Richard Foon

Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Background  Various types of suburethral tapes inserted via the transobturator route (tension‐free vaginal tape obturator route [TVTO] and transobturator tape [TOT]) have been widely adopted for treatment of stress urinary incontinence (SUI) before proper evaluation of their effectiveness and complications.

Nonsurgical treatment of stress urinary incontinence (SUI): grading of evidence in systematic reviews.

Background  The guidance on SUI has not been rigorously assessed using GRADE system.

The effectiveness and complications of graft materials used in vaginal prolapse surgery.

Purpose of review In the last decade, there has been an increase in the use of graft materials in vaginal prolapse surgery. Most of the evidence available is based on case studies produced by the manufacturers, with few randomized controlled trials. In October 2008, the United States Food and Drug Administration issued a safety warning on the use of grafts in vaginal surgery. It has been suggested that there is a greater need to review the evidence on the effectiveness and complication of grafts. Recent findings This article explores the recent literature on the use of grafts in vaginal prolapse surgery. The use of grafts versus standard techniques for vaginal wall repair is examined, looking at subjective and objective cure as well as complications. Summary Despite the wide use of grafts in vaginal prolapse surgery, there is still a need for level 1 evidence to support their use, with long-term follow-up of 3 or 5 years. There is, however, good evidence to support the use of grafts in suburethral slings and abdominal sacrocolpopexy.

A rare obstetric emergency: acute uterine torsion in a 32-week pregnancy

Uterine torsion is rare in pregnancy and the cause in most cases is unknown. It is associated with fetal compromise, with perinatal mortality reported to be around 12%. Our case describes an acute torsion, presenting in pregnancy with severe abdominal pain and vomiting with a viable 32-week gestation. Emergency caesarean section was performed and the 180° uterine torsion was diagnosed intraoperatively. Posterior hysterotomy was required for delivery prior to detorsion of the uterus. This report describes that prompt recognition and intraoperative vigilance can achieve a successful maternal and fetal outcome in this rare and difficult obstetric scenario.

The BSUG national database: concept, design, implementation and beyond

The British Society of Urogynaecology allows members to enter and access pre‐, intra‐ and postoperative data relating to any anti‐incontinence and/or prolapse procedure onto the database. Treatment of patient identifiable data within the database fulfils the Caldicott Guardian principles. The database allows users to create reports based on their own outcomes and complications following surgery. The database is a useful tool for audit, clinical governance, personal development and appraisal.

Does pre-operative traction on the cervix approximate intra-operative uterine prolapse? Comment.

Dear Editor, We read with interest the paper by Chao et al. [1], which demonstrates that the cervix (and uterus) can be pulled down almost to the same degree in the outpatient setting as under anaesthesia. The question is: What does this tell us? We suggest that it only tells us whether a vaginal hysterectomy (VH) would be possible, and indeed how easy that procedure might be. It does not tell us whether it should be performed, or whether it will improve the patient’s subsequent symptoms of prolapse. We have recently shown in our study [2] that cervical traction in theatre in women with anterior wall prolapse will pull all uteri down to POPQ stage II. None of these patients had significant uterine descent pre-operatively. In contrast to Chao et al., we did standardise the traction force by using the mid-quartile mean force of 10 gynaecologists pulling to the degree they would usually apply in theatre, via a spring strain gauge. Using this force (3.6 kg) [2], the uteri of the 35 patients in our study could all be pulled down to within 1 cm of the hymenal ring, yet 34 of these had returned to the preoperative level at follow-up. It is interesting that a traction force of as little as 0.5 kg had already been shown to result in significant uterine descent intraoperatively [3]. We are now completing medium-term follow-up of our patients, and will report soon. In the study by Chao et al., the significant difference between the pre-operative and intra-operative point C measurement in the non-traction group may suggest that many of these women would have undergone VH unnecessarily if the decision had been made in theatre. The smaller but still significant difference between point C measurement in the traction group, preand intraoperatively, suggests that the cervix can be “always brought down” if enough traction is used, whether in theatre or in the outpatient setting. Although Chao et al. show that cervical traction in clinic might be tolerated by and acceptable to women, we believe that it may still lead to over-diagnosis of uterine descent, and subsequent unnecessary VH. Our practice for all patients with prolapse is to perform a POPQ assessment in the clinic, in the standing position with maximum Valsalva, to “naturally” reproduce the maximum degree of uterovaginal descent, while A reply to this comment is available at doi 10.1007/s00192-0121956-z

Cystoscopy for gynaecologists

Cystoscopy is a commonly employed procedure in both urological and gynaecological practice. Unfortunately, the practicalities of when and how to perform cystoscopy are often poorly taught during general gynaecological training. A basic understanding of the equipment as well as a systematic approach to performing cystoscopy is the key to gaining the full benefit of this procedure and ensuring no pathology is missed. The technique and indications for cystoscopy in routine gynaecological practice are discussed.Cystoscopy is a commonly employed procedure in both urological and gynaecological practice. Unfortunately, the practicalities of when and how to perform cystoscopy are often poorly taught during general gynaecological training. A basic understanding of the equipment as well as a systematic approach to performing cystoscopy is the key to gaining the full benefit of this procedure and ensuring no pathology is missed. The technique and indications for cystoscopy in routine gynaecological practice are discussed.Cystoscopy is a commonly employed procedure in both urological and gynaecological practice. Unfortunately, the practicalities of when and how to perform cystoscopy are often poorly taught during general gynaecological training. A basic understanding of the equipment as well as a systematic approach to performing cystoscopy is the key to gaining the full benefit of this procedure and ensuring no pathology is missed. The technique and indications for cystoscopy in routine gynaecological practice are discussed.