Luigi Bombieri

Vaginal evisceration, small bowel prolapse and acute obstruction as a late complication of sacrospinous fixation

We describe the presentation, acute management and subsequent follow-up of a case of vaginal evisceration of small bowel in a woman who had complained of recurrent symptoms of prolapse following a vaginal hysterectomy and posterior repair and subsequent sacrospinous fixation for prolapse. The published incidence, risk factors, potential complications and described options of management are discussed.

How colposuspensions are performed in the UK: a survey of gynecologists' practice

The authors performed a self-administered postal questionnaire survey of 690 consultant gynecologists in the UK to determine the current surgical and perioperative practice in relation to colposuspension; 350 (51%) responded. One hundred and twelve (32%) identified themselves as having a specialist interest in urogynecology. The study shows the variation in the surgical technique of colposuspension and perioperative care among gynecologists, and it provides information that may help in the development of guidelines for those involved in the surgical treatment of female urinary incontinence.

Recurrence of stress incontinence after vault suspension: can it be prevented?

Management of vault prolapse in a patient who has previously undergone successful colposuspension has not been considered in the literature. The two cases presented highlight the risk of incontinence and illustrate measures that should help to reduce it. The approach aims to reveal potential stress incontinence and to prevent excessive stretching of the upper anterior vaginal wall during surgical correction. Potential stress incontinence is revealed by a cough stress test while reducing the prolapse without a speculum, a ‘pessary test’ for a few days, and urodynamics both with and without a pessary. Patients with potential incontinence undergo perineal ultrasound to assess bladder neck position. If sacrospinous fixation is used, epidural anesthesia is recommended so as to allow the patient to cough during the procedure to ensure accurate suture placement. When sacrocolpopexy is done, preoperative assessment of the degree of ‘safe elevation’ ensures accurate suture placement.

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Reply to comment

Dear Editor, We would like to thank Dr Long and colleagues for pointing out the error in our paper [1], i.e. we inadvertently used the word “grade” instead of “stage” for the POPQ. This is a good example of how even those who purport to understand and use the POPQ, still make errors, in our case with terminology. Unfortunately, Dr Long and colleagues [2] have done likewise! In their letter they state that “at least 1 cm above or beyond the hymeneal remnants should be the stage 3 or more of POP-Q”. In fact (as we stated) this is stage II, i.e. leading edge greater than or equal to −1, but less than or equal to +1 [3]. Our baseline data are presented in the results section of the paper [1]: point C was +0.12 for the abdominal and +0.28 for the laparoscopic sacrocolpopexy (i.e. POPQ stage II). At 3 months this was −6.65 (SD 138) and −6.48 (SD 1.50) and the corresponding results at 1 year were −6.63 (SD 1.35) and −6.65 (SD 1.15) for abdominal and laparoscopic sacrocolpopexy respectively. The IUGA/ICS standardization report for the outcomes of prolapse surgery [4] recommends that the leading edge of the prolapse at each site should be reported in detail. This includes all the points as well as the ordinal stage. It could be argued that the points are more meaningful than the stage, but these seem to be reported inconsistently with a recent literature review showing that 47 % of studies used the ordinal stage only and not the points [5]. It is important that there is some form of staging or grading of prolapse and maybe the “simplified POPQ”, which uses the ordinal stage, could be used in routine practice [6], as some clinicians perceive the full POPQ to be “too complex”. The “simplified” system has been validated and shown to have a good association with the full POPQ [6]. However, the latter should be used in all research [4] and those undertaking the examination must be fully trained in the technique to ensure accurate data and reporting. Whether this occurs or not is unclear. It is encouraging to see the improved uptake in the use of the POPQ since our study in 2004, which showed that only 40 % of IUGA and AUGS members used it routinely in their clinical practice [7]. A recent study has suggested that 76 % of AUGS and ICS members are now using the POPQ, but the authors state that the technique “varied considerably” [8]. This raises further concern about training and maybe the reliability of some data. Dr Long’s comments are helpful and allow us to highlight these concerns. The POPQ was originally described in 1998 and maybe now is the time for the ICS, AUGS, SGS and IUGA to revisit it and, more importantly, the training. R. M. Freeman (*) :K. Pantazis : L. Bombieri :M. Waterfield Urogynaecology Unit, Directorate of Women’s Health, Derriford Hospital, Derriford Road, Crownhill, Plymouth PL6 8DH, UK e-mail: robert.freeman@nhs.net

An unusual distended abdomen

An otherwise fit and healthy woman in her early thirties presented 4 days after an elective uncomplicated caesarean section reporting of colicky abdominal pain and marked distension over the past 24 h. The patient vomited several times over this period, but continued to pass flatus and liquid stool. She had also passed several large clots per vaginum, and did not report any urinary disturbance. Endometritis was considered on history …

The management of voiding difficulty after incontinence surgery

Voiding difficulty can arise after any gynaecological surgery. This article focuses on voiding difficulty after anti‐incontinence surgery, where voiding difficulty is more likely to persist and have serious clinical effects. Accurate urodynamic prediction is not always possible. Prevention relies on the appropriate choice of procedure for each individual patient and on subtle adjustments of surgical technique (e.g. avoidance of excessive elevation). The management of prolonged voiding difficulty relies on clean intermittent self‐catheterization. Corrective surgical procedures (e.g. urethrolysis, division or release of sling) may play a role in individual cases. Preoperative counselling is important.

Improving the diagnosis of genuine stress incontinence in symptomatic women with negative cough stress test: the Distal Urethral Electrical Conductance test (DUEC) revisited.

Abstract This retrospective descriptive study was performed to assess the practice of using the distal urethral electrical conductance (DUEC) test to objectively demonstrate urinary incontinence in symptomatic women with a negative cough stress test on examination. One hundred women had stable bladders on cystometry (CMG). Genuine stress incontinence (GSI) was diagnosed during CMG in 45 (45%). DUEC performed prior to cystometry had revealed stress incontinence in an additional 13 with negative CMG, thereby improving the diagnosis of GSI by 13%. The test detected urge incontinence in one (1%). The DUEC test improves the detection of stress incontinence. However, it should not be considered as an alternative to cystometry, but as an additional test when stress incontinence cannot be demonstrated clinically.