IUGA Newsletter

Advancing Urogynecological Knowledge Around the World

The Official Newsletter Volume 7, Issue 3, 2012

37th ANNUAL MEETING

BRISBANE, AUSTRALIA SEPTEMBER 04-08, 2012

Mesh Augmentation in 2012: One Surgeons Perspective..... 5

Controversies in Urogynecology: Levator Trauma ...................... 8

What To Do About Mesh........ 6

My Mozambique Experience...11

Chronic Pelvic Pain in Women.. 7

Maternal Deaths and Morbidity Halved in 20 Years................13

The IUGA Newletter is published by the members of the Publications Committee

Table of Contents

Editor: Alex Digesu

Welcome Letter.................................................................... 3

Associate Editors: Steven Swift Suzy Elneil Editorial Board: Eva De Cuyper Alexandros Derpapas Annette Kuhn Pallavi Latthe Mark Malak Luis Miguel Monteiro Menahem Neuman Paul Riss Kamil Svabik Bary Berghmans Nathan Guerette Kurinji Kannan Deborah Karp Aparecida Pacetta Ash Monga

Expert Opinion Corner........................................................ 5

Graphic Designer: Johanna Gomez The views and opinions expressed by the authors in this publication do not necessarily reflect those of IUGA, and/or its editors.

annual meetings future dates

2013 Dublin, Ireland

May 28 - June 1

2014 Washington DC, USA

July 22 - 27

2015 Lyon, France

June 30 - July 4

2016 Coming Soon

2

by Alex Digesu

Letter from our President.................................................... 3

by Harry Vervest

Letter from the Secretary/Treasurer................................. 5

by Søren Brostrøm

by Mickey Karram & Bob Freeman

Research & Development Committee Update................ 7

by Dorothy Kammerer-Doak

Chronic Pelvic Pain in Women............................................ 7

by Melissa Cohen, & Rebecca McLoughlan

Controversies in Urogynecology....................................... 8-9

by Prof. Hans Peter Dietz Vs. Vik Khullar

News from the Scientific Committee................................. 10

by Michele Meschia

Membership Services.......................................................... 10

by Amy Cassini

My Mozambique Experience.............................................. 11

by Deborah R. Karp

IUJ Corner............................................................................. 12

by Paul Riss

The Fistula Corner................................................................ 13

by Sohier Elneil

Things to do in Brisbane...................................................... 15

by Chris Maher

IT News Corner..................................................................... 15

by Carlos Molina

Dear Friends, Less than 60 days until Brisbane, where I hope to see a great many of you. Although it is a far and long way to go, I am sure the long journey will be worth it! In this issue you will find an exciting discussion between Hans Peter Dietz and Vik Khullar who are debating whether or not the levator ani avulsions, that we can see using imaging techniques, are facts or just artefacts. For the Expert Opinion Corner, Mickey Karram and Bob Freeman have kindly contributed appealing articles about the role of transvaginal mesh augmentation for prolapse repair underlining the need, from now on, of meetings between the Professional bodies (IUGA, ICS), the National Regulators (FDA, MHRA) as well as the Device companies prior to the development and introduction of new devices on the market.

Starting from this issue, there will be a discussion about chronic pelvic pain in women which represents a “not uncommon” and extremely debilitating condition in women attending urogynaecology clinics. This new corner has been included to satisfy the need of our entire readership.

An update from the scientific committee about the numbers of abstracts received, accepted or rejected for presentation at the next IUGA meeting is included and Michele Meschia (Scientific Committee Chair) will explain in detail the criteria adopted to select, judge and score the abstracts received.

Publication Committee Chairperson

Finally, Chris Maher is giving us a taste of the Brisbane meeting, telling us about the scientific and social programs as well as the beauty of the city which deserves to be discovered. Enjoy the read.

See you in Brisbane, Best Wishes, Alex Digesu

Suzy Elneil continues to update us about the trends in maternal deaths and morbidity in the developing countries.

a letter from the president

By Harry Vervest

Dear Members, On June 25, James Gibson passed away at the age of 78 years. This sad news was given through our Australian colleagues.

Jim practiced as an urogynecologist in Sydney, Australia. He was an excellent physician and well respected colleague. He was also a great teacher and scientist. Jim was one of the grandfathers of Urogynecology in Australia.

Jim has been of utmost importance to IUGA. He was a longtime member and served IUGA in numerous committees. He was member of the Executive Board and President from 1992 to 1994. He also was the local organizing chair of two IUGA Annual Meetings. He received the IUGA Lifetime Achievement Award at the Annual Meeting in Como in 2009 for his major contributions.

Jim was a loyal visitor of IUGA meetings, but never alone. Almost everybody within IUGA knows his wife Peggy, who was always at his side. Jim and Peggy were a lovely couple, always prominent and present with a lot of humor and friendly words for everybody.

The death of Jim is a great loss for Peggy and their children, but also for IUGA. We lose an honorable colleague, a scientist but most of all a very good and loyal friend. IUGA would like to express its gratitude for his major contributions to our organization.

A high Mexican decoration for Dr. G. Willy Davila

James Gibson President of IUGA, 1992-1994

At their recent scientific meeting the Sociedad Mexicana de Urología Ginecológica (SMUG) awarded Dr. G. Willy Davila (Cleveland Clinic, Florida, USA) with the title of Honorary Member. Dr. Davila, who 3

Brostrom accepted a highly prestigious and important position in the Danish Public Health Service.

At the Annual Business Meeting in Lisbon last year it was decided to split the position at the end of the current Secretary-Treasurer term and have a Secretary and a Treasurer. This means that we have two new positions within the Executive Board: Secretary and Treasurer. The length of the position of Secretary is three years; Treasurer is two years.

Potential candidates need to be an active IUGA member in good standing for at least five years, have been active in one or more IUGA committees and have attended 3 of the past 5 Annual Meetings. Moreover, the Secretary needs to have made a significant contribution to IUGA (i.e., hosted or organized an annual meeting, regional symposia or eXchange program).

