Excision of Vaginal Mesh Exposure in the Bladder, a Robotic Approach. A 77-year-old, para-zero, post-menopausal patient, status post-hysterectomy for endometriosis at age 37, and subsequent vaginal mesh for asystocele at age 68, presents with complaints of mesh exposure. She was initially presented to another physician with lower abdominal pain. A cystoscopy revealed a mesh exposure in the bladder. On exam, no vaginal mesh exposure was noted. Surgical planning was made for robotic removal of mesh with urology for bilateral urethral catheters. Interoperative cystoscopy revealed mesh inside the bladder with close proximity to the left urethral orifice. We began by identifying ureters bilaterally. A vaginal sizer is used to elevate the apex. The vesicle-vaginal peritoneum is identified and incised as illustrated here. Sharp dissection is used to develop the vesicle-vaginal space. The dissection is continued with a combination of sharp, blunt, and electrocorticoid dissection. The proximal aspect of the mesh is identified and the dissection is further continued. A cystotomy is made in the location of the mesh exposure in the bladder. The dissection is further continued and the bladder wall is carefully dissected off the mesh as shown here. Vaginal urethral catheters are identified. The dissection is continued laterally to where the arms of the mesh enter the obturator foramen. At this point, close proximity to the ureters were noted. The dissection is continued until the distal aspect of the mesh is identified. The mesh is completely mobilized using a combination of sharp and blunt dissection. The mesh is transected using electrocortiary. Special attention is paid to the location of the bladder as well as the ureters. Here, the lateral aspect of the mesh continues to be mobilized. Once the mesh is completely mobilized, the mesh is transected. The mesh is removed almost in its entirety except the distal aspect of the mesh where it enters the obturator foramen. The stotomy is identified and repaired in a running lock fashion in two layers. The bladder is filled and no defect is noted. Epiploica is used to augment the systotomy repair. The dissection is continued laterally to where the ureters enter the obturator foramen. At the conclusion of the case, bilateral uretal catheters were removed. Stotsky revealed no defect in the bladder and clear bilateral uretal efflux. The patient did well and was discharged home post-op day one with a Foley catheter. CT systogram on post-op day 13 was negative and no extravasation was noted. The patient was seen six weeks post-operatively doing well with no complaints of prolapse. Thank you very much for your time.

Robotic approach

Vaginal mesh exposure

Bladder

Surgical planning

Mesh removal