Comment
Earlier this year, all mesh sling and mesh kits were banned from the UK following the Cumberlage report. We should all support the Cumberlage banning of mesh sheets, but not slings1,2 . I write as the co-inventor of the midurethral sling1 (MUS)] to present the historical and other scientific data which supports retention of the MUS. Slings work very differently from mesh sheets. They create new collagen to strengthen the ligaments which suspend the organs, fig1. A tape placed along the anatomical pathway of the pubourethral ligament “PUL”, fig1 cures stress urinary incontinence (SUI) by restoring the urethral closure mechanisms1,2 ,3. The same methodology holds for slings in other ligaments4. A multicentre trial of 616 women4 demonstrated convincingly that mesh sheets are not required to cure major prolapse. Liedl et al reported 90% cure of vaginal prolapse (mostly 3rd or 4thdegree) at 12 months using slings ONLY to repair cardinal and uterosacral ligaments. Vaginal herniations were re-attached, not excised. There were complications, some major, and erosion rates of 0-3%. However, there was a singular absence of the massive urine loss and nerve pain entrapments seen in the mesh sheet operations which develop the “Tethered Vagina” syndrome by fibrosis of the vagina5,6.
Mesh sheets restore neither structural anatomy nor function. They are an ill-proven initiative which relies on blocking descent of the organs. A simple transperineal ultrasound will prove that the prolapse is still there, behind the mesh. The mesh sheets fibrose the vagina, removing the elasticity required for normal bladder function3. Unlike the MUS, mesh sheets placed behind vagina had little testing prior to commercial release and can cause major de novo complications such as massive urine loss from “tethered vagina syndrome”5,6 or nerve entrapment due to mesh shrinkage. Such complications are rarely, if ever, seen with MUS.1,2,4,6
There are many worrying aspects of the Cumberlege report as regards the MUS. Absent from the report is one critical detail: Cumberlage does not differentiate between slings and mesh sheets applied behind vagina, which are a very different technology from slings.
The science for ligament support of organs is well accepted. Ligaments are fundamental to Delancey’s 1992 thesis of organ support, based on his extensive anatomical studies7. The 1990 thesis of Petros and Ulmsten , based on extensive animal and human studies1-4,6,8, emphasizes the role of collagen as the key structural component of ligaments; also emphasized is that the vagina requires elasticity for its role in bladder control