Management of Calcified Eroded Mesh into the Bladder
Calcified mesh eroded into the bladder requires complete surgical removal of the mesh with or without partial cystectomy, as synthetic mesh should never be left in contact with the urinary tract due to risk of ongoing infection, stone formation, and tissue damage. 1
Surgical Approach and Technique
Primary Treatment Strategy
Complete mesh removal is mandatory and should be performed via open cystotomy, laparoscopic approach, or combined endoscopic/open technique depending on the extent of erosion and calcification. 2, 3
Partial cystectomy should be performed when the mesh is densely adherent to the bladder wall or when significant bladder wall inflammation/fibrosis is present (occurred in 31.8% of reported cases). 2
Endoscopic holmium laser excision may be attempted for small, minimally adherent mesh erosions without extensive calcification, though repeated treatments are often necessary and this approach has higher failure rates. 4
Specific Technical Considerations
Laparoscopic transabdominal preperitoneal (TAPP) approach is preferred when mesh is adherent to the bladder wall, as it allows complete visualization of the mesh-bladder interface and facilitates partial cystectomy if needed. 3
Open cystolithotomy with mesh extraction is indicated when large bladder calculi have formed on the mesh (stones up to 4×3 cm have been reported), as endoscopic fragmentation alone is often insufficient. 4, 5
All fixation devices (tacks, sutures, bone anchors) must be completely removed as retained foreign material perpetuates inflammation and stone formation. 3
Perioperative Management
Catheter Drainage Protocol
Dual catheter drainage (urethral plus suprapubic) should be placed for 2-3 weeks post-operatively to ensure adequate bladder healing and allow monitoring for urinary leakage. 3
Fluoroscopic cystography should be performed before catheter removal to confirm absence of urinary extravasation, particularly when partial cystectomy was performed. 3
Critical Pitfalls to Avoid
Never attempt to leave mesh in situ even if partially removed, as retained synthetic material will continue to cause inflammation, infection, and recurrent stone formation. 1
Do not perform simple endoscopic mesh trimming for calcified erosions, as this leaves intramural mesh that will cause recurrent symptoms (one series reported 33% recurrence with incomplete removal). 4
Avoid placing new synthetic mesh during the same operation or in the future at this site, as the AUA guidelines explicitly contraindicate synthetic mesh placement near fresh urinary tract openings. 1
Expected Outcomes and Follow-Up
Most patients achieve complete symptom resolution (irritative voiding symptoms, recurrent UTIs, hematuria) after complete mesh removal with mean follow-up showing no recurrence when adequately excised. 4, 3
Cystoscopy at 3-6 months post-operatively is recommended to confirm complete healing and absence of residual mesh or stone formation. 2
Recurrent hernia risk must be discussed with patients, as mesh removal without replacement leaves the hernia defect unrepaired; however, primary tissue repair without mesh is the only safe option in this contaminated field. 2
Timing Considerations
Mesh erosion can occur anywhere from 3 months to 20 years after initial hernia repair (43.5% occur within 1-5 years, 26.1% occur after 10 years), so this complication should be considered regardless of time since surgery. 2
Urgent surgical intervention is indicated when signs of infection, abscess formation, or sepsis are present, as mesh-related bladder erosion can lead to life-threatening complications. 1