INTRODUCTION: Mesh extrusion and exposure after midurethral sling placement is a rare complication that can occur in the vagina or bladder. Management options vary depending on size, location, and patient symptoms. Risk factors for mesh extrusion and needing reoperation should be considered for all patients undergoing midurethral sling placement. OBJECTIVE: The aim of this video is to review risk factors for midurethral sling mesh extrusion and exposure and review techniques for the management of mesh extrusion in the bladder. METHODS: This case is that of a 61-year-old female who underwent midurethral sling placement via suprapubic top-to-bottom approach. For 6 years after her sling was placed, she had several vaginal mesh exposures that were managed conservatively with topical estrogen and in-office excisions. Mesh was excised three times. Nine years post sling placement, she developed macroscopic hematuria and underwent evaluation with cystoscopy. Initial office cystoscopy revealed a calcification and papillary lesion suspicious for possible malignancy. Given her risk factors for malignancy, including extensive history of smoking, she was sent to urologic oncology for further evaluation and underwent repeat cystoscopy, which revealed extrusion of sling material into anterior bladder wall. She underwent robotic-assisted partial cystectomy to remove the mesh. The available evidence of risk of history of smoking and mesh extrusion was reviewed given this patient’s history and clinical course. This video was created to provide education, with English narration, regarding medical and operative management of midurethral sling mesh extrusion in the vagina and bladder based on a case study. Measures were taken to protect the patient’s privacy and confidentiality throughout the video creation process. The patient gave consent for filming the surgery. The target audience for this educational video includes pelvic surgeons who perform midurethral sling placement. RESULTS: In the operating room, flexible cystoscopy was utilized to locate the area of mesh extrusion along her anterior bladder surface. While cystoscopy was used to directly visualize the mesh and provide transillumination to that area of the bladder, robotic-assisted laparoscopic partial cystectomy was performed to fully excise the area of the bladder with mesh extrusion. The cystotomy was closed in two layers and confirmed to be water-tight. Three months after the procedure, the patient is asymptomatic and satisfied with results. CONCLUSIONS: This video demonstrates risk factors and treatment options for vaginal mesh exposure and bladder mesh extrusion after midurethral sling placement based on a case study, including discussion of the impact of smoking on the risk of mesh extrusion. It also demonstrates the surgical approach to management of bladder mesh extrusion via robotic-assisted partial cystectomy with concurrent cystoscopy. Treatment options include conservative and surgical options depending on the patient’s symptoms, location, and size of mesh extrusion or exposure. With any urinary tract complications, the goal is complete removal of mesh eroded into the urinary tract while balancing concerns regarding continence.
Wang et al. (Fri,) studied this question.