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The management of incisional hernia following radical cystectomy (RC) and neobladder diversion poses a special challenge. Mesh erosion into the neobladder is a potential complication of hernia repair in this setting. We describe our experience and steps to avoid this complication. Three patients developed incisional hernias following RC involving the neobladder. The incisional hernias were repaired by the same surgeon. A systematic dissection and repair of the hernias with an onlay dual-layer mesh (made of polyglactin and polypropylene) was carried out. The critical steps were placing the polyglactin side of the mesh deeper and positioning of an omental flap anterior to the neobladder. The omental flap adds a protective layer that prevents adhesions between the neobladder and abdominal wall, and prevents erosion of the mesh into the fragile neobladder wall. All of these patients had received two cycles of neoadjuvant chemotherapy prior to RC. The time duration from RC to the repair of hernia was 7, 42, and 54 months. No intraoperative injury to the neobladder or other complication was noted during hernia repair. The patients were followed after hernia repair for 20, 22, and 42 months with no recurrence, mesh erosion, or other complications. Careful understanding and attention to details of the technique can minimize the risk of complications, especially incisional hernia recurrence, injury to the neobladder, and erosion of mesh into the neobladder wall.

Objectives To investigate the effect of chlorhexidine gluconate in urethral local anesthetic gel on patients undergoing outpatient flexible cystoscopy. We postulated that chlorhexidine was contributing to the pain and urgency that occurs during and after cystoscopy. Methods A prospective randomized single-blinded study was conducted. A total of 141 patients undergoing outpatient flexible cystoscopy participated in the study. They were randomized to receive 10 mL of 2% lignocaine gel with 0.05% chlorhexidine gluconate (group 1, n = 72) or 10 mL of 2% lignocaine and aqueous gel mixture (group 2, n = 69). Pain scores were recorded on a numerical visual analog scale from 0 to 10. Results The groups were well matched for the purposes of comparison. The mean pain scores were not significantly different between groups 1 and 2 at the insertion of the scope (2.1 versus 2.2, P = 0.7), during cystoscopy (1.8 versus 1.9, P = 0.759), and immediately after cystoscopy (1.4 versus 0.8, P = 0.06). However, a significant difference was found in the mean pain scores between groups 1 and 2 during the first void (1.8 versus 1.0, P = 0.031) and after the first void (2.4 versus 1.2, P = 0.007). A significant increase occurred in the reported levels of urgency after cystoscopy in group 1 (P = 0.018). No difference was found in the level of culture-proven symptomatic infection. Conclusions Chlorhexidine appears to contribute to significant levels of pain and urgency after outpatient flexible cystoscopy.

Chlorhexidine is a bis-biguanide molecule widely used in many preparations as a disinfectant and an antiseptic. We describe four confirmed cases of allergy to chlorhexidine gluconate in urethral gel and review the existing published reports. Pertinent issues in the treatment and investigation of these patients are discussed.