Dr. Davila receives the Diploma of Appreciation from Dr. Arnulfo Martinez Chapa, a former president of SMUG.

I urge members who are interested in these important positions within IUGA to make themselves known and submit a brief CV. This should be sent to the IUGA office via e-mail to Maureen@iuga.org. Candidates will be reviewed by the Nomination Committee and if approved, their name and CV will be posted on the IUGA website. After the Annual Business Meeting in Brisbane no candidates will be accepted. The voting will start within 4 weeks after the end of the ABM and last for 6 weeks. Thereafter, the results of the voting will be published by email and on the website by the Nomination Committee.

The Australian Government’s significant contribution to our joint scientific meeting with the Continence Foundation of Australia The preparations for the Annual Meeting in Brisbane are going well. The meeting has been organized in cooperation with the Continence Foundation of Australia. The C ontinence Foundation of Australia is an important non-profit organization in Australia.

Their goals are to: • raise community awareness about bladder health and the prevention of incontinence

Dr. Willy Davila; Dr. Oscar Flores Racing, Founder/President of SMUG; Dr. Jorge Delgado Urdapilleta, Founding Member of SMUG and Dr. Laura Guadalupe Escobar del Barco, SMUG President-Elect.

• educate people about treatment and management options for incontinence

is originally a native Spanish speaker, received this title for his numerous scientific contributions in general and especially to the Spanish speaking Latin-American countries. It is a great honor for Dr. Davila to receive this title. But it is also a great honor for IUGA that its Vice-President received this honor in the country where IUGA was founded in 1975.

• advocate for the development of accessible continence services across Australia

IUGA congratulates Dr. Davila for receiving this honorable title.

We also would like to acknowledge the Sociedad Mexicana de Urología Ginecológica as an important and founding member of IUGA for the honor of bestowing this title to our Vice-President.

Important vacant positions within the IUGA organization In the last Newsletter, we announced the vacancy of the position of Vice-President as of January 1, 2013. Two other new positions within the Executive Board recently became available and we want to encourage members to apply for these interesting and important positions.

These positions became available as a result of Dr. Søren Brostrøm stepping down as Secretary-Treasurer at the end of this year. Dr. 4

• encourage people with bladder control problems to seek professional help

• facilitate and/or fund continence-related research The Continence Foundation of Australia is a very active society primarily for patients. They also focus on promoting these goals among health care providers like physicians, physiotherapists and nurses, but also among all organizations and government bodies working in the field of urinary and bowel continence.

With the help of the Continence Foundation of Australia, the Australian Government (Department of Health and Ageing) made a significant contribution to our joint meeting as a Bronze sponsor. We would like to thank the Continence Foundation of Australia for their support and look forward to a productive meeting which serves the interest of all health care providers working in the field of Urogynecology. Please visit their web site at www.continence.org.au for additional information.

Sincerely, Harry Vervest, M.D. Ph.D. President of IUGA

Letter form the Secretary/Treasurer

By Søren Brostrøm

I'm happy to report that the preparations for the Annual Meeting in Brisbane has been progressing extremely well, and this is in no small measure due to the hard work of Chris Maher and the rest of the local committee. Shan Fleming is the local meeting organizer, and she is already hard at work on the ground making sure everything falls in place. At the IUGA office, Maureen Hodgson and the rest of the staff are all gearing up to make sure the IUGA event of the year will be a great success. When you read this we will all be busy packing our bags for the long-haul to Australia. Please remember the dress code for the opening reception is beach casual, so remember to pack your flip-flops and sunblock!

The financial situation of IUGA is being challenged. It is getting more difficult to attract sponsorships for our annual meetings and other events. At the same time our expenses have been steadily increasing, as we have decided to professionalize the office, employing more staff including an Executive Director. Down the road the projected move of the IUGA office to Washington DC will also involve more costs for IUGA, though we expect to regain the investment

in staff and office through a better strategic position of IUGA. To control expenses, we will need to adjust our travel policies and other operating procedures, and we will take up this discussion with the Advisory Board and at the business meeting in Brisbane.

Speaking of investments, you may recall from the business meeting in Lisbon that we discussed investing parts of IUGA's reserve fund with a long-term perspective of generating a supplementary income of the investment. Previously, our funds had been held in cash only with no appreciable interest. Based on the need for an investment of a certain size, while still retaining a necessary cash liquidity, we decided to start with an initial investment of $1 million.

Following an extensive search, talking to several investment advisers and references, we decided to use the services of Joel Blau with MEDIQUS assets advisors to manage our investment. Starting in 3rd quarter 2011 we rolled out the investment of the $1 million over a 6 month period, to level out any market volatility, and by 1st quarter 2012 we were fully invested, and so far the investment has performed as expected.

When we meet for the business meeting in

Brisbane I will be happy to report in more details on the structure and performance of our investment.

Finally, and on a personal note: As many of you might have heard, I've left clinical urogynecology and am now working for the Danish government as director of national hospital planning. I'm very happy in my new position, which is keeping me busy. I've realized that this means I will not be able to fully commit the time, focus and energy needed to do my IUGA duties to the high standards I've set for myself, just as I might not be the best advocate and representative for IUGA for the remainder of my 5 year term, as I get more removed from urogynecology. Thus, I will step down after Brisbane and according to our new Bylaws this will open up two new positions of Treasurer and Secretary. I will do what I can to ensure transition and continuity of the new members of the Executive Board as well as the new Executive Director.

