Continued Petition

Thank you for inviting me to speak to the Public Petitions Committee. It is an honour and a privilege, and I appreciate your giving me 10 minutes to make a statement.

I am a surgeon, not a politician, so I am in unfamiliar territory this afternoon. Many communications have arisen from my interactions with Scotland, and I cannot possibly reference all of them today. However, I believe my account to be fair and accurate.

Mesh-injured women who contemplate undergoing mesh removal surgery do not do so lightly. Surgeries on women following partial mesh removals can be the most difficult gynaecological operations.

Mesh-injured women are in pain and distress, and need transparent medical care. I have successfully removed thousands of mesh implants—slings, prolapse mesh, rectopexy mesh and sacrocolpopexy mesh. For more than 20 years, I have been a surgeon of last resort for women who seek other choices or options, and for women who have had partial removals of mesh by other surgeons and are still in pain. Annually, I perform more than 600 surgeries.

I want to talk about the Scotland offer. When the Scottish Government appointed Terry O’Kelly in June 2019, I worked under the assumption that urgency on the mesh-injured women situation was foremost in everyone’s mind. The goal of the project was to provide surgical help for the mesh-injured women; training local surgeons would be a by-product of helping those women.

On paper, it appeared that everything was in place to make a success of the project. I was assured that Scotland’s medical community wanted to work together, with me, to make the project happen. Team Scotland was backed by the First Minister, the Cabinet Secretary for Health and Sport, the chief medical officer and the assigned lead mesh-removal surgeons, with all the influence and power of those officers. Yet, here we are today. No members of that team have been able to complete the regulatory process and no document has ever been issued that could be considered a letter of intent or an employment contract.

In early November 2019, in St Louis, the then CMO promised me that the regulatory process would be completed within a month of her return. She stated that sponsors had to be obstetrics and gynaecology specialists. Although CMO Calderwood is a consultant obstetrician and gynaecologist and could have endorsed my application, she stated that it would be better if that came from the lead clinician, who was Karen Guerrero. CMO Calderwood assured me that she would provide the necessary sponsorships, letters and employment contract.

In return, and on the condition that the regulatory process be completed, I agreed in principle to visit Scotland in spring 2020, primarily to review patient files, schedule surgery and start the project of caring for the women. There is correspondence that includes the detail of possible itineraries that were discussed, but there was never any agreement that I would visit Scotland before the General Medical Council’s regulatory process had been completed: there was no misunderstanding about that. Only when that crucial step had been completed would I finally have been able to make what I hoped would be the first of multiple extended journeys to Scotland to care for and operate on mesh-injured women.

On returning to Scotland from St Louis, CMO Calderwood shifted the goalposts. She asked me to fly to Scotland in spring 2020 to attend an educational event. That request came one day after I had been contacted by Mr Chris Harding, the mesh spokesman for the British Association of Urological Surgeons, who indicated that he had pitched the idea to CMO Calderwood. She contacted me the next day and stated that it was her idea. When I questioned her as to why she was adding that element to the itinerary, she said that it was about sponsorship and requested that I engage with the attendees and ask for their support to sponsor my GMC application. In short, the Scottish team’s medical members would not be endorsing the GMC application.

I clearly communicated to CMO Calderwood that in no circumstances would I fly to Scotland before completion of the GMC application. The more I communicated that position, the more CMO Calderwood glossed over the problem. She continued to send letters with plans for a visit in spring 2020. I read in the press and in the Scottish Parliament’s official record about my visit in spring 2020. That was barren ground. I was bitterly disappointed for the mesh-injured women, and not only those in Scotland.

What were the problems? There were several indications that there was a great willingness to delay real progress in the project. Phase 1 was June to September 2019. In June 2019, when the project started with Mr O’Kelly, who was appointed by the Cabinet Secretary for Health and Sport, I knew that I would be in Europe for the International Continence Society’s meeting in September. Mr O’Kelly had initially extended to me an invitation to visit Scotland when I was in Europe. However, things changed. He stipulated that the Scottish team must visit me at the Mercy hospital in St Louis. With good grace, I accepted and accommodated a visit that was organised for July, but the team cancelled. The grounds that were given were that Karen Guerrero was not sure of her commitment to the project and had childcare issues during the summer.

