Urogynaecology Update. Andrew Tapp Consultant Obstetrician and Gynaecologist Shrewsbury & Telford Hospital NHS Trust

Urogynaecology Update Andrew Tapp Consultant Obstetrician and Gynaecologist Shrewsbury & Telford Hospital NHS Trust

Urogynaecology Training Core module 18. ATSM. Sub-specialty training.

Urogynaecology Training Core Module. History and examination. Indication and limitations of investigations and treatments. Surgery under direct supervision : 1 vaginal repair vaginal hysterectomy Observe mid-urethral tapes. Understand other surgical procedures.

Urogynaecology Training ATSM Previously 2 : urogynae benign vaginal surgery. From August 2011 expanded module. Urogynaecology and vaginal surgery. Work intensity score 2 (12 18 months). More than 1 educational supervisor. Overlap of ATSM resolved.

Urogynaecology Training ATSM. Develops multi-disciplinary working. Undertake investigation. Perform 1 continence and prolapse surgery, cystoscopy/mid-urethral tape/anterior and posterior repair/vaginal hysterectomy (20 each). Understand and able to refer complex or 2 cases.

Urogynaecology Training Sub-specialist Extends into much greater knowledge and understanding of investigation. Surgery extends to ability in full suite of continence/prolapse procedures. Considerable understanding and ability in overlap with urology/colorectal surgery/ neurology.

Service Provision - Urodynamics Joint statement on minimum standards for urodynamic practice in the uk Prepared by a working party representing: Association for Continence Advice British Association of Paediatric Urologists British Association of Urological Nurses British Association of Urological Surgeons British Society of Urogynaecology Chartered Society of Physiotherapists Royal College of Nursing Continence Care Forum United Kingdom Continence Society Urogynaecology Nurse Specialists Network

UKCS joint statements. General considerations. Training standards. Maintaining expertise. Urodynamic department. Aims for accreditation of both personnel and department. Knowledge base. Setting up of equipment. Preparation of patient and conducting test. Training and supervision.

BSUG Accreditation of Units (voluntary) Standards for Service Provision in Urogynaecology Units: Certification of Units Authors: E Adams, S Hill, M Iskander, P Ballard, A Fayyad (Clinical Governance Committee BSUG) R Freeman, P Toozs-Hobson and ARB Smith. Contents 1.Introduction 2.Definition of Urogynaecologist and Standards of accreditation 3.Background 4.Role of Lead Urogynaecologist 5.Clinical governance 6.Assessment visit and list of documents/appeals 7.Nurse Specialists and Continence Advisors 8.Audit 9.Conclusion 10.References 11.Visit proforma and scoring system 12. Reference Urodynamics curriculum and Standards in the Female A1 (on website)

BSUG Accreditation of Units (voluntary) 1. Introduction The RCOG s role in setting standards and identifying auditable topics has been the basis for improving clinical standards in obstetrics and gynaecology. This has been further developed by the Department of Health (DH) with the introduction of Clinical Governance within Trusts and is applicable to all individuals involved in the provision of patient care. The National Institute of Clinical Excellence further recommends that national standards of clinical care should reflect the commitment to patient-centred care and that standards should address the quality of care that a patient with a given illness or condition is entitled to expect to receive from the NHS. In addition, NICE addresses the roles and responsibilities of the various healthcare professionals who will care for the patient (NICE Recommendation 125). BSUG is aware of the pressures placed upon all practitioners by clinical governance, continued professional development, appraisal and revalidation. All these developments have brought additional work and challenges to professionals without always additional support or recognition for this extra work and responsibility. These doctors need to be recognised and supported in order for them to make the improvements necessary to provide the excellent standards of care, which we strive for. If this is carried out in a thorough and professional manner, and is adopted by the Commissions of Care as the acceptable standard, then registered practitioners can use this to substantiate their role, establish their authority and apply pressure to Trusts to provide the facilities needed to deliver a high quality service. It would also persuade colleagues to follow appropriate care guidelines and pathways of referral. In the current climate of these regulatory activities, accreditation of Urogynaecology Centres and Units is both inevitable and necessary. With this in mind, the BSUG feels that a form of voluntary registration for certification of units would be beneficial to its members. The objective of certification of units is based on local delivery of high quality health care, through clinical governance underpinned by modernised professional self-regulation and extended lifelong learning.

UKCS - Grandfathering Process of acceptance that there are trained personnel delivering care now. Open for 2 years from May 2010.

