V265: Abdominovaginal Technique for Complete Removal of Retropubic Mesh Slings

Video

Introduction and Objectives
We have encounterd a growing number patients presenting with suprapubic, pelvic and vaginal pain due to mesh slings. When conservative measures fail, patients may undergo partial or total removal of their sling mesh. Total removal of retropubic mesh is a challenging procedure. The objective of this video is to present an abdominovaginal approach for complete removal of a retropubic mesh sling.

Methods
A retrospective study was performed to identify patients with complications from sling procedures. Patients who underwent removal of retropubic mesh were identified. Data was obtained including symptoms, operative time, length of hospital stay, blood loss, and complications.



Technique of retropubic mesh sling removal:



1) Bilateral oblique distal vaginal incisions are made

2) Vaginal epithelium is dissected away from the periurethral fascia

3) Mesh is isolated and the retropubic space is entered

4) Anterior vaginal wall flap is created

5) The mesh is transected in midline and dissected free transvaginally

6) Suprapubic incision made and mesh identified

7) Retropubic space is entered superiorly freeing the mesh from the pubic bone.

8) Mesh is carefully passed under finger control from the suprapubic region to the vaginal incision and mesh is dissected free

Results
Between 2001 and 2012, 117 patients underwent removal of a suburethral mesh sling alone. Patients with mesh placed for prolapse were excluded. Sixty-eight of these patients had retropubic slings removed. Sixteen of these patients had complete mesh removal with the novel abdominovaginal approach (mean age 52, range 30-65 years). Pre-operative symptoms included pain in 88%, recurrent urinary tract infections in 25%, urinary incontinence in 69%, and mesh exposure in 25%. Average operative time was 124 minutes (57-195 minutes). Average length of hospital stay was 2 days (1-7 days). Average estimated blood loss was 266mL (100-850mL). Only 1 patient had perioperative complications requiring a blood transfusion. Follow up data is available for 10 patients (mean 10.6 months). Four patients underwent additional autologous rectus fascial slings for incontinence. One patient had persistent pain postoperatively.

Conclusions
Complete retropubic mesh sling removal is feasible using this abdominovaginal approach. There is minimal perioperative associated morbidity associated. There is a 25% risk of needing a second procedure for incontinence however almost all patients had improvement in their pain. Long term outcome date is still forthcoming with approach.

Funding: None