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Advancing Urogynecological Knowledge Around the World

The Official Newsletter Volume 7, Issue 2, 2012

37th ANNUAL MEETING

BRISBANE, AUSTRALIA SEPTEMBER 04-08, 2012

The Status of Transvaginal Mesh Repairs for Prolapse............... 4

The PROTECT Project ............ 9

Philosophy of Urogynaecology Surgery................................... 4

Research Grants...................10

Controversies in Urogynecology The “G Spot”: Fact or Fiction.. 6

Provision of Long-Term Catheters and Stoma Bags in Fistula Surgery.....................11


The IUGA Newletter is published by the members of the Publications Committee Editor: Alex Digesu 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 Graphic Designer: Johanna Gomez

Table of Contents Welcome Letter.................................................................... 3 Letter from our President.................................................... 3 Expert Opinion Corner........................................................ 4 Publications Committee Update........................................ 5 Controversies in Urogynecology....................................... 6-8 The PROTECT Project.......................................................... 9 Research Grants.................................................................... 10 IUJ Corner............................................................................. 10 The Fistula Corner................................................................ 11 Membership Sevices............................................................ 11 News from the IUGA Office................................................ 13 Around Brisbane.................................................................. 14 Program Time Table............................................................. 15

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

JEDDAH Saudi Arabia

INTERNATIONAL UROGYNECOLOGICAL ASSOCIATION

2013 Dublin, Ireland

May 28 - June 1

REGIONAL SYMPOSIUM

2014 Washington DC, USA July 22 - 27

NOVEMBER 28-29, 2012

2015 Leon, France

June 30 - July 4

2016 Coming Soon

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Program information and registration www.iuga.org or registration@iuga.org

MARK YOUR CALENDAR!

King Abdulaziz University


Dear Friends, It is with great pleasure that I introduce the “new face “of the IUGA Newsletter. Since I started a year ago, we have been closely working with Johanna Gomez, the IUGA Graphic Designer, on creating a new, improved and exciting layout. More colours and images have been added in order to make the Newsletter more attractive. In this issue, two opinion leaders will debate whether or not the G-spot really exists, a theme which has recently been the subject of discussion in one of the last issues of the International Urogynecology Journal. Donald Ostergard and Eckhard Petri (who we all know to have extensive experience and know-how in urogynecology) have contributed with two interesting articles which I am sure you will find very riveting.

their product (as long as they are legal!). If you are interested in advertising please contact Amy Cassini our Membership Manager at amy@iuga.org.

We are more than happy to discuss other topics and members are invited to suggest any issue which they believe to be controversial in Urogynecology. Please e-mail your article suggestions to

Publications Committee Chairperson

Finally, I am delighted to inform all of you that we have a new printing and mailing house. I am sure this will eliminate all the problems that we had in the last six months which were the cause of such delay in sending out the Newsletter. We deeply apologize for these delays. I hope you enjoy the read! Sincerely, Alex Digesu

amy@iuga.org We have now started including advertisements from Industries which will help us cover some of the printing and mailing costs for the newsletter. Industries are more than welcome to advertise

UPCOMING ELECTIONS: A CALL FOR CANDIDATES By Harry Vervest

Although IUGA is primarily an organization focused on improving health care in the field of Female Urogynecology and Pelvic Floor Medicine, the organization is only possible with the support of its members. Currently we have 8 different committees: Education, Fellows, Publications, Public Relations, Research & Development and Standardization & Terminology. In addition to these committees we also have volunteers participating in publishing scientific studies in our journal and organizing Annual Meetings around the world.

elected members and one member elected by the President.

In order to achieve these important goals IUGA continuously needs enthusiastic members for its committees. Members for committees can show their interest to serve on any committee by contacting the IUGA office. However, members interested in serving on the Executive Committee, the International Board, the Scientific Committee, the Nominations Committee and the chairs of all other committees are elected by the membership. Before candidates are approved for election, they are first screened by the Nominations Committee in order to determine if they are eligible. The Nominations Committee includes: President, Past President, two

• Previous significant contribution to IUGA (i.e., hosting or organizing an annual meeting, regional symposium or eXchange);

At this moment, we have three positions available, for the term beginning January 1, 2013. These positions are: Vice-President and two members for the Nomination Committee. To be eligible for the VicePresident position you must meet the following criteria: • Must be a an active IUGA member in good standing with a minimum active membership of 5 years;

• And/or previous participation in Advisory Board (i.e., Committee Chair, Intl Board Member, etc.); • Must have attended an IUGA Annual Meeting in 3 of the past 5 years. To be eligible for the Nominations Committee you must meet the following criteria: • Must be an active IUGA member in good standing with a minimum active membership of 5 years;

• Must be active in one or more IUGA committees for at least 5 years; • Must have attended 3 of the past 5 Annual Meetings. I urge members who are interested in these important positions, make themselves known and submit a brief CV to the IUGA office at office@iuga. org. Candidates will be reviewed by the Nomination Committee and if approved, their name and CV will be posted on the IUGA website and presented at the Annual Meeting in Brisbane (please be advised, candidates will not be accepted after the Annual Business Meeting). The voting will start on November 1st and will last for six (6) weeks. The results of the voting will be published by email and on the website by the Nominations Committee. More information can be found on the IUGA website under Committee and Nominations. Please do show your interest for these important positions within IUGA! Harry Vervest, President of IUGA 3


