Consent
Vol. 18 No 3 | Spring 2016
Women's Health
UGSA: highlights of the 2016 ASM
Dr Payam Nikpoor
MD, MRANZCOG


This article is 6 years old and may no longer reflect current clinical practice.

The annual scientific meeting (ASM) of the Urogynaecological Society of Australasia (UGSA) was held in New Zealand from March 11–12, in the vibrant city of Auckland. This year’s ASM was a well-designed collection of basic science, clinical practice and critical appraisal of the current practice in urogynaecology, preceded by high-powered workshops and concluding with the RANZCOG Trainees’ Day. The organising committee invited world-renowned speakers, including Prof John DeLancy, A/Prof Pamela Moalli, Prof Linda Cardozo and Prof Don Wilson.

The conference was attended by 250 delegates; we had 27 podium presentations, two roundtable debates and nine oral abstract presentations by delegates.

In the opening session of the conference, ‘Childbirth and the pelvic floor’, Prof John DeLancy delivered the first podium presentation, ‘Biomechanics of childbirth’. This included pelvic floor birth-related injuries and implications of such injuries in large-scale population figures. Pelvic floor birth injuries are latent; they occur during birth and remain dormant for many years, and may lead to prolapse later in life. Potential causes for prolapse following childbirth injury can arise from three different categories of trauma: muscle compression, denervation and muscle tear. It is important to identify the cause because prevention depends on it. For example, if the cause for levator ani injury is muscle compression, then it can be prevented by shortening the second stage of labour; if the injury is due to muscle tear, then prevention can be achieved by slow and gradual delivery, so that the muscles can accommodate the stretch. Indeed, each of these traumas occur during labour to varying degrees, but the main birth-related injury leading to pelvic organ prolapse is levator ani muscle tear. Miller et al1 have demonstrated this on serial magnetic resonance imaging of the pelvis at one and seven months after childbirth. De Lancey et al showed the presence of major levator ani defect in 55 per cent of women with pelvic organ prolapse compared with 15 per cent of those without pelvic organ prolapse.2 Major risk factors for this type of injury are known to be occipito-posterior fetal position and forceps delivery.3 There was further elaboration on this aspect of birth injury by Prof Peter Dietz; he has revealed the magnitude of the impact of forceps delivery on levator ani muscle tear in several studies.4 5

Another outstanding aspect of the meeting was the presentation by Prof Don Wilson on the UR-CHOICE trial.6 URCHOICE is a scoring system developed from long-term prospectively collected data of women, 12 and 20 years from the birth of their child. UR-CHOICE is an acronym that takes into account the important risk factors in pelvic floor dysfunction (PFD):

Urinary incontinence before pregnancy
Race/ethnicity
Child bearing started at what age?
Height (mother’s height)
Overweight (weight of mother, BMI)
Inheritance (family history)
Children (number of children desired)
Estimated fetal weight

These independent factors can be given numerical values that, when added together, provide an antenatal pelvic floor trauma predictive score. This can be used by midwives, obstetricians and mothers to ensure that all are informed of realistic expected outcomes before the onset of labour, and also to help with counselling regarding PFD prevention.

In this scoring system, multiple regression models to predict PFD were developed from collaboration between the ProLong study group, SwePOP and Cleveland clinic groups. The data from of the ProLong7 and SwePOP8 9 studies were used to create a large database. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) and complicated statistical analysis has been used to create predictive models as an online calculator to assess individualised risk of PFD for pregnant women. To follow this great work, the collaboration is planning qualitative studies as well as pilot randomised controlled trials to further evaluate the validity of such a scoring and prediction tool.

This year, the hallmark of the UGSA ASM was the focus on basic science in urogynaecology, specifically the biomechanics of urogynaecological mesh devices and their behaviour in vivo. A/Prof Moalli presented on this matter in detail, through several presentations enlightening the attendees of the cutting-edge science unveiled by the work of her team. The features of a mesh implanted in the vagina play an important role in the behaviour of the mesh. Over the past decade, there has been a move in production of transvaginal mesh devices with lower stiffness, high pore size and high porosity. Lower stiffness is critical for long-term biocompatibility of mesh devices. This is related to a phenomenon called ‘stress shielding’. When two materials are connected in this process, the stiffer material bears the majority of the load and the less stiff material undergoes maladaptive remodelling response, characterised by degeneration and atrophy. This process is directly related to mesh erosion in the vagina. Therefore, lightweight, high pore size and porosity lead to less mesh material in contact with the vaginal epithelium. Furthermore, these features provide more favourable host immune response, that is, more anti-inflammatory and less pro-inflammatory response. Another important feature of the mesh devices is the pore geometry dynamics in relation to the load on to the mesh. Pore collapse and loss of porosity leads to increased mesh load in specific areas, which then leads to increased foreign body response, encapsulation and retraction. These are directly related to pain associated with transvaginal mesh device implantation.10 11 12

