Surgeon’s Corner
ajog.org
A technique of laparoscopic mesh excision from the bladder after sacrocolpopexy Dimitri Sarlos, MD; Thomas Aigmueller, MD; Gabriel Schaer, MD
Problem: mesh associated complications after laparoscopic sacrocolpopexy The 2011 Food and Drug Administration notification about complications of vaginal mesh surgery prompted a worldwide increase in interest in laparoscopic sacrocolpopexy. Several series have demonstrated the feasibility and safety of laparoscopic sacrocolpopexy with a follow-up of up to 5 years.1-4 However, complications such as mesh erosion into the bladder can occur, even years after initial surgery. It is well known that mesh surgery can cause complications. Vaginal, abdominal (laparoscopic and robot assisted) mesh surgery does have risks such as mesh exposure, protrusion into organs, pain, and dyspareunia that often necessitate a surgical intervention.5 Because the use of laparoscopic sacrocolpopexy for pelvic organ prolapse is likely to increase further in the coming years,6 the urogynecology community should be aware of these complications and should be able to treat them. Our solution Over the last 10 years, we have seen and treated 7 patients with mesh erosions
Several series have demonstrated the feasibility, safety, and efficacy of laparoscopic sacrocolpopexy. Nonetheless, complications such as mesh erosion into the bladder can occur years after primary surgery, with accidental cystotomy during the primary operation appearing to be a risk factor for later mesh erosion. Over the last 10 years, we have treated 7 patients with mesh erosion into the bladder after laparoscopic sacrocolpopexy using a technique of transvesical laparoscopic partial excision of the eroded mesh. None of these 7 patients developed recurrent erosions, fistulas, or recurrent prolapse. The video demonstrates laparoscopic excision of intravesical mesh in a patient 5 years after laparoscopic sacrocolpopexy. Key steps are opening the bladder to grasp and dissect the eroded mesh; partial resection of the mesh with formation of a bladder flap; and closure of the bladder. Laparoscopy appears to be a useful tool for the treatment of this problem. Because many urogynecology units around the world have now begun to perform laparoscopic sacrocolpopexy, urogynecologists should be aware of these complications and how to treat them. The video is intended to help and encourage centers performing laparoscopic transvesical excision of mesh eroded into the bladder after sacrocolpopexy. Key words: complications of laparoscopic sacrocolpopexy, laparoscopic sacrocolpopexy, laparoscopic transvesical mesh removal, mesh erosion Cite this article as: Sarlos D, Aigmueller T, Schaer G. A technique of laparoscopic mesh excision from the bladder after sacrocolpopexy. Am J Obstet Gynecol 2015;212:403.e1-3.
into the bladder with partial removal of the mesh via a transvesical laparoscopic approach. None of the 7 patients
developed recurrent mesh erosion, fistulas, recurrent prolapse, or functional problems so we consider the transvesical
FIGURE 1
Grasping of the eroded mesh
From the Department of Obstetrics and Gynecology, Kantonsspital Aarau, Aarau, Switzerland (Drs Sarlos and Schaer), and Department of Obstetrics and Gynecology Medical University of Graz, Graz, Austria (Dr Aigmueller). Received June 17, 2014; revised Aug. 10, 2014; accepted Sept. 3, 2014. The authors report no conflict of interest. Corresponding author: Dimitri Sarlos, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.09.007
Click Supplementary Content under the article title in the online Table of Contents
The eroded part of the mesh into the bladder is grasped and excised after laparoscopic cystotomy. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
MARCH 2015 American Journal of Obstetrics & Gynecology
403.e1
Surgeon’s Corner FIGURE 2
Partial resection of subvesical mesh
Partial resection of the mesh, which is located under the mobilized posterior bladder wall, is performed to prevent recurrence of mesh erosion. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
FIGURE 3
Reconstruction of the bladder
Bladder closure is performed with laparoscopic preplaced interrupted sutures in a single layer. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
403.e2 American Journal of Obstetrics & Gynecology MARCH 2015
