SIG Leadership

Chair: Harpreet Arora (Australia)
Co-Chair: Barry O'Reilly (Ireland)

Description

Usage of minimally invasive endoscopic surgery in the field of urogynecology/female pelvic medicine and reconstructive surgery is increasing as the use of surgical robots in pelvic surgery provides various benefits. Minimally invasive endoscopic surgery has already been successfully used for the treatment of pelvic organ prolapse, in procedures such as sacrocolpopexy, sacrohysteropexy, and uterosacral ligament plication. There has also been an increasing interest in using this method for the treatment of stress urinary incontinence in women.

While this surgery is associated with increased cost, the outcomes in urogynecology/female pelvic medicine and reconstructive surgery are promising. The IUGA Minimal Invasive Endoscopic Surgery SIG offers IUGA members/surgeons with an interest in robotic surgery and laprascopics to obtain knowledge and share experiences and resources among experts, further supporting the advancement of our field in this area.

Goals

Goals of a SIG on robotic surgery by networking and collaboration will be:

• Add knowledge via IUGA worldwide on robot pelvic floor surgery and laprascopics.
• To improve the quality of life for those urogynecolgical patients who are treated with the use of robot surgery and reduce complications.
• Promote knowledge and narrow knowledge gaps for the use of a robot assisted laparoscopic surgery.
• To exchange tips and tricks, technical information and new ideas.
• Discuss clinical indications.
• Develop educational tools.
• Advise IUGA on international training curriculum.
• Advise IUGA on and promote patient information.
• Share our knowledge with patient organizations.
• Develop an IUGA E-Discussion Forum on robotics.
• Shared SIG publications in scientific journals.
• Share knowledge via popular media.

The group aims to have a scientific session during every annual IUGA meeting and will have additional Zoom/Teams meetings and e-mail communication.

Follow the Minimal Invasive Endoscopic Surgery SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

The IUGA Obstetric Pelvic Floor & Anal Sphincter Injuries Special Interest Group is seeking volunteers to contribute to the development of a document: International Guidelines on Obstetric Anal Sphincter Injuries (OASIs).

Vaginal childbirth is associated with the development of anal incontinence and OASIs (recognized and missed injuries) are a major contributor. There are no international guidelines regarding the diagnosis, management, prevention, and management of subsequent pregnancy after OASIs. Roper et al performed a comprehensive search and found 13 national guidelines and used the AGREE tool for overall guideline assessment. They concluded:
The wide variation in methodological quality and evidence used for recommendations suggests that there is a need for an agreed international guideline. This will enable healthcare practitioners to follow the same recommendations, with the most recent evidence, and provide evidence-based care to all women globally.

Aim
To produce the first international guideline that would develop recommendations taking into consideration the facilities and resources available globally.

Objective
To minimize the morbidity associated with obstetric pelvic floor and anal sphincter injuries by providing a guideline and signposting to educational resources for both clinicians and patients

Timeline: This project is expected to begin in July 2023 and conclude by September 2024.

Contributor Expectations:
- The manuscript will be developed using a collaborative process that requires regular communication via email, possible conference calls, and completion of assignments.
- Contributors will produce and deliver all completed assignments and required information on or before the agreed deadlines.
- Contributors will disclose all potential conflicts of interest (see Conflict of Interest Policy here). 

Eligibility
Current IUGA members are eligible to apply.

How to Apply:
Please submit the following to This email address is being protected from spambots. You need JavaScript enabled to view it. by Thursday June 8, 2023:
1. A letter of interest that includes your qualifications and experience related to this topic
2. Your CV (max. 5 pages)
3. Complete the Disclosure Form

Application Deadline:
Applications must be received by 11:59pm CET on Thursday June 8, 2023

Reference
Roper JC, Amber N, Wan OYK, Sultan AH, Thakar R. Review of available national guidelines for obstetric anal sphincter injury. Int Urogynecol J. 2020 Nov;31(11):2247-2259. doi: 10.1007/s00192-020-04464-5. Epub 2020 Aug 13. PMID: 32789813; PMCID: PMC7561538.

