernia repair.

Vesicocutaneous fistula is rare, and due to the rarity of this condition, there needs to be a high index of suspicion. Radiological investigations such as fluoroscopic or cross-sectional imaging such as CT abdomen-pelvis, cystoscopy, and fluid creatinine level are available to confirm this diagnosis 5. In our case, a CTAP showed a thickened anterior wall of the bladder and a localized collection of approximately 9 cm × 3 cm with gas locules with mesh adherent to the bladder as shown in Figure 3.

Figure 3: Thickened anterior wall of the bladder and a localized collection of approximately 9 cm × 3 cm with gas locules with mesh adherent to the bladder

Though Liu et al. recommend partial or complete removal of mesh as the safest and most effective management of mesh erosion,^[3] it might not be straightforward, as in our case, the mesh was strongly adhered to the surrounding soft tissue and surgeons ended up in a surgical dilemma, whether to proceed with a possibility of bowel/bladder resection or adopt a more conservative approach of fistula exploration and urinary bladder catheterization under antibiotics cover. After the multidisciplinary team (MDT) discussion, it was decided to continue conservative management; the patient was improved in 5 months and does not require any surgery.

The diagnosis of vesicocutaneous fistula was not made immediately despite copious watery discharge from the wound which could be due to limited knowledge of fistula; this could be taken as a limitation of this case study.

CONCLUSION

We have described a case of a 74-year-old man who had the right TEP 8 years ago and presented as a right groin abscess secondary to vesicocutaneous fistula due to erosion of the urinary bladder by hernia mesh. Mesh migration can be prevented with good dissection and ensured hemostasis during surgery. The patient was managed conservatively, and the fistula was healed in 5 months. To diagnose vesicocutaneous fistula needs a high index of suspicion and investigations such as fluid creatine, CTAP, and cystoscopy can be used as diagnostic tools. The management should be decided in the MDT meeting considering individual circumstances.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.