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Won Jae Yang, Department of Urology, Soonchunhyang University, Seoul Hospital, 59, Daesagwan-ro, Seoul 140-743, Korea. E-mail: firstname.lastname@example.org
Study Type – Prevalence (prospective cohort)
Level of Evidence 1b
What's known on the subject? and What does the study add?
Managing foreign bodies, including mesh and stones, after anti-incontinence surgery is important because complete removal is necessary to prevent infection and recurrence of stone formation. Traditionally, surgical management of such complications has involved excision using a transurethral approach, with or without a laparoscopic transvesical procedure.
The study shows that mesh complications, including exposure and adherent stones, can be successfully treated and a fast recovery can be achieved using transvesical laparoscopic excision and reconstruction. Transvesical laparoscopy is especially suitable for cases that have a restricted visual field with cystoscopy; the technique allows complete removal of mesh/stones and reconstruction with the help of an excellent visual field.
• To evaluate laparoscopic transvesical excision and reconstruction for the management of vesical mesh or stones around the bladder neck as complications of anti-incontinence intervention.
• To compare the techniques, outcomes and recurrence rates of laparoscopic transvesical excision and reconstruction with published results from studies using laparoscopic transvesical procedures.
PATIENTS AND METHODS
• We conducted a retrospective review of three patients who underwent laparoscopic transvesical excision and reconstruction for vesical mesh and stones around the bladder neck.
• Patients were identified from operating records including recorded video and electronic data records.
• We also conducted a literature review of the available evidence on transvesical laparoscopy for lower urinary tract complications of anti-incontinence procedures.
• Between March 2005 and May 2011, three women underwent laparoscopic transvesical excision and reconstruction. All presented with storage symptoms and gross haematuria. The interval between surgery and the diagnosis of presence of a foreign body was 1–3 years.
• Two women had previously undergone transobturator tape procedures and one had undergone a retropubic procedure.
• Complete excision including the mucosa and muscle layer and reconstruction with intravesical sutures was achieved in all cases.
• Storage symptoms were resolved within 3 days and haematuria was not observed.
• None of the women had recurrent erosion at follow-up.
• Laparoscopic transvesical excision and reconstruction is a technically feasible method.
• This procedure offers excellent visualization of mesh materials and stones, especially in cases of location near the anterior bladder neck.
• In selected patients, laparoscopic transvesical excision and reconstruction is an acceptable technique for first-line treatment of complications of anti-incontinence procedures.
Perforation of the bladder and urethra or erosion of mid-urethral tape mesh after anti-incontinence surgery are not uncommon and have potentially serious complications. Such complications are associated with the use of synthetic material mesh and their incidence ranges from 0.07 to 1.5% [1,2]. Managing foreign bodies, including mesh and stones, after anti-incontinence surgery is important because complete removal is necessary to prevent infection and recurrence of stone formation.
Traditionally, surgical management of such complications has involved excision using a transurethral approach in cases of small tape erosion ; however, in cases of bladder perforation, erosion or stones, various methods have been used including open surgery , transurethral resection  and cystoscopic and laparoscopic combined procedures [6–12]. More recently, transurethral endoscopic excision using a holmium laser  and laparoscopic or single-port transvesical excision have been described [14,15]. The transobturator tape (TOT) procedure is a common surgical treatment for stress urinary incontinence because of its low incidence of complications such as organ injuries ; however, urinary tract injures after TOT procedures have been reported [17,18], typically around the bladder neck and the anterior wall [19,20]. As incomplete excision can cause erosion or stone recurrence and bladder wall scarring, the advantages of laparoscopic transvesical excision are that it achieves complete excision and causes less scarring because of the excellent visualization that it provides.
In the present series, we present our initial experience of laparoscopic transvesical excision and reconstruction for mesh and stones around the bladder neck. The techniques and outcomes are discussed and compared with documented studies that used other laparoscopic procedures.