Vaginal Placement Of Mesh For POP POP seen in 50% of parous women. 7% lifetime risk of surgery. 28,000 operations per year in England and Wales. Increasing by 1,000 operations per year. Symptoms: pressure bulge heaviness discomfort retention of urine incomplete defecation apareunia dyspareunia (embarrassment). Impact on quality of life.

Standard Techniques Anterior colporrhaphy. Posterior colporrhaphy +/- perineorrhaphy. Site specific repair. Paravaginal repair. Vaginal hysterectomy. Sacrospinus ligament fixation. Sacrocolpopexy.

Standard Techniques: Problems Failure rate: - recurrence - lack of improvement in QOL. Effect on vaginal anatomy: - short - narrow. Standard procedure fails to address the underlying deficit: - fascial tear/stretch - quality of tissue. Reliant on scar tissue to provide support. Poor efficacy at resolving massive prolapse in an anatomic manner.

New Techniques Address all defects. Provide strength to repair. Avoids removal of native tissue. Retains the uterus Reduces chance of recurrence. Maintains function.

Considerations We are obliged to make care of the patient our primary concern providing a good standard of practice and care. Philosophy of care makes it incumbent on us to move forward and address the issues if our current techniques are unsatisfactory. When new techniques are available, we are required to work with patients with honesty and integrity to supply care. We cannot withhold new treatments with a sound scientific, anatomic, efficacy basis if the patient understands the limitations of world knowledge and is empowered to make decisions that maintain that personal integrity.

AIM AND METHOD To look at mesh repair outcomes carried out at SaTH. 84 mesh repairs have been carried out at SaTH and 17 privately. All 101 patients were invited to attend clinics at RSH and Nuffield in July, August and November. On arrival they were given 2 questionnaires to complete: Vaginal Symptoms Post Operative Quality of Life.

RESULTS A total of 76 (75%) patients attended the clinics.

Age 20 18 16 14 12 10 8 6 4 2 0 1% 36 to 40 0 41 to 45 4% 46 to 50 12% 11% 51 to 55 56 to 60 24% 25% 61 to 65 66 to 70 8% 9% 7% 71 to 75 76 to 80 81 to 85 Range = 36 to 83yrs Avg age = 65yrs

Post Menopausal 70 81% 60 50 40 30 20 16% 10 0 3% Yes No NR

Previous Gynaecology Surgery Number of Patients Abdominal Hysterectomy 22% Abdo Hyst & Ant repair 1.3% Abdo Hyst & Colposuspension 3% Abdo Hyst & Post repair 1.3% Abdo Hyst & Vag Hyst & Ant rep & Mid Tape 1.3% Anterior repair 1.3% Ant rep & Post rep 1.3% Sub Abdo Hyst 1.3% Vaginal Hysterectomy 11% Vag Hyst & Ant repair 20% Vag Hyst & Ant repair & Colposuspension 1.3%

Previous Gynaecology Surgery Number of Patients Vag Hyst & Ant rep & Mid tape 13.% Vag Hyst & Ant rep & Post rep 5% Vag Hyst & Ant rep & Post rep & Colpo 1.3% Vag Hyst & Ant rep & Post rep & Scarocolp 1.3% Vag Hyst & Ant rep & Post rep & SSLF 3% Vag Hyst & Ant rep & Scarocolpopexy 1.3% Vag Hyst & Ant rep & SSLF 1.3% Vag Hyst & Colposuspension 3% Vag Hyst & Post repair 4% Vag Hyst & Post repair & SSLF 1.3% None 4% NR 9%

Presence Of Co-existent Lower Urinary Tract Dysfunction N=31 (41%) 12 10 8 10 12 6 4 2 0 5 OAB USI Mixed Voiding dysfunction 1 1 1 1 OAB & USI & Voiding dys OAB & USI Catheter for Secondary candequina synd

Type of Surgery NR 4 Anterior and O ther Post and other 1 1 Posterior and Miduretheral tape 3 Anterior mesh and miduretheral tape anterior + posterior 7 7 Posterior repair 25 Anterior mesh 28 0 5 10 15 20 25 30

Operative Complications Bladder injury = 0 Bowel injury = 0 Other injury = 0 Blood loss >400mls = 4 1 pt went into AF but resolved spontaneously

<10 Day Post-Operative Complications Hb fall >2.5g/dl = 1 UTI & voiding dysfunction requiring second catheter = 1 Voiding dysfunction requiring second catheter = 5

10 Day To Follow-Up Post-Op Complications N=12 New onset urinary incontinence = 4 Recurrent UTI = 2% Voiding dysfunction = 2% Rectal prolapse = 1% Local granulation/haematoma = 1% Deep dyspaurenia and post coital bleeding = 1% Loss of bladder sensation = 1% Cough/constipation/SOBOE = 1%

Final Follow Up

New Onset Of Symptoms (N=31) Urinary = 13%. Bowel = 13%. Other = 7%. Prolapse = 13% (8% included above): 10% same site as surgery 90% different site.

