Advancing Urogynecological Knowledge Around the World
The Official Newsletter Volume 10, Issue 2, 2015
41st Annual Meeting 2 - 6 August, 2016 Cape Town - South Africa
2015 Annual Meeting Review............. 3
Pelvic Pain Corner............................ 11
Controversies in urogynecology - Robotic vs. laparoscopic sacrocolpopexy............ 15
The IUGA Newsletter is published by the members of the Publications Committee Editor: Alex Digesu Associate Editors: Steven Swift Sohier Elneil Managing Editor: Amy Cassini Editorial Board: Bary Berghmans Heidi Brown Elise De Kimberly Ferrante Deborah Karp Ervin Kocjancic Annette Kuhn Helena Luginbuehl Paul Riss Ghazaleh Rostaminia Ruben Trochez
Table of Contents 2015 Annual Meeting Highlights..................................................3 Nice 2015 Picture Gallery...............................................................7 Vulvodynia: Assessment & Management ...................................11 Affiliate societies Corner................................................................11 & 13 FIUGA - The foundation needs you!.............................................12 IUJ Corner........................................................................................13 Physiotherapy Corner.....................................................................14 Robotic vs laparoscopic sacrocolpopexy debate......................15 Remembering Prof. Antonio Lomanto.........................................17
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.
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2015 ANNUAL MEETING HIGHLIGHTS The 2015 Annual Meeting in Nice, France proved to be another outstanding meeting thanks to a number of people including the meeting chairs Brigitte Fatton and Emmanuel Chartier-Kastler, the local organizing committee, program committee and IUGA staff and board. IUGA celebrated its 40th anniversary this year in Nice. As part of the celebration, Harold Drutz gave an excellent presentation about IUGA through the years, a group of IUGA members designed a very special commemorative history book and our wonderful Gala Dinner hosts, Brigitte Fatton and Emmanuel Chartier-Kastler, presented a spectacular macaron cake. With such a fantastic meeting scientifically and socially, its no surprise there was record-breaking attendance this year, with 1,869 people having attended! Read below for some more exciting highlights from Nice.
Best abstract winner, Rufus Cartwright
Award Winning Presentations This year's scientific meeting included many outstanding presentations, but these award-winners deserve special mention. University of Geneva, Switzerland's N. Veit-Rubin and J. Dubuisson took home the gold for Best Video Award for their video VID01, "Uterus-preserving prolapse repair by lateral suspension with mesh." This video highlights a laparoscopic procedure that provides lateral and apical uterine support through anchoring a T-shaped polypropylene mesh to the vesicovaginal septum and the anterior abdominal wall (posterior to the anterior superior iliac spines). This approach avoids dissection of the presacral space and has impressive anatomic results and low rates of complications in a series of 220 cases performed by a single surgeon. The authors conclude that this procedure is feasible, safe, and has promising longterm anatomic results for those patients who desire uterinepreserving surgical prolapse repair, with complication rates comparable to those seen with sacrohysteropexy (though a direct head-to-head comparison has not been performed). The Award for Best Abstract went to Imperial College of
London, United Kingdom's Dr. Rufus Cartwright and colleagues for their podium presentation PP27, "Identification of two novel genomic loci associated with stress and urgency urinary incontinence in a genome wide association study." In this elegant paper, Dr. Cartwright and colleagues present replication data for 12 genomic loci with genome-wide or near genome-wide significant associations with stress, urge, or all cause incontinence in their prior work. The authors genotyped these 12 loci in six independent replication cohorts across Europe and the US and identified one locus strongly associated with stress incontinence (rs138724718 SNP on chromosome 2, close to the EN1 and MARCO genes) and one locus strongly associated with urge incontinence (rs34998271 SNP on chromosome 6, close to the EDN1 and PHACTR1 genes), both of which achieved genome-wide significance and represent the first two replicated genomic loci ever identified for incontinence. They identified a third locus (rs78851245 SNP on chromosome 7, intronic for the AGK gene) that showed strong association with all cause incontinence and approached but did not reach genome-wide significance. The authors conclude that future work should clarify the role of these genes within the pathophysiology of incontinence and assess implications for prediction and prognosis. Congratulations to University of Leicester's Dr. Evi Bakali (UK), who received the Award for Best Presentation by a Physician-in-Training for her work PP30: "Cannabinoid receptor expression in the bladder is altered in detrusor overactivity." In this study, Dr. Bakali and colleagues compared expression of cannabinoid receptors in human bladders of patients with and without detrusor overactivity. They found increased cannabinoid receptor expression in the urothelium and decreased receptor expression in the detrusor muscle of patients with detrusor overactivity as compared to healthy controls, and conclude that these findings suggest a potential role for cannabinoid agonists in the treatment of detrusor overactivty. Congratulations to these award-winning presenters and their teams for their outstanding work!
