The tension free vaginal tape was introduced in 1996 (1) and became the standard surgical approach for women with stress urinary incontinence. Late complications such as urethral erosion can be challenging to manage and the incidence of these complications remains unknown. In this video, we demonstrate a novel technique for managing TVT mesh urethral erosion using combined laparoscopic and vaginal approach, followed by urethral reconstruction and Martius labial flap interposition.

A 54 year old diabetic female presented with voiding dysfunction and recurrence of stress urinary incontinence 12 years after retropubic TVT insertion. Cystoscopy revealed TVT urethral erosion into the upper half, and encrustation on the tape. TVT removal was performed using a combined vaginal and laparoscopic approach. Following catheterisation, an inverted U-shaped vaginal incision was made at the level of the mid urethra. The suburethral mesh was not seen or felt and paraurethral dissection was then performed up to the level of the endopelvic fascia. After routine laparoscopic entry, the retropubic space was opened and both arms of the TVT exposed and dissected from the pubic bone all the way down to the endopelvic fascia. The fascia was then perforated vaginally into the retropubic space with curved clamps, and the TVT arms grasped bilaterally and delivered into the vagina. Using the vaginal approach the TVT mesh was then dissected medially towards the urethra at the sites of erosion bilaterally. The ventral aspect of the urethra remained intact and the tape was removed in its entirety by opening the urethra in the lateral wall at the urethral entry points of the tape. Urethrotomy sites were identified and sutured bilaterally with interrupted Vicryl 3-0 sutures.
 
The left labia majora was then incised and Martius fat pad exposed after dissection of the surrounding fascia using scissors and electrocautery. Blood supply was maintained from the inferior aspect of the flap by preserving a broad inferior vascular pedicle containing blood supply from branches of the pudendal artery. The fat pad was then tunnelled through the left paraurethral space to overlie the urethra and sutured in place with 4 interrupted Vicryl 2-0 to prevent migration. The labia majora was closed in 2 layers. A Foleys catheter remained in situ for 14 days post operatively.

The patient was discharged home after an overnight inpatient stay and with no immediate postoperative complications. At 3 months post operatively the patient reported complete cure of her voiding dysfunction and persistence of the stress incontinence.

Recent controversy has brought mesh insertion and removal into the spotlight. Complications such as erosion into the bladder and urethra are rare but difficult to manage. In this video we demonstrate a novel technique for removing TVT mesh to treat urethral mesh erosion with reconstruction of the urethra. This technique has the advantage of being minimally invasive to minimise urethral damage compared to routine midline urethral incision approach. It also allows the tape to be identified and removed even if the TVT cannot be identified or felt vaginally along with complete TVT mesh removal.

Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anaesthesia for treatment of female urinary incontinence. Int Urogynecol J 1996;7: 81–86.