Kind Regards, Søren Brostrøm

THE EXPERT OPINION LEADER CORNER Mesh Augmentation in 2012: One Surgeons Perspective

By Mickey Karram, MD

At the present time significant controversies exist regarding the indications and techniques for vaginal mesh augmentation in patients with symptomatic pelvis organ prolapse. I view this topic as having multiple levels of understanding. For example, if I am a surgeon who has utilized mesh augmentation almost exclusively with very good success and minimal complications, I would think it would be best for my patients to continue this practice regardless of all of the ongoing criticism for the routine use of mesh. Surgeons who routinely utilize mesh augmentation should however also be very comfortable with conventional native tissue suture repairs. This is a significant concern of mine in that numerous surgeons who have utilized mesh on an ongoing regular basis have never taken the time to learn traditional repairs. This

creates multiple potential problems. First, novice surgeons who are not well versed in conventional repairs will have a higher chance of having an adverse event with a mesh kit repair, second if ultimately science proves that mesh augmentation is actually not superior to a native tissue repair how would these surgeons continue to treat patients needing surgery. Finally, at times, albeit rare, certain situations arise intra-operatively that would contradict the placement of synthetic mesh such as an unexpected bladder or bowel injury? In these situations the surgeon should feel comfortable proceeding with a properly performed native tissue suture repair. Also in the author’s opinion, mesh augmentation kits have not adequately addressed apical support. So, I feel that many mesh augmentation repairs need to be

supplemented with an apical suspension using sutures to optimize long term success and durability of the repair.

So, if you are a surgeon who falls into this category of someone who is very pro mesh augmentation and mesh kit utilization, you must ask yourself if you are comfortable with the utilization of native tissue suture repairs. If the answer is no then I think it is extremely important that you go to great lengths to undertake what is necessary to get comfortable with these repairs. While long term durability of traditional cystocele, rectocele and vaginal vault suspension procedures are far from perfect, the durability, when these procedures are performed in an appropriate fashion, 5

is not near as bad as has been perceived and propagated by the makers of synthetic mesh kits.

With the recent voluntary withdrawal of the trocar based mesh kit (Prolift), it will be interesting to see the impact of this on current prolift users. Prolift has been a very popular product with some studies

showing very good long term outcome data. These surgeons will have to make a decision regarding how they manage their prolapse patients in the future. Will they choose to continue with a similar kit made by a competing company? Or will they consider utilizing more conventional repairs or even possibly switching to a different type of mesh augmentation such

as a direct access system or even utilizing biologic mesh augmentation. Finally some may just decide to do more abdominal sacral colpopexies. If you are one of these surgeons I would strongly urge you to spend sometime learning or revisiting vaginal suture repairs as they will definitely come in handy and will ultimately make you a better surgeon.

WHAT TO DO ABOUT MESH?

By Bob Freeman, MD

Johnson & Johnson’s (J&J) decision to withdraw some of its mesh products for vaginal prolapse surgery is a concern as it’s likely to have widespread implications for the use of all vaginal mesh. While we understand that the decision is based on commercial viability, nonetheless, it is difficult to exclude the effects of the FDA warning and current litigation in the USA. Therefore, following the well publicised complications with DePuy hips, PIP breast implants and now transvaginal mesh surely it’s time for the regulatory authorities not just to accept that a new device is ‘substantially equivalent’ before marketing, but demand that we have the same quality of evidence as required for the introduction of new drugs.

How should this be done? Leadership is required from IUGA and ICS e.g. to meet with the regulatory authorities and express the concerns about the quality of evidence required before marketing, work with industry to obtain good quality data through formal and robust processes of evaluation and emphasise the need for

IUGA sponsored research fellow, Dr. Aparna Hegde, with her Best Poster Award for her work “Bulking Agent Injection for Stress Incontinence: Outcomes Assessment with 3D Pelvic Ultrasound” at the Cleveland Clinic Florida Research Day 2012.

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professional responsibility and regulation.

Whilst it is accepted that randomised controlled trials (RCT’s) with long-term follow-up are expensive and not easy for device companies to undertake, nonetheless commercial considerations must not outweigh patient safety and if this cannot be guaranteed because of lack of evidence then surgeons should question using these products.

RCT’s are possible and the PROSPECT Trial in the UK has demonstrated that multi-centre recruitment can be performed. Already over 800 patients have been randomised to a comparison of standard sutures versus non-absorbable or biological mesh for anterior and posterior compartment prolapse. The long-term results will inform us whether these products actually have a place and if so, in which patients.

Large case series with patient-reported outcomes and complications (e.g. using the IUGA/ICS classifications) also have a role in the evaluation of new products.

National registries with at least one year follow-up would be an appropriate method of gathering data but reporting would need to be mandatory. This should be achievable as illustrated by J&J’s evaluation

of the transanal rectal resection (STARR) procedure for rectal intusussception.

Sales are limited to experienced surgeons who have to record all data on a registry. Arguably, this should have been done for vaginal mesh before marketing and there is a concern that inappropriate use has occurred. This highlights the need for Professional regulation in addition to Company regulation.

The device companies should, however, be complimented on their approach to training including cadaver workshops and mentoring. But as surgeons we must adhere to national guidelines on new devices (e.g.

NICE, UK) and audit and review all cases.

The recommendations of the 2nd IUGA Grafts Roundtable published in the IUJ in April this year are particularly helpful in this regard.

To learn and move forward from these experiences we should urgently arrange meetings between the Professional bodies (IUGA, ICS), the National Regulators (FDA, MHRA) and the Device companies.

It is in our mutual interest to agree a robust framework for the development and introduction of new devices but above all it is important for the welfare of our patients.

Research & Development Committee Update

By Dorothy Kammerer-Doak, MD

One of the main functions of the R&D Committee is to review applications, and award the IUGA research grants. A call for IUGA grant research applications went out in April. The grant awards have been extended, and there are now a total of 6: a $20,000 1st place, and $10,000 2nd place for the 3 categories, Basic Science, Clinical, and Least Developed Countries.

The application has been streamlined, and the committee has included guidelines and recommendations on how to complete the application to increase the chances of success. Grant applications were due by July 2nd and were screened for completeness.

Each application was reviewed by at least 3 committee members, and scored. Awards will be announced at the annual meeting in Brisbane. Please note that applicants must be IUGA members to receive a grant.

The Prolapse and Urinary Incontinence Sexual Function Questionnaire-IUGARevised has been completed!! Many thanks to all who participated in this multi-center international project. The results will be presented at the annual IUGA meeting in Brisbane. Translation validation in seven countries is now underway. The manuscript has been submitted for publication in the International Urogynecology Journal along with a second publication that details the scoring methods.