IUGA's President, Bob Freeman, presents the Ulf Ulmsten award to Ian Milsom
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Ulf Ulmsten Lecture This year's lecture on prevention of pelvic floor dysfunction (PFD) presented by Professor Ian Milsom was an outstanding presentation and one of the highlights of the meeting in Nice. The scene was set with an introduction on the prevalence of pelvic floor disorders and their significant effect on quality of life and costs to health systems worldwide. Professor Milsom then summarised some conclusive literature data on the effect of mode of delivery on PFD and presented his own group's data, the Swedish Pregancy Obesity and Pelvic Floor Study (SWEPOP study), which is one of the largest epidemiological data on mode of delivery and PFD. It included a cohort of 10,000 one-parae women with a singleton delivery and no further births stratified by mode of delivery, who were sent a questionnaire 20 years after delivery, to which 64% of women responded. The survey showed that vaginal delivery significantly increases the risk of urinary incontinence (UI) and pelvic organ prolapse (POP) when compared to Caesarean section (CS) delivery. The risk was no significantly different when acute CS were compared to elective ones. Furthermore, the odds ratio of developing UI after vaginal delivery increased progressively with higher birth weight but the same did not happen with CS deliveries. The risk of combined POP and UI was more than three times higher in women who delivered vaginally compared to those who had CS. The authors concluded that there is overwhelming evidence that vaginal delivery significantly increases the risk of UI and POP. Despite the evidence, Professor Milsom noted how many textbooks in Obstetrics & Gynaecology and Midwifery have little or no information regarding the long term consequences of delivery on future PFD. He concluded by acknowledging that CS delivery is not the answer for all women, as it has its own risks, but that better predictive models should be develop to individualise the risk. One such model has already been published (UR-CHOICE) but further collaborative work is underway between Professor Milsom's group in Gothenburg, the PROLONG group in Scotland and Otago, and the Cleveland Clinic group, to add efforts and data, to develop a stronger predictive model. Stump the Experts This year “Stump the Experts” was a new undertaking at the annual IUGA meeting. This lighthearted but probing presentation was moderated by Dr. David Richmond, the current President of the Royal College of Obstetricians and Gynaecologists. The esteemed panelists consisted of Drs. Adrian Wagg, Kari Bo, Linda Cardozo, Pierre Denys, and Marcio Averbeck and encompassed experts from a wide array of specialties including Geriatrics, Physical Medicine and Rehabilitation, Neuro-Urology, and Urogynecology. Three interesting cases were presented. Gaelle Fiard MD, a Urology fellow in Grenoble, presented a refractory case of neurogenic bladder and challenged panelists with complicated urodynamic tracings in a complex patient who had failed standard therapies such as medication, Onabotulinum-toxin, and intermittent self-catheterization. Debjyoti Karmakar MD, an IUGA Clinical Fellow, presented a fascinating but
unfortunate case of a young female patient from a small island 2500km from New Delhi with multiple previous pelvic reconstructive surgeries, severe vaginal and pelvic pain, and recurrent pelvic organ prolapse and mesh erosion. The panel agreed that focused counselling and lifestyle rehabilitation measures in this woman were paramount, and this case helped illustrate the limitations that exist for multidisciplinary care and conservative measures in resource-poor countries where trained experts in complex urogynecology may be lacking. Finally Oliver Daly MD, a Consultant at Western Health in Melbourne Australia, presented a “hopelessly wet” patient with severe and refractory urinary incontinence following multiple surgical procedures and conservative interventions. Panelists debated the optimal surgical approach for this patient. At the conclusion of the session, the audience agreed that the esteemed panelists had truly been stumped!!
Points of View: My operation is best with Intrinsic Sphincter Deficiency Discussant: Pierre Costa; Philippe Zimmern; Dudley Robinson; Reynaud De Tayrac This was an interesting debate by four practitioners on their approach to a unique patient case scenario. The presenters reviewed the concept of intrinsic sphincter deficiency (ISD) including clinical aspects, urodynamics and classification of stress urinary incontinence. They discussed the symptoms and signs related to ISD. They also discussed anatomical mechanism of stress urinary incontinence as well as current urodynamics testing parameters for diagnosis of ISD. The moderator presented the case for discussion (75y/o multiparous patient with mixed incontinence and history of previous Burch Colposuspension with recurrent symptoms refractory to physiotherapy and urethral hyper mobility on examination. Normal cystoscopy and no detrusor overactivity, no residual volume, slightly low flow rate with detrusor contraction 44cm water on urodynamics testing). Dr. Dudley Robinson argued in favor of Urethral Bulking agent. He described the concept of urethral coaptation as an important component of the continence mechanism with bulking agents acting as artificial urethral cushion, increasing urethral resistance without evidence of obstruction or
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increased OAB symptoms. He discussed the advantages of bulking agent including minimal invasive approach, local anesthesia, ambulatory, low morbidity, low voiding difficulty, suitability in women with multiple co-morbidity as well as some disadvantages such as lower efficacy, limited long term studies, durability, effect of repeat injections and cost. He stated a 75% objective success rate with Macroplastique urethral bulking and approximately 20% rate of voiding dysfunction. He also stated that subjective success rates are comparable with pubovaginal sling although objective cure is higher for pubovaginal sling with significantly lower morbidity with bulking. He concluded that a minimal invasive option with proven efficacy and less complication should be the approach in this patient.
the evolving nature of the design including possible postoperative adjustment and on-demand activation. An audience vote showed a majority will perform Synthetic mid-urethral sling TVT for the management of this patient.
Dr. Reynaud De Tayrac discussed in favor of the retropubic TVT mid-urethral sling as the recommended treatment option for this patient. He gave 5 reasons for choosing TVT in this case including long-term efficacy, low morbidity, better result than TOT in ISD, evaluated as second line treatment, recommended by the french guidelines. He stated that 17yrs of follow up of patients with TVT sling has shown excellent long term result, 90% objective continence and 87% subjective cure with high satisfaction rate and low morbidity. He discussed the review of TVT in ISD patients with comparable subjective cure rate, improvement rate and patient satisfaction score. He also discussed the higher rate of repeat surgery for SUI in women after TOT compared with TVT. He concluded that retropubic MUS should be the approach to the management of this patient.
Panelists for the State of the Art Lecture
IUGA and World Congress on Abdominal and Pelvic Pain (WCAPP) Joint Session State of the Art Lecture: Treating Pelvic Pain – a multidisciplinary approach For the first time ever, IUGA offered a joint session with the World Congress on Abdominal and Pelvic Pain. Attendance was high for this session and received excellent feedback from participants. Below is a summary of the State of the Art lecture and one of the abstracts presented during the joint session.
Professor Philippe Zimmern argued in favor of pubovaginal fascial sling as a treatment option for this patient. He stated that SUI is a vaginal disease so the management of this patient should include consideration for pubovaginal fascial sling. He discussed limitations such as tensioning of the synthetic midurethral sling being an art not a science and although it may be tension free in the operating room during the procedure, with retraction, scarring, and misplacement, the end result he felt is not tension free. In support of the pubovaginal fascial sling, he stated the success rate ceiling effect is around 80%, failure rate stated at approximately 10% earlier on but worsens with time. Long term data on rate of urge incontinence at 10yrs was 41% with no data on validated questionnaire and flow pattern. He suggested starting with simpler options first, such as bulking agent but consideration for pubovaginal sling should be made with appropriate patient counseling.