I then received an urgent request from Mr O’Kelly to organise a visit in August 2019. I made arrangements once again, but days before the visit the team cancelled due to schedule clashes. When the team cancelled in August 2019, I reminded Mr O’Kelly that I would be in Gothenburg at the ICS conference from 3 to 6 September, and then in the United Kingdom. He suggested that he might visit me and another surgeon in Gothenburg. No further invitation to visit Scotland was extended to me, and since that time I have had no further communication from Mr O’Kelly.

I will mention two issues of note. I was not aware that any Scottish team members would be at the ICS meeting in Gothenburg. During the meeting, a prominent US colleague approached me and stated that the Scottish clinicians at the ICS meeting needed his help in relation to mesh removal, and that he had informed them that I was the best person to help them. That US colleague sent emails introducing me to the Scotland team and attempted to arrange a visit for the team to meet me in St Louis.

In any case, had the team visited me in St Louis in July—or, indeed, in August—I could have visited Scotland in September, when I would be in the UK, and started the process, and I could even have stayed longer, if needed. That made perfect sense to me. However, the surgeons were not on board with the project, despite all the reassurances that I had been given. At that juncture, I withdrew from the project.

In October 2019, I agreed to return to the project following a brief conversation with the First Minister of Scotland. That was at the direction of CMO Calderwood. The Scotland team eventually visited me in early November. I hosted CMO Calderwood, the two lead mesh clinicians, a member of the nursing staff and a member of the physical therapy team. They arrived at my office at 11 am on Thursday 7 November 2019 and departed at 11 am on Friday 8 November. I remain of the opinion that the Scottish team’s 24-hour trip to St Louis was not an essential part of the project.

When CMO Calderwood left St Louis, it was made clear to me that she would ensure that the regulatory process would be completed, as she stated, within a month. When she returned to Scotland, she did a U-turn on that agreement. She made the unreasonable request that the spring 2020 visit would be used as an opportunity for me to canvass and acquire sponsorship from attendees of the educational symposium.

Mr Harding notified me that he was in discussions with CMO Calderwood about the symposium. Again, I do not know what CMO Calderwood communicated to the cabinet secretary, to the First Minister, to her successor interim CMO Gregor Smith, or to Mr Harding. I know the sequence of events that were promised, the first of which was completion of the GMC process.

Any suggestion to the mesh-injured women that I was arriving in spring 2020 was not transparent. First, at no point did I agree to CMO Calderwood’s suggestion that I attend the symposium. I made it clear, in no uncertain terms, that I would not canvass anyone, ever, for sponsorship. Secondly, even if CMO Calderwood had delivered her promise, the purpose of the visit in spring 2020 would not have been to commence any care or surgical treatment for the mesh-injured women. I could have been in Scotland in September 2019.

In conclusion, my involvement in the project is flavoured by delay and what appeared to be a war of attrition. Whatever the motivations, the outcome demonstrated to me that there was no sense of urgency in delivering the project to help the mesh-injured women.

I am happy to answer any questions.

I listen to the patients. I ask them when the pain started, how it started and where is it located. The trajectory of the slings follows a specific path, with small variations, depending on the type of sling and the woman’s pelvis. The pain is not only in the middle; it is on the left and on the right. It is in multiple areas. Removing only a piece of the mesh is not helpful at all, and actually makes it much more difficult to help the women later.

No—it never really got that far. As a surgeon, I take for granted some things about caring for women. It always starts with their history and a physical in order that I understand their complaints. Then, I discuss with them what is reasonable and what is available. I have a transparent discussion about how the illness could be treated.

My understanding is that the women who were suffering or were injured from mesh surgeries would have undergone surgery under me. I was okay with having surgeons observing me, but I have spent my lifetime mastering, refining and continuing to polish my skills through tens of thousands of hours in the operating room to develop techniques and instruments, which I am happy to share.

However, it is not something that can be learned in a day or a week—it is not a case of “See one, do one”. A transobturator sling can be a TVTO—tension-free vaginal tape obturator—a MonArc, an Aris, an Obtryx halo, an Align curve or an Obtryx curve, and they have variations. They behave differently post-implantation, they have different colours and they curl differently. There are many things that need to be learned, and the learning curve is steep. I suggested to Mr O’Kelly that I would make an initial trip, as part of which I would schedule some surgeries and find the appropriate operating room time. Subsequently, I would travel back and forth, and would train whoever had the requisite skills.

