- Email: [email protected]
Single-port Transvesical Excision of Foreign Body in the Bladder
Surgeon’s Workshop Single-port Transvesical Excision of Foreign Body in the Bladder Michael S. Ingber, Robert J. Stein, Raymond R. Rackley, Farzeen Firoozi, Brian H. Irwin, Jihad H. Kaouk, and Mihir M. Desai OBJECTIVES METHODS
RESULTS CONCLUSIONS
To present a novel technique to remove intravesical polypropylene mesh through a single laparoscopic port placed directly into the bladder. A Triport single-site access system was placed transvesically and carbon dioxide was used for insufflation of the bladder. A combination of straight and articulating laparoscopic instruments was used to dissect the mesh away from the bladder mucosa and transect each end for complete removal of foreign bodies. Mucosal reapproximation was performed on the latter case. Two patients were managed adequately in the outpatient setting. No suprapubic catheters were necessary, and patients were discharged within 23 hours. Removal of foreign bodies of the bladder through a single transvesical laparoscopic port is technically feasible. This procedure offers excellent visualization of mesh material, especially near the bladder neck where these foreign bodies often reside. This approach offers patients a minimally invasive approach through a single small incision. UROLOGY 74: 1347–1350, 2009. © 2009 Elsevier Inc.
M
anaging foreign bodies of the bladder can be difficult, as complete removal is necessary to prevent infection or stone formation. Foreign bodies are often a result of mesh kits that are used for treatment of prolapse or incontinence. These complications may occur during sling placement when trocars are inadvertently passed through the bladder wall, or postoperatively, if the mesh erodes into the bladder. Such injuries may be unrecognized on intraoperative cystoscopy. Alternatively, mesh that is placed either on tension or near to the bladder may erode over time through the bladder wall. Conventionally, removal involves opening the bladder, removing the mesh under direct vision, and placement of a suprapubic tube. Attempts at cystoscopic removal of mesh from midurethral slings may leave residual mesh within the detrusor, which may cause future stone formation, infections, or irritable voiding symptoms. We present a novel technique of removal of foreign bodies of the bladder through a single-port access device placed directly into the bladder.
Raymond R. Rackley is a Meeting Participant/Lecturer in Novartis Pharmaceuticals, Corp, and Consultant and a Meeting Participant/Lecturer in Pfizer, Inc; Mihir M. Desai is a consultant with equity interest in Hansen Medical and is a consultant in Baxter, Inc; and Jihad H. Kaouk is a proctor in Intuitive Surgical. From the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio Reprint requests: Michael S. Ingber, M.D., 9500 Euclid Ave, Q10-1 Cleveland, OH 44195. E-mail: [email protected] Submitted: June 17, 2009, accepted (with revisions): July 14, 2009
© 2009 Elsevier Inc. All Rights Reserved
MATERIAL AND METHODS Patient 1 A 71-year-old woman presented to our office with complaints of urinary frequency and urge incontinence. She had a suprapubic arc (SPARC, American Medical Systems, Minnetonka, MN) retropubic midurethral sling placed 5 years before presentation. She also had complained of frequent urinary tract infections, with 3 culture-proven infections in the year before her office visit. Her urge symptoms had been treated without success with transdermal oxybutynin, solifenacin, and trospium. She denied stress incontinence since her sling was placed. Physical examination was unremarkable, with pelvic examination revealing well-healed nonatrophic vaginal mucosa. Office evaluation included a urinalysis that was also negative. Given her history of the prior mesh sling procedure, as well as persistent irritable voiding symptoms despite anticholinergic medications, she was scheduled for cystoscopy. Cystoscopic evaluation demonstrated a segment of mesh, just inside the bladder neck, at the 2 o’clock position on her left side (Fig. 1A). The mesh had adherent stone formation.
Patient 2 An 83-year-old woman presented to our office with complaints of irritative voiding symptoms. The patient had complaints of de novo urge incontinence that were refractory to conservative medical therapies She underwent a retropubic midurethral synthetic sling 5½ years ago. Her sling had been placed with Stamey needle passers in an antegrade manner, with a 1.1 ⫻ 30 cm strip of polypropylene mesh fashioned by the surgeon. Office evaluation revealed microhematuria. Physical examination was unremarkable. Cystoscopy was performed and demonstrated mesh erosion into the bladder, at the 1 o’clock position near the bladder dome. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.07.1218
1347
Figure 1. (A) Cystoscopic view of patient 1, demonstrating a segment of mesh with calcification just inside the bladder neck. (B) View of the Triport (Advanced Surgical Concepts, Wicklow, Ireland). (C) Curved Maryland forceps and scissors dissecting the bladder away from the polypropylene mesh. (D) Cystoscopic view of the inner ring of the Triport before instrumentation.