Anatomy of pelvi-perineal innervation: Benoit Rabischong Dr. Rabischong reviewed pelvi-perineal innervation from the perspective of “neuropelveology”, focusing on the SOMATIC (femoral, lumbosacral, obturator, sciatic, and pudendal) and AUTONOMIC (hypogastric, splanchnic, inferior hypogastric plexus, visceral branches) nerves. Clinical applications were discussed. The Genito-femoral nerve (L1, L2) provides sensory innervation of the inguinal fold, major labia, and superomedial part of the thigh. Injury during e.g. pelvic lymphadenectomy can lead to pain and paresthesias. The obturator nerve provides adduction (adductor muscles), lateral rotation of the hip (gracilis muscle), and sensory innervation of the inner side of the thigh and knee. Injury can occur during pelvic lymphadenectomy, deep endometriosis, dissection of the paravesical fossa, retzius space, or iliolumbar fossa. Injury can impact adduction and leg crossing, and leading to pain and parasthesias. The pudendal nerve exists in anatomic variations. For example the inferior rectal nerve (a branch) can penetrate directly through the sacrospinous ligament. Injury of this branch can lead to fecal incontinence. The sciatic nerve lies 2 cm from the sacrospinous ligament.
Dr. Pierre Costa argued in favor of artificial urinary sphincter (AUS) as a consideration for this patient. He gave a brief background on the use of AUS since the beginning of its use in 1989. He stated that he would consider a sling procedure or urethral bulking as first option in this patient but will not rule out the option of discussing AUS if patient becomes refractory. He discussed the advantage of AUS including 85% continence rate, very good mechanical life expectance > 14yrs before needing change, proposition of AUS consideration as a good option when the urethra is damaged e.g fistula. He also discussed some disadvantages of this option including complications (infection, extrusion), the need for changes to the device over time, and the need for rigorous surgeon training. He concluded by discussing
In the pararectal fossa lie the sympathetic system (superior hypogastric plexus, hypogastric nerves) whose injury can lead to urinary incontinence and urgency. The hypogastric nerve can be visualized during abdominal sacrocolpopexy. The pararectal fossa also houses the parasympathetic system (pelvic splanchnic nerves, injury of which can lead to atonic
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bladder, decreased sensation, and decreased blood flow/ lubrication to the vagina), inferior hypogastric plexus and the visceral nerve branches (deficit depends on level of injury, e.g. the rectal plexus can be injured by mesh).
patients with pelvic pain and how to collaborate with our colleagues in relevant specialties. Presentation by Dr. Melanie Morin
Global approach to chronic pelvic and perineal pain: JeanJacques Labat Dr. Labat discussed the concept that pain is an emotion, and that it should be analyzable. Chronic pain requires a multidisciplinary approach. To assess patients with pelvic and perineal pain with a negative exam and work up he suggests the following approach: 1. Is it neuropathic pain? 2. Could the pain come from elsewhere? 3. Is there a context of pelvic sensitization? 4. Back-Pelvic-Buttock-Perineum (BPBP) syndrome: Is it a disorder of the lumbar pelvic balance and muscle reactions? 5. Is there a context of general sensitization? 6. Pain post-op or postnatal: Immediate versus secondary? The Physiotherapist and chronic pelvic pain: Maeve Whelan Physical therapy is usually the first line therapy for chronic pelvic pain. The role of the physical therapist role includes treating myofascial pain, musculoskeletal pathology, lifestyle factors, and the postural system. Maeve Whelan discussed the approaches in physical therapy, including working the superficial and deep connective tissue, as well as prevention of catastrophizing. Patient education includes how to sit, stand, pass urine and stool. Ms, Whelan highlighted that the muscles can strengthen only when the ability to release is achieved. Ms.. Whelan provided a comprehensive literature review supporting the fact that those with CPP have abnormal musculoskeletal findings and heightened sensitivity.
One presentation that was particularly interesting during the WCAPP joint session was by Dr. Melanie Morin. She presented a randomized controlled trial evaluating the efficacy of multimodal physiotherapy compared to a frequently used first line treatment overnight topical lidocaine application in women with provoked vestibulodynia. Physiotherapy treatment included education, pelvic muscle exercises with biofeedback, manual therapy and insertion techniques. This large trial involving 212 women diagnosed with vestibulodynia used a rigorous study design with assessors blinded to treatment allocation and validated outcome measures. Results of this study provide strong evidence that multimodal physiotherapy is highly effective in reducing pain during intercourse, decreasing sexual distress and improving sexual function in women with provoked vestibulodynia. Physiotherapy also proved to be more effective than overnight lidocaine topical application. These findings are novel in physiotherapy and of high importance to women with vulvar pain as they support a non-invasive intervention with no side effects. Moreover, this study will likely change clinical practice as the current management of vulvar pain relies mainly on ineffective or non-empirically validated interventions.
Global pain support in chronic pelvic pain: Alain Watier Dr. Watier recommended that the institution offer comprehensive therapy. The nurse practitioner is the first contact and the patient is screened for sleep disorders, constipation (especially if dyssynergic), sexual dysfunction, and pharmacy review. The evaluation should seek inflammation, neuropathy, subtypes of chronic regional pain syndrome, pelvic sensitization, central sensitization, and organ cross- sensitization. If treatment does not work, the patient may catastrophize, and the rate of success is lower. Clinics can offer mindfulness meditation, physical therapy, graded motor imagery, medications (half of patients use alternative medications), psychological services (eye movement desensitization and reprocessing, EMDR), art therapy. Ultimately, when a physical trigger cannot be treated directly, Dr. Watier’s group utilizes neuroplasticity: “use the brain to treat the pain”. The goal includes shrinking the brain’s pain map (in chronic pain the pain map expands). The primary goal is to return patients to the ability to experience pleasure in their lives. The lecture “Multidisciplinary Approach to Pelvic Pain” expanded our view on how to treat our
Medico-legal Roundtable Panelists
Medico-Legal Roundtable The medico-legal roundtable was also a highlight of this year’s meeting, offering attendees the opportunity to hear from experts around the world about how to avoid medicolegal pitfalls. The session included information about taking precautionary steps, the importance of informed consent and what to do in the event of an adverse outcome. Mohan Regmi (Nepal) presented a study that was conducted on 407 patients and how they reacted to medical errors and disclosures. The results found that “non-disclosure increased legal complaints and patient dissatisfaction”. The presenters used real life cases to demonstrate the importance of following set policies and procedures and ensuring proper training is provided to medical staff to avoid medico-legal issues. This is just a taste of what happened at this year’s Annual Meeting in Nice. Thanks to those of you who joined us. We hope to see you next year in South Africa!
