A Roadmap for Training in Urogynecology: IUGA International Initiative

INTRODUCTION AND HYPOTHESIS

Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission.

METHODS

The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities.

RESULTS

The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors.

CONCLUSION

The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Establishment and initial implementation of the Australasian Pelvic Floor Procedure Registry

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders (PFDs). Owing to significant adverse events associated with mesh-related pelvic floor procedures (PFPs) in a proportion of the surgically treated population, and deficits in collection and reporting of these events, the Australian Government identified an urgent need for a tracking mechanism to improve safety and quality of care. The Australasian Pelvic Floor Procedure Registry (APFPR) was recently established following the 2018 Senate Committee Inquiry with the aim of tracking outcomes of PFP involving the use of devices and/or prostheses, with the objective of improving the health outcomes of women who undergo these procedures. This paper will describe the APFPR's aims, development, implementation and possible challenges on the way to its establishment.

METHODS

The APFPR has been developed and implemented in accordance with the national operating principles of clinical quality registries (CQRs). The minimum datasets (MDS) for the registry's database have been developed using a modified Delphi process, and data are primarily being collected from participating surgeons. Patient recruitment is based on an opt-out approach or a waiver of consent. Patient-reported outcome measures (PROMs) providing additional health and outcome information will be obtained from participating women to support safety monitoring of mesh-related adverse events.

RESULTS

Currently in the Australasian Pelvic Floor Procedure Registry (APFPR) there are 32 sites from various jurisdictions across Australia, that have obtained relevant ethics and governance approvals to start patient recruitment and data collection as of January 2023. Additionally, there are two sites that are awaiting governance review and five sites that are having documentation compiled for submission. Seventeen sites have commenced patient registration and have entered data into the database. Thus far, we have 308 patients registered in the APFPR database. The registry also published its first status report and a consumer-friendly public report in 2022.

CONCLUSIONS

The registry will act as a systematic tracking mechanism by collecting outcomes on PFP, especially those involving devices and/or prostheses to improve safety and quality of care.

Do doctors preferring forceps encounter more obstetric anal sphincter injuries: A retrospective analysis

BACKGROUND

Obstetric anal sphincter injuries (OASIS) is a hospital-acquired injury and can affect a woman's quality of life with problems such as anal incontinence, perineal pain, dyspareunia, mental health, psychosexual issues, and concerns about future childbirth choices.

AIMS

The aim of this study was to determine whether there is a correlation between a doctor's preference for instruments, their individual OASIS rate and whether factors such as their fully dilated caesarean section rate, rate of double instrumental and seniority, influences their individual rate of OASIS.

MATERIALS AND METHODS

A population-based retrospective cohort study was performed on 1340 term nulliparous women with singleton pregnancies who underwent an instrumental delivery or fully dilated caesarean section. A survey of doctors involved in these deliveries was performed. The risk of OASIS was analysed for maternal age, ethnicity, birth position, level of training and doctor's instrument preference using a generalised linear mixed model. Doctors' instrument preferences were established in two ways: a self-reported survey and data-inferred preference based on the most used instrument per doctor. The OASIS rate for individual doctors was calculated.

RESULTS

The overall risk of OASIS is higher for forceps compared to vacuum deliveries. Doctors with a preference for forceps compared to vacuum, correlated with both a lower OASIS rate and a higher fully dilated caesarean section rate.

CONCLUSIONS

Doctors preferring forceps report a lower OASIS and higher fully dilated caesarean section rate. Doctors preferring vacuum must consider carefully whether forceps should follow if a vacuum fails as OASIS is more likely to occur.

What not to expect when you're expecting - Postpartum proximal ureteric rupture: A case report

Introduction

Spontaneous ureteric rupture is an extremely rare cause of acute abdominal pain in the intrapartum and postpartum period. We present the case of a right ureteric rupture diagnosed immediately postpartum.

Case

A 23-year-old woman in her second pregnancy (who had had a previous caesarean section) developed acute-onset right-flank pain 12 h after vaginal delivery. A contrast computerized tomography scan suggested a ureteric injury; ureteroscopy diagnosed a proximal ureteric rupture and a stent was placed.

Discussion

This case outlines an extremely rare cause of abdominal pain in the peripartum. There can be serious complications, including urinoma, abscess and sepsis, and therefore the diagnosis should not be delayed.

