For many years, the standard operative management of rectocele was
a posterior colporrhaphy, which usually included a fascial plication and
sometimes a levator plication. Recent surgical developments have led to
the introduction of a number of devices to improve success rates of
posterior compartment surgery. These include the use of mesh or graft
interposition, which may either be a synthetic polypropylene mesh or a
biological auto-, allo- or xenograft. Trocar-based kits, including
Posterior Prolift, Apogee and Avaulta, have also become extremely
popular in the management of PCP. (1)
Surgery for pelvic organ prolapse is traditionally performed bygynaecologists. Almost all postgraduate training programmes inobstetrics and gynaecology include academic, clinical and surgicaltraining in the management of pelvic organ prolapse. Globally, however,surgical training opportunities in gynaecology appear to be decreasingand many gynaecologists will complete their training with inadequateexposure to surgical techniques to address pelvic organ prolapse.
The close association between surgery for stress urinary
incontinence and pelvic floor reconstructive surgery, and the fact that
these operations are often done concurrently, have led to urologists
taking an interest in pelvic organ prolapse surgery. Urologists often
have a broader surgical background than gynaecologists, and this is
certainly the case in South Africa, where many urologists have spent
extensive training in general surgery and trauma. However, urologists
may have limited exposure to surgery for PCP during their registrar
training.
Most experts will agree that while a broad range of procedures for
the management of PCP is available, the optimal approach is still
unresolved.
Structured fellowship training in urogynaecology and female urology
is currently limited in South Africa. This means that for both
urologists and gynaecologists post-specialisation training activities in
pelvic floor reconstructive surgery are currently restricted to
industry-driven training, which occurs locally and internationally.
We felt that the practice of an individual physician would reflect
the overall training that he or she had received. Before commencement of
this study, we hypothesised that gynaecologists would be less dependent
on industry-driven surgical techniques than urologists.
Our aim in this study was therefore to determine the differences in
the investigation and management of PCP by urologists and gynaecologists
in South Africa.
Materials and methods
We elected to sample gynaecologists and urologists practising in
the private sector in South Africa. We obtained ethics approval to
question a cohort of South African urologists and gynaecologists on
their diagnostic and surgical approach to PCP.
Specialists were selected using the websites of a number of private
hospital groups in South Africa. We selected the gynaecologists and
urologists listed at each hospital. The largest hospital groups in South
Africa include Netcare, Medi-Clinic and Life, and we attempted to send
questionnaires to as many of the listed practitioners working nationally
for these groups as possible.
In the questionnaire we asked the doctors to specify theirspecialty and whether they considered themselves to be a subspecialistin urogynaecology or female urology. We also asked them to indicate howlong they had been in specialist practice. The doctors were then askedto specify the number of women with PCP they see in a typical month andhow many operations they perform for this problem.
A question relating to their approach to investigating PCP was also
included. We asked them to state how often they request proctography,
transit studies, manometery and endo-a**l ultrasound, with the options
of 'never', 'occasionally', 'sometimes'
and 'always'.
In the questionnaire we also provided respondents with a list of
procedures (Table I) and asked them to indicate the procedure of choice
for PCP in their practice.
The questionnaire included two items about what the doctor
considers to be an adequate indication for surgery to the posterior
compartment. It also assessed what would be regarded as a successful
outcome. Space was provided for a free-hand answer to avoid any bias
from a leading question.
The doctors were also asked to specify whether they performed
combined surgery with another specialty, and whether they utilised
vaginal hysterectomy for PCP.
A stamped addressed envelope with a return address accompanied the
questionnaire. We assured the respondents complete anonymity, and for
this reason it was not possible to follow up non-responders.
Ethics approval for the study was obtained from the University of
Cape Town Research Ethics Committee (REC REF:506/200 cool . Data were
entered into a Microsoft Excel Database and analysed using SPSS 10.0
software.
Results
Five hundred questionnaires were sent out to gynaecologists and
urologists in the private sector of South Africa. The response rate was
21% (N=106), 25% (N=26) of responses being from urologists and 75%
(N=80) from gynaecologists.
Data on the number of specialists in South Africa are difficult to
obtain. Personal communication with the Colleges of Medicine of South
Africa (May 2009) suggests that many doctors registered in the country
are practising abroad. We estimate that our responses represent
approximately 20% of the total number of South African urologists and
10% of gynaecologists.
None of the urologists reported performing vaginal hysterectomy forprolapse, as opposed to 80% (N=64) of gynaecologists who still utilisedthe procedure. When asked the reason for this, 50% (N=13) of urologistsreported they had never been trained and 26% (N=7) said that it wasnever indicated in their practice.
