Stergios K. Doumouchtsis, Fourth Floor Lanesborough Wing, Department of Pelvic Reconstructive Surgery and Urogynaecology, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK. e-mail: firstname.lastname@example.org
Study Type – Therapy (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
Traditionally, surgical management of mesh/suture erosions has involved excision through a transvaginal or endoscopic approach for urethral erosions, and a transabdominal approach (open or laparoscopic) for bladder exposures.
In the majority of published studies, urethral erosions appear to be a complication of retropubic mid-urethral sling insertion, with incidence rates in the range 0.03–0.8%.
The present study confirms that transurethral endoscopic management has low morbidity, good functional outcomes and potentially low rates of recurrent stress incontinence.
Urethral tape erosions were excised successfully with a transurethral approach, whereas mesh eroded in the bladder required an open procedure.
• To evaluate transurethral endoscopic excision using the holmium laser (TEEH) for the management of lower urinary tract mesh or suture complications of continence intervention.
• To compare the outcomes, complications and recurrence rates of TEEH with the published results from studies using other techniques.
PATIENTS AND METHODS
• A retrospective review of six patients who underwent TEEH for eroded mid-urethral tape or suture into the urethra or bladder.
• Patients with urethral and bladder exposure of mesh or suture material managed by TEEH were identified from the operating records, electronic data records and the Holmium Laser Registry at our institution.
• Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis, voiding dysfunction and recurrent stress incontinence.
• A literature review on the available evidence on holmium laser for lower urinary tract complications of continence surgery was undertaken.
• Between September 2006 and March 2010, six women underwent TEEH. All presented with bladder storage symptoms and/or haematuria with recurrent cystitis. The interval between surgery and the diagnosis of erosion was 1–13 years.
• Four women had previously undergone retropubic mid-urethral tape, one colposuspension and one a suprapubic arc procedure followed by a transobturator tape insertion.
• Complete excision with TEEH was achieved in all cases.
• Two women had postoperative haematuria, which resolved after 2 weeks. There were no other immediate complications.
• Four patients had recurrent erosion at follow-up. Two of them were symptomatic, requiring repeat TEEH. One was asymptomatic and managed expectantly. In one case, recurrent mesh erosion occurred at the bladder neck in the submucosal layer. This was considered unsuitable for further TEEH. A laparotomy and open excision was undertaken.
• TEEH is a minimally invasive technique, with minimal morbidity and complications, compared to open vaginal or abdominal excision of mesh or suture exposure into the lower urinary tract. Open urethrotomy involves risks of damage to the continence (sphincter) mechanism, with subsequent stress incontinence. In addition, anterior wall scarring may lead to dyspareunia, vaginal pain, urethral stricture and/or fistula. When mesh erosion involves the bladder, transabdominal open or laparoscopic excision may be required.
• Although the recurrence rates in our series are high, the majority of them were managed easily by repeat TEEH, with minimal morbidity or expectantly if asymptomatic.
• In selected patients, TEEH is an acceptable novel technique for the first-line management of this complication of continence interventions, although longer or pooled prospective studies evaluating TEEH are now required.
transurethral endoscopic excision using the holmium laser
Exposure, unrecognised penetration, true erosion of mid-urethral tape (MUT) and sutures into the lower urinary tract following continence surgery are uncommon but potentially serious complications. Such complications are associated with the use of synthetic material for MUT or non-absorbable sutures at colposuspension. The reported rates of urethral mesh exposure after MUT are in the range 0.07–1.5%[1,2] and are influenced by the type of mesh insertion, the technique employed and host tissue factors (scarring, atrophy). The first case of urethral exposure following tension-free vaginal tape was reported in 2001 . This complication has subsequently been reported for by other series [4,5]. Clinical presentation varies and symptoms may be non-specific. The most common symptoms include pain, urgency, frequency and recurrent cystitis. True erosion may present years after the index intervention. This may be the result of a failure to recognize the significance of recurrent storage or infective symptoms in the presence of a previous MUT or delayed erosion over time as a result of mesh retraction. Initial excessive tensioning of the sling may lead to ‘cheesewiring’ through the urethra over time in these cases.