13:45

Trust is very fragile, is it not? From literature and my practice, I know that women do not return to the surgeon who operated on them when there is a complication from a hysterectomy or a mesh product. When women perceive that they are not being listened to or are not being given the choices that they want—women have choices—they move on to the next surgeon. As they move on, they acquire more knowledge, do more research and become more aware of what is available to them. Generally, the meshes that I remove have been implanted by other surgeons, not by me. It should be a woman’s choice to seek out whomever she wishes to be her surgeon or her doctor.

That is true.

No.

Well, it is really that simple. The trajectory of a transobturator sling—whether it be a TVTO or another device—is under the urethra. It then perforates the side wall muscles—the obturator muscles—which are lateral rotators of the hip. That is why these women have hip pain: the mesh adheres to the bone and limits the normal function of those muscles. It then passes through the entire abductor musculature. So, removing that portion under the urethra, in the vagina, does nothing. Honestly, if they did a tiny little partial, that would be better than if someone did a bigger partial that removed the mesh all the way out to the muscles. The problem is that the mesh adheres to the bone and then limits the function of normal musculature.

There is no way on God’s green earth that an entire transobturator sling can ever be removed only through the vagina. It requires an incision in the skin lateral to the vulva to identify the end of the mesh in the musculature. There are two techniques that can be used. One involves cutting the muscles, taking them off the pubic bone and trying to reattach them. However, as any surgeon knows, muscles are hard to sew. Therefore, there is a second technique, which I innovated, which does not cut the muscles. Once you find the mesh, which can be very testing, you have to trace it down very specifically and take it off the bone on the groin side—the muscle side—and then on the vaginal side, and remove it. Depending on the variation of the woman’s pelvis, it can be very difficult to find the mesh in the groin. That is why partials are so bad. If the sling is intact, the surgeon can get guidance to trace it from the vaginal side to the bone, identify the trajectory and remove it.

I hope that that simple explanation was brief yet detailed enough to explain the complexities of the implant and why nobody should be putting in any implants if they cannot absolutely manage any associated complications and provide comprehensive treatment to any patient, whether it be a woman or a man, undergoing any surgery.

I do not think that they are useful. They were innovated in 2003 simply because surgeons were having a hard time doing a retropubic sling, which are the original slings, made out of fascia, that were described by von Giordano in 1907. Through the years, the technology evolved.

Retropubic slings emulate normal anatomy. Transobturator slings were innovated for those surgeons who had difficulty doing retropubic slings. They do not follow a normal anatomic trajectory or emulate normal anatomy. Women have variations in their pelvis and their vaginal sulcus—under the urethra, the sulcus dips up—but the mesh follows a straight line, which creates a band effect. A scientific paper said that up to 80 per cent of transobturator slings have a band that is palpated on clinical examination. The conclusion of the study was that they do not know the significance of that. Another paper, by Chauhan, said that 25 per cent of women undergoing a transobturator sling procedure have de novo pain with intimacy. I do not know any woman who would exchange a little bit of leaking, or a lot of leaking, for a 25 per cent chance of pain with intimacy.

If you fast forward 17 years from the initial procedure, you now have an implant in a woman that cannot be removed easily or safely without drastic consequences such as cutting the muscles, which may never be able to be reattached successfully. In my opinion, there was and is no place for transobturator slings.

I think that that point could be held to be arguable by those who carry out the procedure. There was a good rate of success with retropubic slings, but the complexities of that procedure mandated the creation of another technique. In my opinion, the surgeons who were unable to do the retropubic sling procedure should perhaps have referred those patients to someone who had higher volumes of patients requiring that procedure. The literature clearly states that high-volume surgeons have better outcomes. I think that my mother or my aunt deserves the benefit of a high-volume surgeon who carries out that procedure all the time.

The first thing that I do is look at the implant operative report. I try to acquire an implant log that tells me what implant I am looking for. It is common for any implant to be called a TVT. For some reason, that has become the generic term, but it is like saying, “I drive a car”—just as there are different cars, there are different implants.

