herniation of the bladder is not rare and occurs in 1% to 3% of all inguinal hernias . such massive herniation accounts for only 1% of bladder hernias ( bhs ) . in korea , most bhs are asymptomatic and are found incidentally during herniorrhaphy or imaging studies performed for other purposes . patients with bh may have dysuria , frequency , urgency , nocturia , or hematuria . in particular , patients with a large bh may have a pattern of two - stage voiding ( the patient empties the normally located bladder and then voids again after manual compression of the hernia ) . bh can be diagnosed by excretory urography , retrograde cystography , computed tomography ( ct ) , or sonography . , we report a case of inguinoscrotal herniation of the bladder in a 59-year - old man who was treated with laparoscopic intraperitoneal repair . a 59-year - old man presented with a 1-year history of right scrotal swelling and irritative lower urinary tract symptoms ( luts ) . , a 6-cm , nontender , reducible inguinal mass was noted that extended into the right scrotum ( fig . the findings of a scrotal ultrasound examination were consistent with a right inguinal anechoic lesion extending into the right hemiscrotum ( fig . a ct scan revealed that the right side of the bladder wall had herniated through the right inguinal canal ( fig . retrograde cystography showed massive herniation of the right side of the bladder , both anteriorly and inferiorly ( fig . 2c ) . to repair the hernia by laparoscopic surgery an 11 mm trocar , which was used as the camera port , was placed in the subumbilicus and in the right / left lower abdominal quadrant at the level of the midclavicle line . a herniated bladder with part of the peritoneum in the right internal inguinal canal was found ( fig . the herniated bladder and the right inguinal canal area were dissected from the peritoneum , and the herniated bladder was repositioned . the 2 cm right internal canal opening was closed by suturing with 4 - 0 vicryl ( fig . the proximal margin of the herniated bladder portion , which was repositioned , was resected ( fig . 3d ) , and we established a right ureterovesicular opening to the bladder by stretching the tissue . the defective portion of the bladder was closed in two layers by using 3 - 0 and 2 - 0 vicryl . no saline leaked from the sutured portion of the bladder when the bladder was filled with saline through a foley catheter . the estimated blood loss was about 100 ml . the postoperative times to initiate ambulation and diet were 0.8 and 1 day , respectively . seven days after the surgery , follow - up cystography showed a mild irregular contour on the repaired portion of the bladder ( fig . the patient 's bladder capacity was approximately 450 ml . the postoperative period was uneventful , the patient 's symptoms disappeared , the patient 's luts improved , and his ipss was 10 . approximately 1% to 3% of all inguinal hernias involve the bladder , with a higher incidence ( 10% ) in patients aged more than 50 years who have a large bladder . approximately 70% of bhs occur in an inguinal location , most often in men and on the right side . in some cases , the bladder can herniate into the obturator , suprapubic , ischiorectal , or abdominal walls or into other pelvic or abdominal openings . bhs are classified into three main types depending on the relationship between the herniated bladder and the peritoneum . the second most common type is the intraperitoneal type , in which the herniated portion of the bladder is completely surrounded by the peritoneal lining . the extraperitoneal type of bh occurs when the bladder herniates without any relationship with the peritoneum . many factors contribute to the development of a bh , including the presence of a urinary outlet obstruction causing chronic bladder distention , loss of bladder tone with weakness of the supporting structures , pericystitis and perivesical bladder fat protrusion , and obesity . involvement of the bladder in inguinal hernias is often not recognized before surgery to repair the hernia . less than 7% of bhs are diagnosed preoperatively ; approximately 16% of bhs are diagnosed postoperatively owing to complications , and the remainder are diagnosed perioperatively . these risks include hematuria , sepsis , urinary leakage , and fistula formation . other complications of bhs include strangulation , infarction , and perforation . squamous cell carcinoma , transitional cell carcinoma , and caculi have been reported to occur within a herniated bladder [ 4 - 6 ] . therefore , accurate diagnosis and treatment of a bh are important to avoid these potential complications . bhs can be distinguished from a bladder diverticulum on pathological findings but not on gross findings . currently , bladder resection is recommended for cases with bladder wall necrosis , a true herniated bladder diverticulum , a tight hernia neck , or a tumor in the herniated bladder . conservative therapy may occasionally be selected , which may include watchful waiting or intermittent urethral catheterization to reduce the size of the herniated bladder . several recent case reports have shown that repair of a bh by use of laparoscopic and robotic techniques is feasible . velasquez - lopez et al .   reported that they laparoscopically repaired a bh through the obturator foramen by placing a mesh plug . reported a case of a scrotal bh in a 68-year - old man who was diagnosed with prostate cancer ; those authors repaired the herniated portion of the bladder by using a robot after successfully performing a robotic prostatectomy . in our patient , we chose to repair the hernia laparoscopically without the use of mesh , and we found that this technique was safe and effective . patients with bhs who are aged 50 years and older are often diagnosed with an enlarged prostate . whether the luts are caused by the herniated bladder , the prostate enlargement , or both must be carefully determined . although our patient was 59 years old , he did not have an enlarged prostate , and his luts disappeared after repair of the bh . herniation of the bladder is not rare ( incidence , 1% to 3% ) , but it may be confused with other types of inguinal hernia . therefore , thus far , surgical repair has been the treatment of choice , and laparoscopic or robotic - assisted surgical techniques are now highly feasible .
the bladder is involved in 1% to 3% of all hernia cases . 
 we report a case of a large paraperitoneal bladder hernia ( bh ) in a 59-year - old man who had a palpable scrotal mass . 
 several techniques and approaches have been described for managing bhs . 
 we performed a laparoscopic partial cystectomy and herniorrhaphy . 
 this is the first case report on the repair of a large bh by use of a laparoscopic technique in korea .