Background

As urogynecologists, we are specialists who address women’s functional and anatomical changes to the pelvic floor as a result of childbirth, aging, and other factors. Many of these women – our patients who we see daily – also complain of changes in sexual function and genital aesthetic appearance. It is our duty as pelvic floor specialists to understand these concerns and either address them or refer them to the best qualified surgeon.

Cosmetic Gynecology has become one of the fastest growing subspecialties of elective surgery for women and includes specialists in gynecology, urogynecology, urology, and plastic surgery. This area of special interest includes both cosmetic procedures to enhance the aesthetic appearance of the vulvo/vaginal region, as well as functional vaginal repairs to enhance or help restore sexual function following the changes that may occur following childbirth and/or aging.   

Among the first procedures covered by this subspecialty – and the most controversial and discussed – is colloquially named Vaginal Rejuvenation (VR), which is performed to treat the vaginal laxity syndrome (VLS). For many years it has been shown scientifically that prolapse affects sexual function, and when repaired, sexual function improves. Vaginal rejuvenation surgery (vaginal tightening for sexual function) is the repair of VLS that may or may not involve symptomatic prolapse. In the early years of these procedures there was very little scientific evidence to support this type of surgery, however in the recent years scientific studies supporting vaginal rejuvenation are surfacing and being presented at scientific meetings throughout the world. Scientific articles as well as book chapters in very reputable female urology textbooks (example: Cardoza and Staskin) are becoming more prevalent as the procedure is becoming more mainstream. Certainly, however, it is vitally important for more high level scientific studies to be completed to validate these procedures in women.

Female genital cosmetic surgery also includes aesthetic procedures to improve the cosmetic appearance of the external vulvar/vaginal region. Procedures include labiaplasty or labia minora reduction with or without excess prepuce reduction, labia majora reduction or augmentation, vaginal introital repairs for cosmetic issues as well as reduction of lipodystrophy in the mons pubis region. Labiaplasty procedures have been reported to be the largest growing trend of plastic or cosmetic surgery procedures for women in the US and throughout the world. This may be secondary to the increased public awareness created by the media or popular TV shows, or it may be secondary to the fact that in the past women’s feelings about the appearance of their genitalia have been ignored. It has been scientifically shown that the appearance of a woman’s genitalia affects her self-confidence and sexuality. Women now have been empowered with the choice of options to change the external appearance of their vulvovaginal region if they are unhappy with the cosmetic appearance. Studies have also recently shown that this is a trend driven by women themselves, and not their sexual partners. However, with this trend there have been many different procedures described with very little scientific validation and therefore there is a danger that surgeons with very little experience with vulvar or vaginal surgery (inside or outside the field of gynecology) are doing these procedures incorrectly and causing injury or damage to women.    

Recently, new technology has been introduced in the field offering non-surgical/office based procedures to treat female sexual dysfunction (VLS), vaginal health and vulvo/vaginal cosmetic issues for women. This technology includes non-fractional lasers as well as radiofrequency treatments. Scientific studies are currently evaluating this technology for these uses as well as treatment for mild urinary incontinence, urgency/frequency issues as well as vaginal dryness.   

What do doctors who perform these procedures have in common? 

The leaders of these procedures and technology worldwide, with few exceptions, come from the area of urogynecology. This is not surprising considering that of the four subspecialties within Obstetrics and Gynecology (perinatology, reproductive endocrinology, oncology, urogynecology) only urogynecology deals with the management of pelvic floor disorders. Thus, this subspecialty is best suited to address the aesthetic, functional, and sexual concerns of women and should be taking the lead in this newly developing field. No other subspecialty has the expertise that our specialty has in vaginal reconstructive surgery, and we should therefore not let other specialties take the lead on these procedures or the scientific validation of these procedures.  

We may categorically say that there are no less than 20 courses or symposiums on Cosmetic Gynecology running every year worldwide. If we add countless lectures, conferences and training courses, we are facing a new area of gynecology that is growing exponentially and is impossible to stop. We urogynecologists have noted with concern that many of these procedures, whether performed in isolation or in association with other conventional surgeries such as hysterectomies, urinary incontinence correction and prolapse correction, are being performed by other health professionals who, in our opinion, are not the most suitable.

Due to the aforementioned facts, a group of IUGA members with proven experience and interest in aesthetic/cosmetic vulvo-vaginal surgery have created the Cosmetic Gynecology Special Interest Group.

