tension - free vaginal tape ( tvt ) is now the treatment of choice for female stress urinary incontinence because of its ease of use , minimal invasiveness , and high success rate .
mesh in the bladder or urethra following midurethral sling has been reported to occur in somewhere between less than 1% to 6% of patients and can result from intraoperative needle penetration or tape erosion [ 2 - 4 ] . even though the trans - obturator tape ( tot ) procedure has less risk of lower urinary tract injury , surgeons should handle with care to prevent this complication .
bladder injury that is recognized during the operation is not usually related to long - term sequelae . however ,
when bladder injury is missed or the mesh erodes into the bladder or urethra , patients might suffer from painful urination , recurrent urinary tract infection , irritative or obstructive symptoms , and hematuria .
since the first case of urethral mesh erosion was reported in 2001 , several case series have provided various techniques to manage this difficult complication [ 7,8 - 10 ] .
intravesical or intraurethral mesh can be removed by open surgery ( cystorrhapy or urethrolysis and urethroplasty ) or endoscopic surgery .
the objective of this study was to determine the efficacy and complication associated with transurethral removal ( tur ) of the intravesical or intraurethral mesh following midurethral sling procedures .
a retrospective chart review was performed for women who had undergone transurethral surgery for bladder or urethral mesh between january 2002 and december 2010 .
a total of 23 consecutive women were identified , and their demographics , midurethral sling procedures , and removal procedures were reviewed .
the surgical outcomes and complications were evaluated . to remove the mesh , transurethral resection with an electrode loop ( tur - e )
was used until march 2010 , when a holmium laser became available in the study center .
thereafter , transurethral resection with a holmium laser ( tur - h ) was performed .
the usual surgical techniques of tur - e and tur - h are described below .
tur - e was performed for 15 women with intravesical mesh and 1 woman with intraurethral mesh . with the patient under spinal anesthesia in the lithotomy position ,
a urethro - cystoscopic exam was performed with a 25 fr resectoscope and a 0 , 30 , and 70 degree telescope .
when the stone was attached to the mesh , lithotripsy was performed with a lithoclast .
the mesh was then resected with an electrode loop until it was not visible or the perivesical fat was reached .
the resected mesh was removed by foreign body forceps . after confirming that no mesh remained in the bladder or urethra a 16 fr foley catheter was inserted and left in place for a median of 6 days ( range , 3 to 29 days ) .
the median operation time was 57 minutes ( 40 to 135 minutes ) , and the median hospital stay was 8 days ( 4 to 36 days ) .
seven patients were treated with the tur - h procedure with a rigid scope : 5 cases of intravesical mesh and 2 cases of intraurethral mesh .
the surgery was similar to that for tur - e except a holmium laser was used .
when the laser could not cut deeply enough and strings or a portion of the mesh remained , the remnant was evaporated by the laser .
the median energy used was 4.3 kj ( range , 0.7 to 14.9 kj ) . after confirming that no mesh remained in the bladder or urethra , a 16 fr foley catheter was inserted and left in place for a median of 1 day ( range , 1 to 2 days ) .
the median operation time was 125 minutes ( range , 30 to 180 minutes ) and the median hospital stay was 4.5 days ( range , 3 to 10 days ) .
three women required concomitant transvaginal surgery for remnant mesh after tur - h : 2 with intravesical mesh and 1 with intraurethral mesh .
a midline vaginal incision was made and submucosal dissection was performed with mezenbaum scissors . after identifying the mesh , it was grasped with kelly forceps and further dissection proceeded toward the exposed side while carefully maintaining traction on the mesh . after exposing the cut edge of the mesh through the vaginal incision , the whole exposed portion of the mesh was resected and removed .
the wound was closed layer - by - layer with 3 - 0 vicryl sutures .
a foley catheter was left in place for a median of 14 days ( range , 6 to 21 days ) .
the median operation time was 215 minutes ( range , 180 to 220 minutes ) and the median hospital stay was 8 days ( range , 6 to 22 days ) .
tur - e was performed for 15 women with intravesical mesh and 1 woman with intraurethral mesh . with the patient under spinal anesthesia in the lithotomy position ,
a urethro - cystoscopic exam was performed with a 25 fr resectoscope and a 0 , 30 , and 70 degree telescope .
when the stone was attached to the mesh , lithotripsy was performed with a lithoclast .
the mesh was then resected with an electrode loop until it was not visible or the perivesical fat was reached .
the resected mesh was removed by foreign body forceps . after confirming that no mesh remained in the bladder or urethra a 16 fr foley catheter
was inserted and left in place for a median of 6 days ( range , 3 to 29 days ) .
the median operation time was 57 minutes ( 40 to 135 minutes ) , and the median hospital stay was 8 days ( 4 to 36 days ) .
