Guest Editorial Seeing the future by appreciating the past

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1 Volume 2, Issue 3 SEPTEMBER 2014 Editorial Peter de Jong Congratulations to Etienne Henn who produced this Edition of the SAUGA Newsletter. Short and to the point as always. His editorial is appropriate and thought provoking, with good points raised. In the first paper, Hennie Cronje outlines his approach to the use of mesh for prolapse repair. Prof Cronje s papers have always been clinically useful and practical, and this article is no different. In the second paper, Leoanard Juul gives an overview of the incidence of faecal incontinence, and suggests that this topic must be confronted head on and not swept under the carpet. He sticks his neck out on faecal incontinence, and insists that elective caesareans cannot yet be justified to prevent this distressing disorder. And finally, Etienne Henn reminds us that transperineal ultrasound provides information during the initial consultation, and adds value in the post op evaluation of subjects. Most gynaecologists have suitable machines that allow transperineal ultrasound images Guest Editorial Seeing the future by appreciating the past Etienne W Henn, University of Free State Spring is in the air and it is nearly time to reflect on 2014, even though it feels as if it was just recently that we wished each other a Happy New Year. Actual selfie Reflecting is not just part of life in general, but it is also an important element of our discipline. We frequently need to look back and evaluate our management choices and clinical outcomes. We are encouraged to audit certain defined aspects of our clinical practice and the retrospective review process will always retain a central place in generating evidence on which to base clinical management. In this issue of the newsletter we will be reflecting on some very contemporary topics. The true place and use of mesh in prolapse surgery creates a lot of uncertainty. The recently non-retired Prof Hennie Cronje provides us with a very pragmatic approach to this problem. Anal incontinence and its probable causes remain topical with recent articles featuring in the lay press and magazines. Dr Leonard Juul briefly reviews this complex and embarrassing problem with some reflection on recent publications. Lastly we have added some clinical images of post-operative findings that challenges certain beliefs in pelvic floor surgery. We trust that you will find this newsletter a palatable experience without excessive postreading bloatedness.

2 Page 2 My approach to mesh for prolapse repair Prof HS Cronje, Unitas Hospital, Centurion History We have been using mesh for the treatment of pelvic organ prolapse (POP) since the 1980 s. It was used for sacrocolpopexy with materials like Merseline tape and Goretex mesh. Our first sacrocolpopexy with rectopexy was done in 1996, also with Goretex. At that time, we experienced significant problems with mesh. In about 1:4 patients the mesh was rejected. In the early 2000 s we started to use Ultrapro mesh, a product that we still use extensively. Shortly thereafter Prolift came on the market. For a short while it seemed as if Prolift would replace sacrocolpopexy with rectopexy, but we soon realized that sacrocolpopexy was superior. However, Prolift was promoted extensively. Numerous workshops were held focusing on the placement of mesh vaginally. Any doctor was welcome, which invited people without proper training into the field of surgery for POP. The result was an unacceptable incidence of complications with an escalation in litigation. This was a worldwide problem, particularly in the USA. The next important event was a document issued by the Food and Drug Administration in the USA in 2007, and revised in In this document it was stated that mesh for anterior compartment prolapse was questionable, for middle compartment prolapse it was advantageous, but there was no evidence that mesh in the posterior compartment was useful. This document was endorsed by the American Urogynecologic Society and the ACOG. The second important event was the withdrawal by Johnson & Johnson, the largest supplier, of mesh, from the market in This was the result of the rising incidence of litigation against the company. These two important events had the following consequences: Doctors became more aware of the potential complications associated with mesh for pelvic organ prolapse and borderline physicians withdrew from the field of surgery for POP. Both these consequences are welcomed because they promoted an improved standard of surgery for POP. Principles in the use of mesh The following principles will minimize the risk of complications associated with mesh: 1. The indication for the use of mesh should be precise. 2. Mesh should only be used according to the internationally accepted methods. 3. The amount of mesh placed in a patient should be minimal. 4. Vaginal mesh is associated with more complications compared to abdominal mesh. 5. Only light-weight, large pore, polypropylene mesh should be used. My personal approach to the use of mesh Anterior compartment prolapse (cystocoele) The cystocoele is the most difficult form of prolapse to treat, mainly because we don t understand the pathophysiology completely. What we do know, includes the following:

