This video describes the use of robotic-assisted laparoscopic technique in the excision of intravesical and retropubic mesh. The patient is a 40-year-old female, status post-TBT sling 8 years ago, who presents with pelvic pain, recurrent UTI, dyspareunia, dysuria, and incontinence. Her medical history is significant for two vaginal deliveries, including one forcep delivery. Her physical examination did not show any evidence of vaginal mesh extrusion. Her laboratory values are significant for trace blood and nitrite-positive urine. Given the patient's symptoms and surgical history, a pelvic MRI was obtained to evaluate for urethral diverticulum and other pelvic pathology. T2-weighted MRI revealed space-filling defects along the bladder wall. Office cystoscopy confirmed MRI findings revealing large bladder stones with exposed intravesical mesh bilaterally at the bladder dome. The patient was taken to the operating room where she underwent systolevalopaxie and transurethral removal of intravesical mesh. However, the patient's symptoms recurred, and follow-up cystoscopies revealed recurrence of intravesical mesh exposure and bladder stones. Patient options were discussed, and the patient opted for minimally invasive robotic surgery. Quartz were placed in the standard W configuration. Cystoscopic evaluation revealed exposed mesh bilaterally. Given the significant distance of the exposed mesh from the ureteral orifice, ureteral catheters were not placed. After the ureters were identified, the peritoneum was incised, and the bladder was taken down in standard fashion. The space of the reticulum was entered, and the right arm of the retropubic sling was first identified. The sling arm was transected from its insertion into the abdominal wall, and the segment was then carefully dissected free from the bladder. There was no evidence of residual mesh. Similarly, the left side was dissected free, using a combination of blunt and sharp dissection. The left side was dissected free, using a combination of blunt and sharp dissection. And finally, the cystotomies were carefully inspected for residual mesh, and repaired in two layers, using a 2-0 V-lock suture. Prior to undocking the robot, cystoscopy was performed to evaluate for residual intravesical mesh, efflux from bilateral ureteral orifices, and to confirm our water-tight bladder repair. Interoperative blood loss was 50 cc. There were no complications. The patient was discharged to home on post-operative day 1 with an 18-fringe Foley catheter. The catheter was removed on post-operative day 3. The patient was noted to have complete resolution of her pelvic pain and dysuria at her one month follow-up visit. She denied urgency or frequency. In summary, robotic excision is safe and effective, and offers superior visualization and manual dexterity when compared to open and laparoscopic technique. However, cost and access can be prohibitive. Few case reports exist, and to our knowledge, there are no long-term studies. Finally, good, sound surgical principles should always be employed, including complete resection of mesh, water-tight closure, and adequate post-operative drainage. Always maintain a high index of suspicion, especially in patients with a history of anti-incontinence or pelvic organ prolapse surgery. In conclusion, robotic-assisted laparoscopic excision of mid-ureteral mesh is a safe and effective, minimally invasive treatment option for the carefully selected patient.

female patient

TBT sling procedure

pelvic pain

bladder stones

intravesical mesh