A Roadmap for Training in Urogynecology: IUGA International Initiative.

INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse. MATERIALS AND METHODS: An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies. RESULTS: The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention. CONCLUSIONS: Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy.

OBJECTIVE: To evaluate the incidence of prolapse and prolapse-related symptoms following vaginal hysterectomy. METHODS: Data were reviewed from women who underwent vaginal hysterectomy between 1988, and 1995, at St George's Hospital, London, UK, and attended long-term follow-up. Outcome measures included a questionnaire for prolapse, urinary, bowel, and sexual symptoms; and a vaginal examination. RESULTS: Among 94 women attending long-term evaluation, the mean follow-up time was 100.7 months (range 67.0-156.0 months). Before vaginal hysterectomy, urgency was noted among 23 (24.5%), urge incontinence among 11 (11.7%), and stress incontinence among 8 (8.5%) women. At follow-up, these symptoms were observed among 23 (24.5%), 13 (13.8%), and 6 (6.4%) women, respectively. De novo urge incontinence and de novo stress incontinence were observed among 3 (3.2%) and 2 (2.1%) women, respectively. Vaginal examination data were compared for 70 women, of whom 18 (25.7%) had grade 1, 40 (57.1%) had grade 2, and 6 (8.6%) had grade 3 uterine prolapsed before surgery. Postoperatively, vaginal vault prolapse occurred in 7 (10.0%) women and correlated with degree of posterior prolapse (P=0.007), but not with severity of uterine descent (P=0.205) or previous prolapse surgery (P=0.573). CONCLUSION: The incidence of post-hysterectomy vault prolapse correlated with the degree of preoperative rectocele.

Secondary colposuspension: results of a prospective study from a tertiary referral centre.

OBJECTIVE: To evaluate the results of secondary colposuspension in women with recurrent urinary stress incontinence. DESIGN: Prospective cross sectional observational study. SETTING: Tertiary referral urogynaecology unit. POPULATION: Fifty-six women with recurrent stress incontinence. MAIN OUTCOME MEASURES: Determine prognostic factors that may affect the outcome of surgery, long term subjective and objective success rates and identify complications of secondary colposuspension. RESULTS: The mean age was 54 years (range 34-83) and the median parity was 3 (range 1-5). The median length of follow up was four years (range 1.01-7.07). Forty-two (75%) women had genuine stress incontinence and 14 (25%) had mixed incontinence on subtracted cystometry. The subjective cure rate was 71% and the objective cure rate was 80% and, as per Kaplan-Meier life time analysis, 65% had not failed surgery five years after the operation. The complication rate was low. However at follow up, eight women had required a posterior colporrhaphy for rectocele and three had a sacrocolpopexy for vault prolapse. Another eight women required further treatment for stress incontinence (seven urethral bulking agents and one tension-free vaginal tape). There was no correlation of the outcome to age, past hysterectomy, number of previous incontinence procedures, parity, body mass index or blood loss at operation. CONCLUSION: Colposuspension after failed continence surgery has a good outcome with a low complication rate, but many still require further surgery for prolapse.