Patient satisfaction with a multidisciplinary colorectal and urogynaecology service.

INTRODUCTION: Traditionally, the pelvic floor has been described as three separate compartments and problems in each compartment were managed separately. A more contemporary approach is to identify the entire pelvic floor as a single dynamic compartment. Multidisciplinary pelvic floor clinics such as ours with the support of physiotherapy, clinical nurse specialists, urodynamics, and endo-anal ultrasound are uncommon. The aim of this study was to assess patient satisfaction with a joint colorectal and urogynaecology clinic. METHOD: All women who attended our service in 2015 were identified. Women who saw both a colorectal surgeon and urogynaecologist at the same clinic were included. The Satisfaction with Outpatient Services questionnaire, a multi-dimensional outpatient survey, was mailed to all women. RESULTS: A total of 364 new women attended our service in 2015. One hundred thirty-six (35.2%) saw both a colorectal surgeon and urogynaecologist at the same visit. There was a 64% (87/136) response rate to the questionnaire. Overall, all questions regarding their attendance were responded to positively by 94% (82/87) of women. Confidence and trust in the doctor examining and treating them was reported by all women. Seeing multiple specialists was of benefit to 97% (84/87) of women and 94% (82/87) would recommend the Pelvic Floor Centre. CONCLUSION: There is a high level of satisfaction amongst women attending our outpatient service. Being seen by multiple specialities at a single clinic was felt to be of benefit by the majority of women and all expressed physician confidence. Our multidisciplinary service may reduce waiting times, increase satisfaction, and is likely cost-effective.

Blood transfusion after vaginal hysterectomy for pelvic organ prolapse.

BACKGROUND AND AIMS: Hysterectomy is a commonly performed gynaecological procedure, and vaginal hysterectomy for the treatment of pelvic organ prolapse will become more common as our population ages. Red cell transfusion after hysterectomy has been reported in the literature as between 2.5 and 4.3%. This paper aimed to review the rate of red cell transfusion after vaginal hysterectomy for pelvic organ prolapse in three university-affiliated teaching hospitals. METHODS: We reviewed 108 vaginal hysterectomies performed across three teaching hospitals to determine the rate of post-operative blood transfusion. RESULTS: A total of 1.9% (2/108) of women received at least one unit of red cells after their vaginal hysterectomy in our cohort. The mean drop in haemoglobin was 2.0 (95% CI, 1.8-2.3, P < 0.001). CONCLUSIONS: Red cell transfusion remains lower than international figures. This may form part of patient counselling when discussing the route of hysterectomy in the future.

Functional outcomes following surgical management of pain, exposure or extrusion following a suburethral tape insertion for urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: Surgical revision of a tape inserted for urinary stress incontinence may be indicated for pain, or tape exposure or extrusion. This study assesses the clinical outcomes of revision surgery. METHODS: A retrospective review of 47 consecutive women who underwent surgical revision for the indications of pain, tape exposure or tape extrusion. RESULTS: Forty-seven women underwent revision. 29 women (62 %) had initial tape placement at another institution. Mean interval between placement and revision was 30 months. 39 women (83 %) had an identifiable tape exposure or extrusion with or without pain, while 8 women (17 %) presented with pain alone. 11 (23 %) of the tapes were infected clinically and histologically at revision, 10 of the 11 (90 %) being of a multifilament type. In 23 (49 %) cases, the revision aimed to completely remove the tape. Partial excision 24 (51 %) was reserved for localised exposures or extrusions where infection was not suspected. A concomitant continence procedure was performed in 9(19 %) at the time of tape revision. None of these 9 women has experienced recurrent stress urinary incontinence (SUI) compared with 11 out of 38 women (29 %) requiring further stress incontinence surgery when no continence procedure was performed (Fisher's exact p = 0.092). Eight out of 47 underwent revision surgery for pain with no identifiable exposure or extrusion; pain subsequently resolved in all 8 women. CONCLUSIONS: Excision is an effective treatment for tape exposure and pain whether infection is present or not. Tapes of a multifilament type are strongly associated with infection. When infection is present, complete sling removal is necessary. A concomitant procedure to prevent recurrent SUI should be considered if tape excision is planned and infection is not suspected.

