Evaluation of holmium laser for managing mesh/suture complications of continence surgery.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Traditionally, surgical management of mesh/suture erosions has involved excision through a transvaginal or endoscopic approach for urethral erosions, and a transabdominal approach (open or laparoscopic) for bladder exposures. In the majority of published studies, urethral erosions appear to be a complication of retropubic mid-urethral sling insertion, with incidence rates in the range 0.03-0.8%. The present study confirms that transurethral endoscopic management has low morbidity, good functional outcomes and potentially low rates of recurrent stress incontinence. Urethral tape erosions were excised successfully with a transurethral approach, whereas mesh eroded in the bladder required an open procedure. OBJECTIVES • To evaluate transurethral endoscopic excision using the holmium laser (TEEH) for the management of lower urinary tract mesh or suture complications of continence intervention. • To compare the outcomes, complications and recurrence rates of TEEH with the published results from studies using other techniques. PATIENTS AND METHODS • A retrospective review of six patients who underwent TEEH for eroded mid-urethral tape or suture into the urethra or bladder. • Patients with urethral and bladder exposure of mesh or suture material managed by TEEH were identified from the operating records, electronic data records and the Holmium Laser Registry at our institution. • Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis, voiding dysfunction and recurrent stress incontinence. • A literature review on the available evidence on holmium laser for lower urinary tract complications of continence surgery was undertaken. RESULTS • Between September 2006 and March 2010, six women underwent TEEH. All presented with bladder storage symptoms and/or haematuria with recurrent cystitis. The interval between surgery and the diagnosis of erosion was 1-13 years. • Four women had previously undergone retropubic mid-urethral tape, one colposuspension and one a suprapubic arc procedure followed by a transobturator tape insertion. • Complete excision with TEEH was achieved in all cases. • Two women had postoperative haematuria, which resolved after 2 weeks. There were no other immediate complications. • Four patients had recurrent erosion at follow-up. Two of them were symptomatic, requiring repeat TEEH. One was asymptomatic and managed expectantly. In one case, recurrent mesh erosion occurred at the bladder neck in the submucosal layer. This was considered unsuitable for further TEEH. A laparotomy and open excision was undertaken. CONCLUSIONS • TEEH is a minimally invasive technique, with minimal morbidity and complications, compared to open vaginal or abdominal excision of mesh or suture exposure into the lower urinary tract. Open urethrotomy involves risks of damage to the continence (sphincter) mechanism, with subsequent stress incontinence. In addition, anterior wall scarring may lead to dyspareunia, vaginal pain, urethral stricture and/or fistula. When mesh erosion involves the bladder, transabdominal open or laparoscopic excision may be required. • Although the recurrence rates in our series are high, the majority of them were managed easily by repeat TEEH, with minimal morbidity or expectantly if asymptomatic. • In selected patients, TEEH is an acceptable novel technique for the first-line management of this complication of continence interventions, although longer or pooled prospective studies evaluating TEEH are now required. [ABSTRACT FROM AUTHOR]