Promedon Nazca TC Instructions D'utilisation page 5

The legs of the mesh are introduced through a transobturator.
Then, a punctiform cutaneous incision is made taking as reference the edge
of the ischiopubic branch at clitoris level, 2 cm lateral and 3cm downward.
At that point, introduce the Deschamps-type needle on the side of the
patient's right obturator foramen. For that purpose, align the needle at
45º from a middle imaginary line of the patient. Then, go through the
transobturator internal membrane and the muscle. Rotate the needle behind
the ascending ischiopubic branch, guiding it with the index finger until the
needle end comes out through the vagina. Thread the mesh perforated end
in the needle end, and transfer the column through the tunnel previously
created with the needle.
Repeat the technique on the other side (left foramen).
In case the perforation of the silicone eyelet tears while going through the
patient's tissues, make a suture at the end of the arm and thread it in the
needle eye. This maneuver will allow completing the mesh transfer with no
inconveniences.
Note: Before passing the needle, please check that the incision points are
anatomically appropriate by vaginal vulvar palpation using the index finger.
4. Fixing Without Tension
Place a pair of Metzenbaum scissors between the mesh and the urethra to
make tension regulation easier. Pull the prepubic arms up until the mesh
makes contact with the urethra/bladder neck.
Cut the mesh excess in the lower part and fix its body with two non-
absorbable stitches in the cardinal ligaments or the apical vaginal wall.
Then, pull the TOT arms until the mesh makes contact with the bladder.
Finally, cut the arms excess.
The closing of the vaginal wall is made without cutting the excess by
Montgomery technique (Overlap). Once the first flap above the mesh
is sutured, a superficial fulguration of the vaginal wall is made to avoid
epithelial cysts and also to facilitate healing.
The second flap is sutured above the first one with absorbable stitches.
Postoperative care and therapy are at the Surgeon's discretion.
In case a removal of implant is required, please note:
Polypropylene mesh integrate with patient's tissue, so complete removal may
be difficult.
In case a mesh removal is necessary due to pain, we recommend trying to
cut all the tension areas identified by the surgeon.
In most cases, the risk of organ injury caused by mesh removal may be
higher than the benefits resulting from this removal, so each case should be
assessed and decided at the surgeon's discretion.