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I
g
40th Annual Meet A’s in UG
2015 Nic e, F r a n ce
CELEBRATING IUGA’S
40TH ANNUAL MEETING
JUNE 9 - 13, 2015 Nice Acropolis Convention Center www.IUGAmeeting.org
PICTURE GALLERY
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AFFILIATE SOCIETY CALENDAR British Society of Urogynaecology (BSUG) Understanding Urodynamics September 29-30, 2015 London Austrian Urogynecology Working Group (AUB) October 22-24, 2015 Schladaming Australasian Gynaecological Endoscopy and Surgery Society (AGES) Focus Meeting November 6-7, 2015 Hobart
BSUG Annual Scientific Update in Urogynaecology November 12-13, 2015 London Dutch Society of Urogynecology (NVOG) Annual Meeting November 12-13, 2015 Arnhem Mediterranean Incontinence and Pelvic Floor Society (MIPS) Annual Meeting December 10-12, 2015 Ljubljana
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PELVIC PAIN CORNER: VULVODYNIA: A CHRONIC PAIN CONDITION By Erin Crosby, MD Vulvodynia remains a challenging chronic pain condition that can greatly impact a woman’s quality of life. It can be generalized or localized, and provoked or unprovoked. Much of the evidence suggests that it is a neuropathic pain condition. Patients may have had an inciting event, such as a vulvovaginitis or dermatitis, with persistent pain afterwards. This trauma to the vulva triggers inflammation which can then lead to increased proliferation of peropheral nerve fibers as well as central nervous system sensitization.
multidisciplinary approach to the patient and treat comorbid pain conditions in order to maximize the effect of the treatment of her vulvar pain. Additionally, the psychological impact of a chronic pain condition such as vulvodynia should be addressed. This can be through traditional cognitive behavioral therapy or with a sexual health therapist, and it can be beneficial to have the woman’s partner participate in therapy as well.
compounded in an inert base as patients may experience burning or irritation with the application of a topical medication.
Vulvodynia often coexists with other pain conditions such as endometriosis, bladder pain syndrome, irritable bowel syndrome, myofascial pain and pelvic floor muscle spasm. A comprehensive history and physical exam aimed at detecting these common comorbidities should be performed.
Pelvic floor physical therapy is a vital tool and should be offered as a part of any treatment strategy. A discussion should occur before therapy starts about the techniques that may be utilized, and the fact that therapy can seem to initially worsen pain before it starts to improve it. Oral medications for neuropathic pain are commonly used in women with vulvodynia. These include tricyclic antidepressants such as amitriptyline and desipramine, selective norepinephrine reuptake inhibitors such as duloxetine and venlafaxine, and anticonvulsants such as gabapentin and pregabalin. Patients should be counseled about potential side effects, and a titration schedule established.
Recent work evaluating the mast cell response in women with the disorder1, as well as work showing an increased inflammatory response to Candida albicans in women with vulvodynia may bring about new therapies for this disorder2. Advances in our knowledge of the etiology of the disorder, as well as prospective studies on treatment modalities are needed to better care for women with this condition.
Though the number of quality clinical trials on the management of vulvodynia are increasing, there is still limited evidence on which to base treatment recommendations. Education of the patient and her partner is critical, including establishing the goals of care, as disease management is more attainable than cure. It is important to have a
Topical medications can also be useful and have the advantage of fewer systemic side effects than oral medications. Commonly used medications include compounded amitriptyline, baclofen, nitroglycerine, gabapentin or ketamine. These should be
Surgery can be useful for women with localized vestibulodynia, and should be reserved for those in whom multiple conservative therapies have failed. Vestibulectomy with vulvovaginal advancement has reported success rates of 65-90%, but its use should be restricted to those with experience with the technique.
1. Regauer S, Eberz B, Beham-Schmid C. Mast cell infiltrates in vulvodynia represent secondary and idiopathic mast cell hyperplasias. APMIS 2015; 123: 452–456 2. Falsetta ML, Foster DC, Woeller CF et al. Identification of novel mechanisms involved in generating localized vulvodynia pain. Am J Obstet Gynecol 2015;212:x:ex-x.ex Erin Crosby, MD Assistant Professor Department of Obstetrics and Gynecology Albany Medical Center
SOUTH AFRICAN UROGYNAECOLOGY ASSOCIATION By Dr. Jacobus A van Rensburg This year is an important milestone in the field of Urogynaecology in South Africa because of the recent official registration as a subspecialty with the Health Professionals Council in South Africa. Urogynaecology is now the 4th registered subspecialty in Obstetrics and Gynaecology. We now follow other countries such as the UK, USA and the Netherlands in this recognition, and this is a first for the African continent. This milestone has been reached due to an initiative of the SA Urogynaecology Association with representatives from most medical schools in South Africa.
It was pioneered under the chairmanship of Dr. Gunter Rienhardt and Prof. Cronje but the successful application came with the significant contribution of our current chairman Dr. Stephen Jeffery. It is important to mention the names of Prof. Dick Barnes, head of Urology and Prof. Goldberg the head of colorectal surgery at the University of Cape Town for their contributions. We are thankful for the role of the College of Medicine SA and SA Society of Obstetrics and Gynaecology for their role and contribution they have made. Direct communication with Mrs. Vorster and the sympathetic ear of Prof. Lindique (chairman at the College of medicine SA) contributed to this successful application.