SURGICAL MANAGEMENT These patients were taken to the operating room where transvesical removal of the mesh through a single laparoscopic port was performed. The approach for both patients was virtually identical. A suprapubic incision 15 mm in length was made approximately 2 cm above the pubic symphysis for the placement of the single-port access system. For the first patient, this was made in the midline. The second patient had mesh on the right lateral wall of the bladder, further away from the bladder neck. To better visualize this mesh, the incision was made approximately 1.5 cm away from the midline on the patient’s left side. In both the patients, with the bladder maximally distended with saline, a spinal needle visualized through the cystoscope confirmed the direction and location of port placement. A Triport single-port access system (Advanced Surgical Concepts, Ireland) was used for the procedure (Fig. 1B). The port consists of 2 rings that are joined by an adjustable plastic sleeve that serves as a wound retractor. The outer ring is cinched tightly to the skin and contains the 3 channels (2 5 mm and 1 12 mm) as well as an insufflation port. Instruments are passed through elastomeric valves on each of the channels. Carbon dioxide was used through the insufflation valve on the Triport to distend the bladder. An articulating Maryland dissector (Cambridge Endo, Framingham, MA) and conventional laparoscopic endoshears were used to dissect the mucosa away from the mesh (Figs. 1C and D). The dissection was carried out into the perivesical fat and 1348
the mesh was transected on both ends and removed. In the first patient, the bladder defect created from mesh excision was left open. A biological hemostatic agent (FloSeal, Baxter, Deerfield, IL) was placed for hemostatic purposes, and a temporary cellulose cover (Surgicel, Johnson & Johnson Medical, Inc, Arlington, TX), was used for added hemostasis. Efflux was visualized from both ureteral orifices at the completion of the procedure. The port-entry site on the anterior bladder wall was closed under direct vision with 0-vicryl suture in 2 layers. The fascial layer was closed with 0 vicryl, and the skin was closed with 4-0 vicryl suture. A 20F Foley catheter was left for 1 week to allow bladder healing. No suprapubic catheter was placed. The patient was discharged within 23 hours of the surgical procedure. Postoperatively, the patient recovered uneventfully, and her voiding symptoms resolved. However, at 3-month follow-up, cystoscopy demonstrated a small foreign body at the site of the prior resection. This appeared to be a calculus; however, it was immediately dissipated on laser treatment. The bladder mucosa appeared well healed below this, which was thought to be a result of residual FloSeal from her original procedure providing a nidus for stone within the bladder. The second patient had an identical procedure performed. The main difference in presentation was the location of the mesh, being slightly further away from the bladder neck. As in the first patient, an articulating Maryland dissector was used with conventional laparoscopic endoshears performing most of the dissection. AdUROLOGY 74 (6), 2009
Figure 2. Diagram demonstrating difficult angle for cystoscopic resection of mesh. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2009. All Rights Reserved.
ditionally, in the second patient, we elected to reapproximate the mucosa of the bladder defect. A 3-0 vicryl suture was introduced through the 12-mm channel in the Triport, and 2 interrupted stitches were placed in the mucosa using a conventional laparoscopic needle driver through the Triport and a conventional Maryland grasper controlled by an assistant per urethra. This only added a few extra minutes to the procedure and helped with hemostasis. As with the first patient, the bladder was closed under direct vision, and no suprapubic tube was placed.
RESULTS We performed laparoscopic transvesical excision of foreign bodies in the bladder through a single-port access device in 2 patients. Mean age in these patients was 77 years, and they presented with the mesh in the bladder at a mean of 5.25 years after their initial surgery for the stress incontinence. Both of these patients had retropubic synthetic midurethral slings, 1 being a tensionfree vaginal tape and 1 being a self-cut polypropylene sling. Mean body mass index in the patients was 31.55 kg/m2. Mean time of surgery was 113 minutes, with an estimated blood loss of 100 mL. Mean visual analog scale being admitted to the regular surgical floor was 3/10. Length of stay was short in both patients, with a mean stay of 19.25 hours. To date, neither patient has developed any recurrence of mesh erosion at 7 months follow-up. UROLOGY 74 (6), 2009
Figure 3. Illustration showing transvesical placement of the single port into the female bladder. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2009. All Rights Reserved.
