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Friday, November 24, 2006

Important discoveries..and not so important ones!

1794 May 8

Antoine Laurent Lavoisier is beheaded in the early days of the French Revolution. It was Lavoisier who had discovered oxygen.
It is said that he had told his friends that he would start blinking as the guillotine blade fell and they were to to see how long his eyes carried on blinked after his head was severed.............
The result was some 15 seconds!

IUGA 2007

some people are wise, some are otherwise!

14 June 2007
Once again a year has passed since the last IUGA meeting (September 2006 in Athens). On the same basis as with the previous meetings the structure of IUGA 2007 in Cancun, Mexico consisted of pre-congress “workshops”- this time nearly 30- stretching over 2 half days, to be followed by two and a halfday of congress- the business part.

This meant that we had a choice: attend any 2 of the 30! As can be expected each “workshop” had a grand total of least plus minus 6 to 20 attendees- hardly a good feeding ground for the seminar form of these “workshops”.

As was the case last year I came to this meeting totally biased in what I do and how I tackle the problem of pelvic reconstructive surgery in the patient with prolapse:
The way I see it one has only a few alternatives: you plicate the hell out of the bulge, you try to find what went wrong and re-suture the damage or you loosen all attachments and hook a pre-made kit of synthetic material- or if you want to, with a kit with some or other biologic material- behind the bladder and hang it onto the bony pelvis. In the last case one feel like adding: “and starting to pray”!

At the pre-congress workshop THE NAMES preached his or her own preferences: this was from doing nothing, to using all kind of toys. The terms synthetic meshes and biological grafts were used loosely. At times one could predict with quite accuracy which industry sponsored whom. And once again THE LEADERS were not too shy to promote!

With this as the breeding ground it ended in a choice between plicating and tying synthetic meshes all over the pelvis - with one NAME from Australia telling us how dangerous the synthetic meshes are and how he is occupied to take them out: please rather plicate!

Nice progress from last year wouldn’t you say?

No wonder one of the LADIES asked : “should we not take the Marshall- Marchetties, and the Manchester procedures off the rack, and reintroduce them!”

In between, a lonely “workshop” banned to an across the street hotel tried to tell an audience of 10 mostly Spanish speaking attendees that the third alternative could be to not re-invent the wheel, but learn from the experiences of the general surgeons, and to follow the rules of the hernia principles.

To most the biological grafts were all the same and no mention is made of the biological grafts with remodeling capacity available that induce the body to heal itself. Why should that be?

I am also perplexed by the stated opinion that the one arm of any study of any new product must include plications- an operation that do not work, is based on the wrong assumption that the prolapsed is due to stretching ( or if you want a “central” defect), do harm to the patient’s vagina, and to use the words in an editorial “is on tenuous ethical grounds”! One elderly NAME explained to me that although the operation stated is unethically the American College ( RULERS?) expect that it must be included in studies! I would rather include a placebo do nothing “operation” or put a pessary in, than do an operation which I believe is unethical in the placebo arm!
Even worse: and it is expected that this is the operation that must be taught by us, the masters, to the uro-gyneacologists of the future.

Robert Frost said:
“I shall be telling this with a sigh, somewhere ages and ages hence: two roads diverged in the wood, and I – I took the one less travelled by. And that has made all the difference.”

Maybe that is the reason why I still am looking for reasons to believe THE NAMES.

Today the Congress really starts!
Friday, 15 June 2007: 18:00

With a bit of uneasiness I can look back now on two days of IUGA 2007 congress experience. To be honest is it extremely difficult to say that I gain by this experience. The advantage of having had the experience of IUGA 2005 and IUGA 2006 place one in the position of comparing them- and that is my problem.

Either the standards were too high in the previous congresses, or the previous congresses depleted the pool of Urogyneacological knowledge. In the last case one should think that we should meet less frequently that once a year. My wife keep on telling me that our subject consists of only a anterior wall, a posterior wall and the vaginal top! To my mind this cannot be true.

The answer must be the low standard one.

I attended meticulously all sessions available and ended up in the wrong rooms- somewhere else better material must be presented than the lot that I am listening to.
The “state of the art“ lectures lead basically nowhere- with the exclusion of tomorrow’s for I have not heard them yet!- , the industry driven symposiums were just that: industry driven, the meeting sessions came up with little bits of information – that is if you were lucky enough to find the place and topic on the confusing program-, and the video sessions were disasters. Most of the times technical support was poor.

This afternoon I was totally embarrassed by the early afternoon video session: the 2 of the 5 videos that were able to be shown made one thankful that the others could not be shown. I should think that someone somewhere in the corridors of power look at the videos beforehand and screen the quality. This either had not been done or there had been a shortfall of available material. The worse to me was that at the end of a nightmarish two hours the NAME sitting in front did not apologize to the attendees about this. In other words to us the message was: this is OK as far as IUGA is concerned. One of the attendees, I must admit though, did get a bit of comment out of one of them regarding the wrong message of one of the videos.
Suffice to say that I did not attend the later scheduled video session. I have a bad feeling about this for the video sessions always were the highlights of the previous IUGA sessions.

Even the memorial lecture by the past LEADER was clouded by the noise he made at the back of the lecture hall at the end of his oration in total disregard to the small people around him when a little man was trying to deliver his little presentation. Last year the history of urogyne went without mentioning of George White, this year it was the same.

I am serious if I say that if this is the quality I would seriously have to reassess my association with this association. It at times felt as if it was the Urogyneacological Society of Zimbabwe’s annual congress.
Come on: we can do better!