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Ureteric rupture is a rare cause of acute abdominal pain in the postpartum period.

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Pregnancy physiology can increase the risk of spontaneous ureteric rupture.

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CT scan is the imaging modality of choice for the diagnosis of ureteric rupture.

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Complications of ureteric rupture include urinoma, abscess and sepsis.

Postpartum anal incontinence in women with and without obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

Postpartum anal incontinence is common and distressing for women. We sought to look at the prevalence of anal incontinence in women who sustained obstetric anal sphincter injuries (OASI) compared with women who did not, and factors leading to these symptoms during the postpartum period.

METHODS

A total of 129 primiparous women sustaining OASI were compared with 131 women who did not (controls). They were contacted at approximately 6-10 weeks postpartum to obtain information on their symptoms of anal incontinence (AI). The data underwent univariate and multivariate analysis.

RESULTS

There was no difference in the prevalence of AI symptoms, occurring in 30% of women with OASI, and 23% of women without at 6-10 weeks postpartum; however, in women with high-grade tears the prevalence was 59%. Severe OASI (grade 3c and 4) was associated with an increased prevalence of both AI and severe AI, whereas forceps delivery and increasing maternal age were associated with an increased prevalence of severe AI only.

CONCLUSION

Women with less severe (grade 3a and 3b) OASI do not experience a higher prevalence of AI than women without OASI in the postpartum period. Higher grade (3c and 4) tears, forceps delivery and increasing maternal age are associated with higher rates of AI. These factors should be avoided where possible to reduce postpartum AI. All women should be warned of the 23-30% chance of experiencing some mild AI in this period. Whether these symptoms are transient or long-lasting requires further investigation.

Patient attitude and acceptance towards episiotomy during pregnancy before and after information provision: a questionnaire

INTRODUCTION AND HYPOTHESIS

Evidence regarding how women feel about episiotomies is not recorded in the literature. As the most common surgical procedure, there is a need to understand how women feel about episiotomy.

METHODS

The primary outcome was to identify the percentage of women who would accept an episiotomy if required. A literature review was compiled to provide nulliparous women in their third trimester with evidence-based information about episiotomies and perineal tears. Questions eliciting demographics, pre-information level of anxiety and acceptance of episiotomy were asked. After reading the information sheets, anxiety and knowledge were assessed again. Changes in anxiety levels from pre- to post-information were investigated using paired samples t tests. Because anxiety was measured on a scale, we assessed potential departures from normality by using the Wilcoxon signed-rank test. Questions also assessed the value women placed on this form of education.

RESULTS

There were 105 responses, with 88% accepting episiotomy, 2% declining and 10% seeking more information to decide. Eighty-one percent of women agreed that the information provided helped them to understand more about childbirth and 62% agreed that they felt more comfortable with the birthing process after reading the material. There was a reduction in anxiety levels regarding episiotomies after reading information (p = 0.002) and perineal tears (p = 0.02).

CONCLUSIONS

Most women will accept an episiotomy if required. Antenatal education about episiotomies is important to women and helps them feel more comfortable with the birthing process. Written information increases acceptance and reduces anxiety levels regarding episiotomies.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury

BACKGROUND AND AIMS

Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone.

METHODS

Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries.

MAIN OUTCOME MEASURES

Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score.

RESULTS

45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery.

CONCLUSION

The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.

Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials

OBJECTIVE

Recent randomized trials comparing total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) have produced conflicting results. The role of TLH in women suitable for VH remains uncertain.

STUDY DESIGN

This study was a metaanalysis of randomized studies comparing TLH and VH for benign disease. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using random-effects models.

RESULTS

No differences in perioperative complications, either total (pooled odds ratio, 0.87; P = .74) or by grade of severity, were demonstrated. TLH was associated with reduced postoperative pain scores (WMD -2.1; P = .03) and reduced hospital stay (WMD -0.62 days; P < .0001) but took longer to perform (WMD 29.3 minutes; P = .003). No differences in blood loss, rate of conversion to laparotomy, or urinary tract injury were identified.

CONCLUSION

TLH may offer benefits compared with VH for benign disease, although this analysis is likely underpowered for rare complications. Further studies of long-term outcomes, including prolapse, urinary incontinence, and sexual function, are required.

The tension-free vaginal tape in older women

OBJECTIVE

To evaluate peri-operative morbidity, continence outcome and patient satisfaction in older women (>/=65 years) compared with younger women undergoing tension-free vaginal tape.