COMMENT This is the first reported transvesical approach to removal of a foreign body in the bladder through a single-port access system. Original descriptions of the single-access approach for the urologist were limited to renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy.1 Since then, the laparoscopic surgeon’s armamentarium has expanded to include radical prostatectomy, simple prostatectomy, pyeloplasty, ureteroneocystostomy, and ileal ureter in the single-port approach.2-4 Conventional removal of eroded mesh is often done through a suprapubic cystostomy, with excision of the foreign material and closure of the bladder defect. Reports of cystoscopic removal of bladder foreign bodies are extensive. The published data describes the use of lasers, resectoscopes, and conventional laparoscopic techniques.5-7 In our experience, the holmium laser works well when permanent suture material is found in the bladder from another surgery. In these instances, the stitch can be held on tension by an assistant, while the laser fiber or scissors transect the stitch at its lowest point. After 1349
transaction of the stitch, the residual stitch often retracts deep below the transitional cell layer. In our institution, we use this technique with mesh only when a small strand of polypropylene is visible and if all foreign material can be adequately removed from the bladder. We have also reported our experience with transvaginal removal of mesh in the bladder because of prolapse repair.8 However, most of these had eroded through the base of the bladder near the trigone. In our first case, because of the acute angle required to visualize the exit sites of the mesh, we felt this would not be adequately treated endoscopically with a laser (Fig. 2). Additionally, because the mesh was located in a more lateral and anterior position, we felt transvaginal excision would not be feasible. The transvesical approach provided excellent direct visualization of the mesh and allowed a small (1.5 cm) incision in the bladder. The second patient had mesh located in a more accessible position cystoscopically. However, we felt that to completely resect all mesh into the detrusor, endoscopic management would not have been appropriate. Since the introduction of the Triport and other singlesite access systems, patients now have the option of a minimally invasive approach to managing complications of vaginal surgeries. This approach is most useful for patients with a small amount of mesh within the bladder, when extraperitoneal dissection is not required. The natural exposure created by insufflation of the bladder provides a large working space, with excellent visualization (Fig. 3). Relative contraindications include mesh located near the bladder dome or previous retropubic surgery. Such patients might be better suited with an open suprapubic or transvaginal approach.
1350
To our knowledge, this is the initial report of single incision access for excision of a foreign body, but the number of patients is small. As instrumentation evolves and experience with this approach grows, additional studies will be essential to identify benefits when compared with conventional open surgery.
CONCLUSIONS Laparoscopic transvesical removal of foreign bodies of bladder through a single-port approach is technically feasible. This procedure provides patients with a minimally invasive approach, through a single, small incision. References 1. Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic Surgery in urology: initial experience. Urology. 2008;71:3-6. 2. Kaouk JH, Goel RK, Haber GP, et al. Single-port laparoscopic radical prostatectomy. Urology. 2008;72:1190-1193. 3. Desai MM, Aron M, Canes D, et al. Single-port transvesical simple prostatectomy: initial clinical report. Urology. 2008;72:960-965. 4. Desai MM, Stein R, Rao P, et al. Embryonic natural orifice transumbilical endoscopic Surgery (E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73:182-187. 5. Feiner B, Auslander R, Mecz Y, et al. Removal of an eroded transobturator tape from the bladder using laser cystolithotripsy and cystoscopic resection. Urology. 2009;73:681e:15-681:e16. 6. Jung US, Lee JH, Kyung MS, et al. Laparoscopic removal of an intravesical foreign body after laparoscopically assisted vaginal hysterectomy: a case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2008;18:420-422. 7. Feiner B, Auslender R, Mecz Y, et al. Removal of an eroded transobturator tape from the bladder using laser cystolithotripsy and cystoscopic resection. Urology. 2009;73:681e:15-681:e16. 8. Frenkyl TL, Rackley RR, Vasavada SP, et al. Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor Surgery. Neurourol Urodyn. 2008;27:491-495.
