A prevesicule granuloma formation after inguinal herniorrhaphy is an unusual complication due to infection and reaction to silk suture material, sometimes resembling giant vesicular granulomas masquerading as bladder tumors (1, 2). Irritable symptoms predominate the symptom complex and accurate diagnosis is usually obtained after surgery, leading to complete resolution of symptoms (3, 4). Suture granuloma should be considered in patients who have undergone previous inguinal surgery, mainly when using non-absorbable suture material (5). These patients may have a gun under hernia repair for several months to 11 years before presenting urinary symptoms (6, 7). These patients are usually treated by En bloc excision and partial cystectomy (8, 9). However, in our literature review, our patient is the first case report of neurologically managed prevesicul suture granuloma (PSG).
A 47-year-old man with a past surgical history of proper inguinal hernia repair (10 years before) appeared with retracting prevesicule tissue. Moreover, no history of urinary tract infections presented with mild burning micturition and urethral pain. Renal sonography was average; bladder sonography revealed a hypoechoic mass with central heterogeneity and intact mucosal layer extending inside the bladder with normal prevesical fat, urine culture was negative, and CT scan showed a six-centimeter mass balk with heterogeneous appearance retracting prevesicule tissue toward its center (Figure 1). At cystoscopy, there was a yellowish-white color mass protruding like an orange into the bladder with a well-defined margin. The biopsy revealed no malignancy. The patient was a candidate for the mass's deep and total transurethral resection. The resection was started all over the surface of the tumor, gradually deepening universally all over the mass surface to decrease the mass balk as much as possible before perforating the bladder; there was no significant bleeding during resection.
Figure 1. Pre-operative CT SCAN of patient
In contrast, a small black particle resecting the center of the mass was dropped into the bladder, followed by a yellowish-white opaque, dense fluid of about five milliliters discharged into the bladder. We could see a hole in the center of the resected area; from now onward Patient's bladder was resected with caution so as not to have fluid extravasations, and another black particle again fell from the center of the lesion into the bladder; the mass was resected as much as possible without complications, total mass resected was 20gr. At the end of the black surgery, a particle was examined macroscopically, which appeared to be a suture ligation of silk material compatible with the patient history of proper inguinal repair. Histological examination of the specimen revealed patchy mono-cellular inflammatory cell infiltration and granulation tissue formation with no evidence of malignancy and acellular fiber compatible with reaction to silk material. (Figures 2,3) As the pathologic cause seemed to be removed by TUR, the patient was discharged on the second postoperative day, and the urethral catheter was removed on postoperative day 5.
Figure 2. Postoperative CT SCAN of the patient at 6 months
Figure 3. Post-operative CT SCAN of the patient at 1 year
The urinary bladder involves 1-4% inguinal hernias (10). A thorough literature review showed that PSG is a rare case report. Most of the studies (5) have managed patients with bloc excision of the tumor with partial cystectomy. We managed our patient by single deep TUR of the mass as a single procedure, following which symptoms ultimately resolved.
In Kise's study (11) they managed their patient with antibiotics and inguinal wound exploration, which did not lead to symptom resolutions. Finally, they required En bloc excision and partial cystectomy of Vesicular mass as granuloma should be considered for a patient with Urinary symptoms with a history of inguinal herniorrhaphy, which may have been performed many years before the time of presentation. Follow-up of our patient at six months and one year showed that the patient was free of urinary symptoms. CT scan of six months and one-year post-operative demonstrated decreased thickness and gradual normalization of Residual wall anatomy with standard counter pervesical tissue without retraction, so unnecessary major surgery was avoided.
By TUR, silk suture materials were removed and inflammatory granuloma was treated.
All authors had an equal contribution.
We would like to express our appreciation for the Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Conflict of interest
There is no conflict of interest.
There is no funding.
Data will be provided by the corresponding author upon request.
PSG Prevesicul suture granuloma
TUR Transurethral resection