The R&D Committee is also exploring the possibility of a surgical international database that could be used for multinational evaluation of surgical procedures.

This database would complement existing databases already in place. This will be a topic of discussion and planning at the R&D Committee meeting in Brisbane.

The final project underway is “R&D Committee Opinions for Best Practice Guidelines”. This will involve a thorough review of the literature about various “hot topics”, and then an evidence based publication with recommendations and guidelines for evaluation and treatment of various conditions. The Committee Opinions will be published in the International Urogynecology Journal and will include full references and the recommendations will be listed by level of evidence available. We hope these “Committee Opinions” will be helpful to IUGA members in evaluating and treating their patients with pelvic floor disorders.

Chronic pelvic pain in women: From a biomedical to biopsychosocial model of care Part 1

By Melissa Cohen, Clinical Nurse Specialist & Rebecca McLoughlan, Physiotherapist

We think you’ve met our patient: she has had chronic pelvic pain syndrome (CPPS) for nearly ten years. She holds down a job, at the expense of her social life. She attributes difficulties with her marriage to change in mood and impact of pain on intimacy. In consultations she fluctuates between tearful and forcefully requesting that you ‘make the pain go away’. She often talks about her fears for the future, asking unanswerable questions such as, ‘will I ever have children?’ ‘Will I cope with working another year if the pain continues?’ She is keen to engage in interventions that might offer a cure and maybe gradually increasing the use of medication as she reports that it is the only thing that helps her.

What do you offer this patient? The possibility of surgery? Modification or increase in her medications? Referral elsewhere? Further investigation? Can medical interventions benefit this patient?

CPPS, pain perceived in the pelvis or structures of the pelvis that continues beyond the point of normal healing time, is often a difficult symptom for clinicians to manage. It is frequently categorized as a medically unexplained symptom, however,

there is overwhelming evidence to suggest that pain persisting beyond the point of healing is due to the sensitization and associated changes within the central and peripheral nervous system.

Patients with CPPS present at many consultations with urologists, gynaecologists, surgeons and GPs trying to find a service that can provide the relief from pain that they desperately want. However, there is increasing acknowledgement that the biomedical approach to medicine is simply too narrow in scope to accommodate the complexity of CPPS. We advocate that treatment in these cases should address not only the pathology which may be contributing to the pain but to also improve a patient’s daily functional ability regardless of any specific pathology and without necessarily reducing the pain intensity.

While it may seem counter-intuitive to some clinicians to try and ‘manage’ a pain condition before all possible treatment options have been exhausted, we believe early intervention aimed at addressing the complex interplay between the biology, psychology and social factors

(biopsychosocial) is essential in order for the patient to begin regaining control of the impact of pelvic pain on their life.

This approach to CPPS management acknowledges that chronic pain results in an interactive interplay between these major factors and it cannot be separated into distinct, independent psychosocial and physical components. Understandably, the gold standard for biopsychsocial orientated management is multidisciplinary care. Part 2 of this article which will be published in the next issue, will look at possible ways to instigate a biopsychosocial model from the first point of patient contact.

If you have suggestions for a topic you would like to see in the next newsletter, e-mail it to amy@iuga.org.

Your feedback and comments are always welcome!

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controversies in urogynecology Levator trauma

By Andrea Tubaro, MD, FEBU Imaging of the pelvic floor strives to find a way into our daily practice and year after year the consensus remains that the clinical benefit of pelvic floor imaging is still to be proven.

Research in this area is certainly difficult because of the complexity of the pelvis anatomy, the multifactorial pathophysiology of urinary incontinence and genital prolapse but also because of poor research methodology.

The debate of whether levator ani avulsion is a real entity and a genuine clinical problem is not an imaging problem but rather an anatomical one which is usually studied on cadavers. Autopsy data have always been the foundation of our knowledge on anatomical defects and this is not going to change. A totally different issue is whether imaging can demonstrate a condition that has been observed at autopsy. I always said that imaging is anatomy for clinicians but we also know that imaging can be highly misleading and attention should be paid to compare imaging with real anatomy. In the absence of such a fundamental work, years of work and lots of research money can be wasted.

There is no substitute for sound research methodology and investigation into imaging of the pelvic floor could greatly benefit from a more rigorous approach.

Levator trauma: fact, not artefact

By Prof. Hans Peter Dietz Over the last decade it has become clear that anal sphincter trauma is not the only major form of childbirth- related maternal trauma.

In 10-30% of all women delivering vaginally, the puborectalis muscle is traumatically disconnected from its insertion on the os pubis, resulting in a defect (‘avulsion’) that can occasionally be seen in Delivery Suite (Figure 1), that can be palpated and demonstrated with magnetic resonance and Ultrasound, both 2D and 3D/ 4D translabial techniques (Figure 2). It has been confirmed in cadavers and is noticed by women as a loss of vaginal tone and pelvic floor muscle function. Avulsion injury to the levator ani seems to be the main aetiological link between childbirth and female pelvic organ prolapse (FPOP). While anal sphincter trauma has enjoyed much attention for the last 20 years, this is not the case for levator trauma, despite FPOP being much more likely to result in surgical intervention than fecal incontinence, with a lifetime risk of surgery of 10-20%. Many colleagues find it difficult to accept that they should have missed such major pathology for so long. This is probably because such trauma is usually occult, and because FPOP commonly manifests decades after the traumatic event.

While the first mention of levator trauma in the world literature dates to 1943, the realization that abnormalities seen on postnatal pelvic floor imaging are due to actual tears is less than 10 years old. The first series comparing antenatal and postnatal imaging was published in 2005. The main consequence of such defects, prolapse of the anterior and central compartments, has been known since 2006. It is only two years since levator trauma has been identified as a major risk factor for prolapse recurrence (see Table 1), a finding that has since been confirmed by four other studies. In addition, we now know that damage to the levator ani doesn’t just include macroscopically visible tears. There also is irreversible over distension of the levator hiatus, which seems to be even more common than avulsion. Excessive distensibility (‘ballooning’) of the levator hiatus, the largest potential hernial portal in the human body, is associated with prolapse, an effect 8

PRO

that is independent of levator avulsion. In fact, I strongly believe that ballooning also is an independent risk factor for prolapse recurrence.

