V10-10: ROBOTIC PREVESICAL RETROPUBIC EXCISION OF PELVIC MESH
Minimally invasive surgery continues to gain enthusiasm in female pelvic medicine. Here we present our preliminary experience with robotic-assisted laparoscopic prevesical, retropubic excision of pelvic mesh for pelvic pain. We illustrate a robotic approach with enhanced exposure adequate for concomitant bladder reconstruction as indicated and for reliably complete mesh excision.
Retrospective review of females presenting after transvaginal tape for treatment of stress urinary incontinence complicated by mesh erosion or chronic pelvic pain managed robotically over the past year revealed seven patients who underwent robotic excision of proximal mesh arms with or without concurrent bladder reconstruction for mesh erosion or concurrent vaginal approach. The DaVinci robotic platform was used to access the space of Retsiuz. Instruments were limited to curved monopolar scissors, fenestrated bipolar forceps, and an assistant port. Mesh arms were located then dissected proximally through the rectus muscle to the subcutaneous tissues of abdominal wall and distally to the periurethral endopelvic space and removed intact.
Our patient was on average a 53-year-old female with history of mid-urethral sling. One-half underwent mesh excision for pelvic pain; the other one-half for mesh erosion, five for retropubic and two for transobturator slings. Two underwent retropubic robotic and transvaginal approaches for mesh excision concurrently. One maintained the vaginal portion of her mesh. Four underwent retropubic robotic excision of mesh arms alone as they had had prior vaginal mesh excision. Insufflation of the space of Retzius avoids transabdominal access. The mesh arms are clearly visualized and ultimately completely excised intact. Concurrent pathology including mesh erosion and bladder reconstruction can be addressed. Subjectively, patients have less perioperative discomfort. There were no complications. There was no worsening in pain. All have had at least some improvement in their symptoms with one-half having near resolution.
We present an illustrative index patient treated for pain despite transvaginal excision of mesh, however it is clear that the basic surgical approach is applicable across a variety of pathologies including complications of mesh erosion. In our series, we have had encouraging results. We demonstrate a minimally invasive option for excision of pelvic mesh. The main advantages being magnified optics and enhanced exposure for complete mesh visualization and excision.