Letter to the Director of Obstetrics and Gynecology

When fairfax obgyn gynecologists talk about basic gynecology, we all know what this means. When we talk about sub-specialization in Gynecology, we know that we refer to maternal-fetal medicine, endocrinological reproductive medicine and oncological gynecology. When we talk about Urogynecology, things are not so clear fundamentally by the implications of the specialty that is classically competent in the urinary tract of women, Urology.

We all agree that the collaboration of the urologist will be vital in some situations where we are not experts but the issue of urinary incontinence and pelvic floor disorders is at least as important for us as it can be for urologists Or for anorectal surgeons.

The prevalence of pelvic floor disorders and one of its consequences, urinary incontinence, is very high in mature women and especially in postmenopausal women, and this translates into a high percentage of women who will come to our consultations, just with these problems.

It is necessary for us to have in mind that we will need experts in uro-gynecological subjects and that therefore those who are dedicated to the training of specialists should include topics from this branch of our specialty, and I do not refer only to theoretical expositions, but to Outline surgical techniques.

In modern Gynecology it is no longer possible to go directly to a corrective surgical intervention of a urinary incontinence without first undergoing a complete urodynamic study. We know that the results of the treatment of urinary incontinence are not effective in one hundred percent, but we do want to get as close as possible to this figure we will need a correct preoperative diagnosis.

At present we have many resources, both medicated, physiotherapeutic and surgical to achieve very good results.

There are new drugs that decrease detrusor overactivity with more acceptable side effects than we had until recently.

There are endless gadgets that help stimulate the pelvic floor musculature and that used with precise indications may prevent surgical intervention especially in mild incontinence. The same we can say of the techniques based on the exercises of Kegel.

Surgical treatments are undoubtedly the most used and although there are endless techniques described over the years, it is also true that they are selecting a few that have proven their effectiveness and are rejecting others that have not resisted the Proof of time. Among the latter we will mention Kelly or Marion techniques that lose their effectiveness even in the short term.

Basically we can distinguish two major types of interventions for the correction of stress urinary incontinence in women: colposuspensiones and slings. Of the first, we must emphasize the operation of Burch, also practiced by laparoscopic techniques and the Marshall-Marchetti-Krantz. Combined operations using needles have been more the domain of urologists than gynecologists and the long-term results are beginning to be questioned. Recently, colposuspension techniques with pubic bone anchorage have been tested that have the advantage of being fully practiced vaginally. It will take a few years to know if they stand the test of time in the long run.

Sling operations are in vogue today. Some say that they should always be used, in all cases of stress urinary incontinence. They are the ones that give the best results, whether they are applied primarily or used for recurrence cases. Slings can be performed exclusively vaginally using donor fascia lata, which avoids the rejection problems presented by synthetic belts. Very recently, a sling technique called Tension Free Vaginal Tape (TVT) is being popularized, which is very simple to practice and that despite the use of non-absorbable material at the moment, it has not given rise to rejections.

It is evident that we are before the outbreak of Urogynecology. Gynecologists should get on the train of this progress, and if we can drive the machine, the better.


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Open Letter Committee:
Anthony Barnett, Charles Glass, Tony Curzon Price, Roger Graef, Jemima Khan, Henry Porter, Pranvera Smith, Rachel Johnson, Elaine Potter, Vaughan Smith (chair).


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Open Democracy

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Article 19