Creating a gold standard surgical device: scientific discoveries leading to TVT and beyond: Ulf Ulmsten Memorial Lecture 2014.

INTRODUCTION AND HYPOTHESIS: The discovery of tension-free vaginal tape (TVT) began in 1986 with two unrelated observations: pressure applied unilaterally at the midurethra controlled urine loss on coughing; implanted Teflon tape caused a collagenous tissue reaction. METHODS AND RESULTS: In 1987, Mersilene tape was implanted retropubically in 13 large dogs, with the aim of creating an artificial collagenous pubourethral neoligament. Extensive testing showed that the operation was safe and effective. In 1988-1989, human testing was carried out (n = 30). Mersilene tape cured 100 % of stress and mixed incontinence with a sling in situ; however, there was simultaneous recurrence of the two symptoms in 50 % on sling removal. X-rays showed no elevation of the bladder neck. In 1990-1993, collaboration with Ulf Ulmsten took place: a permanently implanted tape was required. Polypropylene was the ideal material. In 2003, the neoligament principle was applied as an adjustable "micro" sling to the arcus tendineus fasciae pelvis (ATFP), cardinal, uterosacral ligaments, and perineal body for cure of cystocele, rectocele, and apical prolapse. It was found that symptoms such as urgency, nocturia, chronic pelvic pain, obstructive defecation syndrome (ODS), and fecal incontinence were frequently cured or improved. CONCLUSIONS: The lecture concluded with advice to younger members. Without new paradigms, there are no randomized controlled trials, no meta-analyses, Cochrane. Indeed, no progress. Be open to new concepts. Read Kuhn's "The Structure of Scientific Revolutions" to understand the discovery process. Examine the relationship among symptoms, ATFP, cardinal, uterosacral ligaments, and the perineal body. This is the next paradigm. Don't disregard anomalies. Pursue them. They are the pathway to discovery. Innovation is born from challenge, not conformity. Persist, even when meeting resistance. Resistance is a sign that your discovery is important.

Evolution of midurethral and other mesh slings--a critical analysis.

We analyzed our original experimental studies on which the midurethral sling was based with reference to FDA mesh warnings. We concluded that: 1. Vascular/organ damage could be avoided by first penetrating the urogenital diaphragm. 2. A non-stretch tape minimizes obstruction and urethral damage. 3. A non-obstructive musculoelastic mechanism closes the urethra. 4. The strength of neocollagen (>92.8 lbs/sq inch) indicates that little mesh is required for prolapse repair. 5. Foreign body (mesh) reaction is different from infection and is related to volume implanted. 6. Urgency is potentially curable by repairing the suspensory ligaments. 7. "Minislings" are promising for incontinence and POP, but more development is required.