**8.2 Procedures for placement of the self-fashioned mesh**

The bladder neck is identified by gently pulling the Foley catheter. The anterior vaginal wall is incised in the midline from the proximal urethra to the apex of the vaginal cuff or cervix (for patients whose uterus is preserved). At the level of the proximal urethra, a tunnel underneath the pubourethral ligament is created on each side of the urethra to reach the insertion of the ligament. The vaginal mucosa layer is undermined from the fibromuscular layer of the anterior vaginal wall on each side to reach the lateral point of insertion into the paravaginal fascia. The retropubic space (Retzius space) is not entered during the dissection of the paravaginal fascia.

A Stamey needle is introduced through the suprapubic incision (less than 5 mm each side), passed blindly through the retropubic space along the posterior surface of the pubic bone (retropubis; avoiding resistance from bones and the bladder wall) (Figure 3), until the needle tip is advanced to the ventral aspect of the pubourethral ligament. The needle tip is advanced laterally along the posterior aspect of the pubis into the tip of the tunnel that was created before and passed through this fibromuscular layer (Figure 4). The 1-0 Vicryl suture is threaded through the needle hole at a certain length. The Stamey needle is withdrawn back from the suprapubic incision until the 1-0 Vicryl suture is present (Figure 5). The 1-0 Vicryl suture is pulled out through the suprapubic incision until the end of the mesh arm passes into the retropubic space (surgeon feels loss of strongest resistance while the 1-0 Vicryl suture is being pulled). The end of the mesh arm is anchored into the ventral aspect of the paravaginal fascia (paraurethral portion, near the original portion of the arcus tendineous fascia pelvis and arcus tendineous levator ani). These procedures are repeated on the other side.

and the size of the mesh is tailored to fit the patient. The length of the mesh can be adjusted according to the length of the patient's anterior vaginal wall since the end of the mesh is anchored to the vaginal apex or pubocervical fascia. The bilateral ends of the mesh are sewn using an absorbable 1-0 Vicryl suture (Ethicon inc., Somerville, NJ, USA) using a Stamey

Fig. 2. The bilateral ends of the mesh are sewn using an absorbable 1-0 Vicryl suture (A).

The bladder neck is identified by gently pulling the Foley catheter. The anterior vaginal wall is incised in the midline from the proximal urethra to the apex of the vaginal cuff or cervix (for patients whose uterus is preserved). At the level of the proximal urethra, a tunnel underneath the pubourethral ligament is created on each side of the urethra to reach the insertion of the ligament. The vaginal mucosa layer is undermined from the fibromuscular layer of the anterior vaginal wall on each side to reach the lateral point of insertion into the paravaginal fascia. The retropubic space (Retzius space) is not entered during the dissection

A Stamey needle is introduced through the suprapubic incision (less than 5 mm each side), passed blindly through the retropubic space along the posterior surface of the pubic bone (retropubis; avoiding resistance from bones and the bladder wall) (Figure 3), until the needle tip is advanced to the ventral aspect of the pubourethral ligament. The needle tip is advanced laterally along the posterior aspect of the pubis into the tip of the tunnel that was created before and passed through this fibromuscular layer (Figure 4). The 1-0 Vicryl suture is threaded through the needle hole at a certain length. The Stamey needle is withdrawn back from the suprapubic incision until the 1-0 Vicryl suture is present (Figure 5). The 1-0 Vicryl suture is pulled out through the suprapubic incision until the end of the mesh arm passes into the retropubic space (surgeon feels loss of strongest resistance while the 1-0 Vicryl suture is being pulled). The end of the mesh arm is anchored into the ventral aspect of the paravaginal fascia (paraurethral portion, near the original portion of the arcus tendineous fascia pelvis and arcus tendineous levator ani). These procedures are repeated

needle for the following procedures (Figure 2).

Prepared self-fashioned mesh and Stamey needles (B)

of the paravaginal fascia.

on the other side.

**8.2 Procedures for placement of the self-fashioned mesh** 

Fig. 3. Stamey needle is introduced through the suprapubic space.