It is time for clinicians to take account of the recent literature on the topic. Pelvic floor trauma is common, and it matters: to women, to obstetricians, and of course to urogynaecologists and female urologists. Most of all it matters to prolapse surgeons, especially to those who are not fundamentally opposed to mesh use. We have modelled the risk of cystocele recurrence based on 334 women seen on average 2.5 years after anterior colpoprrhaphy +/- mesh, obtaining individual risk estimates between 10% and 90% depending on avulsion and the degree of ballooning. Surely we need to know, and surely our patients would want to know that kind of information.

Levator trauma is a fact, not artefact. It’s easy to check, you don’t need fancy machines. Just examine vaginally. Place your finger parallel to the urethra, the fingertip below the bladder neck, and follow the inferior pubic ramus. You should encounter muscle (the puborectalis) immediately. If there is no muscle felt on the bone, that is, if one can follow the bone laterally for 2 fingerbreadths or more without encountering contractile tissue, then that’s not an artefact but maternal birth trauma.

Time to wake up to the facts!

Figure 1: Typical right-sided levator avulsion injury (arrows) as diagnosed in Delivery Suite after a normal vaginal delivery at term, on 3D ultrasound (center) and on magnetic resonance imaging (right) three months postpartum. From: Dietz H, Gillespie A, Phadke P (2007) Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust NZ J Obstet Gynaecol 47:341-344, with permission.

Clinical cystocele Stage 2+ ICS POP-Q No avulsion

Cystocele to >= 10 mm below the symphysis on US

1

1

Unilat. avulsion (n=17)

RR 2.9 (1.7-4.4)

RR 3.8 (2.1- 5.5)

Bilat. avulsion (n=12)

RR 2.8 (1.4-4.3)

RR 4.1 (2.2-5.4)

Table 1: Relative risks (95% Confidence Intervals) for clinical and sonographic recurrence of significant cystocele in women with avulsion. US= translabial ultrasound. N= 83, mean follow-up 4.5 years

Figure 2: Fig. 5: Tomographic translabial imaging of the puborectalis muscle. A complete defect of the puborectalis muscle is visible on the patient’s right (the left side of any single slice) and marked with a (*). From Dietz H. (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329334, with permission.

Levator ani avulsion: It is just a transperineal ultrasound approach artefact!

CON

By Vik Khullar Three dimensional ultrasound has been a great advance in imaging the pelvic floor.

However, there are a number of properties of ultrasound which must be understood when interpreting images particularly when using three dimensional ultrasound. The ultrasound image itself relies on the echogenicity of the tissues rather than density, therefore tissues with a high echogenicity appear white on the ultrasound image and those with a low echogenicity, and this includes structures which are fluid filled, appear black (hypoechoic). This is important as the urothelium and the longitudinal smooth muscle of the urethra appear to be black when insonated along the urethral axis. This has been mistaken as an absence of tissue or a defect in the urethra where it is actually tissue imaged from a particular direction (image 1). Ultrasound frequency determines the resolution of the image but increased frequency has a reduced depth of penetration due to attenuation so that 7.5 MHz is the highest frequency which can be used to image pelvic organs and an ultrasound frequency of 5 MHz produces an axial resolution of 0.9mm. This means that two structures 0.9mm apart cannot be discriminated with a 5 MHz probe unless the structure being imaged is an interface reflecting ultrasound waves. Hence we can see the orientation of a bladder wall to the incident ultrasound waves determines whether it is seen (image 2).

The relevance to pelvic floor imaging is that a transperineal approach is used and the ultrasound waves are travelling caudiocranially. The orientation of the pelvic floor changes from parallel to perpendicular to the incident ultrasound waves. The pelvic floor becomes more “vertical� the greater the degree of vaginal prolapse. This means that the pelvic floor becomes more difficult to image with the transperineal approach, the greater the degree of prolapse as it produces less echoes and thins.

Therefore, we would hypothesise that pelvic floor avulsions are an artefact of the technique which is increased in women where a

substantial part of the pelvic floor is perpendicular to the incident ultrasound waves. In a study by Toozs Hobson et al, using a radial transvaginal ultrasound approach to measure the levator ani hiatus of 156 women with postnatal follow up of 110 women, the attachments of the pelvic floor was imaged in all the women.

Therefore it appears that the incidence of levator avulsions are artificially increased by the transperineal approach! This would explain the high prevalence reported of levator ani avulsions but the lack of association with clinical outcome.

Image 1

Image 2

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News from the Scientific committee

By Michele Meschia, MD

A total of 530 abstracts were submitted for being presented at the next IUGA meeting in Brisbane, of whom 495 were oral/poster and 35 video presentations.

All abstracts were reviewed by 13 reviewers including the Chair and 8 elected members of the Scientific Committee as well as 4 local Australian assessors.

The scoring system ranged 4-20 based on the Originality (15), Study methodology (1-5), Clinical relevance (1-5), Results & Discussion (1-5).

The most common topics covered by the submitted abstracts were: pelvic organ prolapse (144), stress urinary incontinence (101), assessment (48), surgical complications (46), overactive bladder (37), basic science (36), pregnancy and delivery (35).

Quality of life (QoL) (21). Voiding & anorectal dysfunction, sexual dysfunction, urodynamics and epidemiology were covered by 17, 16, 15 and 14 abstracts respectively.

Reviewers were divided into two groups and each one received half of abstracts to score except for the chair who reviewed all.

After the review process was completed, means and SD were calculated for all abstracts and they were organized, according to the scores and SD, from the highest to the lowest.

A web conference was then organized on May 13th to discuss all relevant issues and to draw a preliminary scientific program with most of the scientific committee members being involved.

Thirty-three abstracts were re-assigned to a different category.

2 abstracts were rejected: one was previously presented at the last IUGA meeting in Lisbon and the other focused on male BPH. As there were only 2 videos with data submitted, all videos were considered together.