UROLOGY 74 (6), 2009
RESULTS CONCLUSIONS
To present a novel technique to remove intravesical polypropylene mesh through a single laparoscopic port placed directly into the bladder. A Triport single-site access system was placed transvesically and carbon dioxide was used for insufflation of the bladder. A combination of straight and articulating laparoscopic instruments was used to dissect the mesh away from the bladder mucosa and transect each end for complete removal of foreign bodies. Mucosal reapproximation was performed on the latter case. Two patients were managed adequately in the outpatient setting. No suprapubic catheters were necessary, and patients were discharged within 23 hours. Removal of foreign bodies of the bladder through a single transvesical laparoscopic port is technically feasible. This procedure offers excellent visualization of mesh material, especially near the bladder neck where these foreign bodies often reside. This approach offers patients a minimally invasive approach through a single small incision. UROLOGY 74: 1347–1350, 2009. © 2009 Elsevier Inc.
M
anaging foreign bodies of the bladder can be difficult, as complete removal is necessary to prevent infection or stone formation. Foreign bodies are often a result of mesh kits that are used for treatment of prolapse or incontinence. These complications may occur during sling placement when trocars are inadvertently passed through the bladder wall, or postoperatively, if the mesh erodes into the bladder. Such injuries may be unrecognized on intraoperative cystoscopy. Alternatively, mesh that is placed either on tension or near to the bladder may erode over time through the bladder wall. Conventionally, removal involves opening the bladder, removing the mesh under direct vision, and placement of a suprapubic tube. Attempts at cystoscopic removal of mesh from midurethral slings may leave residual mesh within the detrusor, which may cause future stone formation, infections, or irritable voiding symptoms. We present a novel technique of removal of foreign bodies of the bladder through a single-port access device placed directly into the bladder.
Raymond R. Rackley is a Meeting Participant/Lecturer in Novartis Pharmaceuticals, Corp, and Consultant and a Meeting Participant/Lecturer in Pfizer, Inc; Mihir M. Desai is a consultant with equity interest in Hansen Medical and is a consultant in Baxter, Inc; and Jihad H. Kaouk is a proctor in Intuitive Surgical. From the Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio Reprint requests: Michael S. Ingber, M.D., 9500 Euclid Ave, Q10-1 Cleveland, OH 44195. E-mail: [email protected] Submitted: June 17, 2009, accepted (with revisions): July 14, 2009
© 2009 Elsevier Inc. All Rights Reserved
MATERIAL AND METHODS Patient 1 A 71-year-old woman presented to our office with complaints of urinary frequency and urge incontinence. She had a suprapubic arc (SPARC, American Medical Systems, Minnetonka, MN) retropubic midurethral sling placed 5 years before presentation. She also had complained of frequent urinary tract infections, with 3 culture-proven infections in the year before her office visit. Her urge symptoms had been treated without success with transdermal oxybutynin, solifenacin, and trospium. She denied stress incontinence since her sling was placed. Physical examination was unremarkable, with pelvic examination revealing well-healed nonatrophic vaginal mucosa. Office evaluation included a urinalysis that was also negative. Given her history of the prior mesh sling procedure, as well as persistent irritable voiding symptoms despite anticholinergic medications, she was scheduled for cystoscopy. Cystoscopic evaluation demonstrated a segment of mesh, just inside the bladder neck, at the 2 o’clock position on her left side (Fig. 1A). The mesh had adherent stone formation.
Patient 2 An 83-year-old woman presented to our office with complaints of irritative voiding symptoms. The patient had complaints of de novo urge incontinence that were refractory to conservative medical therapies She underwent a retropubic midurethral synthetic sling 5½ years ago. Her sling had been placed with Stamey needle passers in an antegrade manner, with a 1.1 ⫻ 30 cm strip of polypropylene mesh fashioned by the surgeon. Office evaluation revealed microhematuria. Physical examination was unremarkable. Cystoscopy was performed and demonstrated mesh erosion into the bladder, at the 1 o’clock position near the bladder dome. 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.07.1218
1347
Figure 1. (A) Cystoscopic view of patient 1, demonstrating a segment of mesh with calcification just inside the bladder neck. (B) View of the Triport (Advanced Surgical Concepts, Wicklow, Ireland). (C) Curved Maryland forceps and scissors dissecting the bladder away from the polypropylene mesh. (D) Cystoscopic view of the inner ring of the Triport before instrumentation.
