Transvaginal Approach to Urethral Reconstruction After Mid-Urethral Sling Complication, presented by the University of Illinois Department of Urology. A 45-year-old female with a history of three vaginal deliveries presented with three years of persistent urethral pain following transopterator tape placement for severe stress incontinence. Her symptoms included persistent pain following the procedure, voiding dysfunction, and severe stress incontinence. She was previously managed with pregabalin for neuropathic pain secondary to chronic lower urinary tract pelvic syndrome. Physical examination revealed a grade 1 cystocele, a grade 2 to 3 urethrocele, grade 1 uterine prolapse, positive stress test, a mild urethrolectropion, and severe pain induced with urethral palpation. Preoperative imaging included a cystogram that was unremarkable. A transvaginal ultrasound showed stones and mesh at the level of the urethra. Cystoscopy revealed an intraurethral mesh with stones at the distal urethra. This finding was missed on previous cystoscopies. A weighted speculum was placed in the vagina, and the labia majora were retracted laterally with stay sutures. The urethra was catheterized with a 16 French Foley catheter. An inverted U incision was made horizontally in the anterior vaginal wall. Sharp dissection was carried out to mobilize the urethra proximally from the anterior vaginal wall. Care was taken to avoid entering the urethral wall. A Scott retractor was placed and the posterior urethral wall was exposed by retracting the anterior and posterior incision edges. The lateral wall of the urethra was dissected sharply on each side. A right angle clamp was then used to further mobilize the urethra. Irrigation and dissection continued with a finger placed in the vagina to ensure preservation of the urethral vaginal wall. The mesh entering the urethra was identified and clamped on both lateral sides. The urethral wall overlying the mesh was incised vertically, exposing the mesh inside the urethra. 3-0 Vicryl stay sutures were placed on either side and the intraurethral mesh was clearly visualized. Stones and calcifications were retrieved from the urethra. The mesh was clamped with an Alice clamp, freed from the urethra, and isolated over a right angle instrument. The lateral exit site of the mesh was identified on either side of the right outer urethral wall. The exiting mesh was clamped and the attachments sharply divided. The lateral exit site of the mesh was identified on either side of the right outer urethral wall. The exiting mesh was clamped and the attachments sharply divided. The mesh was then sharply dissected from adhesions. The mesh was pulled out of the right lateral urethral wall The mesh was pulled out of the right lateral urethral wall through the midline urethral incision. The mesh was also dissected on the left side as proximally as possible and then divided. The urethral was closed with a series of 5-0 vicral sutures. Urethral edges were trimmed further to optimize closure. The urethral wall redundancy and laxity were reduced and the urethra was closed. To prevent narrowing of the urethral lumen, a distal flap was used to complete the urethral closure. The previously exposed periurethral tissue was used to create two additional closure layers. Postoperatively, the Foley catheter was removed 10 days following the procedure. A cystogram confirmed there was no urine leak or urethrovaginal fistula. The patient's symptoms improved dramatically, with complete resolution of her periurethral pain and only mild residual incontinence. The patient's symptoms improved dramatically, with complete resolution of her periurethral pain and only mild residual incontinence. This concludes our presentation of a transvaginal approach to urethral reconstruction after midurethral sling complication.

urethral pain

stress incontinence

transvaginal approach

mesh complications

stones in urethra