false
Catalog
PFD Week 2017
Retropubic Robotic Excision of Mesh for the Treatm ...
Retropubic Robotic Excision of Mesh for the Treatment Of Midurethral Slings and Transvaginal Prolapse Mesh Erosion Into the Bladder.
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
This is a video of a retro-pubic robotic excision of mesh and bladder repair for the treatment of mid-urethral slings and transvaginal prolapse mesh erosion into the bladder. We have no relevant disclosures. Mesh kits that are used for treatment of stress urinary incontinence or pelvic organ prolapse are a well-known source of foreign body in the bladder. An advertent passage of the mesh through the bladder wall is usually recognized on interopter cystoscopy. Conversely, erosion of the mesh through the bladder wall may occur when it is placed on tension or too near the bladder. The incidence of mesh erosion, including exposure, extrusion, and perforation, initially described in the literature, varies widely from 0 to 33%. The reported rate of mesh erosion after surgery for female stress urinary incontinence is 0 to 7%. This is low in comparison with the 0 to 21% incidence reported in various randomized controlled trials and prospective studies published on pelvic organ prolapse surgeries by Vaginal Approach. Removal of mesh eroded into the bladder has traditionally been done using a surgical approach involving cystotomy, mesh removal under direct visualization, and reconstruction of the bladder wall. Transurethral removal represents a less invasive procedure but may leave residual mesh within the detrusor, thus causing irritative voiding symptoms up to the urinary tract infections and stone formation. Suprapubic assisted transurethral excision of vaginal mesh eroded into the bladder has also been described using a 26 French and plats sheath, which is placed suprapubically under endoscopic vision. A rigid neproscope with grasping forceps is used to pull the eroded mesh out of the bladder wall while excising it transurethrally with a resectoscope. Transurethral endoscopic excision using a holmium blazer has been used with some success in the past with success rates of 63%. The aim of our study is to evaluate the retropubic robotic assisted laparoscopic excision of mesh erosion into the bladder from tension-free vaginal tape procedures and vaginal mesh for treatment of pelvic organ prolapse. This is a retrospective review of five patients with mesh-related bladder complications after sling procedures and transvaginal bladder prolapse mesh procedures. The patients underwent the corrective procedures from 2013 to 2015 in a single urogynecology practice performed by a single surgeon. Patients with bladder erosion were managed by robotic assisted laparoscopic excision of the mesh from the retropubic space. Five cases of bladder erosion were diagnosed. The mean time interval between placement of the mesh and the diagnosis of erosion ranged from 6 months to 24 months. Two of the women had undergone a retropubic midurethral sling placement and one had a suprapubic midurethral sling placement and two had anterior vaginal mesh kit for anterior vaginal wall prolapse. Our first case is a 66-year-old postmenopausal woman who underwent an anterior elevate for an anterior and apical prolapse approximately 18 months earlier. The procedure was performed without any complications. She began having overactive bladder symptoms approximately three months after surgery and began having recurrent urinary tract infections approximately one a month around the same time. Her surgeon performed two transurethral endoscopic excisions using holmium lasers without any success. This is an animation video demonstrating the placement of an anterior elevate transvaginal mesh kit for the repair of a cysticeum. The distal arms of the mesh are passed through the obturator internus muscle at the level of the arcus tendineus fascia pelvis. The posterior self-fixating tips are tacked to the sacrospinous ligament and the ends are passed through the islets of the proximal ends of the mesh as shown here. The mesh is then adjusted. In this animation the areas of mesh erosion into the bladder are shown with blue circles. And the anterior elevate mesh is shown in light blue. Cystoscopic view of the areas of erosion into the bladder are shown here. A stent is placed before proceeding with the excision procedure for better identification of the ureter during surgery. The peritoneum on the pubic bone is grasped and entered sharply and a dissection in the retropubic space is performed and the bladder is completely mobilized. The mesh is identified and dissection is carefully performed to the distal area of the erosion shown with green circles on the right side of the screen. This is from the left sided distal arm of the mesh as it is inserted into the obturator internus muscle. Once the mesh is removed the area of cystotomy and the Foley balloon are can be seen here. The more proximal portion of the erosion into the bladder is then tackled next. This area is shown with a green circle on the right side of the screen. This area of erosion is from the left self-fixating arm of the anterior elevate. The cystotomy and the Foley bulb are shown here again and the entirety of the mesh removed is shown on the right side of the screen. The cystotomy is then repaired with 3-O-Vicrol in interrupted fashion. This is followed by an embricating layer of interrupted 3-O-Vicrol sutures. Cystoscopy on the left side of the screen once again demonstrates the areas of erosion into the bladder and on the right side of the screen those same areas are shown after repair with efflux of urine from the left ureter. Our next patient is a 70-year-old postmenopausal woman who underwent a SPARC sling procedure in 2012. Almost immediately she began having overactive bladder symptoms, not responding to medication. She began having recurrent urinary tract infections about 6 months after surgery. This is an animation of a SPARC sling placement. The needles are passed suprapubically and retrieved vaginally through the suburethral incision. The ends of the slings are then attached to the needles and pulled through suprapubically and the sling is then tensioned as the plastic sleeves are removed. This is a cystoscopic view of the area of erosion of the left arm of the mesh into the bladder with calcification formation. The area of the mesh erosion is shown on the right side of the screen with a blue circle. This is a cystoscopic view of another patient without any erosion into the bladder but the mesh has been passed through the muscularis as can be seen clearly here. This can lead to irritative bladder symptoms and erosion at a later time. Once the retropubic dissection has been completed, the left arm of the sling is identified. The area of erosion into the bladder is shown with the blue circle on the right side of the screen. The sling arm is then carefully separated from the surrounding tissue into its area of erosion into the bladder. The sling arm as well as the calcification associated with it are then removed. The cystotomy is then closed with 3-O-Vicrol in two layers. The peritoneum is closed with 2-O-Monocryl with Laparotide device at each end. Complete excision including the muscularis and mucosa was achieved in all cases. The frequency of urine tract infections decreased from 6 to 20 per year by history to 1 to 2 per year annually. All patients had post-operative hematuria which resolved in all cases within two weeks. Overactive bladder symptoms improved in all participants except in one patient. Her symptoms improved significantly with anti-cholinergic medication. None of the women had recurrence of erosion on follow-up cystoscopy 6 months after excision. Retropubic robotic assisted laparoscopic excision of mesh is a technically feasible and reproducible method for removing bladder mesh erosion which provided excellent visualization and allows for complete excision of mesh from all layers of the bladder wall and reducing the chance of recurrence significantly. This technique can be considered once more minimally invasive measures such as transurethral endoscopic excision using Holmium laser have not been successful or there has been a recurrence of erosion into the bladder. Thank you for your attention. www.ottobock.com
Video Summary
The video is a recording of a retro-pubic robotic excision of mesh and bladder repair procedure for the treatment of mid-urethral slings and transvaginal prolapse mesh erosion into the bladder. Mesh kits used for stress urinary incontinence or pelvic organ prolapse can cause foreign body in the bladder. The incidence of mesh erosion varies widely, but removal procedures have typically involved cystotomy. The study evaluates the retropubic robotic-assisted laparoscopic excision of mesh erosion in five patients with mesh-related bladder complications. The procedure successfully removed the mesh, improved symptoms, and reduced the recurrence of erosion. The technique is considered when other minimally invasive procedures have failed.
Asset Subtitle
Amir Shariati, MD, MS, FACOG, FPMRS
Keywords
retro-pubic robotic excision
mesh and bladder repair
mid-urethral slings
transvaginal prolapse mesh erosion
mesh kits
×
Please select your language
1
English