SURGICAL MANAGEMENT These patients were taken to the operating room where transvesical removal of the mesh through a single laparoscopic port was performed. The approach for both patients was virtually identical. A suprapubic incision 15 mm in length was made approximately 2 cm above the pubic symphysis for the placement of the single-port access system. For the first patient, this was made in the midline. The second patient had mesh on the right lateral wall of the bladder, further away from the bladder neck. To better visualize this mesh, the incision was made approximately 1.5 cm away from the midline on the patient’s left side. In both the patients, with the bladder maximally distended with saline, a spinal needle visualized through the cystoscope confirmed the direction and location of port placement. A Triport single-port access system (Advanced Surgical Concepts, Ireland) was used for the procedure (Fig. 1B). The port consists of 2 rings that are joined by an adjustable plastic sleeve that serves as a wound retractor. The outer ring is cinched tightly to the skin and contains the 3 channels (2 5 mm and 1 12 mm) as well as an insufflation port. Instruments are passed through elastomeric valves on each of the channels. Carbon dioxide was used through the insufflation valve on the Triport to distend the bladder. An articulating Maryland dissector (Cambridge Endo, Framingham, MA) and conventional laparoscopic endoshears were used to dissect the mucosa away from the mesh (Figs. 1C and D). The dissection was carried out into the perivesical fat and 1348
the mesh was transected on both ends and removed. In the first patient, the bladder defect created from mesh excision was left open. A biological hemostatic agent (FloSeal, Baxter, Deerfield, IL) was placed for hemostatic purposes, and a temporary cellulose cover (Surgicel, Johnson & Johnson Medical, Inc, Arlington, TX), was used for added hemostasis. Efflux was visualized from both ureteral orifices at the completion of the procedure. The port-entry site on the anterior bladder wall was closed under direct vision with 0-vicryl suture in 2 layers. The fascial layer was closed with 0 vicryl, and the skin was closed with 4-0 vicryl suture. A 20F Foley catheter was left for 1 week to allow bladder healing. No suprapubic catheter was placed. The patient was discharged within 23 hours of the surgical procedure. Postoperatively, the patient recovered uneventfully, and her voiding symptoms resolved. However, at 3-month follow-up, cystoscopy demonstrated a small foreign body at the site of the prior resection. This appeared to be a calculus; however, it was immediately dissipated on laser treatment. The bladder mucosa appeared well healed below this, which was thought to be a result of residual FloSeal from her original procedure providing a nidus for stone within the bladder. The second patient had an identical procedure performed. The main difference in presentation was the location of the mesh, being slightly further away from the bladder neck. As in the first patient, an articulating Maryland dissector was used with conventional laparoscopic endoshears performing most of the dissection. AdUROLOGY 74 (6), 2009
Figure 2. Diagram demonstrating difficult angle for cystoscopic resection of mesh. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2009. All Rights Reserved.
ditionally, in the second patient, we elected to reapproximate the mucosa of the bladder defect. A 3-0 vicryl suture was introduced through the 12-mm channel in the Triport, and 2 interrupted stitches were placed in the mucosa using a conventional laparoscopic needle driver through the Triport and a conventional Maryland grasper controlled by an assistant per urethra. This only added a few extra minutes to the procedure and helped with hemostasis. As with the first patient, the bladder was closed under direct vision, and no suprapubic tube was placed.
RESULTS We performed laparoscopic transvesical excision of foreign bodies in the bladder through a single-port access device in 2 patients. Mean age in these patients was 77 years, and they presented with the mesh in the bladder at a mean of 5.25 years after their initial surgery for the stress incontinence. Both of these patients had retropubic synthetic midurethral slings, 1 being a tensionfree vaginal tape and 1 being a self-cut polypropylene sling. Mean body mass index in the patients was 31.55 kg/m2. Mean time of surgery was 113 minutes, with an estimated blood loss of 100 mL. Mean visual analog scale being admitted to the regular surgical floor was 3/10. Length of stay was short in both patients, with a mean stay of 19.25 hours. To date, neither patient has developed any recurrence of mesh erosion at 7 months follow-up. UROLOGY 74 (6), 2009
Figure 3. Illustration showing transvesical placement of the single port into the female bladder. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2009. All Rights Reserved.
