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AUGS/IUGA Scientific Meeting 2019
Transurethral Excision with Holmium Laser for the ...
Transurethral Excision with Holmium Laser for the Management of Intravesical Mesh
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Video Transcription
The miturethral mesh sling is a widely used, minimally invasive treatment for stress urinary incontinence. Mesh related complications can occur following sling placement, but the rate of these complications is low. Furthermore, unrecognized bladder mesh perforation, erosion, and stone formation over the mesh are considered rare. Patients with mesh related complications typically present with nonspecific lower urinary tract symptoms. Initial evaluation should include a detailed history and physical in addition to urinalysis and culture. A cystoscopic evaluation is warranted in the setting of a previous incontinence procedure. Traditionally, surgical management of such complications has involved excision through a transvaginal and transabdominal approach. In this case, we will demonstrate a novel endoscopic approach using a homeom laser. Homeom laser can be delivered via a cystoscope and the energy directed precisely to the cycle quad. It is commonly used in neurologic procedures such as strictures, lithotripsy, and prostate resections. We will demonstrate a novel approach using homeom laser for the excision of intravesical mesh with adherent calculi following a mini sling procedure. A 65-year-old woman presented to our clinic with chronic lower urinary tract symptoms. She had a history of stress urinary incontinence, which had been previously treated with a mini sling six years prior. Her initial evaluation revealed a normal pelvic examination and urine evaluation was notable for pyuria and microscopic hematuria, with a culture that was negative for infection. Given her history of previous incontinence procedure and her clinical presentation, office cystoscopy was performed. The cystoscopic evaluation revealed a calcified sling pledget with mesh that was present at the right base of the bladder wall near the bladder bag. Her case was reviewed at our case conference with Female Pelvic Medicine and Reconstructive Surgery and Urology. The recommended approach for management of her bladder, mesh, and calculi was transurethral excision of the mesh pledget using a homeom laser with a combined transvaginal approach. The combined approach prevented a widening of the cystotomy due to the pledget area. The case was performed by a team that included FPMRS and urology. The case started with the transurethral portion. Cystoscopy was performed using a 23-french continuous flow cystoscope using sterile water. A 30-degree lens was utilized to hone on the area of interest. Using a homeom laser and 550-micron fiber, low-energy fragmentation was used to fragment the stone and excise the mesh flush with the bladder wall. The mesh was excised flush with the bladder wall. The calcified pledget and mesh were removed transurethrally without any complications. Stone fragments were washed out with irrigation, and the mesh entry point was later addressed with repair of the cystorophy from a transvaginal approach. The intravesical component was approximately 1.2 centimeters in length. Next, attention was turned towards the transvaginal portion of the procedure. An inverted U-incision was made after hydrodissection with 1% lidocaine with epinephrine. Careful sharp dissection was performed until the suburethral sling could be palpated. Traction sutures were placed in the mesh using 3-O vinyl. The sling was dissected free and divided in half with a scalpel. The right arm of the mesh sling was then sharply dissected free from the underlying periurethral tissue, from the right of the midline to the point of entry into the bladder neck. The right arm of the sling was completely isolated at the bladder neck. Anchoring sutures of the cystorophy were placed prior to the excision of the mesh. The mesh entry point into the bladder was identified to be approximately 5 millimeters. Cystorophy was performed in two layers with interrupted 3-O vinyl sutures in a tension-free manner. Intermittent bladder backfills with sterile water were performed to ensure a watertight, tension-free closure from the bladder defect. The vaginal epithelium was then closed with 2-O vicryl in an interrupted fashion. Once the vaginal incision was closed, cystoscopy was again performed, confirming no bladder or urethral injuries, no evidence of any residual mesh. The patient tolerated the procedure well. She was discharged home with a Foley catheter in place. On postoperative day 7, she underwent a voiding cystogram, which revealed no extravasation of contrast. The Foley was discontinued. The patient reported improvement in her symptoms and no acute complications. In conclusion, holmium laser is a feasible and minimally invasive technique for excision of intravesical mesh.
Video Summary
In this video, a new endoscopic approach using a holmium laser is demonstrated for the excision of intravesical mesh with adherent calculi following a mini sling procedure. The patient in the case study is a 65-year-old woman with a history of stress urinary incontinence. Office cystoscopy revealed a calcified sling pledget with mesh near the bladder base. The recommended approach involved transurethral excision of the mesh using a holmium laser and a combined transvaginal approach. The video shows the transurethral and transvaginal portions of the procedure, including fragmentation of the stone, excision of the mesh, and repair of the cystotomy. The patient had no complications and reported improvement in symptoms. Holmium laser is an effective and minimally invasive technique for mesh excision.
Asset Caption
Danny Mounir, MD
Keywords
endoscopic approach
holmium laser
intravesical mesh
calculi
mini sling procedure
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