Sometimes the implant operative report is very replete. If there is a photograph, I try to get it; if there is a pathology report, I try to get it. We published a poster stating that the medium length of a transobturator tape sling is approximately 22cm. The sling is 44cm when it is implanted, and it is cut at the edges, to create a length of 22cm. Documentation telling me how much was removed gives me an idea of where to look for the mesh. If 2cm was removed, the mesh should be to the left and right of the urethra. The problem comes when it is 3cm, 4cm or 5cm. Women have different pelvises and, if the patient is a smaller woman with a narrower pelvis, that mesh is going to be further out in the obturator muscles. That is where the problem arises. That mesh retracts and is glossed over with scar tissue. That means that I then need to make selective cuts into the woman’s obturator musculature, through the vagina, to try to look for fibre or to palpate scar tissue. Depending on where the mesh was placed and what the woman’s pelvis is like, it can be much more traumatic to find the end of a cut piece of mesh than to find an intact mesh that I could trace. I might spend up to 30 or 40 minutes trying to find the end of a severed piece of mesh.

I believe that, eventually, the medical community will agree that, if anyone who has a TOT sling has problems, the entire sling should be removed in one surgery.

In my opinion, there are no such situations. Let me explain why. If a woman has a sling, whatever that sling is, and the only symptom that exists is what we call incomplete empty—there is a little retention, they are not emptying their bladder, they are getting bladder infections or they are experiencing urgency—which happens with all slings, even an autologous sling that is made from her own body, a division of the sling is indicated. However, you must understand that, if you have an exposure—a little snip—that is the tip of the iceberg. These implants are in the vaginal wall—they are exposed in the vaginal wall. As an example of what I am talking about, imagine that you are walking on a lake in winter. The edge of the lake is frozen, but, as you get to the middle, the ice gets thin. Where the mesh is exposed, the vaginal wall gets very thin. If you trim part of it, it may come back, and the tissue on top of the sling cannot be pulled together with sutures. What happens then is that the exposure is bigger. If you remove any amount of the sling—even if you divide it—it may not work as well. If you remove 1cm of the sling and the woman has incontinence, when you undertake the second operation to go back and fix her, you will run into the implant.

The best chance for a cure—this is documented in the literature—is with the first sling. So, if a woman has a sling, how do you bring her back to the first sling? You do it by removing and clearing that tissue, letting it heal, and almost starting over.

I have tried all of these things. I have spent my days doing what I like to do most, which is to care for women in the operating room. That is what I am good at. When women have asked me to do everything in the one surgery, I have tried to do so, but the outcomes are not the same. There is literature to support the view that a second sling does not work as well as the first one at one setting. I have good success if I remove the implant and allow the tissue to heal. Ironically—we presented a poster on this—when you do a complete removal, half the women do not leak. I think that that is because of the scarring that ensues.

More than half my practice is managing complications of mesh implantation. I am a gynaecological surgeon. I predominantly do vaginal surgery. I take care of prolapse, fistulas, recurrent prolapse, urinary incontinence and faecal incontinence. I only offer retropubic slings, and I offer three types of them. I offer a sling from their own body and I offer a biologic sling, and, for the sake of completeness and transparency, I mention polypropylene slings. Women only choose polypropylene slings when it is the only option that they want.

The communications seemed serious in the beginning, when Mr O’Kelly tried to schedule a visit, but it became apparent that matters were just not going to progress.

One thing that I never want to take away from my patients is hope. I never want to give false hope, either, and I have maintained during this entire time that I do not want that for the women of Scotland. I moved away from the project because I felt that the women were getting false hope—they were hoping that a resolution would come soon and it just did not seem like that was happening.

There was an opportunity when I was in Europe. I do not know whether, other than those from Mr O’Kelly, the communications were ever serious.

No.

I was a visiting surgeon to the United Kingdom in 1998, when I operated in London. The process was easy. Perhaps things have changed. My understanding is that the scheme requires a sponsor and a contract from the national health service. Neither of those aspects is truly under my control.

Prior to 2000, I visited Spain, Italy and the United Kingdom. Since about 2000, I have dedicated my time to polishing, mastering and teaching surgery. I was the director of the ob-gyn residency programme, which required me to be in the US. Since then, I have not gone anywhere else.

Yes.

Easily 50.

Yes, sir.

It is the latter.

I believe so. Early on, I had a conversation with Mr O’Kelly in which all the clinicians were on the phone. In subsequent discussions with Mr O’Kelly, he stated that one of the clinicians was not on board—she was unsure of the consequences or about my involvement, and so on.

I gave an unselfish offer to help women—that is all that it really was. No one needed to be threatened. I would have cared for the women and trained the doctors who could be trained. I told Mr O’Kelly that not everyone can or should be a mesh removal surgeon. Mesh removal requires surgeons with the finest technique and the most experience who are able to grasp new techniques of surgery.

