Long-term results of transurethral endoscopic excision using the holmium laser for urethral perforation of synthetic slings

Objective: This study reports on the long-term results of transurethral endoscopic excision using the Holmium laser (TEEH) for large urethral perforation (UP; defined as involving one-quarter or more of the urethral circumference) from synthetic slings. Methods: Charts of women treated with TEEH for large UP were reviewed. TEEH was performed using a 365-μm laser fiber passed inside an open-ended ureteral catheter positioned in a holmium laser enucleation of the prostate (HoLEP) sheath to stabilize the laser fiber. Data extracted included patient demographics, clinical presentations, surgical details, postoperative functional outcomes and complications, and any secondary repairs. Results: From 2011 to 2016, 12 women underwent TEEH. The mean interval between sling placement and first TEEH was 47 months (range 10–161 months). The types of slings included transvaginal tape (n = 2), transobturator tape (n = 4), mini-invasive (n = 4), and Solyx (1), or were not specified (n = 1). The mean number of TEEH procedures was 1.6 (range 1–3), and the mean length of initial treatment was 40 min (range 15–79 min), with subsequent treatments <30 min. Mean follow-up time was 43 months (range 14–70). Resolution of UP by TEEH alone was achieved in 6 patients, with 2 requiring multiple TEEH. Six patients underwent secondary vaginal mesh sling excision alone or with an associated repair including 2 small distal urethrovaginal fistulas. Conclusion: TEEH is a minimally invasive procedure that can avoid a more complex initial urethral reconstruction and should be considered for treating large UP. Secondary repairs for residual small UP or associated lower urinary tract symptomatology may be necessary and patients should be counseled accordingly.