Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA.
Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA.
Urology. 2024 Mar;185:e152-e154. doi: 10.1016/j.urology.2023.12.020. Epub 2024 Jan 10.
Depending on the indication, there are multiple surgical approaches for the removal of mid-urethral mesh slings (MUS): transvaginal, endoscopic, open abdominal, and robotic. We demonstrate the robotic approach to treat MUS that have eroded into the bladder. The robotic approach offers excellent exposure, visualization, and accessibility. Compared to endoscopic approaches, the entire arm of the sling can be removed from the bladder wall, the bladder repaired, and the foreign body completely eliminated. Robotic MUS excision is ideal in patients who would be best served by maximal removal of the mesh from the bladder to prevent future complications.
In this video, we display 2 different cases showing 2 unique approaches to robotic MUS excision depending on the location of mesh erosion: 1. If a retropubic sling is eroded through the anterior bladder, we begin by dropping the bladder and entering the space of Retzius to locate the mesh arm. 2. If the sling is eroded into the posterior bladder, a cystotomy is made on the anterior dome to visualize the posterior bladder wall.
Once the mesh is identified, we follow the mesh graft carefully and dissect it away from surrounding tissues. The dissection is immediately close to the mesh, without fragmenting it, to allow for complete excision and protection of adjacent critical structures. The surgical principles and instrument techniques of robotic mesh excision mirror those utilized for transvaginal mesh excision. Complications of this surgical approach include a urinary leak that may require prolonged catheterization or re-operation and recurrent stress urinary incontinence, in addition to typical operative risks.
For treatment of mesh erosion into the bladder, a robotic approach offers excellent visualization, is feasible, and well-tolerated. Compared to fragmenting the mesh using an endoscopic approach, the robotic approach has the advantage of excising the mesh definitively and preventing future recurrences of mesh erosion. Properly selected patients should be offered the robotic approach to mesh excision.
根据适应证的不同，有多种手术入路可用于切除中段尿道网片吊带（MUS）：经阴道、内镜、开腹和机器人。我们展示了机器人入路治疗网片吊带侵蚀入膀胱的方法。机器人入路提供了极好的暴露、可视化和可及性。与内镜方法相比，整个吊带臂可以从膀胱壁上完全切除，修复膀胱，并完全消除异物。机器人 MUS 切除术适用于那些希望最大限度地从膀胱中切除网片以防止未来并发症的患者。
在这个视频中，我们展示了 2 个不同的病例，展示了 2 种根据网片侵蚀位置不同的机器人 MUS 切除的独特方法：1. 如果耻骨后吊带侵蚀穿过前膀胱，我们首先将膀胱放下，进入 Retzius 间隙以定位吊带臂。2. 如果吊带侵蚀入膀胱后壁，在前穹隆行膀胱造口术以观察膀胱后壁。
一旦确定了网片，我们仔细跟踪网片移植物并将其从周围组织中分离。分离立即靠近网片进行，而不会使其碎裂，以实现完全切除并保护相邻的关键结构。机器人网片切除的手术原则和器械技术与经阴道网片切除相同。这种手术方法的并发症包括尿漏，可能需要长时间置管或再次手术，以及复发性压力性尿失禁，除了典型的手术风险外。
对于网片侵蚀入膀胱的治疗，机器人入路提供了极好的可视化效果，是可行的，且患者耐受性良好。与使用内镜方法碎裂网片相比，机器人方法具有明确切除网片并防止未来网片侵蚀复发的优势。应向适当选择的患者提供机器人网片切除术。
