Stephen T. Jeffery

An audit of indications and complications associated with elective hysterectomy at a public service hospital in South Africa

To assess relationships between clinical indication for hysterectomy and postoperative histologic findings, and to audit complications of hysterectomy at the gynecologic surgical unit of a public‐service hospital in South Africa.

The Effect of Vaginal Oestriol Cream on Subjective and Objective Symptoms of Stress Urinary Incontinence and Vaginal Atrophy: An International Multi-Centre Pilot Study.

Aim: Subjectively and objectively assess stress urinary incontinence (SUI) symptoms before and after topical oestrogen therapy. Methods: A prospective study was performed in 3 centres in South-Africa, Australia and the Netherlands. Postmenopausal women with SUI were treated with topical oestriol cream for 6 weeks. The primary subjective outcome was the Patients Global Impression of Improvement (PGI-I) scale. The primary objective outcome was vaginal pH. Secondary subjective outcomes were: the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form, the Incontinence Impact Questionnaire, the Urogenital Distress Inventory (UDI-6) and the most bothersome symptom approach. Secondary objective outcome was the erect cough pad test. Compliance was scored. Results: A total of 68 women were enrolled. Half of the participants reported improvement on the PGI-I scale after treatment. Vaginal pH was significantly lower after treatment (median 5.3 (interquartile range (IQR) 4.5-6.0) vs. 5.0 (4.4-5.4), p = 0.002). Improvement on the UDI stress domain was observed (p = 0.01). No statistically significant differences were found in the other subjective outcomes. Baseline and repeat cough pad tests demonstrated a wide variation with no significant difference. Compliance was high (median 100 (IQR 83-100%)). Conclusion: Topical oestriol cream during 6 weeks improved quality of life and vaginal pH but no other objective measures of incontinence.

Quo vadis, vaginal mesh in pelvic organ prolapse?

The use of vaginal mesh in pelvic organ prolapse (POP) has prompted a new and unprecedented media frenzy. For example, in a highly polarising statement, an Oxford-based professor of evidence-based medicine in a Guardian article recently compared vaginal mesh to the devastation wreaked by thalidomide. We believe that it is now time for a less emotional and more scientific-based voice to be heard on this issue. There is no doubt that there were major complications with vaginal mesh and that certain actions were appropriate, including recommendations for improved education, counselling and evaluation of new products. Unfortunately, there were also actions that we believe to have been unjustified, including the complete banning of vaginal mesh in Australia and the UK. Contrary to public opinion, there are sufficient randomised controlled trials (RCTs) reporting the benefits of vaginal implants over native tissue repair [1]. An excellent example is a Scandinavian Network RCT published in the New England Journal of Medicine, showing better objective and subjective outcomes in women undergoing vaginal mesh versus native tissue repair. They also reported a low re-operation risk for mesh-related complications, with an incidence of 3% [1]. There is no doubt that optimising the outcomes of vaginal mesh surgery requires concentrating mesh surgery in a few high-volume centres. Education in mesh surgery also needs to be improved and coupled with this, accreditation strategies by local societies need to be addressed. In native tissue surgery, no improvements in technique are imminent. In contrast, mesh surgery has huge potential, for example, the textile of the biomaterial can be engineered, the type of biomaterial can be changed and coatings can be added. Diameters of the fibres, patterns of weaving, elasticity, interstitium size and surface characteristics can be adjusted to improve immune resistance and biomechanical characteristics. Surgical delivery methods can also be optimised. With these improvements, the balance between the risks and benefits of mesh surgery is likely to change in such a way that in the future it may even become the standard in primary POP surgery. The mesh industry has been criticised for selling poor products, educating the wrong physicians and not supporting sufficient studies to evaluate the outcomes of their products. However, we need to accept that these activities are all, in fact, our responsibility. It should also be remembered that most companies do not define the requirements that allow them to sell a product, they simply follow what is requested. In the decision to abandon marketing mesh in the UK and Australia, the PROSPECT trial, published in The Lancet, may have played an important role [2]. In this study, after 2 years’ follow-up, mesh surgery did not result in better outcomes and 1 in 10 women had a mesh-related complication. This is much higher than the 3% reported bymany other studies.We believe that a more prudent response would have been to explore reasons for the higher re-operation rate, including indications, training, surgical technique, peri-operative management or organisation of care. In vaginal prolapse surgery, about 20% of procedures are performed for recurrent prolapse. There are not many other fields in which surgical outcomes are that poor. But even more incriminating is the slow pace in improvement in that figure. We believe that there are still endless opportunities to improve the outcomes of mesh surgery. If we decide now to restrict ourselves to performing exclusively native tissue surgery, we believe that there are women who will not receive optimal treatment. European Societies have recognised this and currently recommend that mesh still be available for complex cases [3]. Unfortunately, the media are always ready to misconstrue the results of clinical studies, and coupled with its withdrawal in the UK and Australia, there was collateral damage to the reputation of mesh surgery worldwide. This action was misinterpreted, not only by gynaecologists and urologists, but also by general practitioners, nurses and other healthcare providers. Many now believe that mesh surgery is bad, * Stephen Jeffery stephen.jeffery@uct.ac.za

Hysterectomy Techniques in Prolapse Situations

Despite the large number of options available to us for uterine prolapse, a vaginal hysterectomy and vault suspension remains one of the best options for even the most extensive prolapse. It is essential to remember that simply performing a hysterectomy for uterine prolapse is usually not enough and that the vaginal vault always needs to be supported. A hysterectomy in prolapse situations is usually performed according to traditional principles followed by a vaginal vault suspension procedure. The most common technique involves either a sacrospinous fixation or high uterosacral ligament suspension. Following this, it is essential that prolapse of the anterior and posterior compartment is addressed.

The gynaecological subspecialties: Advances in women's health

Under Professor Dennis Daveys leadership, the Department of Obstetrics and Gynaecology recognised the need for subspecialist expertise and training. Thus, the gynaecological subspecialties were developed, the first of which was gynaecological oncology. We review the research, and subsequent clinical application, which has evolved from the subspecialist units.

Mini-slings – concern regarding marketing of these devices in South Africa

March 2012, Vol. 102, No. 3 SAMJ Consent for children participating in research To the Editor: With reference to the article and more recent letter on the implications for researchers, service providers and policy makers of child consent in South African law,1,2 I wish to put forward a different but more appropriate approach to consent for children participating in research. Although I agree that s71 of the National Health Act of 20033 is not in force, the Guidelines of the National Health Research Ethics Committee are.4 The NHREC is quite clear when it comes to consent for children participating in research. Research should be of minimal risk and consent for minors must be obtained from the parents or legal guardian in all but exceptional circumstances (such as emergencies), as well from as the minor where s/he is competent to make the decision. This is consistent with international practice, and I urge all researchers and Human Research Ethics Committees to be compliant with this guideline in the meantime.