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Vault prolapse and rectocele assessment of repair using sacrocolpopexy with mesh interposition
CORRESPONDENCE 775
detection of women at risk of depressive illness postpartum, regardless of aetiology.
Dorthe Nielsen Forman a & Poul Videbech b a Perinatal Epidemiological Research Unit, Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark b Department Biological Psychiatry, G Psychiatric Hospital, Aarhus, Denmark PII: S 0306-545 6(00)00165-0
Naegele's rule: a reappraisal Sir, We congratulate Baskett and Nagele on their excellent reappraisal of Naegele's rule 1. As they point out, much of the world still has to rely on menstrual dating of pregnancy. However this is likely to change steadily over the years and as more communities acquire ultrasound facilities there will be a need for accurate local ultrasound dating charts. There is a general assumption that ultrasound dating does away with Naegele's rule. This is quite erroneous. The traditional ultrasound dating chart does not provide an expected date of delivery but does provide a virtual last menstrual period from which the expected date of delivery can be calculated using Naegele's rule. As the authors point out, there is considerable evidence that the rule has been misinterpreted or is not accurate enough for today's obstetric practice. All charts at present are based on the last menstrual period with its inherent error in estimating the expected date of delivery. We propose a method for generating ultrasound dating charts which eliminates the uncertainty of the last menstrual period and the uncertainty of the length of gestation. Hermanni Boerhaave used the last menstrual period as a surrogate for the start of pregnancy. Many investigators have continued to use this event to calculate the interval from the last menstrual period to delivery in the normal population 2. We have proposed a method for the generation of ultrasound dating charts which mimics the method of Boerhaave 3 by replacing the last menstrual period with ultrasound scan. There are numerous advantages over the traditional approach 4. The population we studied had normal healthy pregnancy with spontaneous onset of labour (normally 80% of the population) followed by delivery of a healthy infant. This contrasts with the traditional method with a highly selected group of women with a certain last menstrual period, regular and known cycle length and a willingness to participate in the study. In our study routinely available data were used without selection. Furthermore the large amount of data available results in narrow con®dence intervals. Using this method there is automatic compensation for variability which may occur with the length of pregnancy or the size of the infant on the ultrasound scan. The effect of skew, which results from the exclusion of women with induction of labour for post-maturity, can be estimated with some reasonable accuracy. We hope to publish a locally de®nitive crownrump length dating chart in the near future to fully demonstrate the method which expands the original publication 3.
References 1. Baskett TF, Nagele F. Naegele's rule: a reappraisal. Br J Obstet Gynaecol 2000;107:1433±1435. 2. Nguryen TH, Larsen T, Engholm G, Moller H. Evaluation of ultrasound estimated date of delivery in 17450 spontaneous singleton births: do we
need to modify Naegele's rule? Ultrasound Obstet Gynecol 1999;14:23± 28. 3. Hutchon DJR. `Back to the Future' for Hermanni Boerhaave or `A rational way to generate ultrasound scan charts for estimating the date of delivery'. Obgyn.net 1998: http://www.obgyn.net/us/cotm/9807/ cotm_9807.htm. 4. Atlman DG, Chitty LS. New charts for ultrasound dating of pregnancy. Ultrasound Obstet Gynecol 1997;10:174±191.
D. J. R. Hutchon & F. Ahmed Department of Obstetrics and Gynaecology, Memorial Hospital, Darlington, UK PII: S0306 -5 456(00)00166 -2
Vault prolapse and rectocele assessment of repair using sacrocolpopexy with mesh interposition Sir, We read with interest the results of the case series by Fox and Stanton reporting the repair of vault prolapse and rectocele using sacrocolpopexy with mesh interposition. Whilst we congratulate them on the procedure which appears to signi®cantly reduce the presence of prolapse, we share their concerns relating to an apparent increase in bowel dysfunction. They report an increase in the total number of women reporting both constipation and incomplete defecation. We have recently surveyed our own results of sacrocolpopexy and found a persistence or increase in bowel symptoms in 39% of women. These ®ndings concur with previous reports of the treatment of both vault prolapse and rectocele 1,2. Although it is possible that the questionnaire used in their study lacked the sensitivity to detect a slight improvement in bowel symptoms, the increase in the number of women complaining of symptoms suggests that their prolapse repair is unlikely to relieve bowel symptoms. A description of the proportion of women who improved, remained unchanged, deteriorated or developed new symptoms may help to clarify their results. We would recommend that a reliable and validated quality of life questionnaire should be used in the assessment of all surgical procedures for prolapse 3. This form of assessment will allow women to receive appropriate advice concerning treatment of their prolapse where they also have bowel dysfunction. The ability of a surgical repair to improve functional symptoms must be questioned. Women with pelvic ¯oor prolapse are recognised to have anatomical and neurophysiological problems predominantly related to childbirth. Hence an assessment of function is as important as the delineation of the structural abnormality if the purpose of surgical procedures is to treat functional symptoms. In view of the continued reporting of failure of prolapse surgery to improve bowel symptoms we recommend that formal assessment of bowel function be performed preoperatively in women who have bowel symptoms and pelvic ¯oor prolapse.
