What is the recommended treatment for an eroded urethral sling that has calcified into the bladder?

Management of Eroded Urethral Sling with Calcification into the Bladder

Complete surgical removal of the eroded and calcified sling is required, with the specific approach determined by the degree of calcification and location of erosion. 1, 2

Diagnostic Confirmation

• Cystoscopy is mandatory to visualize the extent of mesh erosion into the bladder and assess the degree of calcification 3, 4, 1
• Plain radiography (KUB X-ray) will demonstrate the calcified mesh at the bladder neck level 2
• Cross-sectional imaging (CT or ultrasound) should be obtained to evaluate the full extent of erosion and rule out abscess formation or sepsis 3
• Review the original operative report to identify sling type (TVT vs TOT), location, and tension applied during placement 3, 4

Surgical Management Algorithm

Step 1: Initial Stone/Calcification Management

If significant calcification is present (as in your case), initial urethroscopic laser fragmentation or disintegration of the calcified material is required before mesh removal. 1, 2

• This was necessary in 18% of erosion cases in recent series 1
• Electrocautery knife or laser can be used to fragment the calcified mesh endoscopically 2

Step 2: Definitive Mesh Removal

The approach depends on erosion location and extent:

For Urethral/Bladder Neck Erosions:

• Endoscopic transurethral resection should be attempted first in selected cases with accessible erosions 5, 6
• Complete resection of mesh using electrocautery or laser is performed 2, 5
• This minimally invasive approach was successful in 77% of bladder/urethral erosions as first-line therapy 6
• However, 42% required a second surgery due to re-exposure of mesh, so patients must be counseled about this risk 6

For Failed Endoscopic Approach or Extensive Erosions:

• Transvaginal sling removal with formal urethral repair is required 1, 5
• 86% of patients with urethral erosion required formal urethral repair and indwelling catheter 1
• Alternative: Extraperitoneal laparoscopic approach for high urethral erosions near bladder neck 7

Step 3: Post-Removal Management

• Indwelling urethral catheter for 2-3 weeks to allow urethral healing 3, 1
• Wait 3-6 months before considering any replacement incontinence procedure 3
• All patients should be counseled that UTI symptoms will resolve, but 71% will develop recurrent stress incontinence requiring further intervention 1, 6

Critical Pitfalls to Avoid

• Do not use synthetic mesh for any future incontinence surgery in this patient - synthetic sling is absolutely contraindicated after urethral erosion 3, 8
• Do not attempt conservative management - complete removal is mandatory for eroded calcified mesh 3, 1
• Do not proceed with single-stage revision - the waiting period of 3-6 months is essential to allow tissue healing and reduce infection risk 3

Future Incontinence Management (After Healing Period)

If the patient develops recurrent stress incontinence after mesh removal:

• Autologous fascial pubovaginal sling is the preferred option given the history of urethral surgery and erosion 3
• Bulking agents may be considered for patients who wish to avoid another major surgery 3
• Artificial urinary sphincter has limited role but may be considered in severe cases 3