THE EXPERT OPINION LEADER CORNER THE STATUS OF TRANSVAGINAL MESH REPAIRS FOR PROLAPSE By Donald R. Ostergard, MD

The United States Food and Drug Administration (FDA), on July 13, 2011, issued a notification regarding the use of transvaginal mesh for pelvic organ prolapse (POP) repairs stating that serious complications from the repair of POP with mesh are not rare, a change from the prior notification of October 20, 2008. Additionally a hearing was held September, 8-9, 2011 to further explore this serious public health problem. This author is impressed with lack of understanding by the participants in the hearing and the FDA itself regarding the genesis of mesh complications. Notably, testimony from a biomedical engineer knowledgeable in physical and chemical properties of polypropylene (PP) did not occur and all groups responding or commenting on the hearing showed no acknowledgement of this topic. If such an expert had testified it would have become apparent that the various characteristics of PP which are responsible for the inflammatory reaction, bacterial contamination, shrinkage, scarification and degradation common to the transvaginal

placement of mesh for POP would be apparent as well as the futility of insertion of a permanently implanted prosthesis through the “clean contaminated” environment of the vagina which promotes bacterial contamination. All of the adverse events which we have all seen or heard of were predictable from reports in the medical literature prior to the clearance for marketing of PP mesh kits by the FDA’s 510k process. Mesh shrinkage creates pain for which further surgery may not result in resolution leaving the patient a pelvic cripple. Erosion to the vagina occurs commonly, while erosion in to bowel, bladder, or urethra is less common, yet may be much more devastating and negatively affect the patient’s quality of life on a permanent basis. PP degradation was first reported more than 25 years ago. Such degradation produces toxic by products and greatly increases the surface area of the PP fibers which enhances the entire process. The notification also exhorts physicians to “be aware of the risks of surgical mesh”. Where are surgeons expected to obtain

this information, since manufacturers are not required to do human studies prior to marketing? Physicians have a reasonable expectation that manufactures will educate them regarding all possible adverse events. Or, is it a situation that, as one medical device company vice president responded when questioned regarding adverse events associated with one of their products, “we don’t know but the physicians will tell us when they begin using it”. The FDA is considering classifying future mesh products as Class III which would require clinical studies, but what about the continued sales of mesh products which the FDA considers to have serious complications which are not rare? Shouldn’t the FDA require withdrawal from the market to prevent further serious complications?

PHILOSOPHY OF UROGYNAECOLOGY SURGERY By Eckhard Petri, MD

Over the decades, more than 100 surgical techniques, using both the abdominal and vaginal approach, have been developed to correct pelvic floor disorders. Too often, the choice of procedure and route of approach have been based on the surgeon’s biases rather than on anatomic principles. Improved understanding of both normal and abnormal pelvic anatomy and function, and the many factors contributing to incontinence or prolapse, now allows a more rational selection of procedure based on what is best for the individual patient. The pelvic floor is one unit and surgery in one compartment can adversely affect function and anatomy in another. Sacrocolpopexy, or sacrospinous fixation, may precipitate a cystocele and/or result in urethral sphincter incompetence. Colposuspension may initiate, or make worse, a pre-existing rectoenterocele. Since the development of the “tension-free 4

vaginal tape”, alloplastic materials have “taken over”, with more than 4 million tapes and meshes having been inserted. However, the initial enthusiasm over high success rates has abated due to the emergence of a significant number of complications; many not originally anticipated. The aim of urogynaecological surgery should be to improve symptoms that are bothersome to the patient and to improve a patient’s quality of life. It should not be to fulfill our aesthetic view of the vagina and pelvic floor. The choice of surgery is influenced by clinical features, physical fitness and patient expectations, and has to be individualized, bearing in mind the likelihood of side effects. We should not treat urodynamic parameters, pad-weigh-tests or POPQ measurements, but rather the symptoms and complaints of the patients. Age, quality of tissue, signs of urogenital aging, chronic

bronchitis (nicotine abuse), obesity, diabetes mellitus, spondylolisthesis, lumbar spinal stenosis, together with the willingness and acceptance of possible restrictions to everyday life are the decisive parameters to consider when selecting from a wide variety of surgical procedures, either abdominal or vaginal, with or without the use of alloplastic materials. The major limitation when deciding on a surgical procedure, may be the lack or loss of anatomical and surgical skills and for many medical and paramedical reasons, the lack of experience.


PUBLICATIONS COMMITTEE UPDATE By Alex Digesu, MD

In the last year, individuals with expertise in various fields within urogynecology, as well as, physiotherapy and female urology from different countries have been invited to join the Publications Committee. The international representation of the publication committee includes members representing 12 countries: UK (5), USA (3), Australia (1), Austria (1), Greece (1), Israel (1), Portugal (1), Brasil (1), Netherlands (1), Belgium (1), Czech Republic (1), Switzerland (1). A specific role and responsibility within the Committee has been attributed to each member. The Publication Committees main focus has been on the Newsletter which has been changed from the previous editions in term of structure and content. Different and new sections/corners have been included such as an open “pro” and “cons” debate on specific hot and controversial topics in Urogynecology; IUJ corner; the Expert Opinion corner, etc. The Fistula Corner has been also changed. More information about the real needs and daily life in the fistula countries will be discussed instead of having a generic corner about assessment, management, and prevention of fistula. An Expert Opinion corner has also been created. Opinion leaders will be invited to discuss their personal point of view on specific clinical topics in Urogynaecology. Other sections which have been considered redundant and of minimal interest to the IUGA members have been deleted. More space has been given to: 1. IUGA Office: to update the members

