AGES Pelvic Floor Symposium & Workshop VI

Australian 

Gynaecological 

Endoscopy 

Society 

14 & 15 October 2005 Melbourne 

New Solutions 

Pelvic Floor Symposium & Workshop VI 2005 

Royal Women’s Hospital & Park Hyatt Melbourne 

International Guest: 

Dr Tony Smith, Manchester, United Kingdom 

Program 

& 

Abstracts 

Platinum sponsor of AGES 

Major sponsor of AGES

Message from 

Convenor and 

AGES President 

Conference 

Committee 

International 

Faculty 

AGES warmly welcomes you to the first AGES 

Pelvic Floor Meeting to be held in 

Melbourne. The theme of the meeting is 

‘New Solutions’. The scientific chairs, Dr 

Marcus Carey and Dr Anna Rosamilia, have 

put together a program which will help us 

understand how to apply some of these new 

solutions. The Meeting will focus on both 

vaginal and laparoscopic approaches to 

deal with prolapse with a particular 

emphasis on the use of tapes, slings and 

mesh. AGES has not forgotten the 

laparoscopic pelvic floor surgeons as we 

will also be discussing a laparoscopic place 

of these devices. 

We are very privileged to have a formal and 

detailed lecture on pelvic anatomy 

presented by Professor Norm Eizenberg of 

the University of Melbourne Anatomy School. 

This will be followed by live surgery at the 

Royal Women’s Hospital. There will be 2 

theatres running concurrently. One theatre 

will feature vaginal surgery using tape and 

mesh and the other theatre will feature on 

laparoscopic approaches for various pelvic 

floor disorders. 

Our international speaker, Dr Tony Smith 

from Manchester, will be operating and also 

presenting a series of plenary lectures. 

As with all new solutions there are obvious 

problems. Tape and mesh have now been in 

use in our gynaecological practices for a 

number of years. These devices have their 

own specific problems and the meeting will 

discuss how these problems may present 

and how to deal with them. 

We would like to thank our scientific 

chairpersons and organising committee as 

well as our international and Australian 

faculty for their support with this meeting. 

We look forward to a fantastic meeting in 

Melbourne. 

