INTRODUCTION: Transobturator (TOT) sling placement is a low-risk and effective surgical management option for treatment of stress urinary incontinence. TOT slings provide support to the midurethra through a minimally invasive approach through the obturator foramen via groin incisions. While TOT slings are associated with less bladder injury risk than retropubic midurethral slings, complications such as groin pain, infection, and urinary retention exist. Rare but serious complications include nerve injury, mesh complications, or chronic pain, which may require sling revision or removal. We present the case of a prior TOT placement resulting in fistulization to the left inner thigh. OBJECTIVE: This video illustrates removal of a transobturator mesh fistulizing to the inner thigh, highlighting both a rare mesh complication and surgical approach to fistula removal. Anatomic landmarks for placement of transobturator sling are also reviewed. METHODS: A 54-year-old patient was referred to our clinic with left thigh pain, urinary urgency, and stress urinary incontinence. The patient reported cystic lesions and nonhealing wounds in the thigh after placement of TOT sling 10 years prior. Magnetic resonance imaging noted a vaginocutaneous fistula extending from the anterior vaginal wall to the skin surface of the medial left thigh. The patient had previously seen multiple providers who attempted biopsy and removal of her thigh wound without success. Pelvic exam revealed vaginal mesh exposure. An in-office cystoscopy was performed with no mesh noted within the bladder or urethra. After informed consent discussion, the patient elected to proceed with surgical excision of the mesh and vaginocutaneous fistula. She established care with a general surgeon at our institution to facilitate a multidisciplinary surgical approach. With shared decision making, the patient elected to remove all mesh that could be readily accessed. We began vaginally by dissecting out the 2-cm midurethral mesh exposure. After the epithelial edges were mobilized, an additional 11-cm portion of mesh was removed from the left vagina using gentle traction. This portion seemingly correlated with the entire length of the vaginocutaneous fistula. The cutaneous fistulous tract in the groin was explored by our general surgery colleagues and removed without difficulty. Approximately 2 cm of mesh was removed from the left vagina, which corresponded with the remainder of the mesh, suggesting malposition or migration over time. RESULTS: In the recovery unit, the patient failed a routine voiding trial, so an indwelling catheter was maintained. She was discharged with instructions for wound care and repeat voiding trial within the next week, which was successful. Our patient was seen at 6 weeks postoperatively and recovered well without complication. She reported resolution of her preoperative pain, wound concerns, and urinary symptoms. CONCLUSIONS: While TOT slings remain an effective option for management of stress urinary incontinence, rare mesh complications can occur. Knowledge of the obturator foramen and inner thigh anatomical landmarks remains an important consideration for any surgeon performing TOT or taking care of patients with prior TOT. A multidisciplinary approach to care may be helpful for managing patients with unusual presentations that vary from the expected anatomical course.
Lazenby et al. (Fri,) studied this question.