Yes, sir.

No. Actually, she said that she could make the application happen within a month.

I am not sure that I understood the latter part of that question. Would you be kind enough to repeat it?

I would think so. When CMO Calderwood and I sat down together, it felt genuine. I was reassured, I was trusting and I felt hopeful. I agreed to come to Scotland.

I did not understand the symposium concept. If I was there, I would have been happy to bring my hard drive, which I did when the Scotland team visited me, to show unedited videos, pictures and techniques of thousands of mesh removal surgeries to the clinicians I would be working with.

On the concept of me coming to a symposium to ask people in the crowd, “Would you please kindly sponsor me?”, I am sorry, but I just cannot do that.

Yes.

Certainly.

No. I would not agree to that.

I did not do much—I submitted my curriculum vitae and medical licence; the sponsoring institution did everything.

The women from Scotland whom I have had the privilege of caring for basically had a partial removal under the urethra transvaginally, with the two ends of the mesh remaining in the obturator and adductor muscles. Almost all the women I cared for were in that identical situation in which only the centre portion was removed. Removing the centre portion does not relieve groin pain, which relates to the obturator and adductor muscles.

I am sorry—I use a what?

No, sir, that is not correct; I do not use any scanning techniques. My treatment is based on surgical acumen, an understanding of female pelvic anatomy and an understanding of the implants and knowing where they are. I do not waste patient time or increase costs by carrying out scanning that provides nothing.

That has plagued my offer to come to Scotland. My offer was so that the women would not have to spend their life savings, sell their homes, borrow money or do whatever they needed to do to get to me.

Since June 2019, the situation has escalated in so many ways. I must tell you that I feel uncomfortable with everything that has happened. I do not know how I would be perceived if I came to Scotland. I know how I have been perceived. I do not know how I could possibly work with a medical team in a hospital given that almost the entire population of Scotland knows what has transpired. I do not think that my coming to Scotland can be on the table.

Can the women come to me? They certainly can, and many women do. I regret that not all the women can. As I have stated, I have dedicated my career and life to doing this surgery—it is what I do best. I operate five days a week, and I will continue to do that. I would be delighted to help the women but, at this juncture, they would have to find someone with my skill set or come to me.

I do not know what the mesh centre will involve, although I assume that it will involve physical therapy. There is no data to suggest that that is helpful for those with a mesh implant. Think about what you would do about anything else in your body. Say that you have a piece of dust in your eye. You do not rub it; you leave it alone until it comes out. Physical therapy after removal might be beneficial, and I suggest that to my patients.

You can see how women from Scotland whom I have operated on have done. They have had a partial removal. They are still in pain, but they are doing better.

I do not know what the mesh centre will involve. I do not know how the staff have acquired their skill set. One thing that I do in order to be transparent is to take a picture of every removal and I give it to the patient. They have been through such a journey with mesh that that provides closure for them. I learned that practice from obstetrics: when a mom lost a child, you put the child in her arms to provide closure for her.

The women have been on such an arduous journey, so I take a picture to show that all the mesh is out. Women are strong. They can deal with whatever pain they may have. Usually, they all do better once they know that the mesh is out.

I do not know what the mesh centre involves, I do not know what skill set the staff have and I do not know what protocols they have. Therefore, I cannot comment on whether the women would be better off.

As I have mentioned, there are publications and literature that state that women do not want to go back to the same doctor; they move on. It is rare for any woman to hold a grudge against her doctor; they simply want to move on and get different care from someone else.

When I was in discussion with Mr O’Kelly, I mentioned that I give pictures to each patient and asked him whether he could send me a few pictures of the full removals carried out by the surgeons I would be working with. I never received those.

If anyone with a good skill set was looking to improve it, I would want to see what they were doing and how I could help train them to get better. I would want them to show me their previous 10 mesh removals. I could look at those and tell you whether it was a partial or complete removal, because I have removed thousands of implants.

That is where trust is lost and there may not be proper transparency. That is not ethical.

Patients do okay. If a patient is told that there is a piece of mesh on a major blood vessel that could not be removed and what the consequence would have been if it were removed, the patient will invariably say, “Thank you for not doing that.”