Grading At Time Of Post Anterior Repair Surgery (36pts) Anterior 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Prior to repair Post repair 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Patient

Grading Before & After Posterior Repair Surgery (26pts) Posterior Prior to repair Post repair 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Patient

Grading Before & After Posterior Repair Surgery (26pts) Anterior Prior to repair Post repair 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Patient

NICE Guidance Evidence suggests surgical repair of vaginal wall prolapse using mesh may be more efficacious than traditional surgical repair without mesh. Should only be carried out by gynaecologists with special expertise.

NICE Criteria CRITERION 1) Percentage of pts receiving written information on the procedure and possible complications 2) Percentage of pts having surgery undertaken by a gynaecologist with special expertise in the surgical management of pelvic organ prolapse 3) The percentage of pts receiving surgical repair of vaginal wall prolapse using mesh from whom there was a clinical improvement 4) The percentage of pts receiving surgical repair of vaginal wall prolapse using mesh who have assessment of their quality of life at 1 year SaTH STANDARD 100% 100% Anterior 97% Posterior 100% 39% (30 pts seen within 12 months of surgery)

NICE Criteria CRITERION 7) The percentage of pts receiving surgical repair of vaginal wall prolapse using mesh who suffer Intraoperative complications Complications 30day post op 8) The percentage of patients receiving surgical repair of vaginal wall prolapse using mesh who suffer any of the following complications within 12 months post procedure Mesh erosion Urinary or faecal incontinence De novo dyspareunia Vaginal narrowing secondary to mesh Vaginal pain Chronic sepsis Fistula SaTH STANDARD Blood loss >400cc: Urinary incontinence <15% Mesh erosion <10% Urinary symptoms: 13% Mesh erosion: 0%

Mid-Urethral Tapes Retropubic: probably better for urethral failure; more voiding problems; bladder/intra abdominal and vascular injury Obturator: seems to be just as good in large studies; less voiding problems; urethral injury; no intra-abdominal injury; thigh pain Single incision (mini): difficult to assess efficacy / complications

Midurethral Tapes Surigcal rationale Audit 220 TVTs: 2% bladder perforation rate overall / 10% if previous pelvic surgery Audit 220 TVTs: 25% some deterioration in voiding / 2% tape division predictable Obturator approach for previous pelvic surgery or proven voiding dysfunction

Tale of 3 Pains With Obturator Approach 42 year old. Previous hysterectomy. TVT-O. Major mobility problems post surgery but able to void. Back pain (sacro iliac); symphysis pubis pain; thigh pain. Past history of being wheelchair bound with 2 pregnancies and 3 months after secondary to diastasis pubis. Under orthopaedic surgeons with a view to pinning symphysis

Tale of 3 Pains with Obturator Approach 40 year old. 2 previous LSCS. TVT-O day case. Significant voiding dysfunction and mobility problems post op in patient 3 days. Intermittent self cath. Thigh pain medial aspect left thigh although retention of movement and power. Some resolution. MRI / nerve conduction studies: obturator injury.

Tale of 3 Pains with Obturator Approach 67 year old. Previous vaginal hysterectomy and repair. TVT-O as day case. Voiding dysfunction and thigh pain post op. In patient 2 days. Very motivated patient. Intermittent self cath (5 weeks). Physiotherapy. Clinical examination mass at obturator internus left. MRI large haematoma under obturator internus. Resolution of pain and voiding dysfunction after 8 weeks.

Conclusion Training is changing and may not be all you expect Accreditation of units is coming New is not bad but your rational may need considerable adjustment and thought

Symptom Questionnaire Complete 80 70 60 50 40 30 20 10 0 100% Yes No 0

Grading Before & After Posterior Repair Surgery (26pts) Posterior Prior to repair Post repair 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Patient