Midurethral slings (MUS) with a vaginal mesh are an effective treatment modality for SUI with high cure rates ranging from 64–97% at the 10-year follow-up [123]. Despite their efficacy in treating SUI, these meshes can be associated with a range of complications. Of these, 0.4–6.7% of patients developed mesh erosion in a large series [4567]. Of these complications, however, vaginal extrusion was the most common complication. Despite this, there are few reports and case series of mesh erosion into the urinary tract following sling placement published [8910]. The precise pathophysiology associated with mesh erosion is not completely understood [1112]. This paper presents three cases of recurrent urinary tract infections from urethral mesh erosion after transobturator MUS surgery.

A range of factors may influence mesh erosion in the urethra. Factors associated with the pelvic anatomic condition include urogenital atrophy, previous pelvic radiation, prior vaginal surgery, or concomitant procedures, such as hysterectomy and local infection, as well as a high body weight [3111213]. The affecting factors associated with the surgical technique include excessive tensioning of the sling and excessively light placement of the mesh in the urethra [8]. Other possible explanations are a lack of vaginal tissue for coverage of the mesh and improper dissecting near the urethra, which might damage the urethral tissue and its vascularity [11121415]. Direct surgical injury to the urethra has been suspected as the cause of urethral mesh erosion [16].

The rates of UTI vary widely according to the definition of UTI (symptom-based, treatment-based or cultural-based) or surgical procedure performed (transobturator approach or retropubic approach). Moreover, a low incidence of recurrent UTI has been reported in 0.3–6.4% of patients after MUS surgery compared to pelvic organ prolapsed surgery [41718].

Recurrent UTI due to mesh erosion to the urinary tract is not frequent but can be treated effectively by surgical correction. Therefore, it is important to diagnose mesh erosion into the urinary tract in patients with recurrent UTI because that problem can be treated effectively by surgical correction. On the other hand, there are no definite guidelines for evaluating patients with recurrent UTI after MUS surgery. For this reason, the diagnosis of mesh erosion may be delayed in real practical conditions and takes time to reach a diagnosis with mesh erosion into the urethra after recurrent UTI.

When mesh erosion into the urethra is suspected, surgical exploration, resection of the mesh fragments, and tissue defect repair are required. Therefore, proper preoperative localization of the mesh fragments and the detection of erosion are important. In general, urethrocystoscopy is the most important tool for making a diagnosis of mesh erosion into the lower urinary tract [81920]. Noninvasive pelvic ultrasonography may aid in the identification of urethral erosion and the location of the mesh along the length of the urethra. A study showed that translabial ultrasound might be a good imaging tool for mesh localization and erosion detection in 30 symptomatic women for suspected mesh complications [21]. On the other hand, there is a limitation that this study is a small sized pilot study and experienced sonographers should have a good image for mesh localization. In all cases of this study, translabial ultrasound and transvaginal ultrasound was performed after diagnosis with cystoscopy. Cystoscopy was performed for the diagnosis of mesh erosion into the urethra and translabial ultrasound and transvaginal ultrasound for visualization location of the mesh along the urethra and for deciding the surgical approach. Therefore, in patients with a history of incontinence surgery with vaginal mesh, recurrent UTI with gross hematuria, symptoms of unexplained vaginal or suprapubic pain or new-onset urges or stress incontinence, there should be no hesitation to proceed with urethrocystoscopy.

For urethral erosions, transvaginal urethroplasty was performed to remove the urethral mesh. A study reported the long-term results of transurethral endoscopic excision of the urethra using a Holmium laser [22]. In this study, six out of twelve patients were resolved using that procedure: two with multiple procedures. Six patients required a secondary transvaginal approach, including two small urethrovaginal fistulas. If a regular cystoscope is difficult to work with, a pediatric cystoscope can be used with a clamp and/or scissors alongside the scope to access the mesh to cut it. For larger urethral injuries, reconstructive procedures, including urethra-vaginal fistula repair with a Martius flap, may be required.

This paper presents preventive strategies to reduce mesh erosion-related UTI. Initially, to prevent mesh erosion to the urinary tract, urethrocystoscopy is recommended at the conclusion of every procedure, even if it is a TOT procedure. If the urethra is injured during the procedure, the inserted mesh should be removed and the patient should be allowed to heal with catheter drainage. On the other hand, most surgeons do not perform urethrocystoscopy regularly when inserting a TOT, unlike when performing a retropubic approach. In this case, it is suggested that the use of strategies, such as preprocedure catheter placement to help visualize the urethral injury and check for gross hematuria intraoperatively, may aid in the diagnosis of intraoperative urinary tract injury. During the follow-up, it is important to suspect urethral complications if symptoms, such as urgency, voiding dysfunction, recurrent UTIs, or relapse of SUI, occur after sling procedures. Therefore, the authors recommend investigating the complications related to the mesh through the detailed examination, including the urethrocystoscopy in symptomatic patients. In addition, mesh-related complications can occur early or late [2324]. In this study, the time from surgery to the onset of symptoms was 0.3 to 7 years. For this reason, patients with a mesh should have a long-term (more than 10 years) follow-up to monitor for complications or a delayed onset of symptoms [25].

In conclusion, although the precise pathophysiology of urethral mesh erosion is not completely understood, the current case underscores the importance of cystourethroscopy, particularly in situations where the patients present with recurrent symptoms of urinary tract in UTI after the MUS procedure.