DESIGN

Case controlled study.

SETTING

Tertiary Urogynaecology Unit.

SAMPLE

Women undergoing tension-free vaginal tape for urodynamic stress incontinence between July 1999 and July 2002 were included. Those with detrusor overactivity, voiding difficulty at urodynamics or requiring concomitant prolapse surgery were excluded.

METHODS

Older women were case matched to a younger cohort for BMI, parity, mode of anaesthesia and whether it was a primary or secondary continence procedure.

MAIN OUTCOME MEASURES

Operative morbidity and continence outcome were assessed at six weeks. After a minimum six months follow up, patient satisfaction and continence outcome were assessed using the Genitourinary Treatment Satisfaction Score (GUTSS).

RESULTS

The median hospital stay was one day and overall urinary tract infection rate was similar in both groups. Post-operative voiding difficulty rates were 3% in older versus 15% in younger women (P= 0.09). At six weeks, 65% of older versus 79% of younger women were dry (P= 0.2). At a median of 12 months, 15 (45%) of older versus 24 (73%) of younger women had no urinary symptoms (P= 0.05). Median GUTSS scores for satisfaction with continence outcome were lower for older 90% compared with 100% in younger women (P= 0.003).

CONCLUSIONS

Tension-free vaginal tape is an effective continence intervention in older women but has a lower continence satisfaction rate compared with younger women.

Definition of mild, moderate and severe incontinence on the 24-hour pad test

The values for 'mild', 'moderate' and 'severe' urinary incontinence have not been determined for the 24-hour pad test. To define these values, a prospective observational study was performed on 110 women with the primary symptom of urinary incontinence. Consenting women performed two 1-hour pad tests one week apart, and seven 24-hour pad tests for seven consecutive days. The 1-hour pad test definitions for mild, moderate and severe were translated to centiles, and used to categorise the 24-hour test values. This revealed that the range for 'mild incontinence' was between 1.3 and 20 g, 'moderate incontinence' ranged from 21 to 74 g, and 'severe incontinence' was defined as 75 g or more in 24 hours. Severity of leakage was analysed in relation to urodynamic diagnosis, age, parity and pelvic floor muscle strength. Increasing severity was associated with increasing age and parity. Women with detrusor overactivity were most likely to have severe leakage. In conclusion, this study defines the three grades of severity for the 24-hour pad test, which may help to guide patients' choice between conservative and surgical treatment and is useful for stratified randomisation of controlled trial participants.

The repeatability of the 24-hour pad test

A prospective observational study was conducted in a tertiary urogynaecology unit in women with the primary symptom of urinary incontinence to assess the repeatability of the 24-hour pad test. One hundred and eight women undertook seven 24-hour pad tests over 7 consecutive days together with 7 simultaneous fluid and activity charts. The results were analysed collectively and according to urodynamic subsets. Repeatability was assessed by repeated measures analysis of variance and univariate analysis of variance for each urodynamic diagnosis group (USI, mixed and no USI). Variation between pad test weights over the 7 days was low, supporting good repeatability. The number of days of pad testing required to approximate the 7-day average was 3 days. However, a single 24-hour pad test correlated highly with the 7-day average (r=0.881) and was considered sufficient to gauge leakage severity.

Comparison of the ICIQ-SF and 24-hour pad test with other measures for evaluating the severity of urodynamic stress incontinence

This study compared the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the 24-h pad test with other measures that assess severity of urinary loss in women with urodynamic stress incontinence (USI). Ninety-five women with primary or recurrent (secondary) USI were recruited. Assessment of the severity of urinary loss was made using the ICIQ-SF, a 24-h pad test, continence questionnaire, Stamey grade, and 3-day frequency volume diary. The relationship between these measures of incontinence severity was analysed. The mean age was 54 years (SD+/-12) and median parity 2 (IQR 1-3). In the primary USI group there was a strong correlation between the ICIQ-SF and the 24-h pad test (r=0.458, P =0.000). Both the ICIQ-SF (Kendall's' tau b=0.331, p =0.003) and 24-h pad test (Kendall's tau b=0.399, p =0.002) also correlated with the mean frequency of urinary loss on diary but not with the Stamey grade. No subjective or objective tests correlated with each other in women with secondary USI. These results demonstrate a good correlation between the 24-h pad test diary loss, and ICIQ-SF in women with primary USI. Because it also includes a measure of quality of life impact in a short user-friendly format, we suggest that the ICIQ-SF should have widespread applicability as an outcome measure in patients with stress incontinence.