COMMENT This is the first reported transvesical approach to removal of a foreign body in the bladder through a single-port access system. Original descriptions of the single-access approach for the urologist were limited to renal cryotherapy, wedge kidney biopsy, radical nephrectomy, and abdominal sacrocolpopexy.1 Since then, the laparoscopic surgeon’s armamentarium has expanded to include radical prostatectomy, simple prostatectomy, pyeloplasty, ureteroneocystostomy, and ileal ureter in the single-port approach.2-4 Conventional removal of eroded mesh is often done through a suprapubic cystostomy, with excision of the foreign material and closure of the bladder defect. Reports of cystoscopic removal of bladder foreign bodies are extensive. The published data describes the use of lasers, resectoscopes, and conventional laparoscopic techniques.5-7 In our experience, the holmium laser works well when permanent suture material is found in the bladder from another surgery. In these instances, the stitch can be held on tension by an assistant, while the laser fiber or scissors transect the stitch at its lowest point. After 1349
transaction of the stitch, the residual stitch often retracts deep below the transitional cell layer. In our institution, we use this technique with mesh only when a small strand of polypropylene is visible and if all foreign material can be adequately removed from the bladder. We have also reported our experience with transvaginal removal of mesh in the bladder because of prolapse repair.8 However, most of these had eroded through the base of the bladder near the trigone. In our first case, because of the acute angle required to visualize the exit sites of the mesh, we felt this would not be adequately treated endoscopically with a laser (Fig. 2). Additionally, because the mesh was located in a more lateral and anterior position, we felt transvaginal excision would not be feasible. The transvesical approach provided excellent direct visualization of the mesh and allowed a small (1.5 cm) incision in the bladder. The second patient had mesh located in a more accessible position cystoscopically. However, we felt that to completely resect all mesh into the detrusor, endoscopic management would not have been appropriate. Since the introduction of the Triport and other singlesite access systems, patients now have the option of a minimally invasive approach to managing complications of vaginal surgeries. This approach is most useful for patients with a small amount of mesh within the bladder, when extraperitoneal dissection is not required. The natural exposure created by insufflation of the bladder provides a large working space, with excellent visualization (Fig. 3). Relative contraindications include mesh located near the bladder dome or previous retropubic surgery. Such patients might be better suited with an open suprapubic or transvaginal approach.
1350
To our knowledge, this is the initial report of single incision access for excision of a foreign body, but the number of patients is small. As instrumentation evolves and experience with this approach grows, additional studies will be essential to identify benefits when compared with conventional open surgery.
CONCLUSIONS Laparoscopic transvesical removal of foreign bodies of bladder through a single-port approach is technically feasible. This procedure provides patients with a minimally invasive approach, through a single, small incision. References 1. Kaouk JH, Haber GP, Goel RK, et al. Single-port laparoscopic Surgery in urology: initial experience. Urology. 2008;71:3-6. 2. Kaouk JH, Goel RK, Haber GP, et al. Single-port laparoscopic radical prostatectomy. Urology. 2008;72:1190-1193. 3. Desai MM, Aron M, Canes D, et al. Single-port transvesical simple prostatectomy: initial clinical report. Urology. 2008;72:960-965. 4. Desai MM, Stein R, Rao P, et al. Embryonic natural orifice transumbilical endoscopic Surgery (E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73:182-187. 5. Feiner B, Auslander R, Mecz Y, et al. Removal of an eroded transobturator tape from the bladder using laser cystolithotripsy and cystoscopic resection. Urology. 2009;73:681e:15-681:e16. 6. Jung US, Lee JH, Kyung MS, et al. Laparoscopic removal of an intravesical foreign body after laparoscopically assisted vaginal hysterectomy: a case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2008;18:420-422. 7. Feiner B, Auslender R, Mecz Y, et al. Removal of an eroded transobturator tape from the bladder using laser cystolithotripsy and cystoscopic resection. Urology. 2009;73:681e:15-681:e16. 8. Frenkyl TL, Rackley RR, Vasavada SP, et al. Management of iatrogenic foreign bodies of the bladder and urethra following pelvic floor Surgery. Neurourol Urodyn. 2008;27:491-495.
UROLOGY 74 (6), 2009