about the IUGA activities, regional symposiums, exchange programs etc; 2. Other IUGA Committees: Chairmen have been regularly invited to update the members about the Committee’s activities; 3. IUGA Executive committee: to provide greater opportunity to communicate and update the societies membership; 4. The annual IUGA scientific meeting: a detailed summary of the past meeting has been recently published for those members who were not able to attend the meeting or specific sessions, workshops and/or social events. 5. Chris Maher (the local organizing chair of the 37th IUGA Annual Meeting, which will be held in Brisbane, Australia on the 04-08 September, 2012): in order to provide the most relevant information about the meeting, social events, scientific program, accommodation and more on a regular basis; 6. IUGA website IT Director Carlos Molina: He will explain what are the features of the website, how it can be used etc; 7. The International Urogynecology Journal: Paul Riss, one of the two Editor in Chief of the journal, will update the IUGA Members on the Journal activities and provide information on impact factor, publication time, acceptance and rejection rate for articles submitted for publication and more; 8. IUGA News and Meetings calendar, New Affiliate societies news and Regional symposia news. Finally to keep the members more regularly updated on what is happening with our society, an electronic short version of the Newsletter, in addition to the official hard copy, has been created. “IUGA News and Views” is the name that the Publication Committee has chosen for

the electronic newsletter. This will be emailed to the members in the intervals between the official NL to provide more updated information to our membership, as well as, to promote communication between our members on a more regular basis. The first electronic edition has been already emailed to all IUGA members in December 2011. The hard copy Newsletter will be published 4 times a year in March, May, August and November. The electronic Newsletter will be published in April, July and October. Alex Digesu (UK) - Chair Steven Swift (USA) Bary Berghmans (NL) Paul Riss (AT) Suzy Elneil (UK) Pallavi Latthe (UK) Debby Karp (USA) Eva De Cuyper (BE) Aparecida Maria Pacetta (BR) Annette Kuhn (CH) Kamil Svabik (CZ) Kurinji Kannan (AU) Alexandros Derpapas (GR) Luis Miguel Monteiro (PT) Mark Malak (UK) Menachem Neuman (IL) Nathan Guerette (USA) Ash Monga (UK) Amy Cassini, Membership Manager (USA)

Congratulations! Dr. Dhelma Pellin, IUGA member, was awarded the August Diez Award by the Venezuelan Surgery Society in recognition of her contribution to Urogynecological surgcial education in Venezuela.

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CONTROVERSIES IN UROGYNECOLOGY THE “G SPOT”: FACT OR FICTION, MYTH OR REALITY? By Dorothy Kammerer-Doak, MD The “G Spot”: fact, or fiction, myth, or reality? Since 1st postulated in modern times in the 1940’s, the female “G Spot” has received much publicity in the lay press. Yet, the “G Spot” remains shrouded in mystery. Most American women believe a “G Spot” exists. However, is there any scientific evidence to prove this? It appears that studies are inconclusive, and there is no anatomical area of the anterior vagina that histologically would verify the existence of a “G Spot”. Even investigations that claim to have documented this “bean-shaped” area of the anterior vagina reported to be an erogenous zone, that with stimulation leads to sexual arousal, orgasm, and female ejaculation, have not been able to universally demonstrate a “G Spot” in every study subject. Does “having a G Spot,” explain why a minority of women have orgasm with vaginal intercourse, whilst the majority who achieve climax with clitoral stimulation do not? Does “having a G Spot” and vaginal orgasms make women sexually superior? Of concern is that women may feel sexually inferior if unable to achieve vaginal orgasms, thinking they do not have an adequate sexual life. This fear is documented as women have undergone a totally unproven surgical procedure: “G Spot” amplification, despite the absence of scientific evidence proving the very existence of the “G Spot”!! Thus, we as urogynecologists need to be careful that we do not advocate sexual competition with levels of orgasmic achievements, as each sexual experience is personal to the participants. This hot topic is subsequently debated in this issue of the NL.

THE G-SPOT EXISTS AND CAN BE STIMULATED! By Prof. Sylvain Meyer

The G-spot exists and can be stimulated! … but it is not enough for women. Differences in orgasmic location and intensity are recognised and are as varied as the types of sensory erotica used for arousal. Clitoral stimulation was first recognized as the ultimate activity for triggering sexual release and climax. However, further research has expanded our knowledge into the mechanisms that influence orgasm and revealed vaginally sensitive areas also felt to play a role. The term G-spot was introduced in 1980 at a meeting of the Society for the Scientific Study of Sex in order to pay tribute to the pioneer of the G-spot, Ernst Grafenberg. Early researchers noted an area in the anterior wall of the vagina sensitive to deep pressure, not light touch…consequently making this area more difficult to stimulate in the traditional “missionary” position. Progress in the study of anatomic aspects of orgasm was realised in 1998 with the work of Helen O’Connell. She describes various anatomic arches: 1). A clitoral body with a glans resulting from the fusion of two cavernous bodies (so-called 1st arch), and 2). A complex of two bulbs (measuring 3–4 cm in length in the flaccid state) covered by the bulbo-cavernous muscles (so-called 2nd arch). These two “arches” share the same vascularisation (the venous plexus of Kobelt) are erectile in nature becoming 6

engorged during sexual stimulation. The distal urethra and vagina are intimately related to these two arches and although not erectile in function form a tissue cluster, the so-called “clitoro-uretro-vaginal complex” a term coined in 2008. More recently, after performing microdissection of the nerves endings in the vaginal walls of fresh cadaver, a Korean team found that terminal nerve branches in the vaginal wall are most dense 2/5ths of the way up the anterior vaginal wall, and that vaginal wall is the thickest at this level. Another team described G-spot as a functional reality in 82% of women (most authors agree that about 75% of women experiencing frequently vaginal climax), an anatomical reality in 54% (two small flaccid balloon-like masses on either side of the lower third of the urethra i.e. the two bulbs) and a histological reality in 47% (an area formed of epithelial glandular and erectile tissue). So from these anatomic and functional findings the reality of a “G-spot” can be assumed. Can we measure separately the effects of clitoral stimulation and G-spot stimulation on the pelvic floor neuro-muscular structures? Using a micro-system device able to record continuously pressure (cylindric shape of 5 mm diameter, 11 mm length) which is felt to be a surrogate measure for orgasm, two patients, who reported regularly experiencing both clitoral and vaginal climax, participated in a study. After informed consent, they agreed to stimulate first their clitoris only, then, two weeks later, their anterior vaginal wall only with