ajog.org laparoscopic approach to this problem to be feasible and safe. This Video Clip demonstrates a technique of laparoscopic transvesical removal of a polypropylene mesh erosion into the bladder in a patient 5 years after laparoscopic sacrocolpopexy. Preoperative cystoscopy is used to determine the location of the mesh erosion and its proximity to the ureteral orifices and to plan the cystotomy for the excision procedure. We advise always to put ureteral stents for the following 2 reasons. In our experience, it is not possible to define by cystoscopy alone the margins of the bladder wall and mesh resection. Sometimes it is necessary to resect a part of the bladder wall that is near the bladder base, even if the eroded mesh is identified cystoscopically distant to the bladder base. Often during laparoscopy a much larger erosion into the muscular layer of the bladder is identified, which was not suspected by cystoscopy. The second reason for ureteral stenting is the fact that for good closure of the bladder, a sufficient portion of the bladder wall must be taken with the needle. This could lead to accidental suturing of the intramural part of the ureter. With ureteral stenting, you realize an accidental intraureteral stitch by moving the stent as demonstrated in the video. Usually the stents are removed at the end of the procedure. If some damage to the ureter occurs intraoperatively, then the stents are removed 6 weeks after surgery. Laparoscopic ports are placed according to the patient’s anatomy and to provide good access to the bladder and the vaginal cuff. Usually the camera trocar is placed at the umbilicus and three 5 mm ports are placed in the lower abdomen (one in the lower left quadrant, one in the lower right quadrant about 4 cm from the anterior superior iliac spine, and one in the midline between the symphysis and the umbilicius). The first step is the identification of the polypropylene mesh from its attachment at the promontory down to the vaginal cuff. The bladder is filled with 200 mL and opened in the midline at its dome with the scissors. Any
Surgeon’s Corner
ajog.org bleeding points are coagulated. The eroded part of the mesh is identified and grasped (Figure 1). A full-thickness resection of the bladder wall around the area of the erosion is performed to obtain healthy margins for the healing of the bladder wall. The bladder is mobilized from the anterior vaginal wall to create a mobile bladder flap for later tension free closure of the bladder. The mesh located under the mobilized bladder wall is completely removed. Figure 2 shows the resection of the mesh under the bladder flap. We believe that this is an important step to prevent recurrent erosion. The bladder wall is reconstructed and closed with interrupted laparoscopic sutures in a single layer. We usually use Vicryl 2-0. Figure 3 shows the bladder closure with preplaced interrupted sutures.
Attention is paid not to impinge the intravesical part of the ureter or the ureteral orifices. The respective ureteral stent can be moved gently back and forth as the sutures are tied to rule out impingement of the ureter. After the closure is completed, the bladder is filled to 300 mL to exclude leakage. The Foley catheter is then opened and removed after 7-10 days. We consider the laparoscopic approach useful for this kind of surgery because of the optimal vision and exposure, minimal tissue trauma, and good outcome. REFERENCES 1. Sarlos D, Brandner S, Kots L, Gygax N, Schaer G. Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome—a prospective study with 101
cases. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1415-22. 2. Maher CF, Feiner B, DeCuyper EM, Nichlos CJ, Hickey KV, O’Rourke P. Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: a randomized trial. Am J Obstet Gynecol 2011;204:360. e1-7. 3. Anger JT, Mueller ER, Tarnay C, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5-12. 4. Sarlos D, Kots L, Ryu G, Schaer G. Long term follow-up of laparoscopic sacrocolpopexy. Int Urogynecol J 2014;25:1207-12. 5. Abbott S, Unger CA, Evans JM, et al. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study. Am J Obstet Gynecol 2014;210:163.e1-8. 6. Jonsson Funk M, Edenfield AL, Pate V, Visco AG, Weidner AC, Wu JM. Trends in use of surgical mesh for pelvic organ prolapse. Am J Obstet Gynecol 2013;208:79. e1-7.
