A novel approach to cystoscopic mesh excision presented by Drs. Linger, Yates, and Bolling from the University of Tennessee Medical Center. There are several options for removal of mesh eroding into the bladder. These include cystoscopic, vaginal, and open abdominal procedures. Available cystoscopic removal of exposed urethral mesh spares the patient a more invasive procedure with increased morbidity and mortality. Cystoscopic removal is limited by available traction on the mesh. In the following video, this is overcome by using two Carter-Thomason needles as laparoscopic instruments. As you will see, traction was created by placing suture through the exposed mesh using these needles. We present our experience of a 55-year-old referred for urinary retention and recurrent UTI following transvaginal mesh placement. Six weeks after the initial surgery, the patient was taken back to the operating room for a revision of the anterior graft and cystoscopy in an effort to loosen the most distal aspect of the prolapse attachment arms. No symptom change occurred after the revision. An in-office cystoscopy was performed showing a large obstructing calculus attached to exposed mesh. Therefore, the patient was scheduled for cystoscopic removal of the mesh and stone under general anesthesia. As you can see, the mesh is exposed and has an overlying 2-centimeter stone obstructing the urethra at the bladder neck. A Carter-Thomason needle loaded with 2-O-Micro-Suture was placed above the pubic symphysis puncturing through the abdominal wall into the bladder. A second Carter-Thomason needle was placed directly alongside the cystoscope, allowing the tip to be visualized at all times. The transurethral needle was then passed underneath the exposed mesh at the bladder neck. The abdominal needle passed the suture to the transurethral instrument. The 2-Micro-Suture was then pulled underneath the eroded mesh and taken over top of the stone. The suture was then handed back to the abdominal instrument, which was removed pulling the suture back through the abdominal wall. A hemostat was placed, giving us the ability to manipulate the mesh and stone within the bladder. Cystoscopic scissors were then used to excise the mesh. The traction provided by the Vicryl suture elevated the mesh, allowing the excision to occur below the mucosa, increasing the amount of mesh removed. After excision, the mesh was retracted to the bladder dome by the Vicryl suture. A grasper was then inserted, removing the mesh. A small fiber of residual mesh was obliterated with a bugby device while also ensuring hemostasis. No visible mesh remained at the completion of the procedure. The stone could not be removed intact from the urethra, therefore the stone was broken up and evacuated from the bladder without difficulty. Copious irrigation was then performed, ensuring no fragrance remained. The patient experienced minor postoperative pain from bladder spasms. A Foley catheter was retained until her two-week postoperative visit. At that time, she passed her voiding trial and the bladder spasms had resolved. The procedure resulted in significant improvement in the patient's symptoms and quality of life. By using this novel approach with Carter-Thomason needles as laparoscopic instruments, we prevented a more invasive surgery in a diabetic patient who underwent surgical menopause 20 years prior. Additional traction was instrumental in our ability to achieve mesh excision cystoscopically and decrease patient morbidity. We hope this video has provided you with an alternative approach to achieve cystoscopic mesh excision. We thank you for your time and hope you will consider this method in the future.

cystoscopic mesh excision

University of Tennessee Medical Center

mesh eroding into the bladder

Carter-Thomason needles

laparoscopic instruments