V1-07: Abdominovaginal technique for complete removal of transobturator slings
VideoIntroductions and Objectives
Transobturator vaginal mesh is commonly used for the treatment of female stress urinary incontinence. Complications of transobturator mesh may include hip, groin, or leg pain that can occasionally be debilitating. Total removal of mesh may resolve or improve pain symptoms but can be a challenging or daunting procedure.
In this movie we present complete obturator mesh removal in a 48 year old woman suffering from disabling pelvic pain, dyspareunia and groin pain. Through a transvaginal approach, bilateral oblique distal vaginal incisions are made and the vaginal epithelium is dissected away from the periurethral fascia. The mesh is isolated and anterior and posterior vaginal wall flaps are created. The mesh is transected in the midline and dissected free transvaginally. The obturator fascia is opened and the mesh dissected from the obturator internus muscle, obturator externus and obturator membrane. The cut end of the mesh is secured with a stay suture for later identification. Bilateral incisions are made over the obturator foramen 1 cm lateral to the descending rami of the pubic bone. After opening the adductor longus fascia, dissection is carried through the adductor longus and gracilis muscles. The mesh is carefully passed under finger control from the vagina to the labial incisions and dissected free from the adductor brevis muscle and obturator membrane using a coagulation knife. The mesh is freed from the periosteum of the pubic bone and removed entirely. The urethra is reconstructed by advancing the periurethral fascia with interrupted sutures and a flap of vaginal wall is advance to cover the area of the mesh removal. An indwelling catheter is left in place postoperatively for 5 days.
From June 2009 to August 2013 we have performed 217 surgeries for the removal of vaginal suburethral slings. Of these, 92 have included the removal of transobturator mesh. 16 patients had more than one mesh removed at the time of surgery. Average surgery time for removal of one transobturator sling was 84 minutes. Complete removal of transobturator mesh may improve or completely resolve symptoms of pain. Dissection of the mesh in the inferior and medial portion of the obturator foramen on the inferior pubic ramus is key to avoid injury to the obturator nerve and artery. None of our patients complained of obturator nerve injury postoperatively.
Complete transobturator mesh sling removal is feasible using an abdominovaginal approach. There is minimal perioperative associated morbidity associated. Long term outcome data is still forthcoming.