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Responsibility will now shift to the training units and Universities in SA. The appropriate steps will require official registration with HPCSA as a registered Urogynaecology Unit. However the trainers will need to register themselves first as urogynaecologists prior to fellowship training. Trainers will be allowed to register under the “grandfather clause” with proof of 50% or more urogynaecology involvement in their daily practice. The guidelines as indicated by the College of Medicine give a clear indication of the program and include a final assessment for the exit examination and registration as a urogynaecologist. Urogynaecology Units will have to take responsibility for further development of physiotherapists with an interest in women’s health to assist with post graduate
and undergraduate training. The development of a master’s degree in women’s health for physiotherapists at the University of Stellenbosch will be a great asset. The development of laparoscopic surgical techniques is one example of the further developments which will play a more important role in the field of Urogynaecological surgery. With this milestone of registration of Urogynaecology, the future promises to be even more exciting. Dr. Jacobus A van Rensburg Dept of Obstetrics and Gynaecology, Urogynaecology Unit Faculty of Medicine and Health Sciences Stellenbosch University
FIUGA - THE FOUNDATION NEEDS YOU! By Peter Sand, FIUGA President Fundraising Activities:
disorders throughout the world. We need your help!
The Foundation for International Urogynecological Assistance has been very successful recently in its fundraising efforts thanks to the active support of the IUGA President and the Executive Committee. President Freeman has worked very hard to promote the memberships’ knowledge of the mission and activities of the Foundation to promote its success. Our Vice-President, Lynsey Hayward with the aid of Drs. Davila, Rosamila and Thakar produced the 40th anniversary book and recruited contributions from members and industry in excess of $19,000. The office, with the help of our members working at the booth, sold hundreds of FIUGA pins and recruited contributions from those attending the annual meeting in Nice last month. I believe that Ajay Rane sold more than 100 pins himself in less than an hour. Our second annual silent auction was again successful raising $12,200 thanks to the generous support of our donors, Drs. Combaz, Cundiff, Davila, DeJong, Freeman, Hayward, Kammerer-Doak, Moore, Petros, Rosamilia, Sand, Shull and Van Rensburg. Please think about participating next year. These funds along with anticipated successful grant applications will allow us to continue our work in Ghana and to hopefully begin to fund research grants and the eXchange programs again. On behalf of the Foundation I want to thank all of our members who bought FIUGA pins, contributed monies and bid on the auction items. I want to ask all of the members to make contributions to the Foundation when you pay your dues, visit the FIUGA page on the website or register for the annual meeting in Cape Town. We also need your help in seeking out potential new funding sources. Please contact myself or the other members of the Foundation Board (Drs. Davila, Freeman, Hayward, Rosamilia, and Vervest) if you have a contact with an individual or charitable foundation that might be willing to fund projects consistent with FIUGA’s mission of disseminating knowledge and improving the care of women with pelvic floor
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What’s Going on in Ghana? The Ghana project is doing well thanks to the dedicated work of Lauri Romanzi and her committee. Our physicians have been intermittently visiting for 2 week sessions in Accra and Kumasi to work with the Fellows and faculty in the OR, clinic and classroom with the help of Dr. Lassey and the Ghana College of Physicians and Surgeons. The 3 Urogynecology fellows have been rotating for 6 months with Stephen Jeffrey in Cape Town and Stephen has been remotely lecturing to them on Mondays. Two of the Fellows, Gabriel and Wisdom, again attended our annual meeting and had the opportunity to meet many of our members and participate in the workshops and academic sessions. Stephen and Lauri, who had developed the original academic lecture schedule, want to recruit more IUGA lecturers to give these talks remotely and we are still recruiting faculty who want to visit Ghana to work with the faculty, residents and fellows. Don’t hesitate to contact them if you want to participate. Remember, the FIUGA is your Foundation. It was formed to facilitate and support the activities of the IUGA. Monies raised by FIUGA all go to support IUGA activities throughout the world. We will all benefit from a successful foundation. Contact us if you want to volunteer to help with fundraising or if you know of a potential contributor.
2016 Cape Town, South Africa Upcoming
August 2-6
Annual 2017 Vancouver, Canada Meetings June 20-24 IUGA
2018 Vienna, Austria
June 26-30
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referred to as “link rot”. Second, although the link is still operative the contents may have been moved to another location or another website, sometimes called “contents drift”. In both instances the reader can no longer access the information in the list of references making the citation useless. This fact is called graphically “reference rot”, a term which needs no further explanation.
What is “reference rot”? Every thesis and scientific article contains a list of references listing sources which the author used to develop the study question and to discuss the results. In medical scientific articles this list of references mostly contains citations of other scientific articles or sometimes chapters from books. There are strict rules how to cite with the aim of allowing the reader to access and verify this information unambiguously.
One may ask: where is the problem? We reviewed the 231 articles published in the IUJ in 2013 and found that 63 papers contained URLs in the list of references with an average of 1.7 links per article. Checking these links in February 2015 we found that 27.3% - more than a quarter – could no longer be accessed after 13-25 months. With the passing of time the number of broken links can only increase. What can be done? The use of URLs in lists of references will not go away. Sometimes information from the past of the internet can be retrieved from an archiving service such as archive.org. This internet archive automatically stores billions of pages with a particular date. It calls itself “a non-profit library of millions of free books, movies, software, music, and more.” This is more a hit-and-miss undertaking and other initiatives are under way for academics and scholars such as perma.cc – check it out.
In recent years it has become common practice to cite also information from the internet. The authors give a link to a specific webpage with the information the author wants to cite. The reader clicks on the http/ address and is taken to the webpage which contains the information. However, the question is whether the link has the same value as the citation of a specific article? One hint that something may be amiss is that authors usually also provide the date when the link was used and the information accessed. Indeed the concern that the information behind the link may no longer be what the author wanted to cite is well founded for two reasons.
