In the current video, we describe to our knowledge the first video of a robotic, assisted laparoscopic sling revision and excision. A 50-year-old woman presented with persistent pelvic pain of two years' duration that started shortly after a midurethral synthetic sling placed at another center for stress urinary incontinence. The patient failed to respond to conservative measures and requested a complete sling excision. The patient was carefully counseled that removal did not guarantee cessation of pain, as it is usually multifocal and the incontinence may return. Due to a chronic pain presentation and the desire for complete excision of the graft, an intraperitoneal approach using a robotic-assisted laparoscopic approach was deemed amenable to accomplish both the agnostic and fine dissection of the retroperiotic space. At about 3 cm superior to the bladder reflection, beginning along the medial border of the right obliterated umbilical ligament, we started transperitoneal entry into the space of rhetzius with monopolar scissors. Identification of the loose areolar tissue at the point of the incision confirms a proper place and plane of dissection. After the rhetzius space is entered and the symphysis pubis is identified, we make sure that the bladder is properly draining to avoid injury during dissection. Separation of the loose areolar tissue and perivesical fat using a combination of sharp and blunt dissection is continued until the retroperiotic anatomy is clearly visualized. A large amount of scar tissue can be encountered and extreme care in the dissection is necessary. Notice how we almost transected this sling on the right side. Due to minimal tactile feedback during robotic surgery, it is important to use the visual feedback that develops over time with careful following of tissue planes, resistance of the robotic instruments, and spring back motion and with counter traction from the vaginal assistant to the already dissected vaginal sling. Identification of the sling mesh is most commonly made where it touches the pubic grami approximately 2-3 cm lateral to the midline on both sides as it's seen here. Once identified, the mesh can be grasped and excised from the anterior abdominal wall and then peeled free of the pubic grami periosteum. Here we see the Cooper sling image. When the retropubic space has been invaded with a previous procedure, especially with polypropylene mesh from the sling, a large amount of scar tissue can be encountered and extreme care in the dissection is necessary. Additionally, the surgeon should be aware of the location of vital structures at all times, like the obturator neurovascular bundle as injury to these vessels can be a life-threatening injury and can result in chronic pain and sensory or motor deficits to the inner thigh. Notice that all the instruments are kept in the midline and at view at all times, as well as avoiding hitting of the instruments that can result in sudden and forceful movements of the robotic arms, potentially resulting in injury to nearby organs and vessels. Also note that the assistant holding the suction almost always stays in the midline to avoid injury to the more lateral critical structures including the external iliac artery and vein. Robotic surgery allows for avoidance of retractors that otherwise be used for abdominal exposure that can potentiate these risks. The pneumoperitoneum and careful limited hydrodissection, along with lateral to medial mobilization of the bladder, superior optics and 3D vision, allow for superb visualization and exposure. Midurethral synthetic slings have grown in acceptance and recognition to gain a leading position in stress urinary incontinence surgery. Widespread use is resulting in increasing numbers of complications creating circumstances such as erosion or pain that warrant removal of the mesh either partially or totally from the pelvis. Laparoscopy has been shown to be a safe mode of access to the space of rectus, even with previous retroperiodic procedures and has the advantages of improved visualization with magnification of the operative field, decreased blood loss and a low rate of urinary tract injuries. Although quality of life significantly improves after both midurethral synthetic slings and laparoscopic burge and reoperations are uncommon, persistent vaginal pelvic pain can ensue including postoperative dyspironia that leads to a request for sling removal despite the patient being continent and otherwise satisfied. The single, properly designed study examined risk factors leading to sling revision only considered those performed due to voiding dysfunction and excluded other cases like erosion. The practitioner has to make a difficult decision of performing a complex invasive surgery based on case reports and scarce evidence. Robotic assisted laparoscopic surgeries have advantages in providing a three-dimensional visualization of the operative field, decreasing fatigue and tension tremor of the surgeon and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly and the bulkiness of the equipment. For more information on laparoscopic surgery, please visit www.apmt.us www.apmt.us www.apmt.us www.apmt.us Dissection is then continued along the sling arms toward the bladder and pubic cervical fascia. Extensive scaring is often encountered and the sling mesh needs to be cut out with the scar tissue and passed to the assistant as shown here. The remaining mesh below the urethra is completely removed by the assistant retrieving it with the hemostats that were marked earlier in the case from the suburethral portion of the case. Copious antibiotic irrigation is performed and the normal peritoneal gas pressure is lowered to identify any bleeders. A hemostatic agent or barrier is utilized preventively in this highly vascular space to minimize oozing and postoperative hematoma formation and also to minimize the use of electrocautery. While closing the peritoneum with absorbable interrupted sutures in figures of eight, we repeated cystic urethroscopy after administering IV indigal carmine to retroactively fill the bladder while still having a direct view of the retrobuic space that failed to reveal urinary tract injury.

robotic-assisted laparoscopic sling revision

excision procedure

pelvic pain

midurethral synthetic sling placement

stress urinary incontinence