Surgical Management of Groin Abscess and Urethral Mesh Erosion in a Patient with a Vaginal Mesh

Objectives: To highlight an unusual presentation of a transvaginal mesh complication and describe its surgical management.

Methods: The patient described in this video is a 53-year-old P0 with a medical history of sickle cell disease, beta thalassemia, and myasthenia gravis presented with right groin pain and abscess in the setting of sickle cell crisis. She previously underwent transvaginal hysterectomy, vaginal prolapse repair, and presumed sling at an outside institution but was uncertain of the exact procedure performed. MRI was concerning for groin abscess with possible fistulous communication to the vagina due to a presumed infection of transobturator sling mesh. However, vaginal examination did not demonstrate a vaginal fistula. Office cystoscopy confirmed urethral mesh erosion. Once in the operating room, cystoscopy and dissection of the space demonstrated a mesh erosion into the urethra with an epithelialized fistulous tract extending bilaterally to the medial thighs. On further examination, there were two mesh arms extending into the obturator foramen on either side. Right groin dissection was performed to ensure complete mesh excision as one of the arms was well-incorporated and removed in pieces. The dissection was kept minimally invasive without incising any muscles and a probe was used to follow the entire tract of the mesh. The mesh was able to be excised almost entirely, with the exception of small right proximal fibers that were embedded into the muscle. Examination of the mesh revealed that it was a Prolift vaginal mesh rather than a transobturator sling. Curettage of the fistulous tracts was performed and the urethral defect was repaired in 2 layers and confirmed to be water tight. A cystocele repair added an additional layer of support to the repair followed by closure of the vaginal epithelium. The patient was discharged home with a transurethral catheter and antibiotics. She was doing well at 6 months postoperative.

Clinical Relevance: Mesh complications may have variable presentations and occur years following the index surgery. Mastery of pelvic and medial thigh anatomy and precision of surgical technique are essential to ensuring all mesh material is removed in cases of infection.