As always I invite you to follow me on twitter at @iuj_eic (Paul Riss IUJ). At least once a week I try to tweet an interesting article from the IUJ with a short teaser. Paul Riss Co-Editor-in-Chief International Urogynecology Journal Email: paul.riss@gmail.com
First, the URL (uniform resource locator) may no longer be valid and the reader receives an error message. The owner may have shut down the link or the server may no longer respond to requests. This phenomena is
THE SWISS WORKING GROUP FOR UROGYNAECOLOGY AND PELVIC FLOOR PATHOLOGY (AUB) By Dr.med. Joerg Humburg, AUB Revisor and IUGA liaision
In this position the AUG is responsible for the scientific, clinical (i. e. guidelines) and educational aspects for urogynaecology in Switzerland. It is a non-profit organisation. At the moment we have 97 members that are urogynaecologically interested doctors or are gynecologists mainly working in this clinical field. It is also possible for other people working in this area of pelvic floor disorders, for example physiotherapists, incontinence nurses and others, to join our society.
The Swiss Working Group for Urogynaecology and Pelvic Floor Pathology (AUG: Arbeitsgemeinschaft für Urogynäkologie und Beckenbodenpathologie) is part of the Swiss Society for Gynaecology and Obstetrics (SGGG).
We have a steering committee, which consists of a president, a vice president, a secretary, a treasurer, a revisor and additional members. We meet twice a year as a steering committee and once with all members, where different matters are discussed, such as becoming an affiliate society of the IUGA, financial issues or to welcome new members. For the last few years we had and unfortunately will continue to have one main
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topic to discuss, which is the introduction of urogynaecology as a subspecialty. Like the other subspecialties in Switzerland a curriculum was developed to regulate the different aspects, like the number of surgical procedures you have to conduct and the exam you have to pass. At the moment we are trying to establish this curriculum in consultation with our urology colleagues, which seems to be more difficult than we expected.
committees of international organizations like the IUGA or the ICS. There is a close cooperation with two other German speaking urogynaecolocial working groups in Europe, the German (AGUBe.V.: Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion) and the Austrian working group (AUB: österreichische Arbeitsgemeinschaft für Urogynäkologie und rekonstruktive Beckenbodenchirurgie).
To promote urogynaecology and to support young doctors with interests in our field we donate a prize every year for the best article published and the best presentation held at the annual meeting of the SGGG.
Our homepage is currently under construction and will soon be accessible. You can meet us at our annual congress which is this year held in Ittingen near Frauenfeld or next year in Aarau. Dr.med. Joerg Humburg, AUB Revisor and IUGA liaision Kantonsspital Baselland Women’s Hospital
We are well linked; some of us are members of different
PHYSIOTHERAPISTS CORNER By Bary Berghmans, IUGA Pelvic Floor Rehabilitation Special Interest Group Chair Dear colleagues,
treatment, but would like you to provide more evidence!!!!’
In 2015 the IUGA Special Interest Group (SIG) on ‘Pelvic Floor Rehabilitation’ had a very promising start. Our SIG has been actively involved in several countries spreading ‘IUGA’s voice’ on the conservative management of patients with pelvic floor disorders throughout the world. Several meetings have been organized for health care providers with a special interest in this field who were not able to attend the annual IUGA or ICS meetings.
Next year the Pelvic Floor Rehabilitation SIG’s aim will be to continue providing an evidence–based, practical and high-class education on pelvic floor rehabilitation to the IUGA membership but also to countries with fewer resources in Africa and the Middle East. We aim to visit Mozambique and also join the Pan Arab Continence Society, chaired by Sherif Mourad, Professor of Urology at the University of Cairo, Egypt.
On January 23rd Dr. Marijke Slieker, IUGA ambassador for the Netherlands, and Dr. Maura Seleme, IUGA ambassador for Brazil, organized together in Nunspeet, The Netherlands, an exciting event, hosting more than 300 people. The participants’ feedback on both the program and organization was outstanding. Dr. Maura Seleme, in association with the Brazilian Association of Pelvic Physiotherapy (ABFP) and Faculdade Inspirar, organized a highly educational, attractive and well-received meeting in Fortaleza, Brazil, between the 20th and 24th of May. This course was attended by more than 300 medical doctors and physiotherapists. In several other countries SIG events have been held, with a clear message: ‘IUGA endorses conservative
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Our SIG, chaired by Dr. Bary Berghmans, has visited more than 25 countries to date. Our goal is to improve the quality of Pelvic Floor Rehabilitation education through hands-on workshops. Based on this idea, Dr. Berghmans has developed a so-called “Door-to-Door” concept: a narrow bridge between medical doctors and pelvic physiotherapists, midwives and nurses everywhere in the world. We are very grateful to the support provided to us by the IUGA Board and Scientific Committee. We will continue working hard and doing our best with passion and enthusiasm in order to spread knowledge and information about our fantastic profession among IUGA members. Thanks to all of you who gave us a place at your table of this big family called IUGA.
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CONTROVERSIES IN UROGYNECOLOGY
ROBOTIC VS. LAPAROSCOPIC SACROCOLPOPEXY By Heidi Brown, MD, MAS
INTRO
The first laparoscopic surgery was described over one hundred years ago, and gynecologic surgeons were the true pioneers in clinical adaptation of this technology in the 1970s and 1980s to perform surgeries for endometriosis, ectopic pregnancy, adnexal masses, and tubal ligation (Lee-Kong and Feingold, 2013). Almost a century after the first documented laparoscopic surgery, the da Vinci ® robot became commercially available for urologic indications in 2001 and gynecologic indications in 2005, and many urogynecologists have embraced this innovative technology for performance of minimally invasive abdominal sacrocolpopexy (www.daVinci.com). Proponents of robotic surgery tout its wristed instruments, 3-D visualization, and relative ergonomic ease for the surgeon, as advantages of the robotic approach over straight-stick laparoscopy. Skilled laparoscopists, conversely, contend that the loss of haptic feedback and the excessive cost of the da Vinci system are significant relative disadvantages of this new technology. Below, two skilled minimally invasive surgeons, both of whom completed Female Pelvic Medicine and Reconstructive Surgery fellowships at the Mayo Clinic Arizona, sound off about the benefits and drawbacks of these two techniques, and remind us not to forget about the least invasive surgical approach, also pioneered by our own: the transvaginal one. 1) Lee-Kong S and Feingold DL. The History of Minimally Invasive Surgery. Seminars in Colon and Rectal Surgery 2013; 24(1):3-6.
