Under general anesthesia , the patient is placed in the dorsal lithotomy position, and the vagina and abdomen are prepped and draped in standard fashion. Retrograde pyelograms may be performed to rule out ureteral involvement. If no ureteral involvement is noted, temporary bilateral open-ended ureteral stents are inserted. One percent lidocaine with 1:200,000 epinephrine mixture is infiltrated under the vaginal skin and an inverted U-shaped incision is made. The vaginal wall is dissected to create an inverted U-flap, which serves as the final layer of closure for the repair [in cases where there is a vesico-vaginal fistula (VVF) closer to the vaginal apex a true (noninverted) U-flap is created with the bottom of the U at the VVF site] (Fig. 12.1a). Dissection of the vaginal skin is performed laterally from the U-flap towards the pelvic sidewall (Fig. 12.1b). When only a small area of mesh has eroded into the bladder, the remainder may be found relatively superficially under the vaginal wall. If a substantial volume of mesh has eroded into the bladder, the mesh may not be as easy to find and the detrusor muscle may need to be incised vertically in the area of the mesh (which can be determined with cystoscopic guidance) until one comes across it. A right angle clamp can be used to mobilize the mesh off the bladder in the midline (Fig. 12.1c). An incision is made in the midline of the mesh after which the lumen of the bladder is visible (Fig. 12.1d). Any remaining overlying tissues (superficial to the mesh) are bluntly and sharply dissected. By grasping on the midline (incised edge) of the mesh and pulling laterally, the bladder wall underneath the mesh is carefully peeled off using both sharp and blunt dissection. If there is a fistula present, it can be seen in its entirety at this point (Fig. 12.1e). The mesh is incised as far laterally as feasible and removed (Fig. 12.1f). The ureteral catheters can be both palpated and visualized. The mucosal layer is re-approximated using 3-0 absorbable suture taking care to stay medial to the ureteral catheters. The detrusor layer is then closed in two layers using 2-0 vicryl suture (Fig. 12.1g). The anterior vaginal wall is closed with 2-0 vicryl suture (Fig. 12.1h). Although not mandatory, the open-ended ureteral stents can be replaced with JJ ureteral stents to prevent any potential ureteral obstruction from inflammation and edema involving the bladder. A vaginal packing is placed and an 18 French Foley catheter is left per urethra.

Another option for removal of mesh perforation of the bladder would be a transabdominal approach. A Pfannenstiel incision is made in the lower abdomen. The incision is carried down to the level of the rectus fascia using electrocautery. The rectus fascia is incised transversely and the space of Retzius is entered. The bladder is filled via the indwelling Foley catheter to aid in identification. The bladder is then bivalved with a vertical incision using electrocautery. The mesh can now be visualized. The incision is carried down to the mesh. Bladder flaps are now created lateral to the body of the mesh. The mesh is then excised. The vaginal wall is closed using 2-0 absorbable suture . A portion of omentum may be mobilized and placed as an interposition graft between the vagina and bladder. The bladder is then closed in two layers with 2-0 absorbable suture. A vaginal packing is placed and an 18 French Foley catheter is left per urethra .

Under general endotracheal anesthesia , the patient is placed in the jackknife position, the perineum and buttocks are prepped and the rectum is cleaned with betadine irrigation. A Hill Ferguson retractor is placed to aid in visualization (Fig. 12.2). Mucosal flaps are developed around the exposed mesh. The mesh is then dissected off of the underlying rectal wall and excised. The mucosal flaps are closed with vicryl suture.

Occasionally, a patient will note pain near the fornix and one can palpate a tense arm of mesh at that spot. In such cases, division of the mesh arm may ameliorate the patient’s symptoms. Under IV sedation and local or general anesthesia palpate the arm of interest, inject lidocaine with epinephrine in the vaginal wall overlying it, incise through the vaginal skin at that site, identify and dissect out the mesh arm and then cut it and close the vaginal skin.