3 Volume 2, Issue 3 Page 3 The bladder is supported by a poorly defined structure, the endopelvic fascia. Fascial breaks are well documented, but difficult to diagnose and to treat. A cystocoele can be divided into a pseudo cystocoele and a true cystocoele. A pseudo cystocoele is one that is completely reduced by sacrocolpopexy without the need for further procedures. A true cystocoele needs vaginal repair, whether a sacrocolpopexy is done or not. A cystocoele is a marker of defective levator ani support, usually with an enlarged genital hiatus. As a result of the above mentioned, it is often associated with a culdocoele (a deep and wide pouch of Douglas). An internal cystocoele may develop where the bladder prolapses into the culdocoele, mainly after a previous hysterectomy. The bladder is rich in nerve supply with strong representation in the brain s deep centres, and so must be approached with great care. Taking into account all the above mentioned points, my approach to a cystocoele is as follows: My first choice is a sacrocolpopexy. Once the vault (or uterus) is pushed/pulled upwards, I examine the bladder to see whether the cystocoele has been reduced completely or not. If not, a further procedure is necessary. For mild cases I only trim the vaginal edges of an incision over the bladder. For a well developed cystocoele an anterior colporrhaphy is done in addition to the sacrocolpopexy. If the patient does not qualify for sacrocolpopexy due to age, obesity, co-morbidity, etc., I will place an anterior vaginal mesh with sacrospinous fixation of the deep arms. An important point is to attach the vaginal vault or cervix to these arms. Middle compartment prolapse (uterine and vault prolapse): Sacrocolpopexy offers the best results and is my first choice. If it is not possible, a bilateral sacrospinous fixation is indicated. The cervix or vault is fixed to the ligaments. Sacrospinous fixation creates an increased risk for anterior compartment prolapse. Although not indicated in all cases, an anterior mesh should be considered. Vault prolapse is of particular concern, because of associated pathology cystocoele, culdocoele, enterocoele. For this reason I approach it as for an enterocoele (see below).an important point is that the cervix or vaginal vault (the apex) is slightly higher than the sacrospinous ligaments (Fig. 1). Therefore, a sacrospinous ligament fixation will never provide the same degree of suspension compared to sacrocolpopexy. Another possibility is uterosacral ligament suspension. I do not use it because the ligaments are often of very poor quality. It also involves a risk of ureteric injury. Posterior compartment: Enterocoele I divide this defect into two entities: culdocoele and enterocoele. A culdocoele is a wide and deep cul de sac (pouch of Douglas). The rectum forms its posterior wall, its base and distal part of its anterior wall. The rectum then forms an angle towards the anus. An enterocoele is a true herniation between the rectum and vagina,

4 Page 4 distal to the culdocoele. A culdocoele is seldomly associated with an enterocoele, but an enterocoele is always associated with a culdocoele. The only treatment that effectively eliminates both a culdocoele and rectocoele, is sacrocolpopexy with rectopexy. I use Ultrapro mesh. A new, elevated pouch of Douglas is created, with the following advantages: It is a treatment for an internal cystocoele (see above), as the bladder has a new basis to rest on within the pelvis. It straightens the rectum for improved motions. It minimizes the risk of recurrent enterocoele. Rectocoele A mesh doesn t work for a rectocoele. My approach is to do a longitudinal plication of the anterior rectal wall. A perineal body repair is usually done as well. Conclusion The more I deal with POP, the more I do sacrocolpopexy. The advantages are excellent anatomical results with a low rate of recurrence of prolapse (5% maximum). Organ functions are excellent. The negative side is that it involves major surgery. Figure 1. Position of the sacrospinous ligament in relation to the top of the vagina

5 Page 5 Faecal incontinence associated with childbirth Leonard Juul, Urogynaecology, Dept Obstetrics & Gynaecology, University of the Free State Actual selfie Introduction Faecal incontinence can have a tremendous effect on quality of life (Nelson et al. 1995; Rothbarth et al. 2001). According to the International Urogynecological Association (IUGA) and International Continence Society (ICS) faecal incontinence is defined as the involuntary loss of faeces and anal incontinence as the involuntary loss of flatus as well.a systematic review estimated the prevalence of faecal incontinence, among community dwelling adults, to be 11 to 15 percent (Macmillan et al. 2004). Our primary goal should be the prevention of this condition and at the same time to effectively identify women suffering with it. It is well known that the prevalence of this condition is often underestimated (Melville et al. 2005) and that patients underreport the condition to caregivers. In one article, two-thirds of individuals with faecal incontinence did not discuss it with their primary caregivers (Johanson & Lafferty 1996). In this same article faecal incontinence is referred to as the silent affliction. Faecal continence depends on a number of complex and sometimes overlapping factors: mental function, stool volume and consistency, colonic transit, rectal distensibility, anal sphincter function, anorectal sensation and anorectal reflexes. In postpartum faecal incontinence, anal sphincter injury and neural injury are presumed to be the leading causes. Interestingly it has been shown that the postpartum prevalence falls for up to 12 months after delivery (Hall et al. 2003). Risk Factors Perineal massage has not been shown to be protective against postpartum fecal incontinence (Beckmann & Garrett 2006), but modifying obstetrical practice could possibly decrease the incidence of this debilitating condition. Operative vaginal delivery and median episiotomies have been shown to be major risk factors in the development of obstetric anal sphincter tears (Juul & Theron 2011). Other risk factors include fetal macrosomia and increasing maternal age (Fenner et al. 2003). Childbirth In a recent article published in the South African Journal of Obstetrics and Gynaecology (SAJOG) it was stated that Postpartum anal incontinence is common in our resource-constrained setting and appears to be transient, with most cases resolving by 6 months. Among the women in this study 16.2% sustained perineal tears and 4.1% had third- or fourth-degree tears. Only 0.7% of these women reported symptoms at 6 months (Naidoo & Moodley 2014). We should, however, not be reassured by this data. For instance, in another article from the Netherlands, recently published in the International Urogynaecology Journal (IUJ), although only dealing with obstetric anal sphincter injuries, it showed that at follow-up, prevalence of incontinence was 63 % for flatus,