References 1. Cundiff GW, Harris RL, Coates K, Low VHS, Bump RC, Addison WA. Abdominal sacral colpoperinopexy: A new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse. Am J Obset Gynecol 1997;177:1345±1355. 2. Khan M, Stanton SL. Posterior Colporrhapy: its effect on bowel and sexual function. Br J Obstet Gynaecol 1996;104:82±86. 3. Digesu GA, Khullar V, Cardozo L, Robinson, Salvatore S. P-QOL: A
776 CORRESPONDENCE validated quality of life questionnaire for the symptomatic assessment of women with uterovaginal prolapse [abstract]. Int Urogynecol J 2000;2000(Suppl 1):524.
Graham M. Taylor, Paul Ballard & Gerald J. Jarvis Department of Obstetrics and Gynaecology, St Jame's University Hospital, Leeds, UK PII: S03 06-5456(00)0016 7-4
A comparison of bladder neck movement and elevation after tension free vaginal tape and colposuspension Sir, I would like to congratulate Michelle Atherton and Stuart Stanton for their study looking at bladder neck movement and elevation after the tension-free vaginal tape operation and colposuspension. In our series of 67 women 1, where tension-free vaginal tape was used for recurrent stress incontinence and intrinsic sphincter de®ciency we found that there was no change in urodynamic variables pre- and post- operatively that was statistically signi®cant. These were cystometric capacity, maximum urethral closure pressure, pressure transmission at maximum urethral closure pressure, functional urethral length and maximum urinary ¯ow rates, both preand post- operatively. The tension-free vaginal tape operation as described by Petros and Ulmsten 2 requires a mid-urethral placement rather than a bladder neck placement, therefore making the conclusions of Atherton and Stanton's study valid, that the tensionfree vaginal tape operation does not depend on bladder neck changes, unlike colposuspension. In a few women we have divided the tape in the midline after placing it and removing the plastic sheath, and then closed the vagina with successful results and with no differences in urodynamic variables, compared with the standard tension-free vaginal tape operation. This suggests vaginal tape is not a `pulling up' operation, but an operation that probably creates `neo-pubo-urethral ligaments', and attaches the midurethra to the smooth muscle components of the pelvis, as described by De Lancy 3.
References 1. Rane A, Fraser M. Tension free vaginal tape procedure in recurrent stress incontinence proc. Annual Scienti®c Meeting RANZCOG, Cairns, June 2000. 2. Petros P, Ulmsten U. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scan 1990;69(Suppl 153):1±37. 3. De Lancy JO. Structural support of the urethra as it relates to stress urinary incontinence: `The Hammock Hypothesis'. Am J Obstet Gynecol 1994;170:1713±1723.