The scientific program was organized as follow: • 7 Oral Podium sessions including the 7 highest scored abstracts

from each category (8 min presentation + 4 discussion each: total time allowed 12 min) • 10 Oral poster sessions including the following better scored abstracts from each category (3 min presentation + 2 min discussion: total time allowed 5 min). Each oral poster session is made up of 12 to 18 abstracts • 2 video sessions: each of 6 videos (10 min) In order to define 7 main topics, some categories were combined, according to the number of submitted abstracts and with the objective to achieve rather homogeneous groups (in term of numbers) sessions were organized as follows: Sessions N° abstracts POP 119 Stress Incontinence 78 Assessment & Urodynamics 82 Pregnancy and Delivery & Sexual Dysfunction 58 OAB and QoL 55 Basic Science & Epidemiology 52 Surgical Complications and Voiding Dysfunction 51 Total 495 Forty-nine abstracts were accepted as Podium Presentation, 138 as Oral Posters, 12 as videos and 321 as Non-discussed poster.

A total of 11 abstracts were declined and therefore replaced with the following higher scored abstracts in each category.

Last but not least I want to thank all the scientific committee members for the hard work done in reviewing all abstracts and Maureen for the assistance given to us all.

I hope you will enjoy the 37th IUGA annual meeting in Brisbane.

Membership services

By Amy Cassini

Dear Members, It’s that time of year again to pack your bags and head to the IUGA Annual Meeting! In between the scientific sessions, workshops and meetings, make some time to visit the IUGA Membership Booth. The Membership and Graphic Design departments have been hard at work for the past 6 months creating new marketing materials to help you better understand your membership benefits and other IUGA programs. You’ll also be able to view and purchase some of our online store items, play some interesting games for a chance to win a prize and possibly win a free registration to the 2013 Annual Meeting in Dublin!

Don’t miss out on the IUGA Membership Booth.

Looking forward to meeting you in Brisbane.

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Join IUGA Now! Annual Membership Dues are USD$100 and provides the following benefits: • 12 printed issues and online access to the International Urogynecology Journal • Registration discount for the IUGA Annual Meeting and IUGA Regional Symposia • Eligibility to apply for IUGA sponsored grants that are available only to IUGA members • Access to “Members Only” content on the IUGA web site • Access to a network of over 2,500 like-minded professionals worldwide

MY MOZAMBIQUE EXPERIENCE: A LESSON FOR HOW MEDICINE IS PRACTICED IN RESOURCE-POOR COUNTRIES!

By Deborah R. Karp, MD

During the summer of 2011 after completing my Urogynecology & Pelvic Reconstructive Surgery fellowship at Cleveland Clinic Florida under Dr. Willy Davila and Dr. Vivian Aguilar, I travelled to Maputo, the capital of Mozambique, in Southern Africa to be an apprentice under Dr. Igor Vaz, a reconstructive urologist practicing at the Central Hospital at Eduardo Mondliane University. My trip was set up through IVU Med, a non-profit organization based in Salt Lake City, Utah with a mission to provide urologic surgery to people worldwide. The Central Hospital in Maputo is an academic teaching facility with a medical school, which is the only medical school in Mozambique.

The Urology Division is small with just three Urologists and two Urology residents. They perform general Urology but are a referral center for reconstructive Urology and fistula care throughout Mozambique. They have a high acuity and wide range of problems with little resources. I brought Urologic supplies including foley catheters as well as general medical supplies like intravenous tubing, gloves, and hernia mesh donated from Americares, a humanitarian aid organization based in the United States. Unfortunately, I was severely limited by the 40lb weight restriction on my checked in luggage so was not able to fully transport as many supplies as I would have liked.

women patients range from primary obstetric fistula (a relatively straightforward case in this setting) to congenital pediatric problems (urethral and vaginal agenesis with resultant neurogenic bladder and vesicoureteral reflux) to recurrent large vesicovaginal fistula with vaginal stenosis and urethral destruction. Due to the damage to the bladder wall from longstanding vaginal leakage of urine and consequent severe bladder and vaginal fibrosis, Dr. Vaz has become adept at urinary diversion and will frequently perform a neobladder with sigmoid colon and a Mainz procedure. The hospital is rich with complex bladder pathology but lacks abilities to use radiologic imaging to study this pathology prior to surgical exploration. In the pediatric patients with congenital urogenital tract abnormalities there is a presumption of ureteral reflux though they don’t know really since the fluoroscopy machine is broken, MRI or CT imaging is not available, and they do not have the capabilities to perform intravenous pyelography. For a different patient with uretero-cutaneous fistula, they have no way to divert her with nephrostomy tubes so the patient keeps leaking urine onto a bandage on her abdominal wall as the tissue becomes more and more friable and inflamed. Surgery was performed as it is the only option as there are no nephrostomy tubes in the hospital that can be put into place in the short term to allow self-resolution and healing. This is not a long term viable option anyway so surgery is opted for.

My first impressions of the Central Hospital of Mozambique were that it is an impressive complex of buildings with each department having or sharing their own building. The grounds are very well maintained, and unlike the regional hospital that I had visited in Bahar Dahr, Ethiopia the previous year, it did not seem to be over-run with patients or people camped on its grounds awaiting medical care. The original hospital was built in 1950 and then the complex has expanded over time to what it is now. There is a professionalism and academic aire to the complex with a medical school on the grounds and many Mozambican doctors neatly dressed with pressed white coats. The Urologic building is the oldest building and is fairly decrepit. The patients are spread throughout many small wards with multiple patients per unit. There are several women on the Urology unit, and women generally comprise about 50% of the patient population on the Urology suite at any one time. The urologic problems in the

Unlike in the US and other countries where we have become accustomed to technology such as CT Scan, dynamic MRI imaging, and 3 and 4 dimensional ultrasound of the pelvic floor, in Mozambique you use your ‘best clinical judgement’ i.e. what is common and likely based on the surrounding conditions as well as advanced cases that have been seen before. Thus what is most likely to happen to a patient’s bladder function who lives with a large vesicovaginal fistula for over 5 years? The vagina and bladder walls become contracted and non-functional. In resource-rich countries you have the option of ordering multichannel urodynamics or video urodynamics to actually see what is happening and help you make the diagnosis. Interestingly when I was involved with medical student oral examinations at the end of their rotation on the Urology service, when I asked the students what is the differential diagnosis for urinary incontinence, the only answer many could come up with was genitourinary fistula.

