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Sunday, December 30, 2012

Do No Harm

The vaginal reconstructive surgeon finds himself in 2013 at cross roads: on all levels of this sub-speciality uncertainties are present.

Vaginal Reconstructive Surgery includes the reconstruction of the anterior, posterior and apical compartments of the vaginal wall, plus the integration of all these compartments into a single support structure. The indications for surgery is not well defined, the different surgical approaches differ from surgeon to surgeon and surgical outcome is not always predicable. The pathogenesis of the “disease” that needs to be treated is not understood and not fully defined. The course it will take if left untreated is unpredictable. Uro-Gynaecology of 2013 is not only about the bladder and gynaecological organs -pathology includes the whole pelvic cavity. Even the name the sub-speciality gives itself can be questioned!

If the surgeon admits to himself that his “sub-speciality” is at the best in an experimental phase he needs to assure his patient that his “experiment” is not harmful and have no hidden risks. Poor outcome means that the reconstructive process left no scars and the patient is not burdened with new problems. The worst-case scenario must be that the Patient Global Impression of Improvement (PGI-I) score[1]  is 3 –no change from what it had been pre-operatively.

Faced with this I re-assessed my treatment armature available to the patient with a prolapsed vaginal wall. The painful departure of my “comfort zone” lead to a road of surgical uncertainties outside the box offered to me by my mentors –a box that has well established habits going back to 1976.

The only way a new comfort zone could be created is to clear my mind, re-think all aspects and start anew.

This re-education began in 2004. Meticulous surgical auditing was followed to provide protection to my patients.
In this process the road let via the use of synthetic mesh kits -abandoned as a too risk full procedure on 30 January 2007- to what is being presented in this manuscript.

Surgical Auditing: All patients were well counselled pre-operatively with postoperative surgical outcome data collection (follow-up on 6weeks, 6months and yearly post-operatively), all procedures since October 2007 where video taped, regular peer review sessions where conducted with like thinking colleagues and with the use of full day seminar sessions followed by a full day of hands-on surgical workshops with small groups (up to 10 maximum) of colleagues from all over the world (5 sessions per year with 50 attending per year) –including review sessions by them on a yearly basis. Surgical data –technique and outcomes- where audited on a 6 months to yearly basis.

The golden thread of “do no harm” ran through this is: no suture materials, suture placement, implant material and placement there-of was used if potential harm to the patient could be present. Each step in this surgery was painfully thought thru. If the surgery resulted in sub optimal outcomes, the secondary surgery was ad-on surgery rather that undo-redo surgery, with improved results –a staged process of surgery developed in these cases. Included were the evaluation of video material of poor and good outcomes.

The average yearly surgical turnover since 2008 was 170 procedures with only one surgeon involved- myself. Simplicity of technique and reproducibility of the technique was tested by like thinking surgeons.

Structured reconstructive surgery as to be presented here can be offered to the very young patient with minimal risk of permanent damage and can act as a foundation from where a roadmap of future surgeries, if needed, can be launched.

The final answers are still not in. The book on vaginal reconstructive surgery is still being written!

Andri Nieuwoudt, Terneuzen, The Netherlands January 2013

[1] Srikrishna S, Robinson D, Cardozo L Int Urogynecol J. 2010 May; 21(5): 523-8. Validation of the Patient Global Impression of Improvement (PGI-I) for urogenital prolapse