PATIENTS AND METHODS
This was a retrospective study with a review of case series. From March 2005 to May 2011 five patients presented with an intravesical foreign body resulting from mid-urethral tape mesh. Among them, three patients underwent laparoscopic transvesical excision and reconstruction. Their operating records and electronic data records were reviewed. Data extracted included demographic characteristics, presenting symptoms, ongoing and recurrent symptoms, diagnostic tests, detailed surgical procedures, and outcomes. An electronic database search including Pubmed/Medline (1950–2010) was undertaken using the following terms: ‘endoscopic excision’, ‘bladder’, ‘continence surgery’, ‘laparoscopy’ and ‘mid-urethral slings’.
All three patients were placed in the lithotomy position under general anaesthesia and a 30° operating cystocope was inserted under direct vision. The approach was virtually identical for all patients. For laparoscopic trocars, a radially expanding trocar entry system was applied. After filling the bladder with 300 mL normal saline, a 5-mm VeraStepTM bladeless trocar (Auto-suture, Norwalk, CT, USA) was placed 2 cm above the pubic symphysis using a Veress needle (Auto-suture). Two more 5-mm trocars were placed bilaterally at 3-cm intervals from the initial trocar site. After the saline was drained, the bladder was dilated with carbon dioxide using the trocar site. The pneumovesicum state was maintained at 8–12 mmHg and a 5-mm StrykerTM 30°angle telescope (Stryker, San Jose, CA, USA) was introduced. Using a curved dissector and curved Mayo scissors, the mesh was mobilized from the paravesical tissue and totally removed including the muscle and serosa layer. Interrupted 3/0 vicryl sutures were used to close the defect in a single layer using an Endopath® needle holder (Ethicon Endo-Surgery, Sommerville, NJ, USA). Mesh, with or without adherent bladder stones, was removed through the trocar site using an Endocatch retrieval bag (Auto-suture). The trocar incisions were closed, an 18-F Foley catheter was placed in the bladder, and the surgery was completed.
Five patients who underwent endoscopic treatment of urethra or bladder exposures from March 2005 to May 2011 were identified. The mean (range) age at presentation was 54.6 (48–67) years. The detailed characteristics of these five patients are shown in Table 1. Of the five patients, three underwent laparoscopic transvesical excision and reconstruction. These three patients had mesh exposure around the bladder neck (Fig. 1). Diagnosis was confirmed by cystoscopy (Fig. 2A). One patient had large adherent bladder stones, which were revealed on CT (Fig. 3). The optimum indication of laparoscopic transvesical surgery was the location of mesh around bladder neck and anterior wall. One patient had previously undergone transurethral excision of mesh, which was found to have recurred at the time of diagnosis. The time interval from initial mid-urethral sling surgery was 8–12 months. The main complaints were storage voiding symptoms, including urgency and frequency, and gross haematuria. All of the three patients had a history of recurrent cystitis. Excellent visualization of mesh exposure was possible in all patients (Fig. 2B) and total excision including adherent mucosal and muscle layer was possible (Fig. 2C). Reconstruction with intermittent sutures including mucosa and muscle layer was achieved (Fig. 4A,B). The mean operating time was 75 min. There were no complications during surgery and all patients had an uneventful recovery.
Table 1. Patient characteristics
D, dysuria; GH, gross hematuria; U, urgency; A, anterior wall; BN, bladder neck; LER, laparoscopic excision and reconstruction.
Onset of symptoms, months
Yes, 2 cm
Yes, 1 cm
Type of mid-urethral sling surgery
Recovery of voiding symptoms after operation
Recurrence of erosion or stones
Remnant or recurrence of stress urinary incontinence
The Foley catheter was removed at 3 days after surgery in two patients and at 5 days after surgery in one patient after postoperative cystography. In one patient who needed a longer indwelling Foley catheter (Case 3), the left site 5-mm trocar was substituted with a 12-mm trocar because the patient had large adherent bladder stones and total removal via the trocar site was planned (Fig. 4C).