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The lack of material resources is not the only large issue.

In this governmental hospital they have only three Urologic attendings and a severe shortage of anesthesiologists. Due to the lack of governmental resources both Urologists work in the governmental hospital in the mornings teaching residents and medical students and attend private clinics in the afternoon and evening hours. Dr Vaz’ monthly salary from the governmental hospital where he worked mornings and was chief of urology was the equivalent of 450 US dollars per month. In addition because of the low salaries in the governmental hospitals, they have few ancillary staff available. Due to a severe shortage of scrub nurses (they get paid the equivalent of 200 US dollars per month in the governmental hospitals), many hospital workers leave the public setting for private hospitals where the pay is better. So many days, though there is a surgical waiting list that is months long, only half the operating tables are working due to staff and anesthesia shortages.

What We Learn from the Publisher’s Report

By Prof. Dr. Paul Riss

Exciting news is coming from the IUJ. As co-editor-in-chief I now have a twitter account where you can follow me.

Every week I will announce (“tweet” is the correct word) an article from the current issue of the International Urogynecology Journal. The tweet is a short message of a maximum of 140 characters – similar to a text message – and will be worded to get your interest. What is special about the tweet is that it will contain a link (a shortened URL) which will direct you to the full article on the IUJ website.

Springer has agreed to make these articles free access for at least one week, so you do not have to log in as an IUGA member via the IUGA website or the IUJ Springer website.

How can you find me? It is very easy: https://twitter.com/iuj_eic Paul Riss IUJ @iuj_eic

My month long experience in Mozambique was not only a lesson in exposure to clinical pathology that is rarely seen in the United States, but much more importantly a lesson for how medicine is practiced in resource-poor countries and limitations that clinicians and surgeons work under in the face of severely advanced medical conditions. For example one would be hard-pressed to pursue surgery for vesicovaginal fistula if there is no reliable influx of supplies available for postoperative urinary drainage. In this setting, I learned it is important to start with the basics such as patient and physician education as well as fundamental medical supplies.

The experience taught me an important life lesson: remembering and relying on the basics both inside and outside the operating room will go far in the face of hardship and adversity.

What can you expect? Every week I will highlight an article from the current issue of the IUJ. I will write one phrase explaining the aim or the result of a study or the contents of an article and add a URL which will take you directly to the article. Feel free to download it, save it on your hard drive, and share it with friends and colleagues. Typical recent examples of my tweets were (although when you read this the full article may no longer be accessible): • Does anterior colporrhaphy induce bladder outlet obstruction? the answer is no: http://goo.gl/8hrlS • Ever wondered whether you could detect anal sphincter injury with digital rectal examination? here is the answer: http://goo.gl/j8heV The choice of the articles will be very subjective – just what I find worthwhile or what I think would be of interest to you, ie our readers (and my twitter followers). Twitter will not replace the table of contents alert, but it may contain information of general interest.

Have I got you interested? Go to the website (https://twitter. com/iuj_eic), read the tweets and become a follower. I promise you will not be bored, but find hints and articles which will be useful for your clinical practice and for your research.

Paul Riss Editor-in-Chief International Urogynecology Journal

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THE FISTULA CORNER Maternal Deaths and Morbidity Halved in 20 Years

By Sohier Elneil

The ‘Trends in Maternal Mortality’ report by the World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Bank has just been published. It clearly states that the number of women dying of pregnancy and childbirth related complications has almost halved in 20 years. The report shows that from 1990 to 2010, the annual number of maternal deaths dropped from more than 543,000 to 287,000 – a decline of 47 per cent. While substantial progress has been achieved in almost all parts of the world, many countries particularly in sub-Saharan Africa will still fail to reach Millennium Development Goal (MDG) 5 (reducing maternal death by 75 per cent from 1990 to 2015). Indeed in the top 40 countries with the highest mortality rates in the world, 36 of them are in sub-Saharan Africa.

Tremendous disparity exists within and across countries and regions. The report highlights that: • In sub-Saharan Africa, a woman faces a 1 in 39 lifetime risk of dying due to pregnancy or childbirth-related complications. In South-eastern Asia the risk is 1 in 290 and in developed countries, it is 1 in 3,800. The morbidity figures, which include obstetric fistula, remain unknown but conservative

estimates put the mortality to morbidity ratio at 1:20. This suggests that in subSaharan Africa women are at great risk of developing crippling morbidities associated with childbirth.

• Ten countries have 60% of the global maternal deaths: India accounting for 20% of all deaths (56,000), Nigeria accounting for 14% of all deaths (40,000), Democratic Republic of the Congo (15,000), Pakistan (12,000), Sudan (10,000), Indonesia (9,600), Ethiopia (9,000), United Republic of Tanzania (8,500), Bangladesh (7,200) and Afghanistan (6,400). Thus, obstetric morbidity is estimated to range from 128000 to 1.12 million women for each of these countries • Ten countries have already reached the MDG target of a 75% reduction in maternal death: Belarus, Bhutan, Equatorial Guinea, Estonia, Iran, Lithuania, Maldives, Nepal, Romania and Viet Nam. Despite these encouraging figures, collecting data in these environs is difficult and challenging. It makes it difficult to assess progress accurately due to a paucity of reliable information about maternal deaths.

In many developing countries, deaths may go uncounted and frequently the cause is not recorded accurately, particularly when

IUGA PRESIDENT'S OFFICE VISIT IUGA President, Dr. Harry Vervest, poses with IUGA staff in a recent visit to the office in Fort Lauderdale. During the visit, Dr. Vervest met new staff members and participated in discussions about the staff’s long-term goals for their departments and IUGA.

a woman dies at home.

