Midurethral slings (MUS) are considered the mainstay treatment for stress urinary incontinence (SUI), due to high efficacy with relatively low intra and/or postoperative complication rates.
A recent large cohort study found that the overall rate of sling removal was 3.3% at 9 years(1). The risk of removal was high in those who had retropubic slings. Long term complications, such as sling exposure, erosion are relatively low. However, rare cases of bladder, thigh, prepubic and pelvic abscess, were described. 

We present an unusual case of MUS mesh exposure followed by mons pubis abscess formation occurring 18 years post-op.
The aim of our presentation is to:
1.	Be aware of these rare long-term complications of MUS, as well as the unusual clinical presentation.  
2.	Describe the clinical and surgical approach for removal of sling which was inadvertently inserted superficially to the pubic bone.

A 75-year-old woman, presented with a gradual swelling of her mons-pubis followed by pain, and ongoing PV bleeding, with a history of MUS. Physical examination revealed a palpable, not fluctuant mass, tender to touch, extending about 10-15cm from the mons pubis to the right labia. There was a 2X2cm mesh exposure in the vagina. Ultra-sound scan described a pre-pubic arm of the TVT on the right side (Figure 1). We assumed that at the insertion of the sling the trocar diverted from the intended retropubic path to the prepubic route.
A vaginal approach was undertaken: Physical examination has revealed area of 2X2cm exposed mesh at the mid-urethral area. A 15X4cm mass was palpated on the mons pubis, extending to the right labia.
Area of the vaginal mesh dissected inwards and upwards on its route toward the pubic arch. This could only be reached a depth of 4cm. Therefore, an incision of 5cm created over the labia to reach the superficial edge of the capsule. Further dissection defined the superior border of the capsule and the top edge of the sling. The cavity of the capsule entered and pus was drained. The loose sling was identified and it snapped at its midway to the vagina just on the symphysis bone.  The vaginal end of the sling was clamped and pulled downwards, allowing to identify its end which was adherent to the front end of the pubic symphysis. A sharp and blunt dissection resulted in a complete loosening of the inferior part of the right arm of the sling. The dead space was closed in several layers. The skin was closed as well and a labial draining tube was left. The exposed infected mesh at the mid-urethral site was dissected off and the underlying tissue was closed in layers. A repeated cystoscopy was done at the conclusion of the surgery and an indwelling-catheter and vaginal pack were inserted. The removed sling is seen in Figure 2.

Postoperatively: the surgical site was found with minimal swelling, minimal pain. 
IDC and pack removed the following day and the patient had a successful trial-of-void and no further PV loss. 
The patient was covered with intravenous antibiotics for 2 days followed by 7 days of oral antibiotics. 
6 weeks post-operatively: Surgical sites healed well, no SUI, and no mesh exposure.

1.	Although relatively rare, long term complications of MUS should be considered and recognized.
2.	A thorough medical history, physical examination, and imaging are crucial for planning strategy treatment.
3.	Vaginal approach for mesh removal is a safe method and should be practised in tertiary hospitals by experienced surgeons. 
4.	Patients should be informed on the possibility of being incontinent after sling removal.

JAMA. 2018;320(16):1659–1669. doi:10.1001/jama.2018.14997