What is the treatment for ventral herniation of the urinary bladder in the suprapubic region?

Treatment for Ventral Herniation of the Urinary Bladder in the Suprapubic Region

Surgical repair is the definitive treatment for ventral herniation of the urinary bladder in the suprapubic region, with laparoscopic intraperitoneal onlay mesh plus (IPOM plus) technique being the preferred approach for defects smaller than 10 cm. 1

Initial Management

1. Immediate urinary drainage
   • Establish urinary drainage as soon as possible via urethral catheterization 2, 3
   • If urethral catheterization is not feasible, consider suprapubic catheter placement 2
   • This helps prevent complications such as urinary retention and allows for better visualization during surgical planning

Diagnostic Evaluation

• Imaging studies
  • Cystography is essential to confirm the diagnosis and determine the extent of bladder herniation 4, 5
  • CT scan may provide additional information about the relationship between the hernia and adjacent organs 6
  • Cystoscopy may be needed to evaluate for intravesical mesh migration in cases of previous mesh repair 6

Surgical Management

Laparoscopic Approach (Preferred)

• Laparoscopic IPOM plus technique 1

  • Mobilize the bladder from the rectus abdominis muscle
  • Create a compartment for mesh placement
  • Anchor the mesh to the pubic bone
  • Suture the bladder back into position
  • Benefits include:
    • Shorter hospital stays
    • Fewer perioperative complications
    • Lower recurrence rates

• Technical considerations during laparoscopic repair 7

  • Extensive adhesiolysis is often necessary due to previous surgeries
  • Wide pelvic dissection into the space of Retzius to mobilize the dome of the bladder
  • Use of barrier mesh with intraperitoneal onlay technique
  • Careful tack fixation to the pubic bone and Cooper's ligaments
  • Extensive transfascial suture fixation of the mesh

Open Surgical Approach

• Reserved for cases where laparoscopic approach is not feasible:
  • Defects larger than 10 cm
  • Extensive adhesions
  • Need for concomitant procedures
  • Surgeon preference or expertise

Potential Complications and Prevention

• Common complications 7

  • Symptomatic seroma (8.5%)
  • Prolonged ileus (4.3%)
  • Chronic pain (4.3%)
  • Postoperative urinary retention (4.3%)
  • Bladder injury (2.1%)

• Serious complications

  • Mesh migration into the bladder 6
  • Enterovesical fistula 6
  • Recurrence (6.3%) 7

• Prevention strategies

  • Use of transfascial sutures to reduce seroma formation and recurrence 1
  • Proper mesh placement and fixation
  • Careful bladder mobilization and repositioning
  • Adequate mesh size (hernia-to-mesh ratio of approximately 3:1) 7

Follow-up Care

• Monitor for recurrence, which may occur at the level of the pubic tubercle or laterally 7
• Evaluate for urinary symptoms that may indicate mesh migration or fistula formation 6
• Consider imaging studies if symptoms develop

Special Considerations

• In patients with previous Marshall-Marchetti-Krantz procedures for stress incontinence, ventral bladder herniation may present with suprapubic pain, urgency, and incontinence 4
• Patients with previous penile prosthesis placement may develop bladder herniation through the suprapubic incision 5

Remember that early surgical intervention is key to preventing complications such as mesh migration, enterovesical fistula formation, and urinary symptoms that can significantly impact quality of life.