The 24-hour pad test in continent women and men: normal values and cyclical alterations

OBJECTIVE

To obtain control values for the 24-hour pad test in a wide age range of continent women using accurate weighing scales and to compare the results obtained from pantyliners and pads in women and men.

DESIGN

Prospective anonymous study.

SETTING

A Sydney Tertiary Urogynaecology Unit.

POPULATION

One hundred and forty continent women and 14 continent men.

METHODS

A 24-hour pad test was performed in 120 continent women of widely varying ages, in whom hormonal status and exercise habits were documented. These continent women wore a standardised pantyliner for 24 hours and a high precision beam balance (accuracy 0.1 g) was used to measure the loss on the pad. To assess any variation in pad weights with differing pads, 20 female volunteers undertook the 24-hour test firstly with pantyliners then larger pads. To understand evaporative qualities of the two types of pads, one male wore each type of pad, instilled with 5 mL normal saline for eight hours overnight. Furthermore, to understand the contribution of vaginal secretions, a group of male volunteers performed a 24-hour test with pantyliners followed by pads.

MAIN OUTCOMES MEASURES

Pad weight, with regard to hormonal status, exercise, pad type and gender. The median age of subjects was 48 (interquartile range [IQR] 32-60), with a median pad weight gain of 0.3 g (IQR 0.2-0.6; 95th centile 1.3 g). Subgroup analysis showed no significant trends for pad loss in relation to menopause status, use of hormone replacement therapy or hormonal contraception and exercise status during the 24-hour period. Control values for pantyliners were not significantly different from those for continence pads. In addition, normal values in 14 males showed similar results, regardless of pad type.

CONCLUSIONS

The response rate of 39% might limit the applicability of the results. However, our finding that women lose only 0.3 g of vaginal secretions in 24 hours is much lower than previously reported. This might arise from the use of a highly accurate beam balance and the recruitment of a large sample of women with widely varying ages. This result might lower the threshold for objective diagnosis of urinary incontinence and alters the pad test definition of 'cure'.

Introducing external cephalic version to clinical practice

A service offering external cephalic version to all women with breech presentations at 36-38 weeks' gestation was introduced at St George Hospital in July 1997. This paper describes how this service was established and reports the clinical outcomes over the first three years; 116 external cephalic versions (ECV) were attempted on 114 women and success was achieved in 58 women (51%). Of the 58 women, 43 (74%) subsequently had vaginal deliveries. There were no fetal deaths, immediate Caesarean sections, or placental abruptions as a result of the ECV procedure. There were two (2%) episodes of transient fetal bradycardia following ECV, both of which returned to normal with a subsequent normal neonatal outcome. Pre- and post-ECV Kleihauer levels were collected with no increase in levels as a result of the ECV ECV is a procedure that can, and should, be provided as part of a public hospital service.

Taxotere inhibits in-vitro growth of human colonic cancer cell lines

Taxotere a semisynthetic analogue of taxol, is prepared from a precursor extracted from needles of the tree, Taxus baccata. It is a mitotic spindle poison more potent than taxol, that increases the rate of microtubule assembly and inhibits depolymerization of microtubules. There has been little research on its effects on colorectal cancer. Five colorectal tumour cell lines were investigated using three modes: flow cytometry (to determine how Taxotere affects the cell cycle), MTT assay, (to examine the cytotoxicity of the drug), and measurement of tritiated thymidine uptake, (to see whether Taxotere affects the rate of DNA synthesis and cell turnover). A time-course experiment, using flow cytometry, showed effects beginning between 0 and 2 hours after exposure. 24-hour assays were conducted for flow cytometry, and showed large changes, arresting most cells in G2/M phases (e.g., cell line LIM 1215 exposed to 1 x 10(-6) M Taxotere showed 72% of cells in G2/M compared to 14.7% in controls). 24 and 48 hour assays were conducted for MTT and measurement of tritiated thymidine uptake. MTT showed significant inhibitory effects, with maximum inhibitions varying between 5 and 70% for different cell lines after 48 hours (P < 0.05), while uptake of tritiated thymidine was not altered. While Taxotere has dose-limited toxicity, our results suggest that many human colonic cancers will be sensitive to Taxotere.