In this video, we will present two cases demonstrating a minimally invasive approach to the removal of intravesical mesh. With the widespread use of polypropylene mesh in the treatment of stress urinary incontinence, erosion into nearby organs, including the bladder, is a known complication. Although such erosion is rare, it can cause patient discomfort, as well as become a nidus for infection and bladder calculi. The objective of this video is to demonstrate the use of instrumentation that allows for a safe, minimally invasive approach to intravesical mesh removal. A variety of surgical approaches have been described and include laparotomy and laparoscopy with or without robotic assistance. These techniques utilize an intentional systotomy for visualization. Other techniques avoid the need for a large systotomy by operating cystoscopically or by operating intravesically with laparoscopic instruments placed directly into the bladder. In the first case, we will show the use of traditional laparoscopic instruments placed directly into the bladder, a Maryland fenestrated grasper and an endoscopic scissors. We used pediatric instruments operating through two 3mm ports, each of which is smaller than a 12 French superpubic catheter. In the second case, the use of a cystoscopic scissors with the assistance of a fascial closure device, the endoclose, is demonstrated. The retractable hook at the end of this device makes it well suited for grasping suture and placing it on tension. The first case is a 52-year-old patient who presented with recurrent urinary tract infections. Her surgical history was significant for pelvic reconstruction, including a retropubic mid-urethral sling performed seven years prior. Cystoscopy in the office revealed a through-and-through placement of a sling arm on the right. Shown here, the eroded mesh is identified near the dome of the bladder, far from the trigone. Traveculation is accomplished with sterile water as a non-conductive medium. Once trabeculations are noted indicating distinction near capacity, a 3mm pediatric trocar is placed near the dome of the bladder using a various versus step needle as a guide. A second port is then placed in a similar fashion to allow for two working instruments. Placing the mesh on tension, the distal portion of the arm is excised with close proximity to the bladder mucosa. Freeing this end allows for improved manipulation and traction, facilitating excision of the second attachment. In total, approximately 2.5 cm of the sling arm was removed. The small diameter of the instruments and the approach through the dome of the bladder allowed for same-day discharge without a Foley catheter. After five months of follow-up, the patient is doing well, with no further UTIs and no recurrence of her stress leakage. The second patient was a 70-year-old with bladder calculus and recurrent urinary tract infections. Her surgical history was significant for a retropubic midurethral sling placed in 2007, followed by an attempted mesh removal three years later for similar symptoms. Office cystoscopy revealed a 1 cm bladder calculus adherent to the left wall in close proximity to the left ureteral orifice. This was suspected to be secondary to an eroded foreign material. After litholipaxy was performed by the urology team, the area was examined and a remnant of foreign body remained. An endoclosed fascial closure device was introduced at the dome of the bladder and used to grasp the looped end of the eroded foreign body. After more careful inspection, this appeared to be a remnant of permanent suture. Cystoscopic scissors were then used to transect the suture remnant. This was then removed with the cystoscopic graspers. Inspection of the operative site reveals no additional foreign material, and the procedure did not encroach upon the previously stented ureters. After three months of follow-up, this patient also reported complete resolution of her symptoms. In conclusion, bladder mesh erosion is a known complication of the midurethral sling procedure. Common presentations include recurrent urinary tract infections and bladder calculi. Control of intravesical mesh can be accomplished easily through the use of pediatric and traditional laparoscopic instruments placed directly into the bladder.

minimally invasive approach

intravesical mesh removal

polypropylene mesh

laparoscopy

symptom resolution