This video describes our technique in robotic-assisted laparoscopic excision of retrocubic mesh. The patient is a 53-year-old female who underwent a retrocubic sling in 2006 for stress urinary incontinence. Post-operatively, she developed recurrent urinary tract infections, pelvic pain, dyspareumia, and urinary urgency and frequency. Eight years after her original sling placement, she presented to an outside urologist and was found on cystoscopy to have a mesh exposure and bladder stone. At that time, she underwent a vaginal sling excision with cystoscopy and laser lithotripsy, but had persistence of her symptoms. Her medical history was significant for asthma in addition to her recurrent urinary tract infections, and her surgical history was otherwise unremarkable. There was no vaginal mesh exposure seen on physical exam, and her urine was positive for nitrates and leukocyte esterase. After presenting to our office, she underwent another cystoscopy, which again demonstrated an intravesical mesh exposure and a large bladder stone. At this point, she was taken to the operating room and again underwent a repeat cystoscopy, systolethalopaxy, and cystoscopic removal of intravesical mesh. Unfortunately, she had persistence of symptoms with severe pelvic pain and dyspareumia. A follow-up cystoscopy revealed an erythematous lesion on the left bladder wall, which was biopsied and demonstrated acute and chronic inflammation. After a discussion of options, the difficulty of removing all mesh particles cystoscopically, and the possible effects of chronic inflammation on her pain, the patient elected to undergo a definitive treatment with robotic excision of retropubic and intravesical mesh. The patient was taken to the operating room, and prior to docking the robot, a cystoscopy was done, which demonstrated a raised erythematous area on the left bladder wall, which was consistent with the area of chronic inflammation that had been previously biopsied. This was also consistent with the exit point of the mesh arm from the bladder. Closer to the bladder neck on the left side, a tiny strand of blue mesh was seen from the entry point of the previous mesh strap. The remainder of the bladder was otherwise unremarkable. Ports were placed in the standard line configuration for the da Vinci XI robot, and the patient was placed in steep Trendelenburg. After the robot was docked in the standard fashion, the anterior peritoneum was incised, and the bladder was released from its attachments to the anterior abdominal wall. A tension was drawn to the left side of the bladder, and the blue mesh strap was easily identified in the retropubic space going up to the anterior abdominal wall and entering into the rectus abdominis muscle. The mesh strap was transected and released from its attachment to the anterior abdominal wall. A combination of sharp and blunt dissection was used to dissect the mesh strap away from its attachments all the way down to the level of its entry point into the bladder. We then entered the bladder and removed a cup of tissue surrounding the entry point of the mesh arm. We were able to identify the previously seen area of chronic inflammation and were able to remove this tissue entirely. Once freed completely from the bladder, the mesh was removed from the patient and sent for gross examination. The cystotomy was carefully inspected and there was no evidence of any residual mesh. The bladder was then closed in two layers with a 2-0 bifurcal suture in a running locking fashion. The first layer brought together bladder mucosa. The tail end of the first suture was held with the third arm and a second 2-0 bifurcal suture was used to close the detrusor muscle and perivascular tissue. We then dissected further into the left retrophobic space alongside the bladder neck and urethra near the vagina and pelvic floor to identify the residual left strap of mesh entering from the pelvic floor and attached to the distal most part of the bladder near the bladder neck. This mesh was dissected and freed from its attachments without creating a second cystotomy. The foley catheter was removed and a repeat cystoscopy was done to retrograde fill the bladder while simultaneously evaluating our closure to ensure it was watertight. After the bladder was decompressed, we turned our attention to the right retrophobic space. We identified the right mesh strap and used a combination of blunt and sharp dissection to free it from its surrounding attachments. We then transected the right mesh strap at its level of insertion at the anterior abdominal wall. We continued our dissection, carefully freeing the mesh from any surrounding tissue down to the levator tissue on the right side of the urethra. On this side, there was no entrance to the bladder and we were able to free the mesh from the perivascular tissue without creating a cystotomy. Our increased magnification with the robot allowed for even small fibers of mesh to be carefully identified and removed. A repeat cystoscopy was done, which did not show any injury to the right side of the bladder or any residual mesh. Again, we saw the watertight closure of the left-sided cystotomy. The anterior peritoneal flap was closed with a running 2-ovicral suture to restore normal anatomy. A Foley catheter was left in place and the robot was undocked. All ports were closed in the standard fashion. The patient awoke from anesthesia without difficulty and was sent to PACU in stable condition. Blood loss for the case was minimal. The patient was discharged home on postoperative day 1. She was seen in clinic one week later for Foley removal and recovered well with improvement in her pelvic pain and dyspareunia. Pathology from the bladder wall excised revealed benign polypoid cystitis with non-caseating granulomatous inflammation, calcification, and foreign-bodied giant cell reaction. Strengths of the robotic approach for mesh removal include improved manual dexterity, excellent visualization, near-complete excision of mesh with removal of chronically inflamed tissue, minimal blood loss, and short recovery time. This technique is ideal for residual mesh that is embedded in the bladder wall and is not entirely intravesical. Definitive excision of all strands eliminates a potential source of chronic inflammation, fibrosis, and pain. Limitations of this approach when compared to vaginal or cystoscopic approach include increased cost, the need for intraperitoneal access, and the lack of long-term studies. In conclusion, robotic-assisted laparoscopic excision of retropubic mesh is feasible, safe and effective, minimally invasive, and allows for definitive excision of mesh embedded in the bladder wall.

robotic-assisted laparoscopic excision

retrocubic mesh

mesh exposure

urinary tract infections

pelvic pain