title: Obturator foramen dissection for excision of symptomatic transobturator mesh.
abstract: OBJECTIVE
  Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision.
  
  
  METHODS
  The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery.
  
  
  RESULTS
  Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12).
  
  
  CONCLUSIONS
  Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. william.stuart.reynolds@vanderbilt.edu
authors.forename: W Stuart
authors.initials: WS
authors.lastname: Reynolds
authors.forename: Laura Chang
authors.initials: LC
authors.lastname: Kit
authors.forename: Melissa R
authors.initials: MR
authors.lastname: Kaufman
authors.forename: Mickey
authors.initials: M
authors.lastname: Karram
authors.forename: Gregory T
authors.initials: GT
authors.lastname: Bales
authors.forename: Roger R
authors.initials: RR
authors.lastname: Dmochowski
mesh_terms: D000328:Adult; D000368:Aged; D020878:Device Removal / Q000379:methods*; D005260:Female; D006119:Groin; D006801:Humans; D008875:Middle Aged; D056887:Pelvic Organ Prolapse / Q000601:surgery*; D012189:Retrospective Studies; D053825:Suburethral Slings; D014550:Urinary Incontinence, Stress / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*