1 . seven patients were treated with the tur - h procedure with a rigid scope : 5 cases of intravesical mesh and 2 cases of intraurethral mesh . the surgery was similar to that for tur - e except a holmium laser was used .
when the laser could not cut deeply enough and strings or a portion of the mesh remained , the remnant was evaporated by the laser .
the median energy used was 4.3 kj ( range , 0.7 to 14.9 kj ) .
after confirming that no mesh remained in the bladder or urethra , a 16 fr foley catheter was inserted and left in place for a median of 1 day ( range , 1 to 2 days ) .
the median operation time was 125 minutes ( range , 30 to 180 minutes ) and the median hospital stay was 4.5 days ( range , 3 to 10 days ) .
three women required concomitant transvaginal surgery for remnant mesh after tur - h : 2 with intravesical mesh and 1 with intraurethral mesh .
a midline vaginal incision was made and submucosal dissection was performed with mezenbaum scissors . after identifying the mesh , it was grasped with kelly forceps and further dissection proceeded toward the exposed side while carefully maintaining traction on the mesh . after exposing the cut edge of the mesh through the vaginal incision , the whole exposed portion of the mesh was resected and removed .
the wound was closed layer - by - layer with 3 - 0 vicryl sutures .
a foley catheter was left in place for a median of 14 days ( range , 6 to 21 days ) .
the median operation time was 215 minutes ( range , 180 to 220 minutes ) and the median hospital stay was 8 days ( range , 6 to 22 days ) .
patient demographics and the clinical characteristics of a total of 23 women are described in table 1 according to the removal technique .
sixteen women had the tur - e procedure and 7 women had the tur - h procedure . at the time of surgery , the median age was 51 years ( range , 40 to 67 years ) .
the median period between the midurethral sling and mesh removal was 31.3 months ( range , 2.2 to 247.6 months ) , and the median follow - up period was 2.1 months ( range , 0.3 to 35.9 months ) after mesh removal .
the previous midurethral sling procedures were 11 transobturator slings , 8 retropubic slings , 1 single incision sling , and 3 which were not identified .
most women presented with multiple symptoms , including dysuria , hematuria , and irritative or obstructive urinary symptoms .
table 2 summarizes the preoperative findings , surgical outcomes , and complications for all 23 cases .
overall , 6 women ( 26% ) had a mesh remnant after transurethral surgery : 1 woman ( 6.2% ) after tur - e and 5 women ( 71.4% ) after tur - h .
the woman who had a mesh remnant after tur - e underwent repeat tur - e for the remnant , and no mesh remained on the follow - up cystoscopic exam .
of the 5 women who had remnant mesh after tur - h , 3 underwent concomitant transvaginal removal . on the postoperative cystoscopic exam , 2 women had remnant mesh after tur - h .
one woman had transvaginal removal with no mesh visible on the follow - up cystoscopic exam . in the other woman
she wanted to delay additional treatment for the remaining mesh because she had none of the preoperative symptoms .
two cases of vesico - vaginal fistulas occurred in women treated with tur - e .
one case was found during the tur - e , and the fistula tract was immediately repaired transvaginally .
a foley catheter was placed for 29 days and no sequelae were observed during 9.5 months of follow - up .
the woman experienced continuous urine leakage 7 days after the foley catheter was removed . on the vaginal exam ,
one case of stress incontinence ( stamey grade i ) recurred in a woman who had remaining intraurethral mesh after tur - h .
in this retrospective study , 26% of women ( 6/23 ) had a mesh remnant after transurethral removal of intravesical or intraurethral mesh .
mesh exposure in the bladder or urethra is an uncommon but troublesome complication of midurethral slings .
several authors have described their approaches to this difficult problem , with no consensus on the best approach [ 11 - 16 ] .
frenkl et al proposed a treatment algorithm after reviewing 22 cases of iatrogenic foreign bodies in the bladder and urethra following pelvic floor surgery .
they commented on the technical difficulties of endoscopic resection of the mesh due to the encrusted stone material and the difficulty in applying tension to the mesh during resection .
