Editorial Comment to Robotic removal of eroded vaginal mesh into the bladder

Abstract

The erosion of tape is a challenging complication in the treatment of urinary incontinence. Because of the low number of studies reporting on the surgical approach for mesh removal, it is still controversial. The authors describe the robotic removal of an eroded vaginal mesh in the bladder.1 Because of the inability to remove the entire mesh endoscopically, they chose a transperitoneal transvesical approach with successful outcomes. Based on the rare literature and our personal (non published) experience, transurethral (electro)resection seems to be a successful, simple and minimally-invasive treatment option for sling/mesh removal. Pure transvaginal removal of mesh erosion is also successful described. It is necessary to respect this principle: partial removal of the eroded mesh is possible only if it compensates the bladder defect. Otherwise, the complete removal of the tape is recommended, normally without impact on the continence status. For that, the surgical approach should be adequate and sustainable. Certain issues related to the choice of the surgical approach need to be considered. First, the management of eroded mesh depends on the site and extent of erosion, the type of tape, and the severity of symptoms. The transurethral or transvaginal approach is less invasive than the abdominal approach, because it does not require the opening of the urinary bladder. By the vaginal access, a limited surgical field could result in poor exposure, inadequate visualization and technically difficult dissections. This might explain resection failure leading to a re-intervention. Therefore, optimal visualization and exposure represent one of the surgical goals. Thus, transvesical access might be an option. In the laparoscopic era, robotic assistance leads to improved 3-D vision, higher magnification and easier dissection, as discussed by the authors. However, this type of surgery requires know-how with limited cost-effectiveness. The present case highlights the feasibility and safety of the robotic approach for mesh erosion in the bladder if the transurethral approach is not indicated. Patients should be evaluated individually to devise the best surgical plan. Preferably, we should begin with the minimally invasive, most effective, most safe and also minimally-expensive method. The conclusion of this comment would be not to confuse feasibility and reasonability. An accumulation of cases and prospective studies comparing standard endoscopic and laparo-endoscopic approaches are necessary to properly define the role of this innovative surgery in the management of such cases. None declared.