Discussion
Bladder hernia is a rare condition, accounting for 1-3% of inguinal
hernia5. Most of bladder heriation occur on the right
side and are direct type.1 The pathophysiology of an
inguinal bladder herniation was similar with direct type inguinal
hernia, as the sheath of peritoneum traverse through the weak point of
abdominal fascia5. Some risk factors are associated
with this condition, including obesity, weakness of abdominal
musculature, chronic urinary obstruction, male gender, old age and
benign prostatic hypertrophy5, 6. Most of the patient
are typically asymptomatic while some of them may be suffered by lower
urinary tract symptoms (LUTS). In advance cases, patient may describe
two-stage voiding as they have to complete urination by compressing
scrotal-bladder manually7. As occurred in our case,
previous reports have shown that some patient might developed bilateral
hydronephrosis, acute kidney injury and ureteral obstruction resulting
from bladder compression7, 8.
There are several examinations could be used for diagnosing bladder
herniation. Besides physically examination, sonography provided another
non-invasive, non-radiation method which may demonstrate a hypoechoic
mass inside the scrotum. The size of the mass may decrease after voiding
or Foley indwelling. Sonography could also be used for screening of
hydronephrosis and hydroureter. Voiding cystourethrography may revealed
a dog-ear shape of bladder inside the scrotum, providing adequate
evidence for diagnosis.1 Computed tomography (CT) scan
could provide most detailed information for diagnostic purpose and
surgical planning, including whether there is contralateral herniation
or other organ herniation simultaneously.
While radiology imaging is not routinely performed in the workup of
inguinal hernia, only 7% of inguinal bladder hernias are diagnosed
before operation. Furthermore, complication such as bladder injury or
bladder leakage may occurred during surgery, accounting for 16-23.5% of
all bladder hernia.4, 9 Thus, it is important to
identify bladder hernia prior to operation.
The most frequently reported surgical way of treating bladder hernia is
open repair, yet our patient underwent a laparoscopic total
extraperitoneal approach (TEP) hernia repair. Laparoscopic surgery
provides several advantages including improving visibility of bladder
and surrounding structures, rapid recover, less pain and improved
cosmesis.10 Currently, there were several published
literatures reporting laparoscopic repair of herniated bladder, however,
in best of our knowledge, non-of them provide intra-operative image
clearly.