Urinary incontinence (UI) effects up to 40% of women, while SUI (Stress Urinary Incontinence) is prevalent in at least half of them. Polypropylene tension-free vaginal tapes are highly successful and commonly used to treat that problem. Tension-free vaginal tapes can be placed retropubicly or throw the obturator membrane. Trans-obturator sling (TOT) is inserted through the obturator membrane and placed under the urethra in the mid-urethral portion to provide support for the weak endopelvic fascia to prevent leakage of urine associated with physical activities, sneezing, or coughing.
The complications are voiding dysfunction, urinary retention, and urethral obstruction after sling placement, affecting 3% of women. DeNovo urgency incontinence may affect 6% of women, and mesh erosion (as delayed complications) in 2-4% of women. The sling can be obstructive due to ingrowth, scarring, and inflammation.
In this video, we present the technics for removal of TOT.

To maximize visualization and exact placement of the sling, we place a localization needle in the sling under ultrasound guidance. A urethral manipulator or a Kelly is used to finding the area of urethral obstruction

For maximal visualization, a reverse U incision was made. Once the sling has been located, it is undermined to isolate it from the urethra. Since the sling can retract once cut, a double clamp with heavy clamps such as Heaney on each side is recommended. Afterward, the sling is cut in the middle. Sharp and blunt dissection is used to isolate the sling. For removal of the arms or the anchors, we employ several methods: 
1.	The hole at the tip of a small Babcock clamp can be used to bluntly clear the tissue as the sling is followed to the obturator membrane
2.	A nasal speculum can be used to visualize the sling insertion into the obturator membrane
Since the initial sling placement is due to SUI, we use Kelly plication stitches that can be placed in the bilateral Pubourethal ligaments using two 2.0 PDS sutures for urethral support minimizing the risk of occult urinary incontinence. In the cases of combined intrinsic sphincter deficiency and mesh complications, we advocate concurrent placement of an autologous pubourethral sling rather than a repeat mesh sling.

Removal or revision of a sling tape/mesh requires experience and specific methodologic steps. We recommend doing so with the help of a transurethral instrument and ultrasound. For easier dissection of the sling from surrounding deep endopelvic tissue, we recommend using a Babcock clamp or a nasal speculum.

Shobeiri, S.A. ed., 2018. The Innovation and Evolution of Medical Devices: Vaginal Mesh Kits. Springer
Shobeiri, S.A. ed., 2014. Practical pelvic floor ultrasonography: a multicompartmental approach to 2D/3D/4D ultrasonography of pelvic floor. Springer Science & Business Media
Manonai, Jittima, et al. "Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications." Neurourology and urodynamics 35.3 (2016): 407-411

Continence 2S2 (2022) 100490
DOI: 10.1016/j.cont.2022.100490