A case series of a novel laparoscopic technique for total removal of mid urethral polypropylene slings causing urethral erosion. In this case series of 6 women, all of them had urethral mesh erosion, in this case in the posterior urethral wall. In this video we demonstrate laparoscopic urethroplasty, an approach for complete laparoscopic excision of mid urethral sling for urethral erosion. Under careful preoperative counselling and placement of bilateral ureteric stents, the bladder was instilled with 300ml of normal saline with methylene blue to help delineate the dome. In Trendelenburg, the retropubic space was opened using a monopolar hook at 2cm above the bladder reflection. The space of rectus was developed and under traction the bladder and urethra were separated from the pubic symphysis. This exposes the urethra and the sphincter complex in the midline anteriorly. The relationship of the mesh to the important structures in the retropubic space can be assessed including the obturator vessels and nerves bilaterally. Here the mesh is excised from the rectus sheath, the free edge is grasped with a toothed grasper and under traction it is sharply dissected using diathermy scissors and a monopolar hook, taking care to avoid trauma to surrounding tissues. The sling arm removal is continued carefully to the level of the urethra. The mesh is removed from the urethral wall entirety in one piece. The eroded urethral mesh appeared unintegrated into the urethral wall due to surrounding inflammation and it came away with minimal blunt dissection. Here a monopolar hook is used. It provides traction and counter traction. The tissue is carefully excised using scissors. Bipolar electrocautery is used to dissect the left side of the mesh. Demonstrated here is the complete removal of the TVT mesh in one piece. The mesh is removed through the right lateral port. The tissues are palpated vaginally to assess the extent of damage and where to best place sutures. The urethra is repaired bilaterally with four interrupted sutures with 3-O monocryl. Two sutures are placed bilaterally. As the tissue is so thin here, the vagina can be palpated simultaneously to assess placement of sutures. Polypropylene mid urethral sling insertion for the management of stress urinary incontinence has serious complications including urethral erosion occurring in less than 1% of cases. Which requires either partial or complete removal of the sling. Cystoscopic and vaginal approaches allow partial removal of the portion of the sling eroding into the urethra. However, with a vaginal incision there is a risk of urethrovaginal fistula formation and both techniques have a risk of recurrent erosion. For patients with associated pain, some evidence suggests that complete excision is preferable. With increasing controversy surrounding mesh complications, more patients are now requesting complete excision. The retzia space is closed with one continuous 2-O monocryl suture. In this video we have demonstrated a laparoscopic technique for complete excision of a mid urethral polypropylene sling which has extended into the urethra. This video outlines a technique which we have performed on 6 patients in our centre with a mean age of 57 years, a mean duration of stay less than 2 days and a mean blood loss of less than 50 ml. In this case series we have had no mesh related complications, no recurrence of erosion or fistula formation and at follow up cystourethroscopy there have been no urethral stricture formations. We therefore conclude that this technique is feasible with no adverse outcome to date however we appreciate that more safety data is required. We would recommend this technique for women who have a urethral erosion and symptoms of bladder pain. The strengths of our technique over others are a shorter duration of outpatient bladder catheterisation and the avoidance of the risk of urethrae vaginal fistula.

laparoscopic technique

mid-urethral polypropylene slings

urethral erosion

retropubic space

mesh removal