Intravesical mesh occurs with unrecognized perforation with passage of retroputic synthetic slings, inappropriate passage of arms of trocar-based mesh kits, and mesh placed in the wall of the bladder at the time of any prolapse repair. Proper training and experience is required to avoid these complications. While vaginal mesh erosion from vaginal placement of mesh for prolapse is 9 to 16 percent based on multiple studies, one should always be able to avoid placing mesh in the bladder, but the complication does infrequently occur. These cases can be extremely challenging due to extensive engross of native tissues into the permanent mesh. Biologic materials also cause significant scarring and present similar challenges for removal. This video will describe anatomy of the anterior vaginal wall and proper planes of dissection and present several difficult cases of surgical removal of foreign bodies from the bladder, including TBT mesh, prolift mesh kit, and biological graft. Surgical approaches and tips on successful removal of mesh will be covered. We will first illustrate the correct placement of retropubic sling trocars with a cystoscopic video clip. Note that with the gentle movement of the trocar, it can be seen to freely roll outside the bladder muscularis without tenting or dimpling of the tissues. Next, we have a subtle defect to notice on cystoscopy in which further bladder filling and movement of the trocar reveals a perforation on the left side. Similarly, on the right side, an even more subtle dimpling of the tissue is noted and also identified as a bladder perforation. If such a perforation is not diagnosed on cystoscopy, synthetic mesh material will be placed in the bladder. To avoid placement of vaginal mesh in the wall of the bladder, this illustrates the proper full thickness dissection of the vaginal muscularis off the underlying prevesical connective tissues. The plan of dissection is deep enough to protect against vaginal erosion as well as not increasing the risk of unrecognized bladder injury or placement of mesh in the bladder wall. We will next present three challenging cases in our surgical decision-making process. In general, mesh in the bladder neck and trigone can often be managed vaginally. Mesh erosion or placement at the dome is better managed abdominally in most cases. Liberal use of ureteral stents is recommended. Due to the extensive tissue ingrowth in these procedures, transvesical removal of mesh is rarely appropriate and will not remove all of the intravesical mesh. Often, a combined vaginal and abdominal approach will be required in order to remove all of the mesh. Our first patient presents with hematuria nearly five years following a retropubic midurethral sling. On office cystoscopy, a large bladder stone is noted on the left-hand side. Underneath the stone, TBT mesh can be visualized. The patient complained of severe vaginal pain at the anterior distal vaginal wall as well. Given the patient's symptoms, location and size of the defect, a combined vaginal sling lysis and abdominal procedure to completely remove the mesh was then planned. This cystoscopic clip demonstrates a large intravesical stone on the patient's left bladder wall. Upon careful examination, retropubic synthetic sling material can be visualized underneath the stone. Our procedure begins vaginally with lysis of the sling and partial excision of the sling from that approach. Next, via a fan and steel incision, the area in which the sling advances through the space of rhesus into the left bladder wall is identified and isolated. A cystotomy and partial cystectomy is required to entirely excise the sling from the bladder wall. Our next patient presents with voiding dysfunction, hematuria and pelvic pain after placement of total prolift. Cystoscopy reveals a large stone at the base of the bladder just medial to the right ureter and underlying mesh in the wall of the bladder. On vaginal exam, a palpable ridge of synthetic material is felt just above the bladder neck. Given the location of the defect, a vaginal approach after double J stent placement in the ureters is elected. This cystoscopic view after double J stent placement reveals a large stone just medial to the right ureteral orifice. Mesh fibers can be seen within the wall of the bladder. Our vaginal approach begins with an inverted U-shaped incision in the anterior vaginal wall followed by a wide dissection of the muscularis off the underlying prolift via sharp dissection to the level of the pubic rami. Extensive dissection allows for the bunch mesh to be removed to a very lateral point. The right-sided dissection is carried out and creation of a cystotomy is necessary to remove the portion of mesh seen cystoscopically within the bladder wall. Stents are used as guides to avoid ureteral injury in this dissection and partial resection of the trigone. Bladder mucosa is enclosed with 3-O chromic suture with care in this case to avoid full thickness stitches when possible so as not to distort the trigone. An imbricating layer is placed over this with 4-O Vicryl. Post repair, one can see the suture line in close proximity to the right ureter. Our final patient presents after anterior repair with pelvic call augmentation with new onset of constant urinary leakage. On exam and with cystoscopy she is confirmed to have a sizable vesicle vaginal fistula just above the bladder neck. Also noted is a significant amount of pelvic call underneath the vesicle mucosa. There is close proximity to the ureters especially on the left so plan for stent placement was in order. Vaginal approach repair with a possible need for graft augmentation was then pursued. The fistula is identified both vaginally at the mid-anterior wall and also cystoscopically. Previously placed double J stents are seen here as well as a large jagged ridge of biologic graft and scar tissue in the trigone. The adhered and mostly avascular pelvic call region is removed in several pieces from the periphery of the fistula and the tract is widened until good vascularity of the surrounding tissues is noted for an appropriate closure. The cystotomy is then closed as previously described. Cystoscopic view following repair shows minimal distortion of the trigone after excision of the pelvic call and stents remain in place following the surgery. Note the extensive amount of material removed. Mesh erosion in the bladder can be challenging to correct. Proper training in passage of trocars and correct dissection planes may avoid many of these issues. Careful examination with cystoscopy at the time of mesh placement may prevent some of these complications. Complete excision of mesh from the bladder is essential for a good repair. Wide margins of dissection are also needed to obtain well vascularized tension free closure. Avoiding full thickness stitches of the bladder mucosa may be necessary when in close proximity to the trigone. Stent placement can assist with landmark identification in situations of anatomic distortion.

mesh complications

retroputic synthetic slings

vaginal mesh erosion

surgical removal

bladder