MARCH 2015 American Journal of Obstetrics & Gynecology
403.e3
ajog.org
A technique of laparoscopic mesh excision from the bladder after sacrocolpopexy Dimitri Sarlos, MD; Thomas Aigmueller, MD; Gabriel Schaer, MD
Problem: mesh associated complications after laparoscopic sacrocolpopexy The 2011 Food and Drug Administration notification about complications of vaginal mesh surgery prompted a worldwide increase in interest in laparoscopic sacrocolpopexy. Several series have demonstrated the feasibility and safety of laparoscopic sacrocolpopexy with a follow-up of up to 5 years.1-4 However, complications such as mesh erosion into the bladder can occur, even years after initial surgery. It is well known that mesh surgery can cause complications. Vaginal, abdominal (laparoscopic and robot assisted) mesh surgery does have risks such as mesh exposure, protrusion into organs, pain, and dyspareunia that often necessitate a surgical intervention.5 Because the use of laparoscopic sacrocolpopexy for pelvic organ prolapse is likely to increase further in the coming years,6 the urogynecology community should be aware of these complications and should be able to treat them. Our solution Over the last 10 years, we have seen and treated 7 patients with mesh erosions
Several series have demonstrated the feasibility, safety, and efficacy of laparoscopic sacrocolpopexy. Nonetheless, complications such as mesh erosion into the bladder can occur years after primary surgery, with accidental cystotomy during the primary operation appearing to be a risk factor for later mesh erosion. Over the last 10 years, we have treated 7 patients with mesh erosion into the bladder after laparoscopic sacrocolpopexy using a technique of transvesical laparoscopic partial excision of the eroded mesh. None of these 7 patients developed recurrent erosions, fistulas, or recurrent prolapse. The video demonstrates laparoscopic excision of intravesical mesh in a patient 5 years after laparoscopic sacrocolpopexy. Key steps are opening the bladder to grasp and dissect the eroded mesh; partial resection of the mesh with formation of a bladder flap; and closure of the bladder. Laparoscopy appears to be a useful tool for the treatment of this problem. Because many urogynecology units around the world have now begun to perform laparoscopic sacrocolpopexy, urogynecologists should be aware of these complications and how to treat them. The video is intended to help and encourage centers performing laparoscopic transvesical excision of mesh eroded into the bladder after sacrocolpopexy. Key words: complications of laparoscopic sacrocolpopexy, laparoscopic sacrocolpopexy, laparoscopic transvesical mesh removal, mesh erosion Cite this article as: Sarlos D, Aigmueller T, Schaer G. A technique of laparoscopic mesh excision from the bladder after sacrocolpopexy. Am J Obstet Gynecol 2015;212:403.e1-3.
into the bladder with partial removal of the mesh via a transvesical laparoscopic approach. None of the 7 patients
developed recurrent mesh erosion, fistulas, recurrent prolapse, or functional problems so we consider the transvesical
FIGURE 1
Grasping of the eroded mesh
From the Department of Obstetrics and Gynecology, Kantonsspital Aarau, Aarau, Switzerland (Drs Sarlos and Schaer), and Department of Obstetrics and Gynecology Medical University of Graz, Graz, Austria (Dr Aigmueller). Received June 17, 2014; revised Aug. 10, 2014; accepted Sept. 3, 2014. The authors report no conflict of interest. Corresponding author: Dimitri Sarlos, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.09.007
Click Supplementary Content under the article title in the online Table of Contents
The eroded part of the mesh into the bladder is grasped and excised after laparoscopic cystotomy. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
MARCH 2015 American Journal of Obstetrics & Gynecology
403.e1
Surgeon’s Corner FIGURE 2
Partial resection of subvesical mesh
Partial resection of the mesh, which is located under the mobilized posterior bladder wall, is performed to prevent recurrence of mesh erosion. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
FIGURE 3
Reconstruction of the bladder
Bladder closure is performed with laparoscopic preplaced interrupted sutures in a single layer. Sarlos. Laparoscopic intravesical mesh removal. Am J Obstet Gynecol 2015.
