This is a video of a robotic excision of a mid urethral sling erosion in the superior aspect of the urethra. Stress urinary incontinence is the involuntary leakage of urine on effort, straining, or coughing. Some potential causes are childbirth, older age, obesity, chronic bronchitis, and constipation. In 1996, Petros and Olmsten introduced the mid urethral sling TBT procedure. In 2001, DeLoem described the trans-operator TOT sling to reduce the risk of complications with blind passage in the retropubic space. In 2003, DeLaval introduced the TBTO inside-out procedure, which could potentially be technically more convenient. The third generation single incision slings were introduced in 2006, aimed at reducing complications and increased safety of the procedure. Perioptic bladder perforation is a common complication of retropubic slings. In a Swedish study, 700 patients had a TBT procedure, and the perforation rate was 1.7%. Urethral erosions are very rare, and the first case was reported in 2001. Our patient is a 68-year-old post-menopausal woman who underwent a mini arc sling for stressed urinary incontinence two years earlier. The procedure was performed without complications according to the operative report and the performing surgeon. She began having severe overactive bladder symptoms almost immediately after surgery and began having recurrent urinary tract infections one to two times per month. After two years, she decided to see a different physician, and cystoscopy showed a urethral erosion of mesh on the superior aspect of the urethra. The mini arc is placed through a mid-urethral incision approximately 1.5 to 2 cm from the urethra and passed through the obturator internus muscle as shown here in this animation. The mid-urethral sling is supposed to lay at the level of the mid-urethra suburethrally as shown here in this animation. This is a urethroscopic view of our patient. The urethral erosion is on the superior aspect of the urethra. This animation shows the appropriate placement of the mini arc sling underneath the urethra. The area of mesh erosion in our patient is shown here in orange. We began the surgery by identifying the pubic bone. The peritoneum is grasped and entered and extended laterally. The retropubic space is opened as if performing a paravaginal defect repair with care to cauterize the vasculature of the plexus of Santorini. This dissection is taken all the way down to the area of the mini arc insertion in the obturator internus muscle. The left side of the sling is identified and separated from the obturator internus muscle. The area of erosion into the urethra is again shown here in orange. This is again shown here with red arrows with the right side of the bladder removed in this animation. The mesh is then separated from surrounding tissue all the way into the area of erosion into the urethra on the left side. The mesh fibers can be clearly seen and identified here. The mesh is now excised. The left side of the mesh has now been completely removed. Attention is turned to the right side and once it is excised from the obturator internus muscle, the mesh is separated from surrounding tissue on the right all the way into the area of erosion into the urethra shown here with the red arrow in the animation. Since the sling was cut at the erosion site in the urethra on the left, one must make certain that the remainder of the sling is pulled out on the right. Here is the right side of the sling that was removed and the entire sling is seen in the photo on the right side of the screen in two pieces. Cystoscopy is then performed on the right side of the sling. The sling is seen in the photo on the right side of the screen in two pieces. Cystoscopy is then performed before closure to make certain that all of the sling was removed. The urethral defects are then closed with 4-O-Vicrol on both sides in interrupted fashion in two layers. A few pieces of gel foam are then placed in the space of retches for better hemostasis. The areas of closure of the urethra are shown here. Arista hemostatic agent is also used for better hemostasis. The peritoneum is then closed using O-monocle suture with laparotide device at each end. Cystoscopy is performed one last time to ensure that all of the mesh has been removed from the urethra and to ensure good closure of the erosion sites in the urethra. Post-operatively she had severe urinary leakage with coughing and sneezing and without sensory awareness. She also complained of severe overactive bladder symptoms. She refused to have another sling procedure performed. She received two bulking injections with Coaptide approximately one month apart and was taking an anticholinergic medication. She reports 80% improvement of her symptoms compared to the immediate post-operative period. She has not had any urinary tract infections for six months. I'd like to thank my collaborators on this video, Dr. Nestor Villarada and Diego Villarada. Thank you. For more information visit www.narang.com

robotic excision

mid-urethral sling erosion

stress urinary incontinence

surgical procedures

urethral defects