PRO LAPAROSCOPIC SACROCOLPOPEXY By Jaime Bashore Long, MD Sacrocolpopexy has long been regarded as the procedure of choice for recurrent pelvic organ prolapse in a sexually active woman and is even offered by some experts as first line surgical therapy for women at higher risk of failure with vaginal repair procedures. To meet the needs and expectations of today’s woman, it has become essential for surgeons to offer sacrocolpopexy via minimally invasive techniques, whether done using conventional laparoscopy or a robotic system. For nearly a decade, studies comparing laparoscopic sacrocolpopexy to sacrocolpopexy via laparotomy have documented similar operative times and anatomic outcomes as well as less blood loss and shorter hospital stays with the laparoscopic approach (Freeman RM Int Urogynecol J 2013; Paraiso MF Am J Obstet Gynecol 2005; Klauschie JL Int Urogynecol J Pelvic Floor Dysfunct 2009). Yet, few pelvic reconstructive surgeons adopted this technique, possibly due to the challenge associated with laparoscopic suturing and knot-tying skills. In the advent of widespread robotic minimally invasive surgery systems, however, the procedure flourished, presumably because of industry-funded training courses and ease of suturing with wristed instruments. Invariably, many believe that using a robotic operating system, which offers many purported advantages, allows for more effective and efficient sacrocolpopexy. Yet, no such advantage has been documented to date. In fact, randomized controlled trials comparing conventional laparoscopic with robotic sacrocolpopexy have consistently demonstrated significantly shorter operative times with conventional laparoscopy. Conventional laparoscopic sacrocolpopexy patients bled less and enjoyed a lower incidence of bladder injury intraoperatively.
These patients also had less pain and required less analgesia postoperatively. More importantly, these patients had a lower likelihood of reoperation for recurrent pelvic organ prolapse compared to patients who underwent a robotic assisted procedure (Paraiso MF Obstet & Gynecol 2011, Unger CA Am J Obstet Gynecol 2014). Lastly, laparoscopic sacrocolpopexy offers documented cost savings to both the institution and patient, as there is neither the expense of the robotic operating system nor the need for disposable/ limited-use instruments (Anger JT Obstet & Gynecol 2014). I have experienced the advantages of minimally invasive sacrocolpopexy both with conventional laparoscopic tools as well as robotic systems. In fact, as fellows at Mayo Clinic Arizona, Dr. Dobie Giles and I were among the early adopters of the robotic technology and were co-authors of one of the first large case series describing the procedure (Akl MN Surg Endosc 2009). It is my strong belief that any surgeon who is comfortable performing this procedure with the training wheels of a robotic platform can successfully make the jump to the superior straight stick procedure if motivated. There are some excellent surgical videos available to aid surgeons making this transition at www. academyofpelvicsurgery.com, www.augs.org, or www.aagl. org/surgeryu2014, to list a few. In addition to the evidencebased advantages listed above, it is my experience that the laparoscopic sacrocolpopexy patient has less pain and potential for herniation at trocar sites, which are 5 mm as opposed to 8 mm. Additionally, the haptic feedback in laparoscopic surgery is especially valuable for the presacral dissection and suture placement – a critical component of this procedure. For all of these reasons, I perform virtually all of these cases with conventional laparoscopic tools rather than robotic systems, despite readily available robotic systems in my
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operating rooms. In summary, I urge any pelvic surgeon with the skills to perform minimally invasive sacrocolpopexy to choose conventional laparoscopy. Not only is this approach is supported by level 1 evidence to improve patient outcomes, it also reduces the waste of medical expenses. 1.
FreemanRM, Pantazis K, Tomson A, Frappel J, Bombieri L, Moran P, et al. A randomized controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J 2013; 24: 377-84.
2. Paraiso MF, Walters MD, Rackley RR, Melek S, Hugney C. Laparoscopic and abdominal sacral colpopexies: a comparative cohort study. Am J Obstet Gynecol 2005; 192(5) 1752-8. 3.
Klauschie JL, Suozzi BA, O’Brien MM, McBride AW. A comparison of laparoscopic and abdominal sacral colpopexy: objective outcome and perioperative differences. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20(3): 273-9.
4.
Paraiso MF, Jelovsek EJ, Frick A, Chen CCG, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse. Obstet & Gynecol 2011; 118(5): 1005-1013.
5. Unger CA, Paraiso MF, Jelovsek EJ, Barber MD, Ridgeway B. Perioperative adverse events after minimally invasive abdominal sacrocolpopexy. Am J Obstet Gynecol 2014; 211: 547.e1-8. 6. Anger JT, Mueller ER, Tarnay C, Smith B, Stroupe K, Rosenman A, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet & Gynecol 2014; 123(1): 5-12. 7.
Akl MN, Long JB, Giles DL, Cornella JL, Pettit PD, Chen AH, Magtibay PM. Robotic-assisted sacrocolpopexy: technique and learning curve. Surg Endosc 2009; 23: 2390-2394.