Aims and Objectives of the Group

• Define, spread and explain within IUGA the different surgical and non-surgical procedures and their different applications, including the adequate selection of patients.
• Properly establish that in the vast majority of cases, due to associated pathologies,

urogynecologists are the most suitable professionals to perform such procedures, including non-surgical procedures that also require a previous evaluation by a specialist who will give the patient the best treatment choice to his/her reason for consultation. 

• Promote the presentation of scientific publications on cosmetic gynecology within IUGA.
• Help promote the scientific validation of cosmetic and functional aesthetic vaginal procedures (both surgical and non-surgical) both within IUGA as well as outside the organization.
• Promote IUGA as a leader in the field of Vaginal/Vulvar Reconstructive and Aesthetic procedures.
• Promote women’s sexual health and sexual function through studies, courses, and grants to IUGA.

Follow the Cosmetic Gynecology SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

SIG Leadership

Chair: Keng (KJ) Ng (United Kingdom)

Background

The pelvic floor is a highly complex structure made up of skeletal and striated muscle, support and suspensory ligaments, fascial coverings, and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system is damaged, either directly or as a consequence of an underlying neurological condition, pelvic floor failure ensues along with organ dysfunction. The etiology is inevitably multi-factorial, and seldom as a consequence of a single etiological factor. It can affect one or all three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (fecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalization of the pelvic floor has resulted in the partitioning of patients into urology, gynecology, colo-rectal surgery, or neurology, depending on the patient’s presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialties. While the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. These patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioral and lifestyle changes, conservative treatments, pharmacotherapy, minimally invasive surgery, and radical specialized surgery. It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only necessary, but critical, if good clinical care and governance is to be ensured.

Neural Control of the Uro-genital System

Voluntary control over the uro-genital system is critical to our social existence. Since its peripheral innervation derives from the most distal segments of the spinal cord, integrity of the long tracts of the central nervous system for physiological function is immediately apparent. In a survey of patients referred with bladder symptoms, spinal cord involvement of various pathologies was found to be the most common cause of bladder symptoms. Because of the commonality of innervation shared by the bladder and genital organs, it might be expected that abnormalities of these two systems inevitably occur together. This, however, is not the case because although the organs share the same root innervation and have common peripheral nerves within the pelvis, each is controlled by its own unique set of central nervous system reflexes. The bladder performs only two functions - storage and voiding of urine- and the modern view of the control of these two mutually exclusive activities is that whereas storage is organized within the spinal cord, micturition results from activation by suprapontine influences of a center in the dorsal tegmentum of the pons, the pontine micturition center (PMC). In neurological disease, this delicate interaction can be severely disrupted, and manifests as a disorder of voiding or storage depending on the condition such as multiple sclerosis, Parkinson's disease, multiple system atrophy and others. But commonly, it is direct injury to pelvic nerves that can give rise to quite marked bladder and pelvic floor dysfunction. The peripheral innervation of the pelvic organs can be damaged by extirpative pelvic surgery such as resection of rectal carcinoma, radical prostatectomy, or radical hysterectomy. The dissection necessary for rectal cancer is likely to damage the parasympathetic innervation to the bladder and genitalia, as the pelvic nerves take a medio-lateral course through the pelvis on either side of the rectum and the apex of the prostate. The nerves may either be removed together with the fascia which covers the lower rectum or may be damaged by a traction injury as the rectum is mobilized prior to excision. Urinary incontinence following radical hysterectomy which includes the upper part of the vagina, is probably also due to damage to the parasympathetic innervation of the detrusor and in the case of a radical prostatectomy, there may be additional direct damage to the innervation of the striated urethral sphincter. The focus in the literature tends to focus on the effects of neurological disease on the bladder, but other pelvic floor effects should not be ignored, such as pelvic organ prolapse, pain syndromes, and sexual dysfunction.

Aims and Objectives

This SIG will focus on improving obstetricians and gynecologists understanding of the neurological basis of pelvic floor dysfunction and the associated clinical disorders, which hitherto have not been fully characterized in the literature.

Follow the Neuro-urogynecology & Urogenital Pain SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.