Women continue to die from the same pregnancy-related complications that have always prevailed: severe bleeding after childbirth, infections, high blood pressure during pregnancy, and unsafe abortion. 99% of maternal deaths that occur in developing countries could have been prevented with appropriate interventions including access to voluntary family planning, investment in midwifery skills and access to emergency obstetric care. These interventions have always saved lives and when instituted promote the progress of meeting MDG 5.

The halving of the mortality and morbidity figures is certainly good news, but over a quarter of a million women still die in pregnancy and childbirth each year, and more than 215 million women lack access to modern contraceptives. Meeting the need for voluntary family planning for these women is a fundamental reproductive health right and should be supported by all agencies. By reducing mortality, we will reduce the morbidity encountered by these women thus liberating them from a life of anguish and misery.

The Sociedad Mexicana de Urología Ginecológica honored Dr. Oscar Flores Carreras by naming their 22nd Annual Meeting in his honor. He is pictured here with his children, their spouses and Dr. G. Willy Davila, IUGA Vice President.

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things to do in brisbane

By Christopher Maher

It is now less than one month from the 37th International Urogynecology Association meeting in Brisbane Australia which runs from 4-8th September and co-hosted with Continence Foundation of Australia and Urogynaecological Society of Australasia. The executive, scientific, educational and local organizing committees have worked together to present an exhilarating and varied program that is designed to appeal to IUGA's growing family of professionals dedicated to preventing and treating all aspects of female pelvic floor dysfunction. The academic program commences with 22 smaller workshops and educational courses on Tuesday and Wednesday including: •

anal sphincter and train-the trainer workshops with Abdul Sultan

•

cadaver workshop Professor John DeLancey

•

laparoscopic skills workshop with Michael Wynne-Williams

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Live surgery educational course Professor Mickey Karram

• Role of USS in Prolapse Surgery: Dr. Ranee Thaker and Professor Peter Dietz •

Pelvic floor exercises are overrated

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FDA and Transvaginal Mesh

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Childbirth and Female Pelvic floor

However there is plenty of fun things to do in and around Brisbane in Spring: walking or riding under impossibly blue skies around this city opens up a world of experiences. A well planned series of paths and bridges connect the city centre to South Bank Parklands (right opposite the convention centre) which will be perfect for swimming and outdoor dining by the river.

During the meeting, a cultural feast is occurring in Brisbane with The Masterpieces from the Prado At the Gallery of Modern Art and The Hamburg Series at performing arts centre including the Hamburg ballet, Philharmonic Orchestra and the State Opera.

Don't forget a visit to our local wildlife at Lone Pine Koala sanctuary to cuddle a Koala and a day trip to Steve Irwin's Austraila Zoo will offer unforgettable memories.

Thursday to Saturday sees the scientific program commence after the Wednesday evening welcome reception and includes oral podium, video and poster presentations with the following 5 keynote addresses/debates.

•

Teaching and Training Urogynaecolgy: Mr. Tony Smith

IT news CORner

Within 100 kms of Brisbane are the world famous Gold Coast and Sunshine Coast beaches and you can be snorkelling on the Great Barrier Reef in a day from Brisbane.

So it's not too late... do yourself a favor and visit www.iuga2012.com for a great educational meeting and the holiday of a lifetime.

Photo Gallery Photos from the 36th Annual Meeting in Lisbon are now posted! Check out pictures from the workshops, live surgeries, social programs and more by visiting www.iuga.org and selecting “Photos” from the “Gallery” menu. You can also view other photo galleries from previous annual meetings.

Discussion Forum Don’t forget to continuously check out the IUGA discussion forum, where you can post about any urogynecology topic, including clinical questions or comments and information about the upcoming 2012 Annual Meeting. Your fellow peers might just have the answer you are looking for.

New Feature!

Keep an eye on the left hand side of the IUGA home page for up-to-date urogynecology news. If you come across an article or other newsworthy item for our web site, please send it to amy@iuga.org. If it’s relevant, we will post it!

Don’t forget to follow us to stay up to date with news announcements.

Facebook.com/iugaoffice

Follow US

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Advancing Urogynecological Knowledge Around the World

IUGA Office Staff

IUGA Executive Committee

IUGA International Board

Maureen Hodgson, CMM Administrative Director maureen@iuga.org x. 115

Harry Vervest President hvervest@wxs.nl

Peter DeJong Africa pdejong@medi.co.za

Kendra Busby Finance Manager accounting@iuga.org x.113

G. Willy Davila Vice-President davilag@ccf.org

Lisa T. Prodigalidad Asia prodimd@yahoo.com

Amy Cassini Membership Manager amy@iuga.org x. 112

Peter K. Sand Past-President peterksand@gmail.com

Hans Peter Dietz Australia hpdietz@bigpond.com

Søren Brostrøm Secretary-Treasurer soren@brostrom.dk

Teresa Mascarenhas Europe tqc@sapo.pt

Carolyn Slade Director, Educational Programs carolyn@iuga.org x. 116

Robert Shull North America bshull@swmail.sw.org

Dawn Beale Administrative Coordinator dawn@iuga.org x.111

Enrique Ubertazzi Latin America enrique.ubertazzi@hospitalitaliano. org.ar

Carlos Molina IT Director carlos@iuga.org x. 114 Johanna Gomez Graphic Designer johanna@iuga.org x. 117

IUGA Committees

Education Committee Jan Paul Roovers Chairperson

Public Relations Committee Lynsey Hayward Chairperson

Scientific Committee Michele Meschia Chairperson

Fellows Committee Rufus Cartwright Chairperson

Research & Development Committee Dorothy Kammerer-Doak Chairperson

Terminology & Standardization Committee Bernard Haylen Chairperson

Publications Committee Alex Digesu Chairperson

If you are an IUGA member who is interested in joining a Committee, please e-mail membership@iuga.org

IUGA Office 790 East Broward Boulevard, Suite 300 Fort Lauderdale, FL 33301 USA Phone:+1-954.763.1456 • Fax: +1-954.763.1236 E-mail: office@iuga.org www.iuga.org