Traditionally, surgical management of such complications has involved excision through a transvaginal or endoscopic approach [6,7] for urethral erosions, and a transabdominal approach (open or laparoscopic) for bladder exposure. Holmium laser can be delivered via a cystoscope and the energy directed precisely to the site required. It has an established role in the treatment of ureteric calculi, where effective fragmentation and precision in avoiding injury to the ureter are equally important. In recent case series, transurethral endoscopic excision using the holmium laser (TEEH) has been employed as an alternative method to the endoscopic scissors for the excision of eroded material from the urethra or bladder (Table 1). The first description of the use of the holmium laser in the excision of intravesical tape erosion was provided in 2004 by Hodroff et al. . In this series, we present our initial experience on the use of TEEH for urethral and bladder mesh or suture exposures. The outcomes, complications and recurrence rates are discussed and compared with the published results from studies using other techniques.
Table 1. Published articles on endoscopic procedures for the management of lower urinary tract complications of continence surgery and outcomes
Number of cases
Type of endoscopic procedure
Success rates, recurrence of erosion/repeat excision
Cystoscopic excision (bipolar diathermy) with accessory laparoscopic suprapubic port
PATIENTS AND METHODS
Patients with urethral and bladder exposure of mesh or suture material managed by TEEH, were identified from the surgical database at our institution. The operating records, electronic data records and the Holmium Laser Registry were reviewed. Data extracted included demographic parameters, previous medical and surgical history, details of surgical intervention and postoperative morbidity. Presenting symptoms at the time of diagnosis of urethral or bladder erosion/exposure of mesh or suture, as well as time intervals between the procedure and diagnosis of erosion, were documented. Details of the surgical procedure were recorded. Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis and voiding dysfunction. The time interval to follow-up, ongoing or recurrent symptoms and further investigations or procedures were also recorded. Institutional review board approval (Audit Committee) was obtained (Audit Reg. No. 1849).
An electronic database search was undertaken and included Pubmed/Medline (1950–2010), Embase (1980–2010) and The Cochrane Library. Various searches with the following medical terms and various combinations were undertaken: endoscopic excision, holmium laser, bladder, urethral erosion, continence surgery, mid-urethral slings. The search strategy included three stages. First, the titles of the identified articles were screened and then a review of the abstracts of the selected articles followed. Scrutiny of full-text articles included a review of the reference lists to identify any articles not retrieved by the initial search.
No randomized controlled trials were identified. The majority of articles were case reports or small observational series. In the present review, we included the relevant studies and we present the type of procedure, their outcomes, complications and follow-up.
With the patient under general anaesthesia in the lithotomy position, and following local instillation of Instillagel® (CliniMed Ltd, High Wycombe, UK) for lubrication, as well as empirically for local anaesthesia to the urethra and reduction of postoperative discomfort, a 12° operating cystoscope was inserted under direct vision. Cystourethroscopy was then performed with the use of normal saline (Fig. 1). The eroded mesh or suture is excised with a holmium laser (≈2.5 kW, 0.2–0.4 kJ), as close to the urethral or bladder mucosa as possible (Fig. 2). The excised material is then removed with biopsy forceps. Further cystourethroscopic assessment is performed to identify any residual material and exclude any inadvertent injury (Fig. 3). Cystourethroscopy and TEEH was performed as a day procedure. In the present series, all procedures were undertaken by one surgeon (F.Y.K.L.). At follow-up, clinical assessment of symptoms and vaginal examination was undertaken to exclude suburethral tenderness or scarring. Investigations included outpatient cystoscopy or perineal ultrasonography and, where indicated, urodynamic assessment.
Between September 2006 and March 2010, seven women undergoing endoscopic treatment of lower urinary tract exposures were identified. The mean (range) age at presentation was 65 (49–78) years. One of them had undergone previous periurethral bulking (Durasphere®; Carbon Medical Technologies, Inc. (CMT), USA) followed by a transobturator tape insertion for persistent stress incontinence. At cystourethroscopy, extruded carbon zirconium beads were identified at the bladder neck. These were removed with biopsy forceps via the cystoscope and TEEH was not required. Because this patient did not undergo TEEH, she was excluded from the study. Of the remaining six patients, four had a previous retropubic tape insertion, one a transobturator tape insertion and one colposuspension. Complete surgical excision using TEEH was achieved in all cases.