Ajay Rane Department of Obstetrics and Gynaecology, Kirwan Hospital for Women, Kirwan, Australia PII: S03 06-5456(00)0016 8-6
A randomised controlled trial of ¯exibility in routine antenatal care Sir, It is reassuring to read that the British Antenatal Care Study 1 con®rmed the ®nding in previous trials 2±6 that a reduction in the frequency of antenatal visits caused no detriment to clinical outcomes. It is also of interest that neither women's con®dence about labour and baby care nor attitudes to the baby were adversely affected by the `¯exible' schedule of visits, and since there was an excellent response rate to the questionnaire (90%), this is a robust result. The alarms raised by the report of Sikorski et al. 4 were in any event attenuated by the results of their follow up study 7, which showed no psychosocial differences at 2 years. Although in this study and in others 2±4 signi®cantly more women receiving fewer visits would have liked more, the majority of women in the intervention arms considered the number of visits to be just right and would recommend the schedule to a friend. A modest reduction in visits would, therefore, seem to be safe and acceptable to most women. Savings in the costs of antenatal care are likely to be small 8, but potential savings to women are also possible. Maintaining traditional schedules of antenatal care for low risk women, with no difference between care programmes for women in ®rst and subsequent pregnancies, should not be a high priority for expenditure on health.
References 1. Jewell D, Sharp D, Sanders J, Peters TJ. A randomised controlled trial of ¯exibility in routine antenatal care. Br J Obstet Gynaecol 2000;107:1241±1247. 2. Binstock MA, Wolde-Tsadik F. Alternative prenatal care. J Reprod Med 1994;39:1±6. 3. McDuf®e R, Beck A, Bischoff K, et al. Effect of prenatal care visits on perinatal outcome among low-risk women: a randomised controlled trial. JAMA 1996;275:847±885. 4. Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. BMJ 1996;312:546±553. 5. Munjanja SP, Lindmark G, Nystrom L. Randomised controlled trial of a reduced visits programme of antenatal care in Harare. Zimbabwe. Lancet 1996;348:364±369. 6. Walker DS, Koniak-Grif®n D. Evaluation of reduced frequency prenatal visit schedule for low-risk women at a freestanding birthing center. Midwifery 1996;12:120±128. 7. Clement S, Candy J, Sikorski J, Wilson J, Smeeton N. Does reducing the frequency of routine antenatal visits have long-term effects? Follow-up of participants in a randomised controlled trial. Br J Obstet Gynaecol 1999;106:367±370. 8. Henderson J, Roberts T, Sikorski J, Wilson J, Clement S. An economic evaluation comparing two schedules of antenal visits. J Health Serv Res Pol 2000;5:69±75.
Marion Hall & Janet Tucker Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, UK PII: S0 306-5456(00 )00 169-8
detection of women at risk of depressive illness postpartum, regardless of aetiology.
Dorthe Nielsen Forman a & Poul Videbech b a Perinatal Epidemiological Research Unit, Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark b Department Biological Psychiatry, G Psychiatric Hospital, Aarhus, Denmark PII: S 0306-545 6(00)00165-0
Naegele's rule: a reappraisal Sir, We congratulate Baskett and Nagele on their excellent reappraisal of Naegele's rule 1. As they point out, much of the world still has to rely on menstrual dating of pregnancy. However this is likely to change steadily over the years and as more communities acquire ultrasound facilities there will be a need for accurate local ultrasound dating charts. There is a general assumption that ultrasound dating does away with Naegele's rule. This is quite erroneous. The traditional ultrasound dating chart does not provide an expected date of delivery but does provide a virtual last menstrual period from which the expected date of delivery can be calculated using Naegele's rule. As the authors point out, there is considerable evidence that the rule has been misinterpreted or is not accurate enough for today's obstetric practice. All charts at present are based on the last menstrual period with its inherent error in estimating the expected date of delivery. We propose a method for generating ultrasound dating charts which eliminates the uncertainty of the last menstrual period and the uncertainty of the length of gestation. Hermanni Boerhaave used the last menstrual period as a surrogate for the start of pregnancy. Many investigators have continued to use this event to calculate the interval from the last menstrual period to delivery in the normal population 2. We have proposed a method for the generation of ultrasound dating charts which mimics the method of Boerhaave 3 by replacing the last menstrual period with ultrasound scan. There are numerous advantages over the traditional approach 4. The population we studied had normal healthy pregnancy with spontaneous onset of labour (normally 80% of the population) followed by delivery of a healthy infant. This contrasts with the traditional method with a highly selected group of women with a certain last menstrual period, regular and known cycle length and a willingness to participate in the study. In our study routinely available data were used without selection. Furthermore the large amount of data available results in narrow con®dence intervals. Using this method there is automatic compensation for variability which may occur with the length of pregnancy or the size of the infant on the ultrasound scan. The effect of skew, which results from the exclusion of women with induction of labour for post-maturity, can be estimated with some reasonable accuracy. We hope to publish a locally de®nitive crownrump length dating chart in the near future to fully demonstrate the method which expands the original publication 3.
