Sharif Ismail

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only.

The management of pelvic organ prolapse in England: A 4-year analysis of hospital episode statistics (HES) data

Abstract The aim of this study was to establish the number and trend of surgical procedures and pessary management of pelvic organ prolapse in England, using Hospital Episode Statistics (HES) data. An online search (www.hesonline.nhs.uk) was carried out. The number of various surgical procedures, as well as pessary insertions and removals for pelvic organ prolapse was obtained. Data were available for the 4-year period March 2002 to June 2005. Over 20,000 procedures performed and 600 pessaries inserted annually. The total number of patients having treatment for pelvic organ prolapse as well as the number of patients having surgery and pessary in English hospitals increased by < 10% over the previous year in 2 of the 4 years included and decreased by < 1% in one. Anterior vaginal wall repair was the commonest performed procedure for pelvic organ prolapse and sacrocolpopexy appears to be the most frequent procedure for post-hysterectomy vaginal vault prolapse. There was no change in trends between surgery and pessary over the studied 4-year interval (p < 0.05). The lack of specific codes precluded providing more detailed information. The availability of data sooner and for longer periods as well as the use of more specific codes are needed to provide more useful information.

A questionnaire survey of second year graduate-entry medical students’ perception of obstetrics and gynaecology as a future career speciality

Abstract The aim of this study was to explore the impressions of second year graduate-entry medical students of Obstetrics and Gynaecology, before their attachment in the speciality in the subsequent year, so as to improve its appeal to them and increase their recruitment into it. A total of 74 questionnaires were distributed at the end of the Learning Opportunities in Clinical Setting (LOCS) week in the speciality and 66 (89.19%) completed questionnaires were returned. Over 4% of the respondents were considering the speciality as their career choice and less than half would consider it as a second option. Whilst more than a third perceived some of the demerits of the speciality, more than a third endorsed its merits. This showed the need to explore and address their concerns about training and working in the speciality. Having a health-related primary degree, prior employment and being female were significantly associated with choosing the speciality as a career (p < .001). Barriers for male respondents were flagged, which need to be addressed, and a bias towards Obstetrics was noted, which reflects the narrow focus on the Labour Ward and necessitates a broader exposure to the speciality. Impact statement What is already known on this subject? The perception of third year graduate-entry medical students of Obstetrics and Gynaecology is biased towards Obstetrics, and they have apprehensions about the challenges of training and working in the speciality. What do the results of this study add? The views of second year graduate-entry medical students are consistent with the views of third year graduate-entry medical students, which shows that these views may be formed early. What are the implications of these findings for clinical practice and/or further research? More research is needed to establish and understand the perception of the speciality earlier than second year and explore the value of practical steps that may improve this perception and increase the interest in it and recruitment into its training programmes.

Re: Twelve‐month outcomes following midurethral sling procedures for stress incontinence: impact of obesity

well as neonatal benefits and risks of caesarean delivery, Skinner considers only the maternal benefits. Skinner’s reasoning is clinically incomplete and therefore ethically inadequate reasoning. Next, she cites a descriptive, qualitative study on ‘women’s experiences after vaginal birth trauma’, which study she describes as ‘published’, referencing an abstract, not a full publication, failing to mention that this abstract had not appeared when we submitted our letter and was not published when we submitted our commentary. Notwithstanding, qualitative studies cannot be used to prove hypotheses but only to generate hypotheses that then should be tested by well-designed and conducted quantitative studies. Skinner cites no such studies so her claim that ‘obstetrics does not accurately use informed consent, as is mandatory in general surgery’ therefore remains an untested hypothesis, i.e. speculation. Professional obstetric ethics, andprofessionalmedical ethics generally, should never be based on speculation but only on reliable evidence. Skinner’s claim that biopsychosocial complications of vaginal delivery are ‘devastating’ is another unwarranted generalisation from descriptive, qualitative data. This is methodologically unacceptable in accepted qualitative research methods. Skinner calls our reasoning ‘incongruous’ because ‘[w]omen are individuals and need to be treated accordingly.’ The science of medicine and therefore patient safety and quality of care are based on carefully observed and measured differences in populations of patients who share a diagnosis. The goal of clinical management is to diagnose patients by sorting them into welldefined populations, e.g. nullipara, previous low transverse caesarean section, or intrapartum complete placenta praevia, and then managing the diagnosis using population-based evidence. Individual, anecdote-based patient care is appropriate only when there is no such evidence. In effect, Skinner endorses the resulting uncontrolled variation in the processes of patient care that imperils patient safety and quality of care. Her approach fails to manage the risk of physicians inappropriately invoking patient-choice caesarean delivery as an excuse to perform nonindicated caesarean deliveries. Finally, Skinner claims that we ‘have disregarded women’s severe morbidities after traumatic vaginal birth’ and that we are ignoring facts, opting instead for ‘birth ideology’. Our commentary in BJOG cited relevant scientific reviews, which Skinner ignores. Providing distorted accounts of the positions of others and failing to cite relevant scientific reviews belie Skinner’s ‘birth ideology’, which is antithetical to responding professionally to requests for nonindicated caesarean delivery.n

Re: Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort.