standard transurethral resection had success rates of 90% to 100% in several case series with a small number of patients [ 7,17 - 19 ] . with the electrode loop
our series also showed a high success rate ( 93.7% [ 15/16 ] ) after the tur - e procedure .
on the contrary , the holmium laser completely removed the mesh in only 28% of women ( 2/7 ) .
doumouchtsis et al reported that 4 of 6 women had recurrent erosion after transurethral resection using a holmium laser .
the holmium laser allows sharp incision of the mesh at the entrance and exit points . however , complete excision is difficult with a rigid cystoscope when the mesh is located in the bladder neck or urethra . of the 3 successful cases of holmium laser excision reported by giri et al , none were in the bladder neck or urethra , and a flexible instrument was used . in the present study ,
the mesh was in the bladder neck or urethra in all 5 cases with mesh remaining after tur - h , and we used a rigid scope .
therefore , we suggest that complete removal of the mesh using tur - h depends on the location of the mesh and the range of motion of the instrument .
another reason for the low success rate after tur - h might be less experience with the technique using holmium laser .
two cases of vesico - vaginal fistulas were found during or after the tur - e procedure . as mentioned above
, one advantage of the electrode loop is that it can resect the mesh down to the submucosal portion .
because damaged urethral or bladder mucosa is atrophic , the risk of perforation may be increased .
a laparoscopic trocar was inserted suprapubically into the bladder under cystoscopic control . under traction and fixation by suprapubically
a disadvantage of this technique is that it requires an additional bladder tract , which can increase the hospital stay and morbidity . to avoid bladder or urethral perforation ,
nevertheless , transurethral resection using an electrode loop for intraurethral mesh might have a higher possibility of urethral perforation or incomplete resection . also , with a holmium laser and rigid scope
the median duration from the manifestation of symptoms to diagnosis was more than 7 months .
the possibility of unrecognized tape perforation or erosion and cystosopic exam should be considered in patients with lower urinary tract symptoms after a midurethral sling procedure .
stress urinary incontinence recurred in 1 woman who had a mesh remnant after tur - h .
she wanted to delay further treatment because the grade was minimal and her preoperative symptom was resolved .
given these results , transurethral resection wolud have a good functional outcome and low risk recurrence of stress incontinence .
however , there are only limited data on the effectiveness of transurethral management for bladder or urethral mesh
. our results can provide information on the outcomes and complications of different transurethral removal techniques and can help physicians to choose the best treatment modality .
transurethral surgery is associated with low morbidity and is familiar to urologists . to remove intravesical or intraurethral mesh after midurethral sling procedures
, tur - e has a high success rate , although it has a high risk of bladder perforation .
in contrast , tur - h has less risk of tissue damage , but complete resection seems to depend on the location of the mesh and the range of motion of the instrument .
the evidence for tur - h is not sufficient to conclude that this is an ineffective method for mesh removal ; however , it should be performed in selected patients .
transurethral resection has good functional outcomes and a low risk of recurrence of stress incontinence .
 purposeto present outcomes of transurethral removal ( tur ) of intravesical or intraurethral mesh after midurethral slings.materials and methodsthis was a retrospective chart review of 23 consecutive women : 20 with intravesical mesh and 3 with intraurethral mesh.resultsto remove the mesh , transurethral resection with an electrode loop ( tur - e ) was used in 16 women and transurethral resection with a holmium laser ( tur - h ) was used in 7 . 
 the median follow - up was 2.1 months . 
 twenty - six percent of the women ( 6/23 ) had a mesh remnant : 6.2% ( 1/16 ) of the women treated with tur - e and 71.4% ( 5/7 ) of the women treated with tur - h . 
 of the 5 women treated with tur - h , 3 underwent concomitant transvaginal removal . on the follow - up cystoscopic exam 
 , a mesh remnant was observed in 3 women ( 1 treated with tur - e and 2 treated with tur - h ) . 
 vesico - vaginal fistulas were found in 2 women during and after tur - e , respectively . 
 stress urinary incontinence recurred in 1 woman.conclusionstur-e has a high success rate but carries a risk of bladder perforation . 
 complete resection using tur - h depends on the location of the mesh and the range of motion of the instrument . 
INTRODUCTION
MATERIALS AND METHODS
1. Transurethral resection with an electrode loop
RESULTS
DISCUSSION
CONCLUSIONS