This video presents a case using a combined vaginal and robotic technique for complete removal of a retropubic sling. The authors have no conflicts of interest to disclose. A 45-year-old female who was post-op day 23 from an anterior repair and retropubic midurethral sling presented with a complaint of a periodic rash underneath both arms. She suspected the rash is an allergic reaction to her synthetic mesh. Her past medical and surgical history was significant for a closure of a patent foramina ovale and a hysterectomy. Her allergies included aluminum and penicillin. On physical exam, a rash was observed underneath both arms with no signs of infection. Vaginal examination noted a well-healed vaginal incision without evidence of a mesh exposure. She was evaluated by her dermatologist and hematologist who did not identify a source of an allergic reaction or pathology. Her symptoms did not improve with the use of antihistamines and steroids and she desired complete removal of her sling mesh. She underwent vaginal assisted robotic laparoscopic removal of a sling on post-op day 64. As part of the normal foreign body reaction, type 1 macroporous polypropylene mesh elicits a short acute inflammatory reaction followed by a mild chronic inflammatory phase. However, hypersensitivity to the synthetic material is very rare at approximately 1%. Indications for mesh revision or removal include urinary retention, voiding dysfunction, reoccurring urinary tract infections, mesh erosion, and vaginal pain or dyspareunia. Several studies have demonstrated sling removal rates between 1.4 to 3.7% with the risk of removal increasing over time. The surgery began with a vaginal approach. A vertical incision was made between two alice clamps located at the mid urethral portion of the vaginal mucosa. Sharp dissection was performed on either side of the urethra. The sling was identified and a kelly clamp was inserted behind the sling. Using a combination of sharp and blunt dissection, the sling was further mobilized vaginally from the urethra. You Once urethralysis was complete, kelly clamps were applied to either side of the sling and the vagina copiously irrigated. The surgery was then continued robotically. The bladder was retrograde filled with saline to aid in visualization of the bladder. An incision was made in the peritoneum. The bladder was mobilized off the pubic symphysis in the retropubic space. The dissection was carried down to the urethral fascia. You The arms of the sling mesh were tugged vaginally to assist in locating the mesh abdominally. Dissection was performed to free the mesh from its attachments from the abdominal fascia to the urethra. You The dissection was carried out with a combination of blunt, sharp, and electrocautery techniques as seen here. Once mobilized completely to the urethra, the same dissection was carried out on the contralateral side. Once both arms of the mesh were completely freed from the abdominal fascia to the urethra, the bedside surgeon pulled the mesh through the vaginal incision to completely remove it with very little resistance encountered at that time. The peritoneum was closed and the vaginal epithelium was re-approximated in standard fashion. The mesh measured approximately eight centimeters upon removal. The patient tolerated the procedure well without further complications post-operatively. Additionally, her puritic rash resolved without further intervention. This video demonstrates the feasibility of completely removing a retropubic mid-urethral sling using minimally invasive methods through the use of vaginal and robotic techniques.

retropubic sling removal

vaginal and robotic technique

synthetic mesh allergy

vaginal assisted robotic laparoscopic sling removal

minimally invasive mesh removal