Please don’t get me wrong: all was not entirely negative. Most of the scientific presentations were of good to excellent quality, as were most of the posters. This were unfortunately on a plate that was difficult to digest. The composition of the program was impossible to understand. It was not possible to go from one meeting to another due to bad synchronization of talks and presentations, with the result that you stay with one meeting - ending up with this feeling of wanting to be else.

The ability to rub shoulders with peers in the corridors is always a good way of exchanging ideas. The most irritating part of these, as with all meetings, were that one talk to a NAME who keep on looking over your or his shoulder to see if someone more important than you are not passing by, that is if the NAME is not excusing himself for he is on his way to some or other bigger than you happening. Few realize their responsibility to their subject and peers: these are the only time that the small guy out of not-so-important-hospitals has to improve his/hers direct knowledge.
And I think maybe they can sometime learn from this little person’s experience.
Even more irritating is the maybe to be name that struggle to let himself/herself be seen or heard; they usually trailed the NAME and suck up to him.
These interactions between NAME, name and little person were at this meeting not different from other meetings.

Let my summarize my personal observations:
1. The organization of this IUGA meeting was terrible and not up to international (or third world country, for that matter: Zimbabwe could have done better) standard. The less said over this the better.
2. The venue was supposed to be in Mexico, but Cancun- although nice and beautiful- is not Mexico; it have the same touristy look and feel as any other tourist trap in the world. For us Africans visa requirements make traveling to these spots extremely difficult: me and my wife were nearly jailed on our way here in the US of A because of visas that were not right (this is a tale for another day).
3. The scientific papers were good, but one had a difficult time to find those that you want to attend- once again a organizational fault.
4. The state of the art speakers were bad.
5. To my mind did the main message of the future of pelvic organ reconstructive surgery not came through: there is biological support systems for the repair of the damaged pelvis that can help the body to heal itself. The message was rather: go back to the techniques of the past- although shown to be ineffective and dangerous, at least we know what we’ve got-, with a mixed (and to my mind at times dangerous) message over the use of synthetic meshes ( to satisfy the industries for where else will all the money come from to drive the congress).
6. The dominance of industry will always be a problem.
7. The ever present bad command of the English language by some speakers need to be addressed. This is getting in the way of communicating the messages, which I am certain are present.

And tonight is “Gala dinner” night and tomorrow the closing ceremony- I do not have to attend these to know that THE LEADERS and THE NAMES are going to tell each other how wonderful the Cancun experience had been. They who are here basically to do networking and leaving as soon as their bit are done and who do not see the need to sit through it all as we do; they know enough and we not.

Maybe if the BIG men listen the next one in Taiwan will be better, or shall we have the same? Ask me next year.

Mr NAME, mr LEADER; This little guy do not think that what you created here is the worth to leave his patients for a week and travel 11 hours at great expense to himself, just for this. You can do better, no, you need to do better.

Surgical Options in Vaginal Prolapsed Pelvic Organ Reconstruction

In the surgical repair of the damaged pelvis a few ground rules apply: the most important of these is surely that no further damage must be done, especially if the surgical results are suboptimal - the so-called “do no harm” effect.
The “classical” prolapse surgical techniques in common use in Europe, and elsewhere in the world, do not follow this ground rule. The main aim is to get rid of the bulge!
In this conquest, new anatomical structures are developed, present anatomical organs are mutilated, and new lines of pull directions are designed. Thus taking over a new godlike role! There was success in the conquest, but in others failures left the patient with a mutilated pelvis, with a resultant new attempt at rectifying the bulge with a repetition of the initial attack! Let us call this option POR option A.

To improve results tissue graph techniques were designed to supplement the defective area weakness, either from surrounding tissues (incorporating muscle for instance in areas where it normally are not found) or from distant body areas. These gave poor results with, once again, mutilation of the prolapsed area.
Keeping the above “do no harm” effect in mind and hoping to obtain at least the same results in reconstructing the damaged pelvis, a paradigm shift is to my mind necessary.

1. With the normal anatomy (and the functional anatomy) as a template the pelvic organ reconstruction surgeon can repair in the true sense of the word!

2. Knowing what the pathogenesis was in damaging the pelvis, especially with childbirth, will also support the resultant rectifying surgery.

3. Using proper surgical dissection techniques flow from this, with a resultant lesser risk for intra operative complications.

4. Adhering to the basic surgical principles of hernia surgery can diminish failure rates.

5. Do not use any technique that mutilate the pelvic organs, and remove redundant tissue, if really necessary, with care.

6. The use of graphs must be highly individualized.

Pointers in decision making can be age of the patient, the type of defect and the area in the pelvis where the tissue needs to be used.
A protocol for the type of pelvic reconstructive surgery is possible.
This pelvic organ reconstructive (POR) protocol will be dependant on the following options:
1. POR option B:
Site specific repair, the so-called vaginal paravaginal repair (VPVR), using only native tissue of the patient: repairing the damaged tissue directly.
A new approach is to augment or strengthen this with a Side Specific repair: the endopelvic fascia is sutured on both sides to the obturator fascia, following the ATFP as a guide.
2. POR option C:
Above is done and by using an overlay of a second generation Xenograph the tension is decreased on the tissue supporting the hernia repair
3. POR option D:
Using a synthetic graph to decrease tension on the tissue surrounding the hernia.
With this there is no PORoB done.
In the following of the options from PORo B thru PORoC to PORo D, the risk, especially long-term, may be increasing ( “do no harm effect!”), but with possibly a better long-term success rate.

The young patient can qualify for PORoB, or C, with the sexually inactive older lady, or possibly a patient with a faillure after previous surgery, for PORoD
With the necessary individualization based on above, the correct procedure can be done on the correct patient, with less harm to the patient, especially if the procedure did not give the optimal desired effect.
Only the future will give the answers.
extra reading

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We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and action becomes mindless.
~ James William Fulbright