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Saturday, July 08, 2006

Primum Non Nocere

IUGA 2006: Athene 6-9 September 2006

If you attend a world congress you go with a few preset ideas: you would like to test your own quality of medical practise against that of your peers and if you pass that first hurdle, you would like to increase your knowledge.

This delegate had the following as the basis of his pre-congress perspectives as far as the reconstruction of the damaged female pelvis is concerned:
The primary basis of choosing an option for pelvic reconstructive surgery is that, whatever you do, you must do no harm.
What are these options? Using the hammer of vaginal surgery, one has four nails (options) to choose from:
Option A for getting rid of the bulge would be to plicate the “endo-pelvic fascia” . This is the classical method used since 1913 as advocated by Howard A Kelly.
Options B, C and D have as a basis a site specific approach. The difference being that in Option C a biomesh is put between the bladder and the vaginal skin, and in option D a synthetic mesh. The only synthetic mesh used by me is Prolift from Gynecare.
Options C and D can be seen as “ side specific” repairs.

In my daily practise plications is seen as an un-anatomical operation in which tissue are permanently damaged and scarred, with a proven high failure rate. If one has to re-operate on these, the patient will be at a distinct disadvantage. Option A is thus never done, not even in conjunction with the other options.

Option B is done only in the very young patient, and Option D is kept for the elderly women who is no longer sexually active , and who is not going to start with this activity in the foreseeable future.

The vast majority will fall under Option C. The only biomesh used by me is the second generation biomeshes, Surgisis or Symphasis, because of their distinct tissue engineering properties.

The damage in the pelvis is reconstructed with the normal anatomy as a guide.

Athens: IUGA 2006 - covering the bare essentials

IUGA 2006 in Athens consisted of different sub-settings :
1. Review sessions were the basis of the pre-congress workshops. These were summary sessions of the past, present and future of the subject matter.
2. Scientific and poster sessions in which studies were presented.
3. “State of the art” lectures by prominent figures in the field.
4. Seminars presented by industry on their different products.
5. Meetings of the societies and committees.

The most satisfaction to this delegate came from the pre-congress “ workshops" during which the opinions were unbiased and presented as reviews on different aspects. The state of the art lectures will also fall under this heading. The scientific meetings, although a necessity, gave me at times the feeling that I probably could have learned more if I attended the meeting next door.

The seminars where the industry backed their products were the most disappointing. Biased opinions were given by “big names” who were supposed to be unbiased. I really do not think that people in leading positions in our societies should participate as speakers on these forums. It degrade their positions and also their names.

A few catch phrases were created. The most rewarding were the statement by Mark Slack in which he referred to high and low volume surgeons in reference to results and complications of operations. Hispareunia also come to mind – meaning the pain and discomfort of the male during intercourse due to the presence of an eroded mesh in the vagina!

The scientific meetings and workshops, including the state of art lectures, had one common lesson: we do not know enough to introduce synthetic meshes into the vagina to re-enforce the walls. The good that it does is not proven and the harm it can do is unknown. More studies are needed. The moment you feel convinced that you should stay away from these new products, an industry driven session was on the agenda to highlight the advantages and safety of these products!

Sober messages were that new is not always better (the Boeing 747 from the 1970`s is still flying, the Concord not!)- Eureka experiences from Archimedian times did not always end in changes for good. One must stay critical before you change your present day practises.

Bad surgical results are due to three factors: the patient herself change with time, techniques differ from surgeon to surgeon, and even from procedure to procedure, and surgeons differ in acumen ( “low and high volume surgeons”- Mark Slack).
In a quest to improve results a drive is on towards reliance on graphs and use of different approaches (via the obturator fossa). These may make the surgeon more “competent”, but it may be at the cost of the patient!
Looking back on past experiences, it can take 10 to 15 years for a specific bad technique before it loses popularity! We need to self-regulate, else we will be regulated! (Chris Maher).
The situation does came to a point where someone even stated that there are two kinds of gynaecologists: one who put meshes in, and those who take it out: you choose which one you would like to be! (Sultan). This obviously is where one will end if meshes are being used indiscriminately.

In his talk about the past, present and future of urogynaecology, Mickey Karram gave an overview of the masters of the past. In the mirror image one realises that in the past new technologies were embraced indiscriminately and bad ones were stopped with extreme reluctance. Maybe it was because we did not talk about our failures and complications, or knowledge was poor as far as pathogenesis and anatomy were concerned. To his mind the future must depend on scientific credibility, ethical issues, training and certification before new techniques were integrated.

I must say that I came out of that lecture with a bid of confusion. A pointer to me was that he named Kelly without alluding to George R White: a typical sliding door of the past where the wrong direction was taken - a good example of embracing wrong techniques and reluctance to stop harmful practises! It is nice to control everyone with certifications etc, but down this road the individual’s inventiveness may be lost.

The war on the type of synthetic mesh is apparently over, the war on what type of biomesh to be used has begun. Interference of industry, with resultant clinging to types that is not good, clouded to my mind this congress. The crossed linked biomeshes is behaving like an allograph (Deprest) and this is enough reason not to use them. If the answer lies in the non-crossed linked ones with their new tissue engineering properties, time will tel. It looks promising though, and follows the golden rule of do no harm.

We are at this stage confronted with a lot of issues, but the biggest could be that we do not even know exactly what to call ourselves. Urogynaecology is not good enough - it was a way of including the bladder into the field of the gynaecologist. The expanding of the field into reconstructing the damaged pelvic organs included the anterior and posterior vaginal walls, and thus the bladder, vagina and the rectum. In fending off the urologists, plastic surgeons and general surgeons from our domain - the vagina - we need to do a lot of rethinking. Stress incontinence was a prominent issue in the life of the uro-gynaecologist of yesteryear, today it is only one of the functional defects of the damaged pelvis. Exit the prominence given to bladder function on the agendas of IUGA meetings of the past. In IUGA 2006 mention of rectal function and functional defects came to the fore, and in future meetings this will be given it’s rightful place. To my mind vaginal surgery as the prominent route of treatment of the damaged pelvis should have more prominence.

Unfortunately did the IUGA 2006 not help to clarify matters: it defined to me the problems, but there was not enough solutions. The influx of industry into deciding how we should treat the patient (as was seen during the rise of oestrogen therapy in the late 90´s) has arrived. This is deeply disturbing. We need them, but then as supporters of science and not as rulers of science.

If one practise with the motto of Primum Non Nocere (do no harm to the patient) we must be certain in which direction one should go with this.

To what extent did IUGA 2006 influence my practise? In general probably not a lot. Knowing that one at times sees and hears only what you want to see and hear, I must admit that support for my chosen direction did come through.


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