This video will describe techniques to facilitate transvaginal removal of synthetic mesh from the urethra. Erosion of retropubic synthetic slings into the vagina occur in less than 1% of cases. Most cases of mesh erosion involving the urethra occur due to initial placement of the sling within the wall of the urethra. Ingrowth of native tissues into the permanent mesh usually precludes transurethral excision as an approach. In comparison to retropubic slings, transopterator slings and some single incision slings require a larger plane of dissection. Relative contraindications to synthetic material placement include urethral diverticulum, prior urethral fistula, prior radiation therapy, and prior erosion of other synthetic materials. This video will describe the anatomy of the anterior vaginal wall and the dissection of the distal anterior vaginal wall and urethra. We will also present several difficult cases on surgical removal of mesh within the urethra. We will discuss surgical pearls and tips on successful removal of mesh and also discuss biologic techniques for anti-incontinence measures when needed. In this cadaveric specimen, the anterior vaginal wall is dissected to the midurethra. Above the level of the bladder neck, the anterior vaginal wall becomes fused with the posterior urethra, as this is perineum. This creates a less obvious plane of dissection for midurethral sling placement. The remainder of the anterior vaginal wall from the proximal urethra to the bladder base possesses an easy-to-identify plane of a dissection under the vaginal muscularis that continues to the pubic rami laterally. Our first case is a patient who presented with severe recurrent stress urinary incontinence and urgency frequency after a TDT secure procedure. Office urethroscopy revealed a small piece of polypropylene mesh in the urethral lumen and at the level of the midurethra. Due to voiding symptoms and patient discomfort, complete surgical removal of the sling was felt to be appropriate. Additionally, a cadaveric fascist sling was planned as an anti-incontinence measure. The TDT secure sling is laced in the midline to allow for extensive dissection of the tissues laterally to the retropubic space. With Kelly clamps placed on each end of the mesh, dissection is carried back sharply to the level of the attachments of the sling within the obturator internus muscle bilaterally, completely excising the sling. Next, the urethrotomy is closed in several layers with 3-O chromic at the level of the mucosa and 4-O vicryl as an imbricating layer. Note the tissue appears to be healthy and well vascularized and for this reason it was not felt that a vascular pedicle was necessary. Following reconstruction, a cadaveric fascia sling was placed. Our next patient presents after a retropubic midurethral sling with complaints of urgency and frequency. On urinalysis, she had trace hematuria. Cystoscopy revealed sling placement proximally near the bladder neck with transection of the proximal urethra and a second area of mesh transection in the bladder from the right-sided trocar. The complex nature of this case required sling lysis via urethrotomy and excision of much of the posterior urethra followed by reconstruction of the urethra from a vaginal approach. This was followed by an open abdominal approach and cystotomy for full sling removal from the bladder. This urethroscopic view with a 0-degree scope reveals mesh from a midurethral sling within the urethra at 6 o'clock. Proximal erosion of the sling is just distal to the bladder neck. Additionally, on cystoscopy, a strut of mesh from the right trocar perforation of the bladder is noted. Removal of the sling from the urethra was accomplished with resection of most of the posterior wall of the urethra followed by mobilization of well-vascularized urethral and periurethral tissue for closure in multiple areas. Our last patient presents with severe recurrent stress incontinence after two previous synthetic midurethral slings. Incontinence is easily demonstrated on exam and the patient also complains of urgency symptoms. On initial cystoscopy and urethroscopy, no sling erosion was noted into either the urethra or bladder. The decision was made to perform a urethralysis of both slings and place a bladder neck rectus fascia sling for the recurrent incontinence. Anterior wall dissection is extended laterally to the pubic rami. The first sling is identified at the proximal urethral sling and the second sling is located at the proximal urethral sling. The first sling is identified at the proximal urethra and is noted to be laid loosely at the bladder neck. This sling is sharply dissected and laced in the midline. Alice clamps are placed on the sling for traction and wider excision. Next, attention is turned to the second sling, which is noted to be in a much deeper plane of dissection at the midurethra. As the dissection proceeds, it's clear that the sling lies within the wall of the urethra. Therefore, lysis and excision will require a urethrotomy. After removal of the sling, the urethrotomy is closed as previously described in multiple layers. A rectus fascia sling is then harvested and placed as an anti-inflammatory. The sling is placed in the urethral sling. A rectus fascia sling is then harvested and placed as an anti-incontinence measure. In closing, we feel that the majority of patients who present with mesh in the wall of the urethra or the lumen result from inappropriate initial placement of a sling. Few urethral mesh erosions occur with proper dissection and proper sling passage. Always confirm, following placement of a sling, that there is no mesh in the urethra on cystoscopy. When sling material is found in the urethra, dissecting out the sling will create an effective sling lysis. If a urethrotomy is necessary for removal of the mesh, wide planes of dissection with good vascular supply are required for a successful repair. Pedicles and flaps with good vascular supplies may be used to augment the repair if necessary.

transvaginal mesh removal

urethral mesh erosion

sling placement

surgical tips

anti-incontinence measures