A novel technique for managing Tension-free Vaginal Tape (TVT) urethral erosion using combined laparoscopic and vaginal approach along with Martius labial flap interposition
IUGA Academy. Loganathan J. Jun 30, 2018; 213286; 238 Topic: Stress Incontinence
Ms. Jemina Loganathan
Ms. Jemina Loganathan

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A novel technique for managing Tension-free Vaginal Tape (TVT) urethral erosion using combined laparoscopic and vaginal approach along with Martius labial flap interposition

Loganathan, J1; Ibrahim, S2; Fayyad, A2

1: NHS; 2: Luton and Dunstable University Hospital NHS Foundation Trust

Introduction: A 54 year old diabetic female presented with voiding dysfunction and recurrence of stress urinary incontinence 12 years after retropubic TVT insertion. Cystoscopy revealed bilateral TVT urethral erosion and encrustation on the tape.

Objective:To demonstrate a novel technique for managing TVT mesh urethral erosion using combined laparoscopic and vaginal approach followed by urethral reconstruction and Martius flap interposition.

Method: Following cystoscopy an inverted U-shaped vaginal incision was made at the level of the mid urethra. The suburethral mesh was not seen or felt and paraurethral dissection was then performed up to the level of the endopelvic fascia. After routine laparoscopic entry, the retropubic space was opened and both arms of the TVT exposed and dissected from the pubic bone all the way down to the endopelvic fascia. The fascia was then perforated vaginally into the retropubic space with curved clamps, and the TVT arms grasped bilaterally and delivered into the vagina. Using the vaginal approach the TVT mesh was then dissected towards the urethra at the sites of erosion bilaterally. The ventral aspect of the urethra remained intact and the tape was removed in its entirety by opening the urethra on either side at the urethral entry points of the tape. Urethrotomy sites were identified and sutured bilaterally with interrupted Vicryl 3-0.

The left labia majora was then incised and Martius fat pad exposed after dissection of the surrounding fascia using scissors and electrocautery. Blood supply was maintained from the inferior aspect of the flap by preserving a broad inferior vascular pedicle containing blood supply from branches of the pudendal artery. The fat pad was then tunneled through the left paraurethral space to overlie the urethra and sutured in place with 4 interrupted Vicryl 2-0 to prevent migration. The labia majora was closed in 2 layers. A Foleys catheter remained in situ for 14 days post operatively.

At 3 months post operatively the patient reported complete cure of her voiding dysfunction and persistence of the stress incontinence.

Conclusion:Recent controversy has brought mesh insertion procedures, and mesh removal, into the spotlight. Complications such as erosion into the bladder and urethra are rare and difficult to manage. In this video we demonstrate a novel technique for removing TVT mesh to treat urethral mesh erosion with reconstruction of the urethra. This technique has the advantage of being minimally invasive to minimise urethral damage compared to routine midline approach. It also adds the advantage of complete TVT mesh removal.


Work supported by industry: no.

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