We learnt from Prof Kate Moore’s presentation the role of bacteriuria in detrusor overactivity (DO), with exciting pilot study results suggesting the importance of low-count bacteriuria in refractory DO. Women with refractory DO have bacteriuria rates of 39 per cent on midstream urine and 27 per cent on catheter specimen urine without acute dysuria at time of acute exacerbation of urge and that newly diagnosed DO have odds ratio (OR) of 5.9 for low count bacteriuria compared to those with a stable bladder.

Another noteworthy aspect of the meeting was the discussion led by Dr Behnia-Willison on the application of CO2 laser therapy for treatment of vulvovaginal atrophy, specifically with the use of MonaLisa Touch™. So far, we have seen results of short-term studies investigating this modality of treatment. The session ended with the conclusion that there is not enough evidence in favour of this treatment and we need more long-term, high-powered studies to be able to critically appraise and recommend CO2 laser therapy for the treatment of vulvovaginal atrophy.

The closing session was a focus on urogynaecology in the elderly and Prof DeLancy presented ‘The Michigan four star apical suspension procedure’. In this procedure, he demonstrated a surgical technique for vault suspension, which starts at vaginal apex, excises excess vaginal length, includes both the anterior and posterior vaginal walls, attaches open vaginal cuff to ligaments and avoids descent of contralateral wall. In doing so, it creates a durable apical suspension, optimises each operative step, returns normal vaginal length, re-establishes alignment so pressures are balanced and encourages posterior repair to compensate for enlarged levator hiatus. This presentation is available on the UGSA website in the members-only section.

Dr Lin Li Ow won the UGSA travel scholarship award, while Dr Nevine te West won the best oral abstract presentation for ‘Quantitative mass spectrophotometry oestriol serum levels in new and chronic users of vaginal oestriol cream’.

It is virtually impossible to highlight every presentation from such a great scientific conference; we apologise for any omissions in this short review. This meeting was the result of tremendous work and contribution from the local organising committee together with UGSA scientific committee members. We would also like to acknowledge the significant role of our sponsors who are part of our society and make these meetings possible. We hope to see you at next year’s UGSA ASM in Victoria, Australia.

References

  1. Miller JM, Brandon C, Jacobson JA, et al. MRI Findings in Patients Considered High Risk for Pelvic Floor Injury Studied Serially Post Vaginal Childbirth. AJR Am J Roentgenol. 2010 Sep;195(3):786-791.
  2. DeLancey J, Morgan DM, Fenner DE, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 2007 Feb;109(2 Pt 1):295-302.
  3. KL Shek, HP Dietz, Intrapartum risk factors for levator trauma, BJOG. 2010 Nov;117(12):1485-1492.
  4. Memon HU, Blomquist JL, Dietz HP, et al. Comparison of levator ani muscle avulsion injury after forceps-assisted and vacuum-assisted vaginal childbirth. Obstet Gynecol. 2015 May;125(5):1080-7.
  5. Trutnovsky G, Kamisan Atan I, Martin A, Dietz HP. Delivery mode and pelvic organ prolapse: a retrospective observational study. BJOG. 2015 Oct 5 [Epub ahead of print].
  6. Wilson D, Dornan J, Milsom I, Freeman R. UR-CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? Int Urogynecol J. 2016;27:511-512.
  7. MacArthur C, Glazener C, Lancashire R, et al. Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG. 2011 Jul;118(8):1001-7.
  8. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013 Jan;120(2):152-60.
  9. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013 Jan;120(2):144-51.
  10. Barone WR, Moalli PA, Abramowitch SD.Textile properties of synthetic prolapse mesh in response to uniaxial loading. Am J Obstet Gynecol. 2016 Mar 18 [Epub ahead of print].
  11. Brown BN, Mani D, Nolfi AL, et al. Characterization of the host inflammatory response following implantation of prolapse mesh in rhesus macaque. Am J Obstet Gynecol. 2015 Nov;213(5):668.e1-10.
  12. Liang R, Abramowitch S, Knight K, et al. Vaginal degeneration following implantation of synthetic mesh with increased stiffness. BJOG. 2013 Jan;120(2):233-43.

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