Tips and tricks for the diagnosis and management of midurethral sling mesh complications. Midurethral slings are the most well-studied surgical modality for treating stress urinary incontinence. They are highly effective and have low overall morbidity. While the majority of pelvic mesh complications occur following transvaginal prolapse repairs, complications can occur following midurethral slings. We will highlight findings on physical exam that may reveal or suggest a mesh complication, then provide tips on surgical management. The workup for complications begins in the office with a history and physical exam. If symptoms of a mesh complication are present, evaluate the temporal onset of these complaints relative to when mesh surgery was performed. Reviewing prior operative reports provides information about the sling type and any intraoperative difficulties. On physical exam, while digitally assessing for mesh exposure or tenderness, attention is paid to whether objective findings produce the patient's complaints. An exam may be enhanced for the use of a clear plastic self-illuminating speculum. Here we show a monovalve speculum exam on a patient with vaginal mesh exposure. With the speculum placed posteriorly to evaluate the anterior vaginal wall, the mesh is not visible. However, when the clear speculum is placed over the mesh on the anterior vaginal wall, it places retraction on the vaginal rugae and allows for visualization of mesh exposure. We recommend a rectal exam for any woman presenting with mesh complications and cystoscopy following complaints from a midurethral sling or anterior vaginal wall mesh. Here we present the case of a 51-year-old patient with prior TVT retropubic sling placement, complicated by a retropubic hematoma. Since the time of placement, she complained of pain, straining to urinate, and recurrent urinary tract infections. Her exam revealed focal and reproducible tenderness when palpating on the right side of the urethra. Office cystoscopy revealed no mesh in the bladder or urethra. Intraoperatively, the sling was identified with the midurethra, dissected free, and transected. During the course of this dissection, a gush of fluid was seen consistent with entry into the lower urinary tract. A tonsil clamp was placed on the transected sling mesh. During urethroscopy, there was mesh in the urethral lumen. It appeared that the mesh had been in the wall of the urethra, thus explaining entry into the urethral lumen during mesh removal. The location of the urethrotomy was on the right side in the same location as her tenderness on exam. The mesh was excised. The urethrotomy was visualized and found to be less than one centimeter in length. It was repaired in a running fashion with 3-O-Vicryl. Following the repair, watertight closure was confirmed with a dye test. Methylene blue was injected into the urethra with an angiocatheter while the Foley bulb was on tension, such that the urethral lumen was filled. Dye expelled through the urethral meatus, but did not extravasate from the repair, indicating a watertight closure. Sterile milk is another agent that can be used instead of methylene blue for this evaluation. After completing the closure, an indwelling Foley catheter was kept for two weeks to promote healing of the urethrotomy. She has had complete resolution of her pain and has not developed recurrent stress urinary incontinence. Next, we show a case of a 45-year-old woman with a history of retropubic sling placement. Since the time of her surgery, the patient experienced lower pelvic and tearing bladder pain on the right side. On exam, the tenderness was isolated entirely to the right arm of the sling. Office cystoscopy confirmed the mesh arm was indented into the right lateral wall of the bladder. She had the rest of the mesh visible through the urethelium and areas of microperforation. She was counseled that the mesh needed to be removed. We opted for a laparoscopic retropubic mesh excision in order to ensure that all of the mesh penetrating into the bladder wall could be removed. On laparoscopy, the retropubic space was identified. At the upper border of the bladder, the peritoneum superior to the pubic symphysis was entered with monopolar cautery. The lateral dissection was carried inferiorly to avoid the inferior epigastric vessels. During this dissection, the right mesh arm was identified. Note that it is not hugging the back of the pubic bone as would be expected with optimal retropubic sling placement. Haptic feedback assisted in the identification of the mesh and distinguishing the implant from the surrounding native tissue and bladder. The mesh arm was dissected free, superior to its perforation into the bladder. The mesh was transected and the cut edge tagged with cortex to aid with the identification during the subsequent dissection of the mesh from the bladder wall. Counter traction on the mesh facilitated sharp dissection to free the bladder wall from the sling arm. Identification of the ureter was facilitated by placement of ureteral catheters and their location noted throughout the dissection. Cystoscopy was repeated during the laparoscopy to ensure all of the mesh had been removed from the bladder wall. Once this was confirmed, the mesh was cut and excised. Cystoscopy identified the location of the resultant cystotomy. Its size and location were consistent with the length of the excised mesh and was remote from the ureteral orifice. Here is the excised mesh being removed. 3-O-Vicor was lubricated with sterile mineral oil to facilitate laparoscopic suturing. The cystotomy was closed with a series of interrupted figure of eight sutures with care to obtain full thickness bladder tissue. The sutures at the lateral margins of the repair were left long until watertight closure confirmed, as it is difficult to see the extent of the original defect following its closure. Repeat cystoscopy confirmed watertight closure and ureteral patency. The retroperitoneal space was closed. Immediately following surgery, the patient noted an improvement in her pain with continued improvement as she healed. The foley was removed to accept a surgery without issue. In conclusion, the diagnosis of complications from sling mesh begins with a thorough history focusing on the temporal relationship between placement of mesh and onset of symptoms. On physical exam, focal tenderness in the location of prior mesh placement is highly suggestive of a mesh complication. Often, minimally invasive approaches to mesh removal can be successfully pursued. Thank you.

midurethral sling mesh

complications

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tips and tricks