In one patient (Case 1), although complete excision was achieved, a follow-up cystoscopy for persistent storage symptoms 7 months later showed persistent mesh erosion at the bladder neck. Furthermore, adjacent portion of the eroded tape was seen just underneath the mucosa. Excision was thus undertaken by laparotomy, removing the portion of the tape that was incorporated into the bladder to ensure complete removal.
Three of the remaining cases also presented with recurrent eroded fibres at follow-up cystoscopy. Two of them underwent repeat excision, and one was offered a second excision but deferred it, preferring expectant management because she was asymptomatic (Table 2). Two women had haematuria postoperatively, which was treated with bladder irrigation, and resolved after 2 weeks. No other immediate or early complications were encountered. There were no fistulae at follow-up. In Table 2, the operative findings and the type of repeat procedure are presented for those cases with recurrent erosions requiring further treatment.
Table 2. Patient demographics and clinical parameters
A literature search identified 24 relevant articles. The type of intervention, outcomes and complications are presented in Table 1.
The role of TEEH as a novel and minimally invasive technique is examined in the present study. In the majority of published studies, urethral erosions appear to be a complication of retropubic mid-urethral sling insertion [3,4,6,9], with incidence rates in the range 0.03–0.8%. In the present study, the time interval between continence surgery and clinical presentation was in the range 1–13 years. Urethral erosions are considered to be secondary to ‘host’ factors (vaginal atrophy, scarring and post-radiation), or iatrogenic (intra-operative urethral injury, deep dissection in a wrong plane close to the urethral mucosa, excessive tensioning of the sling or postoperative urethral dilation to resolve outlet bladder obstruction) . Sling factors (material, weight, pore size) may also play a role . In the present study, all patients presenting with postoperative sling complications had undergone a mid-urethral tape insertion using a Type 1 monofilament macroporous polypropylene mesh.
Preoperative or intra-operative urethral injuries during placement of the sling are more likely to result in immediate postoperative erosions. In addition, excessive tensioning of the sling at the time of placement is more likely to result in early postoperative voiding difficulty. In these women, delayed mesh exposure into the urethra may occur as a result of ‘cheesewiring’ over time. Biomechanically, this may occur more often with a retropubic, compared to transobturator sling, with the inherent issue of mesh retraction and remodelling over time. Alternatively, the more common identification of mesh erosion in relation to retropubic slings may be a result of these techniques being performed more widely and over a longer period of time.
The clinical presentation of urethral or bladder erosion after mid-urethral slings includes pain, voiding dysfunction, storage symptoms and recurrent urinary tract infections. Clinical examination may show suburethral scarring or tenderness on palpation. Ultrasonography may assist in the diagnosis of urethral and bladder erosions. Although perineal ultrasonography (2D/3D) is more effective than abdominal ultrasonography in diagnosing urethral erosions, both modalities can usually identify bladder erosions [4,10]. Diagnosis is confirmed on cystourethroscopy. Cystourethroscopy remains the ‘gold standard’ for identifying the presence of mesh exposure, the level within the urethra and the extent. Urodynamic assessment both pre- and post-operatively will evaluate storage and voiding symptoms and facilitate informed patient consent with regard to the risks and benefits, including possible resolution of symptoms of frequency, urgency and dysuria, as well as the risks of recurrence of stress urinary incontinence. Further surgical intervention may be planned, based on clinical and urodynamic findings.
For urethral mesh exposure, erosion or unrecognized penetration, surgical management has been traditionally undertaken by transvaginal removal of the mesh through an open urethrotomy followed by urethral reconstruction. Interposition of a Martius graft has been advocated to reduce the risk of urethrovaginal fistula. However, the use of Martius graft may be associated with surgical complications, including wound haematoma, infection and healing defects. Other potential complications include labial asymmetry or pain, and secondary psychosexual sequelae. The transvaginal approach is associated with a 76.5% resolution of symptoms but a high rate of postoperative incontinence (64.7%) , and a significant risk of fistula formation .