6 Page 6 50 % for liquid stool, and 20 % for solid stool respectively (Visscher et al. 2014). Interestingly, the same authors of the SAJOG article reported a 6.4% persistence of anal incontinence at 6 months in an earlier article (Naidoo et al. 2012). Why these differing results? Anal incontinence, with or without faecal incontinence, is a complex multi-factorial condition. It is relatively common, but vastly underreported. Younger patients tend to compensate with their pelvic floor musculature and neuropraxia generally improves over time. In the above mentioned SAJOG article the median age of the paients was 24 years, while in the IUJ article the mean age was 38. Obstetric anal spincters are more common in older woman (Lewicky-Gaupp et al. 2009). Also, in the IUJ article the authors had a 5 year follow-up compared to only 6 months in the SAJOG article. (The patient populations are also vastly different - black Africans and Indians vs Dutch women Ed). Conclusion What can we therefore learn from these articles? The 2 studies, mentioned in the above paragraph, have many variables that make direct comparison unfair. What we can conclude from the above brief literature review, however, is that anal incontinence is common, underreported and that new onset incontinence may present years and probably decades after the initial pregnancy or delivery. Typically, in our unit, we see perimenopousal women presenting with anal incontinence and the only identifiable risk factors being traumatic obstetric events many years ago. It is our duty as urogynaecologists to be vigilant for anal incontinence and to increase awareness among medical students, registrars, primary care givers and the public of this silent affliction. As was stated in the title of a recent article in the Washington Post: It s time to end the taboo on talking about accidental bowel leakage We should strive to investigate methods to identify high risk patients for developing obstetric anal sphincter injuries and prevent this from happening in the first place. Elective caesarean delivery for the prevention of faecal incontinence cannot be justified at present, without taking the individual risk factors into account. The management of women with a previous anal sphincter laceration or faecal incontinence, remains controversial, but experts advise that a woman with persistent faecal incontinence and a poorly functioning anal sphincter should be offered an elective caesarean section after a thorough work-up. DATES TO REMEMBER AND DIARISE: 25 December Christmas 01 January New Year July IUGA Cape Town Meeting Steve Jeffery Chairman, SAUGA IUGA Africa Rep

7 Volume 2, Issue 3 Page 7 Images in urogynaecology Etienne Henn, Urogynaecology, Dept Obstetrics & Gynaecology, University of the Free State Transperineal ultrasound has gained significant ground in the assessment of pelvic floor disorders in recent years. The most commonly used modality remains 2Dultrasound with the use of a curved array probe, although 3- and 4D images are also increasingly popular due to further information obtained. The value of 3- and 4D is particularly for the assessment of the levator ani muscle and possible areas of muscular avulsion from the pubic rami. Ultrasound provides valuable information during the initial evaluation, but also adds value in the postoperative evaluation of patients. The most recent Cochrane review on surgery for pelvic organ prolapse states that there is no benefit for the use of mesh in the posterior compartment. Many surgeons would however still consider this for the correction of rectoceles. We have been of the opinion in our unit that a rectocele is a defect of the anterior rectal wall in conjunction with a damaged rectovaginal septum. We therefore focus our repairs on the anterior rectal wall and perineum in cases of symptomatic rectoceles. In recent years we have furthermore noted the persistence of rectoceles with the use of posterior mesh in cases where a rectocele repair was not added. These two images are those of 2D transperineal ultrasound evaluation in 2 women who have had a posterior mesh repair without a posterior tissue repair in addition. It is clear that the rectocele persisted beneath the mesh in both cases, despite optimal middle compartment support and despite the distal part of the mesh reaching to the perineal body. Does this detract from the view that repair of the rectovaginal septum and site-specific repair is sufficient for the correction of a rectocele? I will let you decide. Figure 1: Diagrammatic illustration of 2D transperineal image (Dietz, et al.)

8 Page 8 Figure 2-3: 2 Cases of rectocele recurrence beneath posterior mesh. The mesh is seen as an echogenic structure anterior to the rectum.

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