PRO

the micro-system inserted deep in their vagina. This experiment was carried on in the quiet of her home in “arousal” conditions they described as “optimal”. In patient #1, clitoral stimulation only (Fig. 1a) resulted in increases in intra-vaginal pressures greater then those noted with G-spot stimulation only (Fig 1b). Subjectively the subject reported orgasms with clitoral stimulation were more quickly and easily reached then with vaginal wall stimulation. In patient #2, clitoral stimulation only (Fig 2a) as well as G-spot stimulation only (Fig 2b) elicited similar waves of intra-vaginal pressures, the highest being as high as 30 cm H2O. These orgasmic waves were similar regardless of which area was stimulated; however, they were more difficult to elicit with the G-spot stimulation only. We can conclude that the existence of the G-spot seems to be widely accepted among women, despite conflicting study results regarding behavioural, anatomical, and biochemical studies attempting to prove its existence. It may be simply that its presence or relative absence in any given woman is variable. It seems reasonable to accept that some women possess a zone of tactile erotic sensitivity on the anterior vaginal wall, and about 70% of the women are able to find this appropriate place. However, orgasm seems to be most easily reached by clitoral stimulation.


Fig 1a (Patient No 1: 32 years old, para 1, baby 3800 g, clin.exam: no prolapse, levator contraction Oxford scale 4): intra-vaginal pressures during a clitoral stimulation only : time three minutes with two orgasms waves : the first one with an intra-vaginal pressure of 73 cm H2O, then after five attempts, a second orgasm is reached inducing an intra-vaginal pressure of 63 cm H2O.

Fig 1b: intra-vaginal pressures recorded during a G-spot stimulation only: time four minutes and half with three orgasms waves inducing intra-vaginal pressures between 20-30 cm H2O.

Fig. 2a (Patient No 2: 55 years old, para 1, baby 3200 g, clin.exam: no prolapse, levator contraction Oxford scale 4): intra-vaginal pressures during a clitoral stimulation only. Time: five minutes with numerous orgasms waves. The highest wave induced an intra-vaginal pressure of 30 cm H2O (after 206 seconds).

Fig. 2b: intra-vaginal pressures during G-spot stimulation only. Time: four minutes and twenty seconds with numerous orgasms waves being responsible of intra-vaginal pressures increases between 20- 30 cm H2O.

The microsystem device: The head of the device (in blue) introduced into the vagina records continuously a pressure event each two seconds. It is connected to an EEPROM ( electrically erasable programmable random ordinary memory) (in red) and finally it is connected to a battery * Wellborn Microsystem Device, Prof. F. Salchli, Head Institute of Micro-Nano-Technology, University of Applied Sciences, Yverdon, Switzerland 7


THE G-SPOT DOES NOT EXIST!

By Prof. Vincenzo Puppo and Penny Robshaw

The G-spot does NOT exist! It is only a term used by some sexologists which is not accepted or shared by experts in human anatomy! The existence of the G-spot and its role in female orgasm is a highly debated and controversial issue. Many argue that the G-spot was invented in 1950 by Ernest Grafenberg. In fact, it was Addiego, Whipple et al in 1981 that coined the term, G-spot. They published a case study of a woman with a cystocele who had identified an “erotically sensitive spot” in the same zone as the G-spot and concluded from this that “the area palpated in the subject was the Grafenberg spot” and that “the orgasms she experienced was in response to the Grafenberg stimulation”. In a subsequent study, Perry and Whipple examined women’s responses to stimulation of the G-spot. In order to establish the response of the subject to palpation of the G-spot, the authors first asked: “what do you feel?” followed by “does it feel good or bad?”. Firstly, these are not appropriate scientific questions and secondly, often the subjects would say nothing. In my opinion, the hypothetical area named the G-spot should not be defined with Grafenberg’s name. The conclusion by Addiego et al has no scientific basis because Grafenberg, in 1950, did not report an orgasm of the intraurethral glands. Grafenberg in his article doesn’t speak of a vaginal spot, but of “the role of the urethra in female orgasm”. He did describe some cases of male and female urethral masturbation and the corpus spongiosum of the female urethra. He did write that the intraurethral glands could release a fluid that is not urine during orgasm; however, he did not report an actual orgasm of the intraurethral glands. In 2001, Hines wrote an article entitled “The G-spot: a modern gynaecologic myth”. In it, he reviews the behavioural, biochemical and anatomic evidence for the reality of the G-spot. He concluded that “Grafenberg discusses no evidence for a G-spot. Just how later writers transformed these reports into evidence for a G-spot remains unclear”. The “G-spot” is not a term used in human anatomy. The so called “G-spot” of the anterior vaginal wall is located in Pawlick’s triangle (which corresponds to Lieutaud’s triangle in the bladder) that has a smooth vaginal mucosa and it is only a space with minor resistance. Burri et al in 2010 wrote, “the existence of the G-spot seems to be widely accepted among women, despite the failure

