Open, laparoscopic and robotic mesh sacrocolpopexy procedures are commonly considered in the repair of vaginal vault prolapse. Tensioning the mesh and degree of pull on the vaginal vault is generally difficult to control in a patient in Trendelenburg position, not counting the natural retraction of the mesh material itself during the healing period. Therefore, although secondary complications such as mesh exposure have been long recognized, accessing them can be hard at times  because of their high apical locations, frequently in a recessed area of the vagina on the left or right side, and often times associated with a transfixing non-absorbable suture. Complete removal of such an exposed vaginal mesh segment in a tented-up vaginal cuff after open or robotic mesh sacrocolpopexy represents a challenge for complete removal.  We report on a technique of localized treatment with Holmium laser to avoid a repeat abdominal approach.

Based on our experience with Holmium laser of exposed mesh in the bladder and urethra (1), and given the very narrow and limited access of this right vaginal corner, we attempted a holmium lasering under cystoscopic guidance. Under anesthesia, the 17,5 Fr female scope with a 365 micron laser fiber inside a 5 Fr open ended ureteral catheter was used to gradually laser the exposed mesh fibers. The holmium laser used a setting of 0,8 Joule and 10 Herz, with continuous fluid irrigation to maintain adequate visualization. Even with clear fibers, the scope resolution was very good and resulted in complete mesh ablation. At the completion of the 15 minute procedure, the area was freed of mesh material and no bleeding was noted.

This report illustrates the case of a 51 y old with complaints of vaginal pain and recurrent bleeding. The MRI indicates a very long and verticalized vagina (TVL 14 cm) pulled up by a mesh secured to the promontory (figure 1). There was no evidence of mesh infection, bladder or bowel loops adjacent to the mesh, and the original operative note indicated that the mesh was retroperitonealized. The patient failed a prior apparently successful vaginal attempt at excising this exposed mesh transvaginally.  Some mesh material was found exposed again at 3 months after this vaginal procedure during office vaginoscopy with a flexible scope advanced up to her narrow right upper vaginal corner. Following  holmium laser treatment demonstrated in this video, a repeat vaginoscopy 3 months later confirmed complete vaginal healing with no mesh resurfacing, and no residual symptoms, specifically no pain and return to sexual activity with no dyspareunia or bleeding.

Conventional methods to remove vaginal mesh exposure at the vaginal apex after mesh sacrocolpopexy include vaginal excision, and seldom open or repeat robotic repairs. Vaginal anatomy can be distorted after mesh sacrocolpopexy with some apex tented-up and hard to reach, despite proper long instrumentations and retracting tools. Given our experience with Holmium lasering of exposed mesh in the bladder and urethra, we chose this last resort approach in a patient who ultimately failed a seemingly successful vaginal mesh excision procedure. This technically simple solution to a vexing problem may be of assistance to reconstructive surgeons dealing with mesh exposure complications. A pre-operative imaging study like an MRI is key to ensure no adjacent organs and the laser must be delivered on the mesh surface and not penetrating into the tissues, like with Holmium.

Exposed mesh vaginally in a high and narrow location can be treated with a rigid cystoscopy and Holmium laser in a manner similar to mesh exposure in the urinary system.

Wang, C. et al. LUTS 2018