Sir, Thank you for your interest in our work. One of the limitations of the EDEN cohort was that women were recruited during pregnancy and their pre-pregnancy continence status was not available. We agree that a future cohort of young women recruited before pregnancy would enhance our understanding of how prior continence status influences the risk of incontinence during pregnancy and after childbirth. We previously observed that higher urethral mobility in early pregnancy was a risk factor for postpartum urinary incontinence. Table 3 shows a comparison between women who developed urinary incontinence(de novo incontinence group) and those who remained continent at 24 months (persistent continence group). More details are available in table S1. The Student’s t-test is robust with regards to deviation from the normal distribution: when the number of subjects is greater than 30 any continuous variable distribution approximates normal distribution, which allows the use of this test. The rules for using the chisquare test depend on not only the frequency (p or q) but also the number of observations (n): the test can be used when np and nq are greater than 5. These tests were used to compare women who responded at 24 months postpartum (N = 1409) with those who did not (N = 480; figure S1). Our main analyses were based on multivariate logistic regressions adjusted for centre and education level. Our results show that postnatal urinary incontinence (at 24 months postpartum) was associated with being overweight, older age, parity of three or more, continuing pregnancy, and breastfeeding duration longer than 3 months, but not with mode of most recent delivery (table 1); we conclude that the pathophysiology of urinary incontinence is influenced by many individual factors independent of the mode of delivery, some of them prenatal and others postnatal. It seems essential for us to take account of all of these multiple individual factors when building a predictive model of postpartum urinary incontinence.&

Re: Trends in urinary incontinence in women between 4 and 24 months postpartum in the EDEN cohort

It could be considered the weakest part of our study, as only 71.4% of the patients completed the urodynamic examination at the 1-year follow-up. In case of an abnormal curve but no subjective symptoms no repeat flow curve was performed. Five women had a normal curve prior to surgery and an abnormal curve 1 year post-operatively, whereas three women experienced normalisation of a previously abnormal curve. The residual urine measurements were combined with the voided volume to evaluate bladder emptying. No significant difference was observed for any urodynamic parameter comparing the pre-operative values with the values 1 year after surgery. Transient post-operative urinary retention is well known after rectal resection and this is in agreement with our own experience. The aim of the study was to evaluate the long-term effects of laparoscopic bowel resection on pelvic organ function. We find that the data from the non-invasive urodynamic testing support our conclusion primarily based on the questionnaire data that laparoscopic bowel resection does not have a negative impact on longterm bladder function. In agreement with recent findings our study highlights the fact that urinary tract symptoms are highly prevalent in patients with deep endometriosis regardless of previous surgery. The aetiology of pelvic organ dysfunction is complex and includes pathophysiology of the pelvic nerves and plexuses. The new discipline of neuropelveology focuses on these matters. Finally, we would like to emphasise that bowel surgery for endometriosis that affects the bowel wall should only be performed when medical therapy has failed.&

Re: Cost‐effectiveness of a pro‐active approach of urinary incontinence in women

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The increasing number of surgical procedures for female genital fistula in England: analysis of Hospital Episode Statistics (HES) data.

Abstract The aim of this study was to describe the number and trend of surgical procedures for female genital fistula in England. An online search of Hospital Episode Statistics (HES) data was carried out. Data were available for the 4-year period from 2002–03 until 2005–06. The total number of surgical procedures carried out for female genital fistula steadily increased by 28.7% from 616 in 2002–03 to 793 in 2005–06. The number of surgical procedures performed for rectovaginal fistula exceeded the total number of surgical procedures carried out for vesicovaginal and urethrovaginal fistula in each year of the study period. This pattern needs to be monitored and investigated further.

Laparoscopic urethrolysis followed by trans-obturator tape sling insertion for long standing voiding dysfunction after Burch colposuspension.

This case report describes laparoscopic urethrolysis followed by trans-obturator tape sling insertion for voiding dysfunction after colposuspension. A 50-year-old patient presented with predominant stress incontinence of urine 14 after Burch colposuspension. There was no anterior vaginal wall prolapse on examination and urodynamic assessment confirmed voiding dysfunction in the absence of urodynamic stress incontinence. Clean intermittent self-catheterisation was tried, but failed to improve the patient’s symptoms. Laparoscopic urethrolysis was carried out, leading to the relief of voiding dysfunction, but was followed by recurrence of stress incontinence. A trans-obturator tape sling was subsequently inserted with significant improvement in stress incontinence and the patient was discharged.