References 1. Baskett TF, Nagele F. Naegele's rule: a reappraisal. Br J Obstet Gynaecol 2000;107:1433±1435. 2. Nguryen TH, Larsen T, Engholm G, Moller H. Evaluation of ultrasound estimated date of delivery in 17450 spontaneous singleton births: do we
need to modify Naegele's rule? Ultrasound Obstet Gynecol 1999;14:23± 28. 3. Hutchon DJR. `Back to the Future' for Hermanni Boerhaave or `A rational way to generate ultrasound scan charts for estimating the date of delivery'. Obgyn.net 1998: http://www.obgyn.net/us/cotm/9807/ cotm_9807.htm. 4. Atlman DG, Chitty LS. New charts for ultrasound dating of pregnancy. Ultrasound Obstet Gynecol 1997;10:174±191.
D. J. R. Hutchon & F. Ahmed Department of Obstetrics and Gynaecology, Memorial Hospital, Darlington, UK PII: S0306 -5 456(00)00166 -2
Vault prolapse and rectocele assessment of repair using sacrocolpopexy with mesh interposition Sir, We read with interest the results of the case series by Fox and Stanton reporting the repair of vault prolapse and rectocele using sacrocolpopexy with mesh interposition. Whilst we congratulate them on the procedure which appears to signi®cantly reduce the presence of prolapse, we share their concerns relating to an apparent increase in bowel dysfunction. They report an increase in the total number of women reporting both constipation and incomplete defecation. We have recently surveyed our own results of sacrocolpopexy and found a persistence or increase in bowel symptoms in 39% of women. These ®ndings concur with previous reports of the treatment of both vault prolapse and rectocele 1,2. Although it is possible that the questionnaire used in their study lacked the sensitivity to detect a slight improvement in bowel symptoms, the increase in the number of women complaining of symptoms suggests that their prolapse repair is unlikely to relieve bowel symptoms. A description of the proportion of women who improved, remained unchanged, deteriorated or developed new symptoms may help to clarify their results. We would recommend that a reliable and validated quality of life questionnaire should be used in the assessment of all surgical procedures for prolapse 3. This form of assessment will allow women to receive appropriate advice concerning treatment of their prolapse where they also have bowel dysfunction. The ability of a surgical repair to improve functional symptoms must be questioned. Women with pelvic ¯oor prolapse are recognised to have anatomical and neurophysiological problems predominantly related to childbirth. Hence an assessment of function is as important as the delineation of the structural abnormality if the purpose of surgical procedures is to treat functional symptoms. In view of the continued reporting of failure of prolapse surgery to improve bowel symptoms we recommend that formal assessment of bowel function be performed preoperatively in women who have bowel symptoms and pelvic ¯oor prolapse.
References 1. Cundiff GW, Harris RL, Coates K, Low VHS, Bump RC, Addison WA. Abdominal sacral colpoperinopexy: A new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse. Am J Obset Gynecol 1997;177:1345±1355. 2. Khan M, Stanton SL. Posterior Colporrhapy: its effect on bowel and sexual function. Br J Obstet Gynaecol 1996;104:82±86. 3. Digesu GA, Khullar V, Cardozo L, Robinson, Salvatore S. P-QOL: A
776 CORRESPONDENCE validated quality of life questionnaire for the symptomatic assessment of women with uterovaginal prolapse [abstract]. Int Urogynecol J 2000;2000(Suppl 1):524.