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CON of numerous behavioural, anatomical and biochemical studies to prove its existence”. In 2008, Gravina, Jannini et al studied 20 women with ultrasonography in order to evaluate the anatomical variability of the urethrovaginal space in women with and without vaginal orgasm. They showed a direct correlation between the presence of vaginal orgasm and the thickness of the urethrovaginal space and concluded that ultrasonography was a suitable tool to “explore anatomical variability of the human clitoris-urethrovaginal complex, also known as the G-spot”. This infers that the G-spot is a structure that can be imaged, however, in their article, there is no ultrasound of the G-spot! Only this year, Kilchevsky et al wrote, “Reports in the public media would lead one to believe the G-spot is a well-characterised entity capable of providing extreme sexual stimulation, yet this is far from the truth”. They concluded that, “Objective measures have failed to provide strong and consistent evidence of an anatomical site that would be related to the famed G-spot”. The G-spot has become the centre of a multimillion dollar business. Various vaginal procedures are being offered by medical practitioners as ways to enhance appearance or sexual gratification. G-spot amplification is one such procedure. The published ACOG committee opinion in 2007 states that such procedures are not medically indicated and, more importantly, that the safety and effectiveness of these procedures have not been documented. Besides, if the G-spot is located on the anterior vaginal wall between the vagina and the urethra, why is collagen injected into the bladder-vaginal septum? Clitoris-urethrovaginal complex, clitoral bulbs, internal clitoris, urethrovaginal space, female ejaculation and G-spot are terms used by some sexologists, however, they are not accepted or shared by experts in human anatomy, and they should not be used by urologists, gynaecologists, sexologists, the mass media, and all women. Findings from the disciplines of embryology, anatomy and physiology should form the basis of our understanding of the female orgasm. All the published scientific data point to the fact that the G-spot does not exist. Moreover, G-spot amplification is not medically indicated, and an unnecessary and inefficacious medical procedure.


THE PROTECT PROJECT

By Ranee Thakar and Abdul Sultan Prevention and Repair Of Perineal Trauma and Episiotomy through Comprehensive Training Background:

AIM:

Perineal repair after childbirth affects millions of women worldwide. In the United Kingdom approximately 85% of women sustain some form of perineal trauma during vaginal delivery and of these 69% will require suturing. The prevalence of perineal trauma varies as it is dependent on obstetric practice including rates and types of episiotomy.

To promote worldwide knowledge of birth attendants, obstetricians and midwives in the management of perineal trauma and episiotomy through structured training with a view to minimising pelvic floor and perineal morbidity associated with childbirth.

Obstetric anal sphincter injuries (OASIS) occur in 1.7% (2.9% in primiparae) of woman in centers where mediolateral episiotomies are practised compared to 12% to 19% (19% in primiparae) in centers practising midline episiotomy. Unfortunately it has been shown previously that up to half of OASIS are not recognised by the accoucher. Inadequate training of doctors and midwives in perineal and anal sphincter anatomy is believed to be a major contributing factor. In a survey of 75 doctors and 75 midwives in the United Kingdom, Sultan et al demonstrated inconsistencies in the classification of perineal trauma, as one third of doctors were classifying third degree tears as second degree tears. Most trainee doctors admitted that their training in recognising (84%) and repairing (94%) OASIS was poor. Furthermore in another study 64% of consultants reported unsatisfactory or no training in the management of OASIS McLennan et al also raised concern about training in the USA. They surveyed 1,177 fourth year residents and found that the majority of residents had received no formal training in pelvic floor anatomy, episiotomy or perineal repair, and supervision during perineal repair was limited.

Complete theoretical Modules on IUGA website and pass theoretical knowledge test

However despite recognition and primary repair of acute OASIS, 39 to 61% have symptoms of anal incontinence and 92% have persistent anal sphincter defects on ultrasound within 3 months of delivery. The morbidity associated with perineal trauma depends on the extent of perineal damage, technique and materials used for suturing and the skill of the person performing the procedure. It is therefore important that practitioners ensure that procedures such as perineal repair, are evidence-based in order to provide care that is effective, appropriate and cost-efficient. Unfortunately, there is no standardised approach to prevention and repair of perineal trauma and episiotomy. Based on this background, in 2000, Sultan and Thakar developed the first international hands-on course for repair and diagnosis of perineal and obstetric anal sphincter trauma. Two surveys of midwives and doctors conducted a few months after attending the course have indicated that there was an improvement in diagnosis and repair of perineal and anal sphincter trauma. Based on this experience we would like to develop a worldwide program to improve knowledge in this area. PROTECT PATHWAY FOR TRAINERS Prevention and Repair Of Perineal Trauma and Episiotomy through Coordinated Training

The program consists of 4 parts as outlined below: Part 1

 Part 2

Book OASIS hands-on workshop at the IUGA Annual Meeting2 1

 Part 3

Afternoon session: Train the Trainers IUGA sponsored workshop which includes teaching of episiotomy repair

 Part 4

Send videos to steering group of 1 Episiotomy & 1 OASIS repair3 to demonstrate live surgical technique

Notification of successful completion of train the trainer Perineal Trauma Course4 1 OASIS = Obstetric Anal Sphincter Injuries. 2. Exempt if possess a valid IUGA certificate of attendance of hands-on repair of OASIS workshop. within 2 years of attending the train the trainers workshop. 3. This will be uploaded through the IUGA website. 4. A certificate will only be issued when the steering group are satisfied with the repair video. More information to follow.

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RESEARCH GRANTS Mission The IUGA Basic Science and Clinical Research Grants are designed to fund original research by an IUGA member or trainee. Annual grants will be granted, based on the Research Proposal, as judged by the Research and Development Committee. The Research Grant is designed to fund development of the proposed research projects including all materials and testing, statistical analyses, and services required to complete the research. IUGA will fund basic science as well as clinical research studies. In addition, IUGA funds applicants from Least Developed Countries (http://www.unohrlls.org/en/ldc/25/) for basic science or clinical research. Grant Application Purpose The purpose of the IUGA-sponsored Research Grant is to fund the development of research in the field of urogynecology. Four grants will be awarded:

IUJ CORNER WHAT WE LEARN FROM THE PUBLISHER’S REPORT By Prof. Dr. Paul Riss

On May 11 and 12, 2012, the IUJ editors and Roisin, the editorial assistant, met with the publisher, Springer, and the IUGA executive for the biannual Editors’ Retreat in New York. Personal interaction, information, strategic planning are all part of such a retreat – with the aim of making the IUJ better and more relevant. Every year Springer prepares a publisher’s report which contains interesting information regarding the IUJ. For some reason it is marked “confidential”. However, we can share with you some interesting numbers from the summary:

$20,000.00 for a clinical research project (first prize)

patient-oriented

$10,000.00 for a clinical patient-oriented research project (second prize)

he International Urogynecology Journal is now T in its 23rd year.

