Combined Cystoscopic and Vaginal Removal of a Malplaced Single-Incision Midurethral Sling

INTRODUCTION: Sling malplacement into the bladder is an uncommon complication following midurethral sling (MUS) placement for stress urinary incontinence. Bladder injury rates vary by surgical technique, ranging from 3.6% to 10.1% with retropubic sling placement, 0.2% to 0.7% with transobturator sling placement, and 0% to 0.85% with single-incision placement. Usually, these injuries are detected on cystotomy after placement and are treated conservatively with simple removal and replacement. If not seen on cystotomy, however, exposed mesh in the bladder can cause more serious complications including recurrent UTI, bladder stones, hematuria and chronic bladder pain and overactive bladder symptoms. OBJECTIVE: The objective of this video is to demonstrate a combined cystoscopic (using holmium laser) and vaginal approach for the removal of a single-incision MUS that was malplaced through the bladder and became exposed through the vaginal mucosa. METHODS: The video was recorded during the surgical management of a patient with a single-incision MUS that had been incidentally placed through the bladder and had also become exposed through the vaginal mucosa. A combined cystoscopic and transvaginal approach was employed using a holmium laser to excise the mesh and overlying stone within the bladder followed by removal of the exposed sling segment via a vaginal incision. Key operative steps were edited and annotated for emphasis. The primary author narrated the video, which was created using CapCut. RESULTS: The exposed sling mesh and bladder stone were successfully removed using a combined cystoscopic and vaginal approach. The vaginally exposed mesh was also successfully removed. Cystoscopy demonstrated complete intravesicular removal and a water-tight closure. CONCLUSIONS: This surgical video highlights key steps in the management of complex MUS excisions for the rare complications of mesh malplacement and exposure. The utility of a cystoscopic approach using holmium laser ablation combined with vaginal excision of the mesh is demonstrated. This approach minimizes morbidity by reducing the required vaginal dissection without compromising the thoroughness of mesh removal.