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Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape
Evrim Erdemoglu1, Volkan Öztürk2, İlyas Turan2
1Department of Obstetrics and Gynecology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey (all authors)..
Study Objective:
To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape.
Design:
Demonstration video.
Setting:
Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2).
Interventions:
(1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3).
Conclusion:
Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.
Insights
This study presents a vaginally assisted laparoscopic urethrolysis and mesh excision technique for midurethral sling complications. This combined approach offers a safe and effective solution for urethral obstruction following midurethral sling surgery.
Area of Science:
- Urology
- Minimally Invasive Surgery
- Gynecologic Surgery
Background:
- Midurethral sling surgery (MUS) complications, including urethral obstruction, necessitate surgical intervention.
- Existing urethrolysis techniques (retropubic, transvaginal) have limitations, with transvaginal approaches sometimes proving unsatisfactory for mesh identification and removal.
- Laparoscopic approaches offer advantages in visualizing surrounding structures, potentially leading to safer procedures.
Purpose of the Study:
- To present a novel technique: vaginally assisted laparoscopic urethrolysis and mesh excision.
- To demonstrate a combined surgical approach for managing complications after tension-free vaginal tape (TVT) procedures.
- To highlight the benefits of a combined approach for difficult cases involving mesh dislocation or dense fibrosis.
Main Methods:
- The study presents a video demonstration of the vaginally assisted laparoscopic urethrolysis and mesh excision technique.
- The technique involves a 5-step process, utilizing the arcus tendineus as a key anatomical landmark.
- Preoperative diagnostic cystoscopy is essential to rule out mesh erosion, with intermittent catheterization recommended prior to surgery.
Main Results:
- Laparoscopic urethrolysis is a safe and successful procedure for urinary obstruction post-MUS, especially after a failed vaginal approach.
- The combined vaginal and laparoscopic approach facilitates complete mesh removal.
- This technique is particularly useful for complex cases at the junction of the retropubic urethra and mid-urethra.
Conclusions:
- Vaginally assisted laparoscopic urethrolysis and mesh excision is an effective treatment for midurethral sling complications.
- This combined approach can be considered as a primary option in select cases of urethral obstruction.
- Mastery of various techniques, including this combined approach, is crucial for gynecologists to provide individualized patient care.
