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A laparoscopic technique for excision of retropubic midurethral sling arms eroding into the bladder
IUGA Academy. Cartwright R. Jun 30, 2018; 213258; 147 Topic: Stress Incontinence
Rufus Cartwright
Rufus Cartwright

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147

A laparoscopic technique for excision of retropubic midurethral sling arms eroding into the bladder

Stratta, E1;Cartwright, R1; Goodall, L1; Arshad, I1; Jackson, S1; Price, N1

1: Oxford University Hospitals NHS Trust

Introduction: Midurethral polypropylene slings have a range of uncommon but serious complications including erosion into the bladder. Women with mesh eroding into the bladder may present with pain, haematuria, or recurrent UTI. Cystoscopic approaches for removal of eroding mesh, including use of cystoscopic trimming, or holmium laser ablation, carry a high risk of recurrence of erosions. Cases series have described vesicoscopic approaches to bladder mesh erosions with incision at the dome[1,2]. These approaches provide good exposure for mesh erosions close to, or within the trigone, but retropubic slings typically erode more laterally. Cystotomy at the dome allow removal of intraluminal and submucosal mesh but leaves the intramural portion of the mesh.

Objective: We demonstrate in this video a modification of these techniques for retropubic slings that can be used for total laparoscopic excision of an eroding sling without cystotomy at the dome.

Methods: After placing ureteric stents, the bladder is instilled with 300mls of normal saline with methylene blue, to help delineate the dome of the bladder. With the patient in Trendelenberg position the retropubic space is opened using a monopolar hook at 2cm above the bladder reflection. The space of Retzius is developed, and the bladder is reflected down bilaterally to expose the urethra and sphincter complex in the midline, and the obturator vessels and nerves bilaterally. The arms of the mesh can then be identified, and the relation of the mesh to the important structures in the retropubic space can be assessed at this stage. Under traction the mesh can be sharply dissected out from the surrounding structures. This can be continued down to the level of the bladder. The cystotomy is then made where the sling erodes into the bladder. The cystotomy is closed in two layers using a polyglactin suture. An indwelling catheter is left for two weeks to allow bladder healing, with a cystogram performed prior to the catheter removal.

Results: We identified 6 women undergoing this procedure at a median 45 months post midurethral sling insertion. The procedures took a median 112 minutes (excluding one patient with bilateral erosion and bilateral cystotomy: 240 minutes). There were no early complications, and no cases returned to theatre. We followed up all patients with a questionnaire at minimum 24 months post surgery. For the four patients with pre-operative pain associated with the mesh, there was a median 7 point decrease in pain (10 point scale). For two women where the suburethral portion of mesh was left in situ, there was recurrence of erosion, whereas for the four women with complete sling removal there was no further erosion.

Conclusion: Our series confirms the feasibility of this technique [3], with advantages over cystoscopic or open approaches. These include precise dissection under direct vision, which gives better exposure and identification of anatomical structures, and the opportunity for a complete excision to prevent recurrence without risk of creating a fistula.

  1. Int Urogynecol J22, 1593–1595 (2011).
  2. Urology102, 247–251 (2017).
  3. JSLS 10, 220 –225 (2006)

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Figure 1a to d: Laparoscopic excision of mesh eroding into the bladder. a) a cystotomy is made where the tape breaches the bladder wall b) the tape is completely freed from the bladder using scissors c) the cystotomy is sutured in two layers with polyglactin suture d) a check for watertight closure is made

Disclosure:

Work supported by industry: no.

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