V264: Transvaginal Removal of Intraurethral Mesh
VideoIntroduction and Objectives
Transvaginal mesh has been used in the management of a multitude of female urologic conditions, most commonly vaginal prolapse and stress urinary incontinence. However, in the event of a complication related to the use of such mesh, there is scant literature on its safe and efficacious removal. We present a technique for transvaginal removal of an intraurethral mesh erosion.
Via a midline transvaginal approach, with dissection over the periurethral fascia, the sling is identified laterally and transected. With traction on the edge of the transected sling, a combination of sharp and blunt dissection is used to free the sling from lateral to medial. The soft tissue is released and a stay suture is used to secure the cut end of the sling prior to entry into the urethral lumen. The contralateral transected end of the sling is likewise dissected lateral to the urethra up to the limit of the urethral lumen. Once freed of all attachments, the sling can safely be pulled through the urethra without further urethrotomy or transection of the urethra, leaving the stay suture traversing the urethral defects on either side. The stay suture allows easy identification of the urethral defect created by the eroded sling, to facilitate obtaining a watertight closure. The urethra is then closed in multiple layers and the stay suture is removed. A urethral catheter is left indwelling postoperatively.
The patient is discharged when ambulatory and tolerating a regular diet. A voiding cystourethrogram (VCUG) is obtained in 1-2 weeks and if urinary extravasation is not seen, the urethral catheter is removed.
Despite the common use of midurethral mesh slings for stress urinary incontinence, literature describing operative techniques to remove slings in the setting of urinary tract erosion is lacking. The described technique avoids significant manipulation of the urethra and further disruption of the periurethral fascia while ensuring a watertight closure.