If someone knowingly states that there has been a full mesh removal, has knowingly cut it at two points with scissors and said in their mind that there has been a full removal from the vagina, but implies to the patient that there has been a full removal so that the patient thinks that her entire mesh is out, that is not right.

I think so. The mesh centres were going up, so I would agree with that.

To put things into perspective, conservatively a transobturator sling can be placed in 20 to 30 minutes. It takes me over two hours to remove one, millimetre by millimetre, without cutting the muscles. As I mentioned earlier, TVTO is very common. In some ways, it is easier to remove and in some ways it is harder to remove, but it is clear that it is different from the Coloplast Aris sling, the Obtryx slings and the Align slings. It is not a matter of “See one, do one”. There is a learning curve for a transobturator removal, and it is the hardest of all gynaecological operations.

We do not really study that area of the human body in medical school. I had to go back to cadavers and talk to multiple orthopaedic surgeons as I was developing the technique. I have refined it, because I have done hundreds upon hundreds of those operations, but they are still difficult for me. Last week, I spent six hours removing two TVTOs in a 38-year-old woman who had one placed at age 31 and a second placed at age 38.

It takes dedication, devotion and discipline, and it takes time. You need to know that you are not going to stop and that you are going to do the right thing. It is not “See one, do one”; it might be “See 50 and do one.”

There need to be transparent standards of excellence and detailed operator reports. Every piece of mesh that is taken out should be sent to pathology, with documented pictures on what was removed. There will be people on the planet who can do it, but it must be proved that it can be done safely and effectively, and that requires commitment. No matter what you do—whether you play a sport or you are a politician, a surgeon or a mechanic—it requires commitment, devotion and transparency about what can be done and what you can do, and the intent that you will continue to strive to do the best that you possibly can.

As I mentioned, patients are understanding. If I did my absolute best, but I could not get a piece out of the tendon, I think that any woman would understand that and would say, “Thank you for not cutting my tendon.” They might or might not have pain there, but I did not cut their tendon.

I do not know how to train someone. I have a partner who I trained, and I have other residents whom I teach vaginal surgery, although they do not all remove mesh. Surgery is an apprenticeship. You need to work with someone who can quickly elevate and refine your skill set, because that is what patients need. They do not need someone learning slowly and getting complications.

As I have told my young partner, a community pays a price for a surgeon. A surgeon practices on the community and will get some complications, but we hope that the surgeon will be able to learn from those and will serve his or her community better over time. As I said, that takes dedication. Not everyone can publish papers and give speeches. Someone needs to be in the operating room teaching and performing surgery.

14:30

I do not know how I would work in the system with everything as it is at this point. When I first talked to Mr O’Kelly, he told me that, in the United Kingdom and Scotland, people worked in teams and that I would be put in a team, and so on. With everything that has happened, I do not want to keep giving women false hope. We have been at this for almost 18 months now. In the time that I have spent engaging, I could probably have operated on 50 women.

I have never had an offer from the Scottish Government. I made an offer, unselfishly, to come and operate. I said, “Give me an operating room, six days a week, and I’ll be able to deal with three to four cases a day, depending on the number of rooms.” That was the offer. I cannot just show up in Scotland and say, “Here I am—I’m ready to do surgery.” There are processes, regulations, licences and GMC regulation. The Scottish Government has never made an offer. I have never had a letter of intent. There has never been a contract. It was my offer to help so that the women would not have to use their life savings, as they told me that they would have to, sell their homes or borrow from their relatives. That is my answer to your first question.

My answer to your question about my message to those women is that I have never given them false hope. I have always tried to make sure that they understood, as I did, that there was hope, but I have never given them any false hope. I have always been transparent.

I would limit it to three mesh removals per day, especially when transobturator tape is involved. The average time is two to two and a half hours, but it can take longer than that. I would be able to do three surgeries per day. Are you asking how soon could I do that?

I am scheduling surgery in December.

It is not a chronological limitation. If the women have partial after partial after partial, you reach a point at which it might not be feasible any more to do anything without creating even more scarring and injury.

If someone were to perform a very good partial vaginally and one attempted partial in the groin, that would leave a section of mesh in the groin. Although I have been successful in such cases, I can see situations in which multiple revisions of mesh prolapse implants would make it impossible to do any more.

No. Thank you for the opportunity to speak to you today. I applaud your sincerity. It is one thing to stop the utilisation of mesh, but it is another thing to go back and help these women, so I very much applaud your efforts.