Robotic-Assisted Laparoscopic Removal of Mid-Urethral Mesh Slings Eroded into the Bladder.

INTRODUCTION AND OBJECTIVES: Depending on the indication, there are multiple surgical approaches for the removal of mid-urethral mesh slings (MUS): transvaginal, endoscopic, open abdominal, and robotic. Here, we demonstrate the robotic approach to treat MUS that have eroded into the bladder. The robotic approach offers excellent exposure, visualization, and accessibility. Compared to endoscopic approaches, the entire arm of the sling can be removed from the bladder wall, the bladder repaired, and the foreign body completely eliminated. Robotic MUS excision is ideal in patients who would be best served by maximal removal of the mesh from the bladder in order to prevent future complications.

METHODS: In this video, we display two different cases showing two unique approaches to robotic MUS excision depending on the location of mesh erosion: 1. If a retropubic sling is eroded through the anterior bladder, we begin by dropping the bladder and entering the space of Retzius to locate the mesh arm. 2. If the sling is eroded into the posterior bladder, a cystotomy is made on the anterior dome to visualize the posterior bladder wall.

RESULTS: Once the mesh is identified, we follow the mesh graft carefully and dissect it away from surrounding tissues. The dissection is immediately close to the mesh, without fragmenting it, to allow for complete excision and protection of adjacent critical structures. The surgical principles and instrument techniques of robotic mesh excision mirror those utilized for transvaginal mesh excision. Complications of this surgical approach include a urinary leak that may require prolonged catheterization or re-operation and recurrent stress urinary incontinence, in addition to typical operative risks.

CONCLUSIONS: For treatment of mesh erosion into the bladder, a robotic approach offers excellent visualization, is feasible, and well-tolerated. Compared to fragmenting the mesh using an endoscopic approach, the robotic approach has the advantage of excising the mesh definitively and preventing future recurrences of mesh erosion. Properly selected patients should be offered the robotic approach to mesh excision.