$20,000.00 for a laboratory-based/basic science research project (first prize)

he IUJ ranks high in two journal categories: T Obstetrics & Gynecology 15 / 77 and Urology & Nephrology 25 / 69.

$10,000.00 for a laboratory-based/basic science research project (second prize)

There were 165.425 full text downloads in 2011.

I n 2011 a total of 657 Original Articles were submitted to the IUJ – plus Editorials, Clinical Opinions, Reviews and Letters.

he rejection rate was 53% for 2011. We like T to think that this means that only high quality papers are accepted.

ime from acceptance to online first publication T is now just 24 days (compared to 34 days in 2010). However, time from acceptance to publication in print is much longer, ranging from 3 to 7 months depending on the number of manuscripts accepted.

hrough so-called online consortia subscription T deals the IUJ is now accessible in 8.202 institutions.

Least Developed Countries: •

$20,000.00 for a clinical research project (first prize)

patient-oriented

$10,000.00 for a clinical patient-oriented research project (second prize)

Each will be awarded per year to IUGA members who complete and submit the required application prior to the stated deadline. Deadline: July 2, 2012 Observership Grant Five Observership grants per year are now being offered, in the amount of $4000.00 each. Observership grants are meant to offset costs of visiting an approved host site which has proven expertise for a specific specialty (selected by applicant). Recipients will spend 2 to 4 weeks at an approved site, with the agreement that a formal report of the observer’s experience will be submitted to the IUGA office at the completion of the observership. The report is published in the IUGA newsletter and posted on the IUGA website. International Fellowship Grant Application • 10

One International Fellowship grant for a 12 month period, per year

Where do the submissions come from? The IUJ is proud that in 2011 they came from all over the world. The 10 countries with the highest number of submissions were: United States (172), United Kingdom (53), China and Australia (40), Brazil (34), Taiwan (27), Turkey (26), India (25), Italy (22), Netherlands (21). Overall, 283 manuscripts were accepted for publication in 2011. Where do we go from here? All editors at the IUJ work hard to make the IUJ the best clinically oriented urogynecology journal in the world. We are always adding new features such as the Urogynecology Digest, and are working on IUJ Video. Maybe you will even see us on Twitter.


THE FISTULA CORNER

AN UNMET NEED: PROVISION OF LONG-TERM CATHETERS AND STOMA BAGS IN FISTULA SURGERY By Sohier Elneil In the past, most fistula surgeons focussed on “fixing the hole” and achieving closure rather than attaining continence and an acceptable quality of life. However, there has been a substantial shift in view with many clinicians now stating that the surgical treatment of urogenital fistulas, should also involve the care of its consequences on the lower and upper urinary tract function, in particular the long term management of complex urological reconstruction procedures.

The pathophysiological hypotheses remain urethral sphincter trauma during labour, soft tissue destruction of the intrinsic sphincter mechanism and permanent denervation or changes in bladder function. However, it appears these complications may be prevented or treated by slings such as fibro-muscular or apo-neurotic slings.

Repairs of fistulas are determined by size, location, amount of scarring, degree of destruction of the continence mechanism, degree of ureteric injury and avulsion and pre-existing co-morbidities. After complex fistula repair, two issues remain a problem that of persistent incontinence in spite of an intact bladder, and of failure of repair.

Long-term surgery and management of urinary diversion procedures remains a major obstacle in the developing world. The complexities of complicated fistula surgery present many problems to the clinician. Continent diversions are not always accepted by the patients or their relatives, thus creating a dilemma for the

The training and education of surgeons undertaking these procedures needs to be well structured and focussed, and remains an unmet need. But, importantly this cannot be achieved without adequate and sustained surgical supplies, such as catheters.

patient, the urologist/urogynaecologist and the family. Moreover, specific catheters/ devices/bags are needed to collect the urine and they are not always available to the patient and may be quite costly. Stoma support services are usually not available in many of these countries. Therefore, the need for continent support devices, such as catheters and stoma bags needs to be addressed, as well as personnel recruitment and development. These are the real needs in the fistula world!

Figure 1: Catheter sited to help elucidate the cause of fistula repair failure. It is clear that the continence mechanism is damaged and the urethra has two urethro-vaginal fistulas (UrVF). Note the vulval skin condition (showing excoriation from continual urinary leakage) (V) and scarring of the anterior bladder wall (S).

MEMBERSHIP SERVICES By Amy Cassini

Dear Members, Over the past few years, IUGA’s Affiliate Societies have been growing exponentially. Our Affiliate Society members make up about 50% of our membership! Affiliate Societies provide an opportunity for physicians to enjoy an IUGA membership at a discounted rate. National, international, or regional organizations with a focus on urogynecology, with at least 30 members may apply for affiliation through the IUGA office.

Affiliate Society members also receive a discount to attend the Annual Meeting and Regional Symposia, the opportunity to apply for IUGA sponsored grants and 12 issues of the IUJ. Starting this year, we are also allowing our Affiliate Societies to advertise their Annual Meeting on our industry calendar, which will be featured in every issue of IUGA News & Views and posted on the IUGA web site. Just another reason to affiliate your society with IUGA!

