Transvaginal mesh excision with urethral reconstruction: tips and tricks

Abstract

Share our surgical technique with tips to safely perform urethral mesh removal. Retropubic midurethral sling is commonly performed for the treatment of stress urinary incontinence. Transurethral mesh erosion occurs rarely with an incidence of 0.02-0.03%. Our patient with a history of transvaginal tape procedure done 13 years ago was found to have a urethral mesh erosion when she complained of recurrent urinary tract infection, incomplete bladder emptying and increased frequency. She was consented for mesh removal with urethral reconstruction. Intraoperatively, urethral obstruction was noted with no patent, visible lumen. Vaginal dissection was done, and urethral tunnels were created. Mesh was felt, grasped using Kocher clamps and released from retropubic arms after lateral dissection. Urine extravasation was noted when dissecting the mesh near the urethra. Flexible cystoscope was introduced through the orifice and retroflexion of the scope confirmed this to be a urethrotomy which was noted to be approximately 1 cm after removing the mesh completely. Transurethral catheter was difficult, hence urethral dilator with ureteral guidewire was used to facilitate trans-urethral placement. Urethrotomy was closed in multiple layers using 4-0 monocryl for the urethral mucosa, 3-0 vicryl for the second layer and 2-0 vicryl for the epithelium. Foley was removed and cystoscopy performed with ease. Urethroscopy revealed no further defects or mesh inside the urethra. Foley was replaced and removed 7 days postop. She continued to report ease of voiding 6week postop. Smaller gauge scope or flexible cystoscope is a helpful alternative tool to do cystourethroscopy when rigid scope cannot be passed. Urethral dilators with a guidewire can help with difficult catheter insertion. Cystotomy and urethrotomy should always be distinguished intraoperatively.