The present study confirms that transurethral endoscopic management has low morbidity, good functional outcomes and potentially low rates of recurrent stress incontinence. Diagnostic cystoscopy at follow-up to check for recurrent erosion of residual material is useful, especially in symptomatic patients. Velemir et al.  reported one failure out of four endoscopic transurethral excisions requiring additional endoscopic excision of the remaining sling. Although one would expect that the precision of the holmium laser achieving an excision plane ‘flush’ to the mucosa may have lower recurrent erosion rates, the present series failed to confirm this. However, the follow-up period in the present study is longer, and the recurrence rates following endoscopic excision may become higher over time. To date, there are no direct comparative studies.
Frenkl et al.  reported a case series of 11 patients who were managed endoscopically, with the use of a holmium laser in four cases. The success rates were 50% with respect to removing eroded mesh from the urethra with the endoscopic approach. Technical difficulties reported in their study included difficulty in resecting the mesh secondary to encrusted stone material and a failure to apply tension on the mesh during resection.
TEEH is an acceptable option in selected cases. In the present series, urethral tape erosions were excised successfully with a transurethral approach, whereas mesh eroded in the bladder required an open procedure. Although Frenkl et al.  suggested that ‘sutures can most often be managed successfully with endoscopic techniques, whereas mesh is best managed with cystorrhaphy and/or urethroplasty’, we have successfully excised urethral mesh erosions with TEEH, although the eroded mesh that was traversing the submucosal area of the bladder required an open procedure. This patient had a strip of the bladder removed measuring 4 × 2 cm according to the histopathology report. She has recurrence of stress urinary incontinence but felt that the severity was not enough to warrant treatment. The cause of the recurrence of her stress incontinence may be a result of the natural history of the mid-urethral tape; in this case, ‘device failure’ 5 years after insertion. Furthermore, the excision of part of the tape, albeit a short length (4 cm) and at a perivesical site away from the mid-urethra, may disturb the functioning dynamics of the mid-urethral tape.
In this lady with eroded tape into the bladder plus tape embedded in the submucosa, we would now advocate the use of a transurethral resection technique akin to that used in transurethral resection of bladder tumour (Table 1). However for urethral erosions, TEEH is still the preferred method based on our experience.
Advantages of endoscopic excision include a minimally invasive approach and low morbidity. Furthermore, the use of holmium laser has the advantage of precision and excision of the eroded material ‘flush’ to the urethral or bladder mucosa, with minimal risk of injury in trained hands. Urethrotomy carries substantial risks of injury to the urethral sphincter with subsequent stress incontinence and/or fistula formation [10,11]. Despite apparently adequate excision with TEEH, in the present series, recurrence rates were high. Extrusion of the synthetic mesh fibres through the mucosa may be caused by increased mobility of the tissues following excision of the eroded sling, or by the inability to excise the submucosal portion. The majority of them can be managed successfully with repeat laser excision, or expectantly in asymptomatic patients. In general, transurethral endoscopic resection, either by biopsy forceps or by holmium laser, appears potentially less harmful for the urethra.
Given the increased availability and ease of performing mid-urethral sling procedures, urethral erosion is likely to be encountered more often . Prevention of urethral erosions may be achieved by appropriate patient selection, careful dissection of the suburethral tissues, insertion of the sling at the level of the mid-urethra, tension- free adjustment, intra-operative cystourethroscopy to exclude lower urinary tract injury, and the avoidance of urethral dilation in cases of postoperative voiding dysfunction secondary to bladder outlet obstruction.
We acknowledge the limitations of the retrospective study design and the small number of cases in the present series. However, there is limited evidence on the effectiveness of TEEH for this complication, with published data consisting only of case reports or small series (Table 1). For this reason, we consider that the present study may add useful information to the currently available literature on the management, complications and outcomes of the use of the holmium laser for urethral or bladder mesh/suture complications. Prospective multicentre studies with larger numbers of pooled cases and longer follow up are required to further evaluate the success rates of the different methods of endoscopic resection of these complications. Given their complex nature and potentially high morbidity with open urethrotomy, including incontinence and fistula, TEEH appears to be an acceptable first-line minimally invasive approach in appropriately trained hands for the treatment of these cases.