Fig. 4. The Stamey needle tip is advanced laterally into the retropubic tunnel that was created before and passed through this fibromuscular layer.

Suburethral Slingplasty Using a Self-Fashioned Mesh

M: self-fashioned mesh.

incontinence and prolapse.

**9.1 Comparison of relevant published articles** 

commercial mesh kits (Jelovsek et al. 2007; Gomelsky et al., 2011).

for Treating Urinary Incontinence and Anterior Vaginal Wall Prolapse 227

Fig. 6. The mesh is tension-free flatted under the suburethreal area. B: Bladder; U: Urethra;

Our results for using self-fashioned mesh for the treatment of concurrent stress urinary incontinence and pelvic organ prolapse showed a relatively high success rate in curing urinary incontinence (continence was 80%, improvement was 17%) and less recurrence of anterior vaginal wall prolapse (none with recurrent prolapse greater than stage II) in a threeyear follow-up. However, mesh erosion was not completely averted. Exposed vaginal mesh was removed uneventfully. None of these patients experienced recurrent urinary

There are three similar articles using self-fashioned mesh for treating stress urinary incontinence and anterior vaginal wall prolapse have been found in recent five years (Mustafa and Wadie, 2006; Amrute et al., 2007; Eboue et al., 2010 ). Character of mesh, patient number, mean follow-up period, success rates, and complications of these articles and ours are as tabled below (Table 1). Outcomes of using self-fashioned meshes are promising. Mesh erosion rates in these case series are acceptable compared to that of

The rationale for using self-fashioned mesh is: (1) to support the proximal urethra, bladder neck and anterior vaginal wall so they are simultaneously free of tension; (2) to provide a frame for augmenting the vaginal wall; (3) to fashion the size of the mesh to fit the defect in the vaginal wall; (4) to avoid complications induced by mesh arms by not using additional fulllength mesh arms. A mesh patch lessens the amount of synthetic materials present in the wound bed which might diminish potential complications. Technically, it would be easier to remove the mesh patch than the full-length mesh if late complications occur (Tsui et al. 2005).

**9. Outcomes and complications of using self-fashioned mesh** 

Fig. 5. The Stamey needle is withdrawn back from the suprapubic incision until the 1-0 Vicryl suture is present.

The mesh arms are adjusted by pulling the 1-0 Vicryl suture through the suprapubic incision until the mesh is placed underneath the dorsal aspect of the pubourethral ligament, proximal urethra, and bladder neck without tension and mesh unfolds. Surgeons have the option, according to their preference, of performing plication of the fibromuscular layer of the bladder before placing the mesh underneath the bladder and dorsal aspect of the paravaginal fascia. The mesh is also flattened without tension so that the bilateral edges of the mesh reach the lateral sulci of the vagina (Figure 6). The Smead-Jones suturing method is used to close the suburethral mucosa and anterior vaginal mucosa to create a mass cushion on the suburethral mucosa and anterior vaginal wall. Concomitant pelvic reconstructive procedures are performed after closing the anterior vaginal wall.

Fig. 5. The Stamey needle is withdrawn back from the suprapubic incision until the 1-0

The mesh arms are adjusted by pulling the 1-0 Vicryl suture through the suprapubic incision until the mesh is placed underneath the dorsal aspect of the pubourethral ligament, proximal urethra, and bladder neck without tension and mesh unfolds. Surgeons have the option, according to their preference, of performing plication of the fibromuscular layer of the bladder before placing the mesh underneath the bladder and dorsal aspect of the paravaginal fascia. The mesh is also flattened without tension so that the bilateral edges of the mesh reach the lateral sulci of the vagina (Figure 6). The Smead-Jones suturing method is used to close the suburethral mucosa and anterior vaginal mucosa to create a mass cushion on the suburethral mucosa and anterior vaginal wall. Concomitant pelvic reconstructive procedures are performed after closing the anterior

Vicryl suture is present.

vaginal wall.

Fig. 6. The mesh is tension-free flatted under the suburethreal area. B: Bladder; U: Urethra; M: self-fashioned mesh.
