Transvaginal mesh implants independent review: final report

Chapter 10: Chair's concluding remarks

I would firstly wish to acknowledge the strength of views, care and professionalism that have been brought to this topic both during, and previous, to my time as Chair of this review.

SUI and POP are conditions which, while not life threatening, cause considerable distress to many women, with disruption of their normal lives. The hope of a treatment which can reduce that distress and return their lives to normal is understandably sought eagerly. Similarly, the gynaecologists and urologists who see these symptoms and the distress they cause to their patients seek to test and find new and better ways of producing good outcomes for their patients. The use of mesh in this clinical area came about because of that desire, and many women have had a good outcome from these operations. However, no surgery is without complication, and a number of women have had both minor and major complications due to the surgery itself. Indeed, some have found their lives completely transformed, for the worse, unable to pursue a normal family, personal and working life.

Balancing both good outcomes and very bad experiences has been one of the difficult tasks faced by this review. We have taken an approach of both seeking and sifting the best available research information on both safety and effectiveness, as well as the epidemiological information provided by the routine NHS linked information which is so rich in Scotland. While extensive, there are, nonetheless, many gaps, and we have been cognisant of these in forming our conclusions and recommendations. In addition, we decided to listen and to reflect on what both our patient and clinical members told us when applying their expertise and experience to that research and epidemiology. This led us to the specific recommendation we make on the use of mesh tape in particular circumstances and to ask for work on the clinical pathways to take this concern into account.

We can now see a way by which transvaginal mesh implant surgery can be supported on a case by case basis but it will require a number of actions to ensure lessons are learnt and good and safe patient care is ensured. These are outlined in our recommendations but include:

• informed consent is obtained using approved processes and information;
• an approved clinical pathway is followed;
• information, including adverse events, is recorded in a universal and robust way;
• patient treatment and audit is considered as part of a clinical network involving all practitioners;
• the Expert Group develops a pathway and supporting information for the retropubic approach in SUI as the routine mesh procedure with any variation considered as part of the multi-disciplinary team discussions; and
• the Expert Group develops a pathway for the treatment of POP where transvaginal mesh is not used routinely but which supports patients to have access to clinicians with expertise in this area wherever they live. Any variation in the future must be considered through a specific multidisciplinary team discussion after shared decision making with the patient.

Finally, listening is a key part of good and compassionate healthcare. The many women who began the process leading to this review, together with the women who valued this surgery and wanted that benefit to continue, I hope will feel that they have been listened to and that patient care will benefit as a result.