Functional outcomes for surgical revision of synthetic slings performed for voiding dysfunction: a retrospective study.

OBJECTIVE: To determine the functional outcomes after synthetic sling revision surgery performed for voiding dysfunction. STUDY DESIGN: A retrospective review of 63 women who underwent surgical revision of a synthetic sling (SS) over an 11 year period between 2000 and 2010 inclusive, for the treatment of voiding dysfunction. Voiding dysfunction was defined as a persistently raised post-void residual of >150 ml. Patient review included demographics, a comprehensive medical history, all surgical reports and a detailed proforma with details of lower urinary tract symptoms, physical findings and bladder diaries. Variables were compared between methods of sling revision using the Fisher exact test (Freeman-Halton extension) with a 2 by 3 contingency table. Statistical significance is defined as P ≤ 0.05. RESULTS: Sixty-three women underwent SS revision for voiding dysfunction with an overall success rate of 87%. Three types of surgical revision were performed; simple SS division (46/63, 73%), partial excision of SS material (13/63, 21%) and either division or excision but with a concomitant procedure to prevent recurrent SUI (4/63, 6%). Persistent voiding dysfunction following revision in each of the three groups was 5/46 (10.9%), 1/13 (7.7%) and 2/4 (50%) respectively (P=0.09). Subsequent surgery for recurrent SUI in each of the groups was 1/46 (2.2%), 3/13 (23.1%) and 0/4 (0%) respectively (P=0.04). CONCLUSIONS: Surgical revision of a SS is an effective treatment for postoperative voiding dysfunction. Both simple division and partial excision of the SS are successful, but simple division carries a lower risk of recurrent SUI. A concomitant SUI procedure at the time of revision may prevent recurrence but may increase the risk of persistent voiding dysfunction.

Does pre-operative traction on the cervix approximate intra-operative uterine prolapse? A randomised controlled trial.

INTRODUCTION AND HYPOTHESIS: This study aims to compare pre-operative Pelvic Organ Prolapse Quantification (POP-Q) point C with and without cervical traction to that obtained intra-operatively in women undergoing pelvic organ prolapse surgery and to assess acceptability of examination with cervical traction without anaesthesia. METHODS: Eighty-one women were randomised to having pre-operative examination with or without cervical traction to measure point C. Visual analogue scale (VAS) pain scores were recorded for each pre-operative examination. Comparisons were made between pre-operative and intra-operative findings. RESULTS: The mean difference between pre-operative and intra-operative point C in the non-traction group was statistically higher than in the traction group (3.2 vs 1.6 cm, p = 0.0001). The level of agreement between pre-operative point C measurement with traction and intra-operative point C measurement was better than pre-operative point C measurement without traction and intra-operative point C measurement on Bland and Altman plots. Women having cervical traction reported significantly greater pain score on the VAS (3.4 vs. 1.2, p < 0.0001). CONCLUSIONS: Compared to routine pre-operative examination with Valsalva and cough manoeuvres only, pre-operative examination with cervical traction had better agreement with intra-operative point C findings. Although women reported greater pain score when examined with cervical traction, it was still a tolerable and acceptable examination without anaesthesia.

Mesh-related chronic infections in silicone-coated polyester suburethral slings.

INTRODUCTION AND HYPOTHESIS: despite claims of equivalence to the tension-free vaginal tape, a variety of suburethral slings have been introduced, with various modifications. Complications in certain synthetic slings and meshes have led to a recent FDA public health notification. METHODS: we report the case histories and management of five women with complications following implant of an InFast sling. RESULTS: four of the five patients presented with symptom of chronic vaginal discharge, one presenting with irritative voiding symptoms and bladder pain. Resolution of presenting symptoms requires total removal of this silicone-coated polyester mesh, which often requires a combined vaginal-abdominal approach. CONCLUSIONS: the silicone-coated mesh of the AMS InFAST sling, can become a focus for chronic infection forming a sinus tract into the vagina or other viscus, causing symptoms years after its placement.