Transvaginal Removal of Synthetic Midurethral Sling: Watch How It’s Done (Video)

It is estimated that 10 to 20 percent of women will undergo a surgical procedure for stress urinary incontinence (SUI) in their lifetime. The synthetic midurethral sling is considered the current gold-standard surgical treatment for SUI.

Urethral complications due to synthetic midurethral sling are uncommon (0.4 to 4 percent). Causes of urethral perforation after synthetic midurethral sling include unrecognized intraoperative entry into the urethra or excessive sling tension, which may lead to erosion over time. Currently, there is no consensus as to the surgical management of urethral complications. If urethral perforation occurs, transvaginal and endoscopic removals are options. Flaps may or may not be used, and surgeons are divided on the feasibility and safety of concomitant incontinence procedures such as a pubovaginal sling. An individualized approach is used based on patient presentation and surgeon expertise.

In this video, urological surgeon Howard Goldman, MD, of Cleveland Clinic’s Glickman Urological & Kidney Institute demonstrates the pre-procedure patient evaluation and surgical technique of transvaginal sling removal from the urethra and concomitant urethral reconstruction. The patient as a 66-year-old woman with a history of anterior and posterior colporrhaphy and a retropubic, midurethral sling 12 years prior. The patient reported difficulty voiding since the time of the surgery, saying that she had to stand and bend over in order to urinate. Physical exam revealed tenderness to palpation of the anterior vaginal wall and no mesh extrusion.

In the past, she had undergone three prolapse repairs, the last one in 2005 with a concomitant vaginal hysterectomy. During an outpatient cystourethroscopy, the bladder was normal, but there was a urethral perforation distal to the bladder neck, and her urodynamics were consistent with obstruction.

The surgery was the subject of a presentation at the American Urological Association’s 2016 annual meeting.