V2-03: Removal of obstructing synthetic sling from urethra

V2-03: Removal of obstructing synthetic sling from urethra



Urethral complications due to synthetic midurethral sling are uncommon_x000D_ Possible causes of urethral complications after sling placement may include unrecognized intra operative entry into the urethral lumen or Excessive tension placed on the sling. When excessive tension is not recognized and addressed, over time the mesh may erode into the urethra._x000D_ An individualized approach is used based on patient presentation and surgeon expertise._x000D_ In this video we will demonstrate removal of an obstructing synthetic midurethral sling that has perforated the urethra and the concomitant urethral reconstruction_x000D_


A 66-year-old woman was referred with a history of anterior and posterior colporrhaphy and a retropubic synthetic midurethral sling 12 years prior. _x000D_ The patient reports difficulty voiding since the time of surgery – She has to stand and bend over to urinate. During the last year she had had recurrent UTIs. _x000D_ She also complains of mild stress incontinence but no urgency or urgency incontinence_x000D_ Physical exam revealed tenderness to palpation of the anterior vaginal wall and no mesh extrusion. _x000D_ During an outpatient cystourethroscopy the bladder was normal but there was a urethral perforation at 7 o’ clock, just distal to the bladder neck. _x000D_ Urodynamics were consistent with obstruction._x000D_ The patient was apprised of treatment options and wished to undergo a transvaginal sling removal and urethral reconstruction._x000D_


We were able to remove the mesh that was very deep in the anterior vaginal wall perforating the urethra._x000D_ The video demonstrates several tips on how to find and remove this kind of mesh perforation and subsequent urethral reconstruction. _x000D_ 2 month post op there was no pain or bleeding, the force of stream was much improved, but she reports some urgency with moderate SUI. The anterior vaginal wall was healing well, without evidence of fistula. The PVR was zero_x000D_


A urethral perforation after sling placement should be suspected in patients with bladder outlet obstructive symptoms and/or recurrent UTIs_x000D_ Careful cystourethroscopy should be performed. Had the perforation in this case been missed it would have been very difficult to locate the sling at the time of surgery given its depth in the tissue. Furthermore, entry into the urethra would have been thought to be iatrogenic._x000D_ The transvaginal approach to removal of mesh within the urethra allows for complete removal of any mesh in proximity to the urethra and straightforward reconstruction with excellent results._x000D_

Funding: none