For additional information about becoming an affiliate society, please visit www.iuga.org and select affiliate societies from the menu, or email amy@iuga.org. Sincerely, Amy Cassini, Membership Manager

Join IUGA Now! Like what you see in our newsletter, but haven’t become a member yet? Join IUGA now by visiting www.iuga.org and selecting Membership from the menu. Annual Membership Dues are USD$100 and provides the following benefits: •

12 printed issues and online access to the International Urogynecological 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

If you have any questions about joining, please contact Amy Cassini, Membership Manager at amy@iuga.org. 11


NEWS FROM THE IUGA OFFICE By Maureen Hodgson, CMM

News from the IUGA office:

the IUGA family:

The IUGA staff has been very busy as we continue to grow and expand our operations to better serve our members. For those that may not have read the e-newsletter, News & Views, I wanted to provide a quick recap on our two new team members we've added to • Carolyn Slade is our Manager of Education Programs. Carolyn previously worked for the Society of Investigative Dermatology for the last 9 years. During her time at SID, she was responsible for planning all their educational programs in addition to the annual meeting. Carolyn will be the staff liaison to the following committees: Education, Fellows and Research & Development. • Dawn Beale is our Administrative Coordinator; Dawn previously worked for a local meeting planning company for the last 12 years. She was responsible for planning all incentive meetings, plus registration, and contract negotiations. At IUGA she will be responsible for helping with our registration system plus various administrative duties.

Our Staff: First row: Maureen Hodgson, Kendra Busby, Amy Cassini Second Row: Johanna Gomez, Dawn Beale, Carlos Molina, Carolyn Slade.

In the coming weeks, we will be launching a new membership campaign. We are asking all members to update their membership profile. Those that do update their profile will be entered into a drawing to win a free registration to the annual meeting in Dublin. More details will follow shortly. We hope you will join us in Brisbane for our annual meeting. Chris Maher and the entire local organizing committee have put together an incredible scientific program which includes 2 live surgeries, a cadaver lab, meet the expert’s lunch discussions, state of the art lectures and much more! For those that like to network amongst your peers, the social programs will be a great way to reconnect with old friends, while making new ones. Our number one priority is to provide outstanding customer care to all of our members. We hope that you are noticing the small, but subtle differences we are making. We look forward to seeing you in Brisbane! Sunny Regards,

Staff pose with IUGA member, Dr. Xiaoming Gong, who delivered this tapestry as a gift from Lang, Jinghe, MD, Chair of the Department of Ob/Gyn, Peking Union Medical College Hospital. The writing translates: “Protect your pelvis, care the women”

IT NEWS CORNER There’s an app for that! Many industries are currently using smart phone and mobile device apps to enhance their services to customers and also to get answers themselves. We want to know from our members: what medical apps are you using? Submit the name of the app, along with its best feature, to membership@iuga.org and you could win a FREE one year IUGA membership. We will post the list of the top 3 apps on our web site and in the next edition of our electronic newsletter, IUGA News & Views, which will be published in July. 13


THINGS TO DO IN BRISBANE The Local Organizing Committee for the IUGA 2012 Annual Meeting has been hard at work planning an exciting scientific program complete with Cadaver courses, live surgery and laparoscopic skill sessions. We are only 4 months away from what will prove to be another successful Annual Meeting, which means it’s time to start planning your visit to Brisbane’s local destinations and attractions! With an average temperature of 74 degrees fahrenheit in September, it’s the perfect time of year to explore the beauty of Brisbane. AROUND BRISBANE: While you are in Brisbane, be sure to vist our City Beach, which is just a short walk from the convention center. Enjoy worldclass art galleries and a vibrant urban precinct culture.

to the top of the Story Bridge or abseil down the Kangaroo Cliffs. Escape to the Moreton Bay and island region for aquatic adventures, dolphin feeding and to see the southern humpback whales as they migrate to warmer waters for the winter. Approximately 1 hour north or south of Brisbane are the beautiful Sunshine and Gold Coast beaches. Within 100 kms of Brisbane are some of the greatest Beaches and coastlines of the world. Perhaps Noosa just north on the Sunshine coast would be an ideal family destination and has much to offer with crystal clear north facing patrolled beaches, walks in the Noosa National Park and great restaurants and shopping on Hastings Street. Noosa is a good base for tours to Fraser Island and the Everglades at the end of the Noosa river (www.noosaeguide.com) The Gold Coast, less than an hour to the south of Brisbane, is also a diverse holiday destination perfect to cuddle a koala, climb a mountain, visit famed theme parks or just enjoy the world renowned beaches (www. visitgoldcoast.com)

the crystal clear waters of the Whitsunday islands on a skippered or self skippered yacht. It’s an invigorating and unique holiday experience that your family will never forget ( www.charteryachts.com. au). Finally for those looking for a little indulging, a break at Lizard or Hayman Island on the reef is just the medicine. AROUND AUSTRALIA: With an extensive network of domestic flights, Brisbane is the ideal launch pad for further Australian adventures. Explore Uluru, Kakadu or even Sydney with its iconic Harbour Bridge and Opera House. For additional holiday ideas and more information about the meeting, visit www. IUGA 2012.com

AROUND QUEENSLAND: Brisbane has a wide variety of outdoor fun and activities. Fly high above the City in a hot air balloon, complete with a champagne breakfast. Take a cruise across the River to Lone Pine Koala Sanctuary where you can hand feed kangaroos and emus and of course, cuddle a koala! Climb

37th ANNUAL MEETING

BRISBANE AUSTRALIA BRISBANE CONVENTION & EXHIBITION CENTER Registration Opens April 2, 2012

No trip to Queensland is complete without a visit to the great barrier reef. With the world’s largest coral reef system, it is an underwater playground perfect for snorkeling, diving, swimming and sailing. Base yourself in tropical Cairns with access to the reef and Daintree rainforest. Or sail

SEPTEMBER

37th ANNUAL 04-08,2012 MEETING

Ulf Ulmsten Memorial Lecture “Teaching and learning in urogynaecology” Anthony R. Smith, UK