Unfortunately, 23% (N=7) of urologists and 8% (N=7) of
gynaecologists failed to specify their first choice of procedure for
PCP. Of the urologists who did denote their preference, 58% (N=11)
reported that they would use a mesh kit, including Posterior Prolift,
Apogee or Avaulta. Only 17% (N=14) of gynaecologists used mesh kits as
their first choice. Nearly two-thirds of the gynaecologists still
preferred a traditional technique, including fascial plication (10%),
levator plication (5%) or posterior repair (48%) (Table I).
Of the gynaecologists, 27% (N=22) considered themselves to be
sub-specialists or practising with a special interest in urogynaecology.
Of the urology cohort, 42% (N=11) reported having a special interest in
female urology.
The gynaecology cohort had been in practice for a mean of 17.3
years (standard deviation (SD) 10.4, range 2 - 40) and the urologists
for a mean of 16.6 years (SD 9.8, range 2-44).
The number of patients seen with PCP in a typical month varied
between gynaecologists and urologists, with 66% (N=53) of the
gynaecologists and 46% (N=12) of the urologists seeing at least 5 women
per month with this problem (Fig. 1).
The number of operations for PCP performed in a typical month also
varied between the two specialties, with urologists performing
statistically less. Twenty-three per cent (N=6) of the urologists
performed between 1 and 5 cases in a typical month, compared with 60%
(N=4 cool of the gynaecologists (p=0.0003, [chi square] 11.1) (Fig. 2).
In an open-ended question on the definition of successful outcome
following surgery for PCP, only 12% (N=3) urologists and 14% (N=11)
gynaecologists mentioned sexual function. A larger proportion of
urologists (46%, N=12) than gynaecologists (37%, N=30) included bowel
function in their criteria for successful treatment.
When asked about investigations performed for PCP, the majority of
the respondents were not using any form of imaging or physiological
study (Fig. 3).
Both specialties reported collaborating with other surgical
specialties in the operating room, 43% (N=34) of the gynaecologists
saying they operate with either a surgeon (14%) or a urologist (28%),
and 50% (N=13) of the urologists operating with a gynaecologist.
Discussion
A major finding in this study was that PCP is currently being
managed differently by urologists and gynaecologists in South Africa.
Urologists use significantly more mesh kits and gynaecologists perform
more traditional repairs, with only 17% of gynaecologists who responded
to this question selecting mesh as a treatment option whereas 58% of the
urology cohort used mesh. Both groups appeared to be making minimal use
of posterior compartment investigations.
The fact that urologists use more mesh kits may reflect surgical
training patterns in their specialty. In South Africa most gynaecology
registrars are exposed to the traditional types of surgery at the
postgraduate level, whereas this may not be happening in urology
training programmes.
Urological surgeons are definitely seeing women with PCP, and it is
therefore necessary for them to have the skills to address this
condition. Mesh repair kits have only recently been introduced into the
country, but nearly two-thirds of urologists use these devices for PCP.
Evidence supporting the use of these kits was until recently very
scarce.
Only 19% of the gynaecologists would select a mesh as their first
choice, whereas 58% of the urology cohort reported that a posterior
Prolift, Apogee or Avaulta would be their first choice. The
urologists' responses indicated the traditional repair methods were
not taught as part of their postgraduate training, leading them to be
more receptive to more recent industry-driven methods.
Both treatment modalities have a place in treating PCP, but one
should not be limited in choosing one over the other simply because of
lack of expertise. Postgraduate teaching therefore plays a vital role in
managing PCP in general. We suspect that the traditional training void
among urologists has been capitalised on by the industry.
Clinical experience indicates that women seldom present with a pure
anatomical posterior compartment defect, and it is more typical for them
to have a variable range of pelvic floor symptoms, including bladder,
bowel and sexual problems. We believe that PCP can and should be managed
by urologists, colorectal surgeons and gynaecologists. The operator must
be adequately trained in the full range of procedures so that the
correct procedure is performed and patient wellbeing optimised.
The latter point is further emphasised by our study, which showed
that none of the urologists performed vaginal hysterectomies for
prolapse, most reporting lack of training to be the reason. On the
contrary, 80% of the gynaecologists reported that they were still
performing vaginal hysterectomy during PCP repair. Vaginal hysterectomy
is still considered to be a standard procedure for apical prolapse. (2)
It remains an essential operation in the armamentarium of the pelvic
floor surgeon.
A study by Anger et al., looking at concomitant prolapse repairs at
the time of incontinence surgery, found that urologists add a prolapse
operation in 29% of cases, while gynaecologists performed prolapse
repairs in 55%. (3) They concluded that early prolapse management by
gynaecologists corresponded to fewer prolapse repairs in the year
following the sling procedure. They also suggest that gynaecologists are
more likely to identify and manage prolapse at the time of the
evaluation of urinary incontinence. The above finding may also be
related to the training received by the different specialties. (3)
There has been shown to be a poor correlation between the severity
of anatomical prolapse and bowel function. (4) A finding of some concern
in our study is the low number of surgeons from both cohorts reporting
bowel and sexual function as an important aspect of outcome. We
recognise that we investigated this rather crudely in our study, but
nonetheless failure to recognise function as an important outcome
measure must be guarded against by both specialties.