In all patients, bladder storage symptoms recovered immediately after Foley catheter removal. The interval between the mid-urethral sling placement and surgery was 14–20 months. Follow-up was carried out every 1 month after surgery for the first 3 months and every 3 months thereafter. Follow-up was 5–9 months and there was no recurrence of mesh erosion or stones. Two patients who had persistent stress urinary incontinence to a mild degree were offered additional surgery, but they refused and preferred to undergo conservative therapy.
A literature search identified nine relevant articles about laparoscopic transvesical surgery for mesh, with or without adherent stones, after mid-urethral sling surgery. Details of the procedures, including excision or suturing, site involved, outcomes and recurrence, are given in Table 2[6–12,14,15].
Table 2. Published articles on the laparoscopic transvesical approach for the management of mesh complications
In contrast to tension-free vaginal tape (TVT) surgery, there is little risk of bladder injury with TOT surgery and many surgeons do not recommend intraoperative cystoscopy [16,18]. Nevertheless, several patients have experienced bladder injury after TOT surgery [17,19]. Although theoretically the TOT does not penetrate the retropubic space, the tip of the tunneller can injure the bladder, the bladder neck, or the urethra if its course is misaligned or if placed in an oblique direction .
The involved site of injury or erosion is often located in the anterior bladder wall and bladder neck [19,20], a location that has a limited visual field using cystoscopy. Consequently, evaluation of lesions located in the base or neck of the bladder and the mucosal structures in the diverticulum is difficult . Generally, the 10 o’clock and 2 o’clock positions on the bladder neck have a limited visual field using cystoscopy.
Transobturator tape mesh has a tendency to be located in or near the bladder neck because of its direction of insertion; being more transverse, there is a risk of injury in the posterolateral part of the bladder neck, either during dissection with scissors or during passage of the needle . The present study clearly reflects this scenario as two of the cases involved the posterolateral part of bladder neck and anterior wall.
The clinical presentation of mesh complications after mid-urethral slings includes pain, voiding dysfunction, storage symptoms and recurrent UTIs. In the present series, the major complaints were dysuria with urgency and gross haematuria. Diagnosis is usually confirmed on cysto-urethroscopy, which remains the ‘gold standard’ for identifying mesh complications. In the present series, we used CT and vaginal sonography for detection purposes but these failed to identify the mesh itself. Instead, mesh complications and mesh exposures were confirmed by cysto-urethroscopy.
Various methods have been used to treat mesh complications, including cystoscopic excision, transurethral resection and endoscopic excision with a holmium laser, but incomplete removal or early recurrence requiring additional procedures has been reported [3,23–28]. One reason for this is that cystoscopic scissors typically work well for cutting intravesical sutures but synthetic sling material can be tougher and, without any grasping mechanism, can be difficult to cut with cystoscopic instruments alone.
For complete removal of mesh, an excellent visual field is important. Recently, Huwyler et al.  reported a successful outcome for intravesical mesh using standard transurethral resection. Because complete removal of mesh was possible no recurrence was detected, but it took a long time (>1 month) for recovery of symptoms. To overcome the limited visual field of cystoscopy, intravesical approaches have been applied. Among these, most cases underwent only excision [6–12] but Ingber et al.  and Yoshizawa et al.  reported successful outcomes using single-port and laparoscopic transvesical removal and reconstruction with suturing. We believe that reconstruction with suturing in addition to complete removal is an important factor for fast recovery. In the cases in the present study, complete removal, including the muscle and serosa layer, was possible and full layer intermittent suturing was also feasible. We believe that transvesical laparoscopy with a pneumovesicum approach provided an excellent visual field that was not interrupted by intravesical bleeding during the whole procedure, and was more amenable to the suturing procedure than single-port transvesical laparoscopy.
In conclusion, mesh complications, including exposure and adherent stones, were successfully treated and a fast recovery was achieved using transvesical laparoscopic excision and reconstruction. This technique is especially suitable for cases where cystoscopy provides a restricted visual field as it provides an excellent visual field which facilitates complete removal and reconstruction.