V2-12: A Novel Technique for the Removal of Transobturator Mid-Urethral Sling Excision
With the development and dissemination of synthetic mid-urethral slings, management of subsequent complications has become a prominent focus. Complications can occur over 10 years following surgery. Up to 30% of patients have been reported to experience persistent pain, while 0-40% percent experience retention or urinary erosion in the literature. For patients who fail conservative management, mesh excision has a high rate of success. _x000D_ _x000D_ Transobturator slings pose a unique challenge given the complex and often unfamiliar anatomy of the obturator canal. We demonstrate a novel technique for transobturator synthetic mesh removal which optimizes removal of foreign material while minimizing risk of infection and damage to surrounding structures._x000D_
The patient was placed in high lithotomy and the obturator foramen was marked. After the initial dissection, the sling was identified lateral to the urethra and incised after clamps were placed at both ends of the sling. After both arms were mobilized laterally to the level of the obturator foramen, a longitudinal incision was made over the medial border of the obturator foramen. The incision was carried down to the level of the adductus muscle and an elastic body wall retractor was secured. A Satinsky clamp was attached to a silk stay suture placed through the medial end of the sling. The clamp was brought from inside to out along the medial border of the obturator foramen and the suture was pulled through the thigh incision. This allowed for dissection of the remainder of the attachments in a lateral to medial fashion.
At 1 month post-surgery, the patient reported resolution of suprapubic pain and significant improvement in the vaginal and pelvic pain for which she underwent the surgery. She reported onset of mild stress urinary incontinence with activity. She experienced no complications from the surgery.
Mesh excision is an increasingly important component in the urologist’s armamentarium. Transobturator mesh excision involves navigation of the complex anatomy of the obturator foramen, with potentially severe complications if poor technique is used. The described technique is a safe and reproducible method for the excision of transobturator mesh in patients with pelvic pain and can be modified further for use in the setting of mesh erosion or exposure.