Robotic repair of intravesical mesh erosion and a mental interposition following sacral colopexy. A 72 year old lady presented with a one day history of gross hematuria with clots and had an intermittent history of this for 9 months prior. She also had worsening urge and urge incontinence. Past surgical history was significant for a hysterectomy and an anterior and posterior repair. In January of 2010 she underwent a robotic sacral colopexy and an incidental cystotomy at the time which was repaired. A week later a catheter was removed and she developed continuous urinary leakage following this. Subsequently in April of 2010 she underwent a transvaginal vesicofaginal fistula repair with excision of mesh. The examination was unremarkable. Cystoscopy demonstrated mesh with calcifications in the midline above the trigone and ureters. A 2 cm papillary lesion consistent with the urethelial cell carcinoma was identified above the right ureteric orifice. Cystoscopy confirms mesh fibers with calcifications on them above the trigone. We can also see the left ureteric orifice which is identified here. Also the right ureteric orifice we can identify here and above this is a papillary lesion consistent with the urethelial carcinoma. In March 2016 the patient underwent resection of the bladder lesion and homeom ablation of the mesh erosion. Pathology demonstrated a urethelial carcinoma. Patient had surveillance cystoscopy for occurrence of bladder cancer. In October of 2016 cystoscopy showed recurrent mesh fibers in the bladder. Patient is also developing worsening urge and urge incontinence. A bladder biopsy was negative for malignancy and mitomycin C had been instilled at this time. Pathology prior to surgery demonstrated a recent bladder biopsy and superior to this is a mesh erosion. Patient was consented for robotic excision of intervestigal mesh erosion and omental interposition graft. Patient was placed in the dorsal lapotomy position, da Vinci robot was docked. In arm 3 a fenestrated grasper was placed, in arm 2 a PK and in arm 1 a scissor was placed. You can see that the mesh is densely adherent to the small bowel which is carefully dissected off the mesh. Dissecting out the Y portion of the mesh I developed a plane between the anterior arm of the mesh and the bladder. The bladder is freed up from the anterior portion of the mesh. The bladder is continued to be dissected off the mesh and here you can see where we enter the bladder and the mesh erosion is identified. The posterior wall of the bladder is then mobilized off the mesh. Erosion is then carried out distal to the trigone. You can now see the trigone with ureteric catheters in place. Closure of the cystotomy was then performed with the 2-0 V-lock in two layers. The bladder closure was tested with 300cc of normal saline and was found to be watertight. Fomental interposition graft is then sutured in place with 2-0 Vicryl sutures. A CT cystogram was obtained 3 weeks postoperatively and showed no leak and the Foley catheter was removed. In conclusion, robotic excision of recurrent mesh erosion following sacral colpopexy is a viable option for treatment. Fomental interposition can add an additional layer between the bladder and the anterior vaginal wall and decrease the risk of recurrent mesh erosion.

case study

mesh erosion

robotic excision

fomentel interposition

reducing complications