Tension-free vaginal tape (TVT) is a minimally invasive treatment for female stress urinary incontinence (SUI). However, it is not without risks and is associated with a rate of long-term chronic pain of 2% for retropubic TVT and 5.3% for trans-obturator slings(1). Removal of retropubic TVT is performed via a combination of transvaginal and open, laparoscopic-assisted or robot-assisted transabdominal approach. The authors present a case of a retropubic TVT that was unexpectedly found intra-operatively to be incorrectly placed into the obturator fossa during her robot-assisted removal of retropubic TVT.

This is a case report of a 49-year-old lady who presented with a history of dyspareunia and pelvic pain. Her previous surgical history includes laparoscopy and placement of Mirena, laparoscopic-assisted vaginal hysterectomy, insertion of retropubic tension-free vaginal (TVT) tape, anterior and posterior colporrhaphy and sacrospinous fixation. Her symptoms of dyspareunia, suprapubic and vaginal pain started immediately following her pelvic organ prolapse repair and TVT insertion. On examination, she had no significant recurrence of her POP. The retropubic TVT was tender to palpation with no visibly exposed mesh. Urodynamics study revealed detrusor overactivity and bladder outlet obstruction with no recurrent stress urinary incontinence. Transvaginal 3D ultrasound was performed and the TVT appears to be under tension. The ultrasound reported the slings to be positioned more laterally than expected but still identified in the suprapubic region. After informed consent, patient proceeded to a robot-assisted removal of TVT.

Patient was placed in a low lithotomy position with 15 degrees of Trendelenberg. An open vaginal dissection was performed to remove the vaginal portion of the retropubic TVT. Cystoscopy was performed at the beginning to rule out any underlying urethral and bladder erosion. A 14Fr catheter was placed. Inverted U-flap vaginal incision was used. A tight sub-urethral sling was identified, dissected from the urethra and divided in the midline. Each arm of the sling was dissected cephalad towards the endopelvic fascia. Suture was placed to mark the location of the mesh. Standard port-placement for pelvic dissection was used. Da Vinci Xi robotic surgical system was side docked. The video demonstrates the intra-abdominal dissection using a robot-assisted approach. During the dissection it was apparent that the retropubic TVT was incorrectly positioned on the right-hand side. Tracing of the mesh shown the mesh was placed into the obturator internus. The mesh was dissected out to its maximal extent and divided. As this was an unexpected finding, the patient had not consented to a groin dissection for complete removal of the right arm of the mesh. The left arm of the mesh was removed in its entirety and measured to be 18cm in length and a total of 23cm of mesh was removed. The patient had an uneventful post-operative recovery and was discharged day 3 post-operatively. She is awaiting ultrasound and magnetic-resonance imaging (MRI) of the right groin region for mapping of the location of mesh. A groin dissection for completion removal of the TVT mesh will be performed in the event of chronic groin pain associated with the mesh on follow-up.

This video demonstrates a robot-assisted trans-abdominal approach in the removal of an aberrantly placed TVT mesh. This case highlights the variation of retropubic TVT position in patients who present with chronic pain associated with mesh. Pelvic floor (transperineal, transvaginal) ultrasound may not always identify the malposition of the TVT, and MRI may be necessary if suspicious of an incorrectly positioned mesh. The improved visualisation, dexterity and range of motion of a robot-assisted approach was beneficial in the dissection of incorrectly positioned retropubic TVT.

Blaivas JG, Purohit RS, Benedon MS, et al. Safety considerations for synthetic sling surgery. Nat Rev Urol. 2015;12(9):481-509.