In this video, we will discuss a novel minimally invasive trans-urethral approach to treat mesh extrusion in the bladder. Mid-urethral slings have become one of the most common surgical procedures to correct the stretch urinary incontinence in women. Common complications from this procedure include transient urinary retention, the novel urinary urgency, and mesh extrusion. The presence of mesh in the bladder or urethra following a mid-urethral sling placement has been reported to occur somewhere between 0.7 and 6% of the time. This can result from intraoperative needle perforation or mesh extrusion. Our patient is a 64-year-old baratree who presented with a sudden onset of microscopic hematuria after starting warfarin anticoagulation. She also reported urinary urgency and frequency since the time of her sling placement four years prior. Her medical history includes two myocardial infarctions treated with stent placement, atrial fibrillation, hypertension, and dyslipidemia. Her prior surgeries include cardiac catheterization and retropubic mid-urethral sling in 2010. Operative reports from our sling procedure show no bladder perforations, ideal placement of the sling, and a normal cystoscopy post-operatively. As part of the workup of hematuria, the patient underwent a CT urogram. You can see here that the CT scan shows a right-sided intravesical calcification. It's approximately 2 cm in size in the right lateral wall at 9 o'clock position. Due to the radiologic characteristics of the polypropylene mesh, the sling was not visible on the CT scan. An in-office cystoscopy confirmed the right-sided intravesical calcification. In the office, grasping forceps were used to remove the calcification to reveal the underlying mesh. Different approaches were discussed, including vaginal, abdominal, or cystoscopic. Given the patient's multiple comorbidities and need for anticoagulation, a cystoscopic approach was chosen. After general anesthesia, cystoscopy was performed. Grasping forceps were used to grab the mesh to pull and expose the protruding mesh from the bladder wall. Due to the characteristics of the jaws of the forceps, they provided a mixed effect of cutting and traction. Decision was made to use a laser holmium to debilitate the mesh due to inability to introduce more than one instrument and provide adequate traction with the traction during the mechanical resection of the mesh. The holmium laser at 2 joules and 5 hertz was then used to debilitate the mesh so the cystoscopic forceps could break through the mesh. The laser was adjusted to 1.8 joules and 25 hertz in order to minimize the damage to surrounding tissue and minimize the dermal spread. After the mesh was debilitated by the laser, it was easily removed with the cystoscopic grasper. The final specimen showed a 1.8 by 0.3 centimeters piece of mesh. The Foley catheter was left in place for 7 days. The patient returned for a 3 month follow-up visit. She did not have any further evidence of hematuria and her urgency and frequency dramatically improved. An office cystoscopy at the time showed no evidence of mesh in the bladder. Most cases of mesh in the bladder or urethra are related to mesh extrusion. The most common clinical symptoms are dysuria, recurrent urinary tract infections, urethra dip or obstruction avoiding dysfunction symptoms and hematuria. There are many case series in the literature describing different methods to remove intravesical mesh. This includes transvesical either through abdominal or vaginal approach and transurethral. The minimally invasive endoscopic removal of mesh can be done via various methods either mechanical, laser, electrosurgical or combination. In conclusion, removal of extruded mesh in the bladder can be challenging. Homeolaser can safely be used to excise the mesh from surrounding tissue. Human management of mesh extrusion appears to be a feasible and less morbid procedure than transvesical procedures via abdominal or vaginal approach.

minimally invasive trans-urethral approach

mesh extrusion

mid-urethral sling procedures

bladder complications

endoscopic removal