Synthetic midurethral sling surgery remains a gold standard therapy for treatment of female stress urinary incontinence.  While uncommon, full thickness mesh exposure through the vaginal wall occurs in approximately 0% to 4.4% of cases, with mesh exposure rates at follow-up slightly higher in transobturator slings compared to the retropubic approach [1].  Vaginal wall mesh exposure may occur in the early postoperative period or in a delayed fashion.  If symptomatic, patients can present with vaginal bleeding, discharge, pain, or partner dyspareunia.  Management strategies typically include observation and topical estrogen cream for asymptomatic or small mesh exposures, respectively.  For symptomatic and/or larger areas of exposure, operative intervention either by creation vaginal flaps overlying the exposed segment or partial mesh excision can be performed.

The patient is a 41-year-old female s/p retropubic synthetic midurethral sling placement three months ago at an outside facility.  She recently noticed what felt like suture material on self-examination and reported partner discomfort during intercourse.  Physical examination revealed an approximately 1 cm area of exposed synthetic sling in the midline anterior vaginal wall with mild tenderness to palpation.  There were no additional areas of exposed mesh on pelvic exam.  Given the above findings, the patient was counseled on treatment options and elected for in-office transvaginal excision under local anesthesia.

Local anesthesia using 1% lidocaine with epinephrine is administered along the anterior vaginal wall. The area of exposed mesh is clamped in the midline, and fine-tipped scissors free up the mesh from the underlying vaginal tissue. Dissection is performed directly on the mesh using Metzenbaum scissors. The mesh is dissected bilaterally in order to create healthy vaginal epithelial flaps and trace the mesh away from the incision.  The exposed mesh segment is then incised in the midline using a #15-blade scalpel.  Further dissection directly on the mesh is extended laterally to allow for sharp excision approximately 1.5-2 cm away from the midline.  A similar technique is completed on the contralateral side using a combination of sharp and blunt dissection with the surgeon's digit to fully isolate the mesh arm from excision.  The incision is copiously irrigated and hemostasis confirmed.  Palpation of the remnant mesh arms can be felt several centimeters laterally from the midline incision on each side.  The incision is then closed using a running, locked 2-0 Vicryl suture.  Final inspection reveals a hemostatic vaginal vault and no residual exposed mesh.

Successful in-office partial mesh excision is dependent on the location of the mesh, patient tolerance to the procedure, and surgeon experience.  In our experience, partial mesh excision under local anesthesia is a feasible option for select patients, such as those without a significantly elevated BMI and exposed mesh fully accessible on exam in the office setting.  At 4-month postoperative follow-up, the patient reported continued complete resolution in her symptoms and no recurrent stress urinary incontinence.

Goldman, HB. Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology), 2nd Ed., 2017