403.e2 American Journal of Obstetrics & Gynecology MARCH 2015
ajog.org laparoscopic approach to this problem to be feasible and safe. This Video Clip demonstrates a technique of laparoscopic transvesical removal of a polypropylene mesh erosion into the bladder in a patient 5 years after laparoscopic sacrocolpopexy. Preoperative cystoscopy is used to determine the location of the mesh erosion and its proximity to the ureteral orifices and to plan the cystotomy for the excision procedure. We advise always to put ureteral stents for the following 2 reasons. In our experience, it is not possible to define by cystoscopy alone the margins of the bladder wall and mesh resection. Sometimes it is necessary to resect a part of the bladder wall that is near the bladder base, even if the eroded mesh is identified cystoscopically distant to the bladder base. Often during laparoscopy a much larger erosion into the muscular layer of the bladder is identified, which was not suspected by cystoscopy. The second reason for ureteral stenting is the fact that for good closure of the bladder, a sufficient portion of the bladder wall must be taken with the needle. This could lead to accidental suturing of the intramural part of the ureter. With ureteral stenting, you realize an accidental intraureteral stitch by moving the stent as demonstrated in the video. Usually the stents are removed at the end of the procedure. If some damage to the ureter occurs intraoperatively, then the stents are removed 6 weeks after surgery. Laparoscopic ports are placed according to the patient’s anatomy and to provide good access to the bladder and the vaginal cuff. Usually the camera trocar is placed at the umbilicus and three 5 mm ports are placed in the lower abdomen (one in the lower left quadrant, one in the lower right quadrant about 4 cm from the anterior superior iliac spine, and one in the midline between the symphysis and the umbilicius). The first step is the identification of the polypropylene mesh from its attachment at the promontory down to the vaginal cuff. The bladder is filled with 200 mL and opened in the midline at its dome with the scissors. Any
Surgeon’s Corner
ajog.org bleeding points are coagulated. The eroded part of the mesh is identified and grasped (Figure 1). A full-thickness resection of the bladder wall around the area of the erosion is performed to obtain healthy margins for the healing of the bladder wall. The bladder is mobilized from the anterior vaginal wall to create a mobile bladder flap for later tension free closure of the bladder. The mesh located under the mobilized bladder wall is completely removed. Figure 2 shows the resection of the mesh under the bladder flap. We believe that this is an important step to prevent recurrent erosion. The bladder wall is reconstructed and closed with interrupted laparoscopic sutures in a single layer. We usually use Vicryl 2-0. Figure 3 shows the bladder closure with preplaced interrupted sutures.
Attention is paid not to impinge the intravesical part of the ureter or the ureteral orifices. The respective ureteral stent can be moved gently back and forth as the sutures are tied to rule out impingement of the ureter. After the closure is completed, the bladder is filled to 300 mL to exclude leakage. The Foley catheter is then opened and removed after 7-10 days. We consider the laparoscopic approach useful for this kind of surgery because of the optimal vision and exposure, minimal tissue trauma, and good outcome. REFERENCES 1. Sarlos D, Brandner S, Kots L, Gygax N, Schaer G. Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome—a prospective study with 101
cases. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1415-22. 2. Maher CF, Feiner B, DeCuyper EM, Nichlos CJ, Hickey KV, O’Rourke P. Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: a randomized trial. Am J Obstet Gynecol 2011;204:360. e1-7. 3. Anger JT, Mueller ER, Tarnay C, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014;123:5-12. 4. Sarlos D, Kots L, Ryu G, Schaer G. Long term follow-up of laparoscopic sacrocolpopexy. Int Urogynecol J 2014;25:1207-12. 5. Abbott S, Unger CA, Evans JM, et al. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study. Am J Obstet Gynecol 2014;210:163.e1-8. 6. Jonsson Funk M, Edenfield AL, Pate V, Visco AG, Weidner AC, Wu JM. Trends in use of surgical mesh for pelvic organ prolapse. Am J Obstet Gynecol 2013;208:79. e1-7.
MARCH 2015 American Journal of Obstetrics & Gynecology
403.e3