State of the Art Lecture “From research to commercial reality: trials and tribulations with the cervical vaccine” Ian Frazer, Australia

PRO & CON/Interactive Session “The FDA got it all wrong on transvaginal meshes” Affirmative: Michel Cosson, France and Dennis Miller, USA Negative: Matthew D. Barber, USA and Kaven Baessler, Germany

BRISBANE AUSTRALIA HIGHLIGHTS

50 podium presentations 150 oral posters 300 posters 0ver 20 small group workshops John Delancey: cadaver course (off site) CONVENTION & EXHIBITION CENTER BRISBANE Mickey Karram: live April surgery Registration Opens 2, 2012 course Welcome Reception: “Brisbane Style” - on the Beach Closing Night Celebration

* Speakers subject to change

Roundtable

14

For more information: www.iuga2012.com

PRO & CON/Interactive Session “Pelvic floor exercises are overrated” Affirmative: James Malone-Lee, UK and Soren Brostrom, Denmark Negative: Kari Bo, Norway and Helena Frawley, Australia

Ulf Ulmsten Memorial Lecture “Teaching and learning in urogynaecology” Anthony R. Smith, UK

State of the Art Lecture “From research to commercial reality: trials and tribulations with the cervical vaccine” Ian Frazer, Australia

PRO & CON/Interactive Session “The FDA got it all wrong on transvaginal meshes” Affirmative: Michel Cosson, France and Dennis Miller, USA Negative: Matthew D. Barber, USA and Kaven Baessler, Germany

Roundtable

“Can the Pelvic floor withstand vaginal delivery: Mechanics of childbirth and the pelvic floor” John O. DeLancey, USA “Perils of vaginal delivery in 2012” Don Wilson, New Zeland

INTERNATIONAL UROGYNECOLOGICAL ASSOCIATION

SEPTEMBER 04-08,2012

“Can the Pelvic floor withstand vaginal delivery: Mechanics of childbirth and the pelvic floor” John O. DeLancey, USA “Perils of vaginal delivery in 2012” Don Wilson, New Zeland

INTERNATIONAL UROGYNECOLOGICAL ASSOCIATION For more information: www.iuga2012.com

PRO & CON/Interactive Session “Pelvic floor exercises are overrated” Affirmative: James Malone-Lee, UK and Soren Brostrom, Denmark Negative: Kari Bo, Norway and Helena Frawley, Australia

HIGHLIGHTS

50 podium presentations 150 oral posters 300 posters 0ver 20 small group workshops John Delancey: cadaver course (off site) Mickey Karram: live surgery course Welcome Reception: “Brisbane Style” - on the Beach Closing Night Celebration

* Speakers subject to change


15

7:00 PM

6:30 PM

6:00 PM

5:30 PM

5:00 PM

4:30 PM

4:00 PM

3:30 PM

3:00 PM

2:30 PM

2:00 PM

1:30 PM

1:00 PM

12:30 PM

12:00 PM

11:30 AM

11:00 AM

10:30 AM

10:00 AM

9:30 AM

9:00 AM

8:30 AM

8:00 AM

7:30 AM

7:00 AM

6:30 AM

Pan Asian Meeting

Monday Sep- 3

Registration Opens: 7:00 am - 5:00 pm

TIME

Workshop Sessions

Workshop Sessions

Break

IUGA Scientific Committee Meeting

OFF SITE Cadaver Lab: Applied Anatomy with Professor John DeLancey & Team Medical Engineering Reasearch Facility

Exhibitor Set up

Tuesday, Sep 4

Registration Opens: 6:30 am - 6:00 pm

Registration Opens: 6:30 am - 6:00 pm

Ibero American Urogynecological Session

Workshop Sessions

BRISBANE, AUSTRALIA SEPT 4-8, 2012

Break

LIVE SURGERY

LIVE SURGERY

Exhibitor Set up

Fellows Day

Wednesday, Sep 5

PROGRAM TIME TABLE

IUGA Committee Meetings

Scientific Session

Scientific Sessions

Scientific Sessions

State of the Art Lecture

Symposia Time Available

Symposia Time Available

Coffee Break

Lunch

Coffee Break

Welcome Remarks

Fellows Research Network

Interactive Session

Meet The Experts Lunch (additional cost)

Exhibit Opens 8:00 am - 5:00 pm

Thursday, Sep 6

Symposia Time Available

Coffee Break Exhibit Hall

IUGA Annual Business Meeting

Scientific Sesions

Ulf Ulmsten Memorial Lecture

CFA Breakfast Meeting

Scientific Session

Roundtable

Lunch

Coffee Break

Symposia Time Available

Scientific Session

Exhibit Opens 8:00 am - 5:00 pm

Friday, Sep 7

Registration Opens: 7:30 am - 1:00 pm Registration Opens: 7:00 am - 5:00 pm

Registration Opens: 7:00 am - 6:00 pm

Closing Ceremony/ Awards Lunch

Interactive Session

Symposia Time available

Break Exhibit Hall

CFA Breakfast Meeting

Scientific Session

Scientific Session

Exhibit Opens 8:00 am - 12:30 pm

Saturday, Sep 8


Advancing Urogynecological Knowledge Around the World

IUGA Office Staff Maureen Hodgson, CMM Administrative Director maureen@iuga.org x. 115 Kendra Busby Finance Manager accounting@iuga.org x.113 Amy Cassini Membership Manager amy@iuga.org x. 112 Carolyn Slade Director, Educational Programs carolyn@iuga.org x. 116

IUGA Executive Committee

IUGA International Board

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

Lisa T. Prodigalidad Asia prodimd@yahoo.com

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

Harry Vervest President hvervest@wxs.nl

Peter DeJong Africa pdejong@medi.co.za

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

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

IUGA Newsletter Volume 7, Issue 2  

IUGA Newsletter

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