Ralph Webb

An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) & grafts in female pelvic floor surgery

Introduction and hypothesisA terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery.MethodsThis report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus).ResultsA terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication).ConclusionsA consensus-based terminology and classification report for prosthess and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) and grafts in female pelvic floor surgery.

A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery.

International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related to native tissue female pelvic floor surgery

A terminology and standardized classification has yet to be developed for those complications related to native tissue female pelvic floor surgery.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related to native tissue female pelvic floor surgery

Introduction and hypothesisA terminology and standardized classification has yet to be developed for those complications related to native tissue female pelvic floor surgery.MethodsThis report on the terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many external referees. A process of rounds of internal and external review took place with decision making by collective opinion (consensus).ResultsA terminology and classification of complications related to native tissue female pelvic floor surgery has been developed, with the classification based on category (C), time (T), and site (S) classes and divisions that should encompass all conceivable scenarios for describing operative complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/ntcomplication).ConclusionsA consensus-based terminology and classification report for complications in native tissue female pelvic floor surgery has been produced. It is aimed at being a significant aid to clinical practice and particularly to research.

Developing evidence-based standards for diagnosis and management of lower urinary tract or pelvic floor dysfunction

The International Continence Society (ICS) has a key role in standardizing terminology related to lower urinary tract and pelvic organ dysfunction. The ICS Standardization Steering Committee (SSC) presents the new structure and process by which future ICS Standards will be developed. The new processes aim to meet present‐day evidence‐based practice requirements, and to foster unbiased, inclusive, and transparent development. For each new ICS Standard, the SSC will oversee a dedicated ad hoc Working Group (WG). Applications to chair or contribute to a WG will be invited from the ICS membership. The SSC will select the Chairperson, and work with him or her to select the WG composition, balanced to represent key disciplines, stakeholders, and regions. Consultants can be invited to contribute to the WG where specific need arises. Every WG will review current knowledge, adhering to evidence‐based medicine requirements. Progress reports will be reviewed by the SSC, and amendments recommended, culminating in a first draft. The draft will be offered to the ICS membership and additional relevant experts for comment. Further revision, if needed, will result in a document, which the SSC will submit to the ICS Trustees, as arbiters of whether the document should be adopted as an ICS Standard. The SCC will then coordinate with the WG to ensure that the new ICS Standard is published and disseminated. Implementation strategies, such as education, audit, accreditation, and research initiatives will be linked to the Standards where appropriate. Revisions of ICS Standards will be undertaken to maintain contemporaneous relevance. Neurourol. Urodynam. 31:621–624, 2012.

Multifocal symptomatic intracerebral metastases as the first manifestation of prostatic carcinoma: a report and literature review.

We report an unusual case of prostatic carcinoma in a middle-aged man with symptomatic multifocal intracerebral metastases as its initial manifestation to highlight the importance of its accurate diagnosis and implications on its management and review relevant literature.

The use of intra-gastric pressure measurements via esophageal manometry catheters to determine Pabd in urodynamic investigations.

The derivation of detrusor pressure (Pdet) during cystometry requires the measurement of intra-abdominal pressure (Padb) as well as the vesical pressure (Pves). Typically a rectal pressure line is used to measure Pabd. In some patients the use of a rectal catheter is difficult or impossible. Lax anal sphincters due to obstetric tears or weak pelvic musculature can make retention of a rectal catheter difficult. If the anal sphincter is sufficiently weak then rapid rises of intra-abdominal pressure during coughing and Valsalva maneuvers will often be equalized to atmosphere, leading to attenuated responses and poor subtraction. In some, constipation and/or fecal impaction may render a rectal catheter ineffective. Patients with anal fissures may find the insertion of a rectal catheter intolerable and in patients who have undergone colorectal surgery the rectal route may be unavailable. In the latter group a pressure line inserted into the ileal conduit may be possible, although there can be problems with increased pressures if the line cannot be inserted far enough. In females, a vaginal pressure line may be used though this route may also have the same difficulties as a rectal line. Intra-gastric pressure should be a measure of intra-abdominal pressure and, in normal circumstances, is isolated from atmospheric pressure by two sphincters – the cricopharyngeus and the lower esophageal sphincter. Over the past 5 years, four patients have not been able to maintain satisfactory rectal lines. In one, with ulcerative colitis, the rectal line was lost due to high rectal pressures during straining at the start of the voiding phase (Fig. 1); in another previous surgery for, and recurrent, rectal prolapse excluded a rectal line; in a third, with previous radiotherapy and a low anterior resection for adeno-carcinoma of the rectum, rectal pressures were very low, giving poor subtraction (Fig. 2); and in the fourth the nasogastric option was preferred over the use of the patients ileal conduit. The patients attend ‘‘nil by mouth’’ for 6 hr prior to intubation-to minimize the risk of emesis and aspiration. A standard 8-lumen esophageal manometry catheter (4.5 mm OD, 0.8 mm internal diameter) was passed by an experienced operator using topical nasopharyngeal anesthesia. The catheter was passed to 55 cm from the nares, at which point the distal 10 cm of the catheter would be expected to lie within the stomach. Confirmation of catheter position was achieved by passing 20 ml of normal saline down the catheter and checking for its escape in the stomach with a stethoscope. Once connected to the transducer and flushed, the tracing was checked for a positive excursion on inspiration, thus confirming that the recording port lies below the diaphragm. The most distal of the eight ports was connected to the rectal transducer and flushed with saline, as would a normal rectal catheter. The remaining ports were occluded at their proximal terminations. The filling and vesical lines were placed in the bladder in the usual manner. After flushing, zeroing, and checking subtraction by asking the patient to cough, the cystometry and voiding phases of the urodynamics investigations were completed without further complication. For a recumbent patient the hydrostatic pressures in the gastric and vesical lines should be similar. For sitting or standing patients then an appropriate allowance must be made for such differences-or adjustments made via the software. Satisfactory recordings were obtained in all cases where standard urodynamics using rectal lines had failed (Figures 3 and 4). The use of intragastric pressure for Pdet derivation is alluded to by Ref. 1 but evidence of this technique in the literature is scant. Our urodynamics suite sits within a unit providing esophageal and anorectal physiology investigations, making access to manometric techniques of abdominal pressure measurement relatively easy. Many of the technical considerations pertinent to rectal pressure measurement also apply when using the nasogastric route: The internal bore of the catheter must be sufficiently small to support a column of liquid of 100 cm or so of length, but its external diameter must be great enough to allow easy nasogastric intubation. We initially used an 8-lumen esophageal manometry catheter and in subsequent tests changed to a three channel pediatric esophageal manometry catheter. Placement of the catheter should pose few problems for most patients providing the investigator has received appropriate training in nasogastric intubation. We recommend the use of topical anesthesia and catheter lubrication. The ‘‘nil by mouth’’ requirement may pose problems for obtaining a free flow at the start of the test. We would recommend such patients be the first of the day so that ‘‘nil by mouth’’ just means going without breakfast. We would also recommend performing the nasogastric intubation first, checking the position and patency of the nasogastric catheter and, if satisfactory, then proceeding with bladder catheterization. We have found the use of a nasogastric catheter for measurement of intra-abdominal pressure a viable alternative where other routes are precluded. Pdet derivation was