Graham M. Taylor, Paul Ballard & Gerald J. Jarvis Department of Obstetrics and Gynaecology, St Jame's University Hospital, Leeds, UK PII: S03 06-5456(00)0016 7-4
A comparison of bladder neck movement and elevation after tension free vaginal tape and colposuspension Sir, I would like to congratulate Michelle Atherton and Stuart Stanton for their study looking at bladder neck movement and elevation after the tension-free vaginal tape operation and colposuspension. In our series of 67 women 1, where tension-free vaginal tape was used for recurrent stress incontinence and intrinsic sphincter de®ciency we found that there was no change in urodynamic variables pre- and post- operatively that was statistically signi®cant. These were cystometric capacity, maximum urethral closure pressure, pressure transmission at maximum urethral closure pressure, functional urethral length and maximum urinary ¯ow rates, both preand post- operatively. The tension-free vaginal tape operation as described by Petros and Ulmsten 2 requires a mid-urethral placement rather than a bladder neck placement, therefore making the conclusions of Atherton and Stanton's study valid, that the tensionfree vaginal tape operation does not depend on bladder neck changes, unlike colposuspension. In a few women we have divided the tape in the midline after placing it and removing the plastic sheath, and then closed the vagina with successful results and with no differences in urodynamic variables, compared with the standard tension-free vaginal tape operation. This suggests vaginal tape is not a `pulling up' operation, but an operation that probably creates `neo-pubo-urethral ligaments', and attaches the midurethra to the smooth muscle components of the pelvis, as described by De Lancy 3.
References 1. Rane A, Fraser M. Tension free vaginal tape procedure in recurrent stress incontinence proc. Annual Scienti®c Meeting RANZCOG, Cairns, June 2000. 2. Petros P, Ulmsten U. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scan 1990;69(Suppl 153):1±37. 3. De Lancy JO. Structural support of the urethra as it relates to stress urinary incontinence: `The Hammock Hypothesis'. Am J Obstet Gynecol 1994;170:1713±1723.
Ajay Rane Department of Obstetrics and Gynaecology, Kirwan Hospital for Women, Kirwan, Australia PII: S03 06-5456(00)0016 8-6
A randomised controlled trial of ¯exibility in routine antenatal care Sir, It is reassuring to read that the British Antenatal Care Study 1 con®rmed the ®nding in previous trials 2±6 that a reduction in the frequency of antenatal visits caused no detriment to clinical outcomes. It is also of interest that neither women's con®dence about labour and baby care nor attitudes to the baby were adversely affected by the `¯exible' schedule of visits, and since there was an excellent response rate to the questionnaire (90%), this is a robust result. The alarms raised by the report of Sikorski et al. 4 were in any event attenuated by the results of their follow up study 7, which showed no psychosocial differences at 2 years. Although in this study and in others 2±4 signi®cantly more women receiving fewer visits would have liked more, the majority of women in the intervention arms considered the number of visits to be just right and would recommend the schedule to a friend. A modest reduction in visits would, therefore, seem to be safe and acceptable to most women. Savings in the costs of antenatal care are likely to be small 8, but potential savings to women are also possible. Maintaining traditional schedules of antenatal care for low risk women, with no difference between care programmes for women in ®rst and subsequent pregnancies, should not be a high priority for expenditure on health.
References 1. Jewell D, Sharp D, Sanders J, Peters TJ. A randomised controlled trial of ¯exibility in routine antenatal care. Br J Obstet Gynaecol 2000;107:1241±1247. 2. Binstock MA, Wolde-Tsadik F. Alternative prenatal care. J Reprod Med 1994;39:1±6. 3. McDuf®e R, Beck A, Bischoff K, et al. Effect of prenatal care visits on perinatal outcome among low-risk women: a randomised controlled trial. JAMA 1996;275:847±885. 4. Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. BMJ 1996;312:546±553. 5. Munjanja SP, Lindmark G, Nystrom L. Randomised controlled trial of a reduced visits programme of antenatal care in Harare. Zimbabwe. Lancet 1996;348:364±369. 6. Walker DS, Koniak-Grif®n D. Evaluation of reduced frequency prenatal visit schedule for low-risk women at a freestanding birthing center. Midwifery 1996;12:120±128. 7. Clement S, Candy J, Sikorski J, Wilson J, Smeeton N. Does reducing the frequency of routine antenatal visits have long-term effects? Follow-up of participants in a randomised controlled trial. Br J Obstet Gynaecol 1999;106:367±370. 8. Henderson J, Roberts T, Sikorski J, Wilson J, Clement S. An economic evaluation comparing two schedules of antenal visits. J Health Serv Res Pol 2000;5:69±75.
Marion Hall & Janet Tucker Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, UK PII: S0 306-5456(00 )00 169-8