Jay Iyer

Prospective study of the Perigee™ system for treatment of cystocele – our five‐year experience

Objectives:  The Perigee™ transobturator cystocoele repair system (AMS) was designed and first used in Townsville, Australia. In this study, we are reporting our five‐year experience with the Perigee™ system in the management of cystocoele stage III and above.

Perineal outcome and the risk of pelvic floor dysfunction: A cohort study of primiparous women

Pelvic floor dysfunction (PFD) is the most common complication of childbirth. Assumptions have been made that perineal trauma increases the risk of PFD compared to an intact perineum, however the evidence for this is lacking. The aim of this study was to explore the relationship between perineal outcome and postpartum PFD.

The sacrospinous ligament: Conveniently effective or effectively convenient?

Summary The sacrospinous ligament has been used for over 50 years as a convenient structure for treating vaginal vault and more recently, uterine prolapse. The procedure has evolved over the years and its efficacy has been hotly debated with invariable comparisons made to abdominal sacral colpopexy. Mesh surgery has introduced a newer dimension to the debate. This review is an attempt to clarify the anatomy, reflect on various techniques and offer a critique on the current ‘status’ of the sacrospinous ligament.

Posture and micturition: does it really matter how a woman sits on the toilet?

The position that we adopt to evacuate “waste matters” may potentially have an impact on the efficiency with which these are expelled. Proponents of squatting have eloquently described associated “health benefits” and have hinted that nonsquatters may be prone to urological, gynecological, and colorectal disorders. In this original piece of research, the effects of posture on micturition have been studied in various positions with interesting results.

Effects of posture and squatting on the dynamics of micturition: response to Bush and Liedl

1. The biomechanical explanation advanced by the authors correlates well with our research question and is complementary to our conclusions. 2. One of the primary drivers of this research was to develop a mechanism to construct a user-friendly and inexpensive device that would confer the health benefits of squatting to the population at large, without the actual need to squat (the Duneze device mentioned in our article).

Pearls and Pitfalls of Mesh Surgery

AbstractsObjectivesThis article attempts to offer balanced insight into the use of transvaginal mesh for pelvic organ prolapse especially in the light of the negative publicity in recent times. The role of transvaginal mesh has been in the limelight for a number of reasons and it is important to address this issue in an objective, fair, and balanced manner. The conventional approach to prolapse surgery has undergone a paradigm shift and the principles of mesh replacement surgery sharply contrast with many traditionally held beliefs. This has created a new set of challenges that has revealed a sharp division of opinion among specialists and sub-specialists alike.ConclusionThe article is an attempt to explain how mesh surgery can be safely and efficiently performed in carefully selected cases and is based on the combined wisdom of some of the leading surgeons in the sub-specialty today.

Perineal outcome following educational intervention: a retrospective audit of primiparous women

Abstract The management of vaginal delivery appears to offer an opportunity to reduce the morbidity of pelvic floor dysfunction (PFD) which is very common in the postpartum period. Research by the authors suggests that an episiotomy is protective against PFD, in particular urinary incontinence. The aim of this subsequent audit was to see if educational intervention can alter the common medical practice of episiotomy and in turn reduce postpartum PFD. Nine hundred and fifty four primiparous women with a non-instrumental vaginal delivery were included, of which 30% had an intact perineum, 51% a spontaneous tear and 19% an episiotomy. The intervention was a teaching session by the Head of Urogynaecology encompassing the anatomy, the impact of a vaginal delivery on PFD, in addition to local and international research. Whilst no significant difference was noted overall in the episiotomy rates as a result of the educational intervention (p = .17), significant differences were noted with the different accoucheur types. Where the accoucheur was an obstetrician or obstetrics registrar, the episiotomy rates increased from 56% to 70% (p < .01); where the midwife was the accoucheur the episiotomy rate changed minimally (11–18%, respectively; p = .27). This demonstrates that feedback about the provider’s own practice patterns can change the behaviour to conform with the agreed upon standards. Impact Statement What is already known on this subject? Pelvic floor dysfunction (PFD) is the most common complication of childbirth, affecting approximately 85% of Australian women following a vaginal delivery. A link has been made between the perineal outcome and PFD, which has a significant impact on the quality of life. Previous research suggests that the management of a vaginal delivery offers an opportunity to reduce its morbidity, with an episiotomy being protective. However, there is a wide variation in the use of episiotomy which ranges from 9% to 100%. What the results of this study add? The literature suggests that the strongest factor associated with the episiotomy rates arises from differences in the attitude and training. Consequently, this study explored whether an educational intervention can change the common medical practice of episiotomy and in turn reduce postpartum PFD. What are the implications of these findings for clinical practice and/or further research? No significant difference was noted overall in the episiotomy rates as a result of the educational intervention, however, the response to the educational intervention was varied among the different types of accoucheurs with the obstetricians, obstetric registrars and student midwives significantly increasing their rate of episiotomy, whilst the midwives demonstrated no significant change. This suggests that there are contributing factors which may include past education and experience; this is an area for further research.

Can We Deliver Better

Human childbirth has been described as an “obstetrical dilemma”. Evolution favours enlargement of the foetal brain, whilst bipedal locomotion demands a reduction in pelvic breadth for improvements in biomechanical efficiency. The result of this conflict is a human pelvis incongruous with the dynamics of childbirth. Acute genital distortion at delivery can inflict lasting damage to female pelvic function. Pelvic organ prolapse, urinary, faecal incontinence and sexual dysfunction are long-term sequelae rarely discussed at antenatal care, impacting upon the expectant mother’s ability to make an informed decision. The alternative option is the elective caesarean section, an abdominal incision bypassing the maladies of a vaginal delivery, although not without complications of its own. Childbirth remains an emotive event where evidence-based medicine can be disempowered, and the rising trend to “normalise” birth can disrupt care of the woman. This needs to be maintained in a healthy balance to best provide competent and safe care for women.

Laparoscopic Sacrocolpopexy in Vault Prolapse

Laparoscopic sacrocolpopexy for Level 1 vaginal prolapse has demonstrated excellent anatomical and functional outcomes [1, 2]. Laparoscopy allows better exposure and surgical detail, reduces blood loss and the need for excessive abdominal packing and bowel manipulation, which all contributes to reduced morbidity.

Management of Sling Surgery Complications

The management of urodynamically proven stress urinary incontinence underwent a paradigm shift with the focus changing from bladder neck suspension to support of the mid-urethra in the last two decades. This has resulted in the replacement of Burch colposuspension and pubovaginal slings to synthetic mid-urethral slings as the primary surgical option in women with stress urinary incontinence (SUI). The introduction of synthetic mid-urethral slings has resulted in good objective and subjective cure rates but can be associated with complications that pose a challenge to the treating surgeon. Surgical treatment for SUI has rapidly evolved and the initially introduced mid-urethral sling, retropubic tension-free vaginal tape (TVT), is accepted worldwide as a standard treatment for women suffering from SUI. However, slings have been associated with a few early and delayed complications which may result in varying degrees of morbidity. Serious complications such as bowel injury, major vascular injury, and even death have been reported with mid-urethral sling procedures.