Jaime Bashore Long, MD Director, Center for Pelvic Health Chief, Section of Urogynecology Reading Health Center Pennsylvania, USA
PRO ROBOTIC SACROCOLPOPEXY By Dobie Giles, MD, MS, FACOG Dr. Jaime Long and I were lucky enough to train together in Female Pelvic Medicine and Reconstructive Surgery at Mayo Clinic Arizona. This training covered all the typical aspects of surgery – vaginal, open, laparoscopic and robotic – to repair pelvic organ prolapse. I would like to state that I am not a proctor for the robot company (Intuitive Surgical), nor do I run an “epicenter” for robotic training. I believe the majority of urogynecologists would agree that sacrocolpopexy is the most durable repair for apical prolapse (Siddiqui et al 2015). It has been utilized in one shape or another for almost 60 years and today we have 3 possible variations (open, laparoscopic and robotic). Despite the open procedure having been shown to be more painful, with longer operating time and more complications, it is still being performed frequently today. Many will argue, including Dr. Long, that we should abandon the robotic sacrocolpopexy in favor of traditional laparoscopy because of higher costs with no obvious difference in benefit between the two techniques. Some will bring up the wonderful randomized controlled trials (RCTs) by Paraiso et al (Obstet Gynecol 2011) and Anger et al (Obstet Gynecol 2014), but these trials do not take into account the fact that sacrocolpopexy is considerably more technically difficult with traditional laparoscopy. Why else has the procedure not replaced open technique since it was first shown to be successful by the Drs. Nezhat (Obstet Gynecol 1994) over two decades ago? In twenty years laparoscopic sacrocolpopexy has not been incorporated into the armamentarium of the masses. The known difficulties of intracorporeal knot-tying and advanced dissection have inhibited the wide spread use of laparoscopic sacrocolpopexy. Luckily, the advent of the robot has given more surgeons around the world the tools necessary to perform minimally invasive
surgery. Many benefits have been attributed to the robot, such as high definition optics or tremor reduction due to scaled movement, but I believe the reason most people gravitate to the robot is the hand movement. Unlike the counter-intuitive motions of traditional laparoscopy, with the robot, if you move your hand left, your instrument moves left. Up is up and down is down. Your maneuvers are the same as with an open case. Another reason for wide adaption of robotic sacrocolpopexy is the availability of resources for training. There are numerous robotic training centers set up around the United States, as well as robotic sacrocolpopexy courses available to help with instruction. Unfortunately, the same training resources do not exist with traditional laparoscopic sacrocolpopexy because there is no centralized entity, like Intuitive Surgical, and thus there are limited structured courses available for surgeons who would like to learn the technique. While I agree with the two aforementioned RCTs that show robotic sacrocolpopexy to be more expensive and, in some hands, more time consuming, than laparoscopic sacrocolpopexy, I must point out that very few surgeons have actually adopted laparoscopic technique. Li et al (Can Urol Assoc J 2014) reported on the most recent United States inpatient data from 2009-2010 with a nationally weighted estimate of 11,080 (82%) open cases and 2,381 (18%) robotic cases. If laparoscopic surgery is truly superior, why are so many more surgeons operating robotically? The main issue of cost using the robot does not take into consideration the cost of not performing minimally invasive surgery. Until there are more training centers or societysponsored training courses, such as those offered at the next IUGA annual meeting by Dr. Jan Deprest, it is unlikely the masses will adopt laparoscopic sacrocolpopexy and therefore, there is still a need for robotic sacrocolpopexy. We will not be able to answer this debate of robotic versus laparoscopic sacrocolpopexy today. I think we should
first address the issue as to why are open procedures still being performed when the majority of the evidence points to the benefits of minimally invasive surgery. We should then focus our efforts to increase the number of training courses and mentors to assist the practicing surgeon in the transition to minimally invasive surgery. Once that has been accomplished, we can revisit this debate. Finally, one topic that is rarely discussed is the strain on the surgeon. Franasiak et al (Gynecol Oncol 2012) and Tarr et al (J Minim Invasive Gynecol 2015) have both discussed the impact of laparoscopy and robotic surgery on the surgeon. After two back surgeries, one hip surgery and one hand surgery, I feel more comfortable in the seated position when I operate. Maybe that is the reason why I like vaginal surgery most of all. 1.
Siddiqui NY, Grimes DL, Casiano ER, et al. “Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and metaanalysis. Obstet Gynecol 2015;125(1): 44-55.
2. Paraiso MF, Jelovsek JE, Frick A, et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse. Obstet Gynecol 2011;118(5):1005-1013. 3.
Anger JT, Mueller ER, Tarnay C, et al. Robotic compared
with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014; 123(1):5-12. 4.
Nezhat CH, Nezhat F and Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1994;84(5):885-8.
5. Li H, Sammon J, Roghmann F, et al. Utilization and perioperative outcomes of robotic vaginal vault suspension compared to abdominal or vaginal approaches for pelvic organ prolapse. Can Urol Assoc J 2014;8(3-4):100-6. 6. Franasiak J, Ko EM, Kidd J, et al. Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery. Gynecol Oncol 2012;126(2):180-185. 7.
Tarr ME, Brancato SJ, Cunkelman, et al. Comparison of postural ergonomics between laparoscopic and robotic sacrocolpopexy: a pilot study. J Minim Invasive Gynecol 2015;22(2):234-238.
Dobie Giles, MD, MS, FACOG Assistant Professor, UW School of Medicine & Public Health Division Director of Gynecology and Gynecologic Subspecialties Chief, Female Pelvic Medicine and Reconstructive Surgery Departments of Obstetrics & Gynecology and Urology Wisconsin USA
REMEMBERING PROF. ANTONIO LOMANTO It is with a heavy heart we report the passing of Honorary Professor and Emeritus Antonio Lomanto Moran. Prof. Lomanto was a true leader in the field of female pelvic floor medicine in Colombia. He is responsible for establishing the first Urinary Incontinence Clinic at the Universidad Nacional de Colombia in 1981 and founder of the Colombian Association of Urology and Gynecology, ASCOGUR. He used the association to spread his knowledge and expertise, contributing immensely to research and the medical community in Colombia. In his 50 year career, he held various academic posts at his alma mater including Head of Undergraduate, Graduate and Department Director of Gynecology & Obstetrics. He received the highest honors from the Universidad Nacional de Colombia, scientific societies and other hospitals where he worked. He was a prolific researcher and academic, with work published in over one hundred national and international journals and spoke at many events, leaving a lasting impression on those who had the opportunity to hear him speak. Prof. Lomanto leaves behind a legacy of honesty, integrity, commitment, discipline and respect for his patients and colleagues. Rest in peace to our teacher, friend and leader, Prof. Lomanto. Sincerely, Jorge Alberto GarcĂa President ASCOGUR
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IUGA Board
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