A major limitation of the study is the overall response rate of
23%. Studies of this nature have been known to have poor response rates,
with a similar questionnaire-based study of International Continence
Society members reporting a response rate of 34%. (5) A study of
anterior repair in South Africa described a response rate of 30.2%. (6)
Nonetheless, despite the small numbers and low return rate, we feel that
we have made important conclusions.
This study should be repeated using an alternative method of
questionnaire rollout such as an on-line or e-mail questionnaire.
The study also did not include the academic centres, limiting the
data to the private sector. This may have impacted on the overall
results, as treatment options and cost restrictions differ substantially
between the private and public sectors.
This study may pose more questions than answers, but we do believe
that in the management of PCP in South Africa a broader engagement may
be required between urologists and gynaecologists. The issue of
postgraduate training in both specialties may also need refinement, so
as to allow for an overall improvement in the management of patients
suffering from the debilitating condition of PCP.
Conflicts of interest. None.
Ameera Adam, MB BCh
http://www.youtube.com/watch?v=KFamLHAqS9o
Department of Obstetrics and Gynaecology, Stellenbosch University
Stephen Jeffery, MB ChB, FCOG (SA), Sub Spec Urogyn (RCOG)
Groote Schuur Hospital and University of Cape Town
Ahmed Adam, MB BCh, Dip PEC (SA)
Department of Urology, University of Pretoria
Peter de Jong, MB ChB, FCOG (SA), FRCOG (Lond)
Groote Schuur Hospital and University of Cape Town
Yusuf Arieff, MB ChB
Private practice
(1.) Silva WA, Karram MM. Rectocele-anatomic and functional repair.
In: Cordozo L, Staskin D, eds. Textbook of Female Urology and
Urogynaecology. Oxon: Informa Healthcare, 2006: 1042-1044.
(2.) Pakbaz M, Mogren I, Lofgren M. Outcomes of vaginal
hysterectomy for uterovaginal prolapse: a population-based,
retrospective, cross-sectional study of patient perceptions of results
including sexual activity, urinary symptoms, and provided care. BMC
Women's Heabth 2009;9:9.
(3.) Anger JT, Litwin MS, Wang Q, Pashos CL, Rodriguez LV.
Variations in stress incontinence and prolapse management by surgeon
specialty. J Urol 2007;178(4 Pt 1):1411-1417.
(4.) Burrows LJ, Meyn LA, Walters MD, Weber AM . Pelvic symptoms in
women with pelvic organ prolapse. Obstet Gynecol 2004;104(5 Pt
1):982-988.
(5.) Madjar S, Evans D, Duncan RC, Gousse AE. Collaboration and
practice patterns among urologists and gynecologists in the treatment of
urinary incontinence and pelvic floor prolapse: a survey of the
International Continence Society members. Neurourol Urodyn
2001;20(1):3-11.
(6.) Henn EW, Van Rensburg JA, Cronje HS. Management of anterior
vaginal prolapse in South Africa: national sunrey. S Afr Med J
2009;99(4):229-230.
Table I. Procedure of first choice for each specialty
Gynaecologists Urologists
(N (%)) (N (%))
Mesh kit (Prolift, 14 (17) 11 (42)
Avaulta, Apogee)
Fascial plication 8 (10) 2 ( cool
Levator plication 4 (5) 0 (0)
Posterior repair 39 (4 cool 6 (23)
Transanal repair 1 (1) 0 (0)
Post repair with 7 (8. cool 0 (0)
synthetic mesh
Posterior repair 0 (0) 0 (0)
with biological mesh
Post repair with 1 (1.3) 0 (0)
STARR procedure
Did not specify 7 (8. cool 7 (23)
Fig. 1 Number of women with posterior compartment
prolapse seen in a typical month.
Percentage of respondents Number of women seen per month
Gynaecologist Urologist
<1 14% 30%
1 to 5 66% 46%
>5 20% 23%
Note: Table made from bar graph.
Fig. 2 Number of operations for posterior compartment
prolapse done in a typical month.
Percentage of respondents Number of women seen per month
Gynaecologist Urologist
<1 36% 73%
1 to 5 60% 23%
>5 4% 3%
Note: Table made from bar graph.
Fig. 3 Number of urologists and gynaecologists who
never use certain investigations.
Investigations Number of Responders
Urologist Gynaecologist
Proctography 22(85%) 69(87%)
Manometry 22(85%) 73(91%)
Transit Studies 24(92%) 71(89%)
Endoanal Ultra-Sound 23(88%) 57(71%)
Note: Table made from bar graph.
http://www.thefreelibrary.com/Do+urologists+and+gynaecologists+manage+posterior+compartment...-a0252449262