Yours sincerely, 

Dr Robert O’Shea Dr Jim Tsaltas 

President AGES Conference Chair 

Dr. Jim Tsaltas – Chair 

Dr. Marcus Carey – Scientific Chair 

Dr. Anna Rosamilia – Scientific Chair 

A/Prof. Alan Lam 

Dr. Robert O’Shea 

Dr. Anthony Lawrence 

AGES Board 

Dr. Robert O’Shea President 

A/Prof. Alan Lam Vice President 

Dr. Jim Tsaltas Hon Secretary 

Dr. Geoffrey Reid Treasurer 

Dr. Greg Cario 

Dr. Jenny Cook 

Prof. David Healy 

Dr. Krish Karthigasu 

Dr. Chris Maher 

Dr. Anusch Yazdani 

Australian Faculty 

Dr. Haider Ahmed 

Dr. Mark Ashton 


Dr. Marcus Carey 


Dr. Caroline Dowling 

Dr. Peter Dwyer 

Dr. Geoff Edwards 

Prof. Norman Eizenberg 

Ms. Helena Frawley 

Prof. Judith Goh 

sponsored by Gynecare 

Victoria 

Victoria 

New South Wales 

Victoria 

South Australia 

Victoria 

Victoria 

Victoria 

Victoria 

Victoria 

Queensland 

Prof. David Healy Victoria 

Dr. Peta Higgs Victoria 

Dr. Emmanuel Karantanis New South Wales 

Dr. Krish Karthigasu Western Australia 

A/Prof. Alan Lam New South Wales 

Dr. Anthony Lawrence Victoria 

Dr. Annie Leong Victoria 

Dr. Yik Lim 

Queensland 

Dr. Chris Maher Queensland 

A/Prof. Peter Maher Victoria 

Dr. Jane Manning New South Wales 

Dr. Robert O’Shea South Australia 

Prof. Ajay Rane Queensland 

sponsored by American Medical Systems 

Dr. Geoffrey Reid 

Dr. Anna Rosamilia 

Dr. Lore Scherlitz 

Dr. Elvis Seman 

Dr Alison de Souza 

A/Prof. Joe Tjandra 

Dr. Jim Tsaltas 


AGES Secretariat – Conference Organiser 

Michele Bender, Director – Conference Connection 

Phone: 02 9967 2928 

Fax: 02 9967 2627 

Mobile: 0411 110 464 

E-mail: conferences@ages.com.au 

Post: 282 Edinburgh Road CASTLECRAG NSW 2068 

Dr. Tony Smith 

United Kingdom 

sponsored by tyco Healthcare 

New South Wales 

Victoria 

Victoria 

South Australia 

Victoria 

Victoria 

Victoria 

Queensland

Australian 


Endoscopy 

Society 

New Solutions 

Pelvic Floor Symposium & Workshop VI 2005 

Contents 

2 Conference 

3 Social 

Program 

Program 

4 Abstracts 

Platinum sponsor of AGES 

Major sponsor of AGES

Live Operating Session 

Yvonne Bowden Auditorium 

Royal Women’s Hospital 

132 Grattan Street 

Carlton Victoria 

sponsored by 

Stryker 

AGES Pelvic Floor Symposium 

& Workshop VI New Solutions 

Ballroom 

Park Hyatt Melbourne 

1 Parliament Square, off Parliament Place 

Melbourne, Victoria 

Friday 14 October 2005 

Saturday 15 October 2005 

0730–0745 Coach transportation from 

Park Hyatt 

0800–0825 Conference Registration 

0825–0830 Conference Opening and Welcome 

0830–0915 Pelvic Anatomy with Anatomedia 

Demonstration 

Prof. Norm Eizenberg 

Professor of Anatomy, 

University of Melbourne 

0915–0930 Discussion 

Surgeons Dr. Tony Smith 

Dr. Marcus Carey A/Prof. Alan Lam 

Dr. Geoff Edwards Dr. Ajay Rane 

Prof. Judith Goh Dr. Anna Rosamilia 

Moderators Morning 


Moderators Afternoon 

A/Prof. Peter Maher 

Dr Geoff Edwards 


Theatre 1 

0930 Prolift 

Perigee Apogee with uterine 

conservation 

Monarc transobturator sling 

Laparoscopic pelvic floor repair 

Theatre 2 

0930 Laparoscopic sacrocolpopexy 

and TVT-O 

Laparoscopic mesh hysteropexy 

Paravaginal repair 

1600 NASOG AGM 

1615 Coach transportation to Park Hyatt 

1700–1830 Welcome Cocktail Reception 

Trilogy Room, Park Hyatt 

Surgery will run from 0930 until 1600. Lunch, 

morning and afternoon tea will be included. 

0800–0810 Conference Opening and 

Welcome 

AGES President: 


Conference Chairman: 


SESSION 1 - PELVIC FLOOR DYSFUNCTION 

sponsored by Stryker 

Chair: Dr. Robert O’Shea 


0810–0825 Pelvic Floor Dysfunction – The 

How, Who and How Many 


0825–0840 Assessment of Pelvic Organ 

Prolapse 

Dr. Elvis Seman 

0840–0855 Assessment of Urinary 

Incontinence 

Dr. Yik Lim 


SESSION 2 - NEW SOLUTIONS FOR PELVIC 

ORGAN PROLAPSE 

sponsored by 

Olympus Australia 

Chair: Dr. Greg Cario 

Dr. Krish Karthagisu 

0905–0920 Surgery for Pelvic Organ 

Prolapse – Current Practice 


0920–0935 Mesh and Biological 

Prostheses 


0935–0945 Extraperitoneal Uterosacral 

Ligament Suspension 

Prof. Peter Dwyer 

0945–0955 Laparoscopic Approach to 

Prolapse Repair 


0955–1005 Prolapse Surgery with Uterine 

Conservation 

Dr. Christopher Maher 

1005–1015 Outcomes of Prolapse 

Surgery 



PR&CRM Pre-Questionnnaires 

to be handed in at Morning Tea 

1030–1100 Morning Tea and Exhibition – 

Foyer and Fairmont Room 

SESSION 3 - NEW SOLUTIONS FOR URINARY 

INCONTINENCE 

sponsored by 

Olympus Australia 

Chair: Prof. David Healy 

Dr. Geoff Edwards 

1100–1110 Lying, Sitting, Standing: Does 

Assessment Position Make a 

Difference 

Ms. Helena Frawley 

1110–1120 Electrical / Magnetic 

Stimulation 

Dr. Lore Scherlitz 

1120–1130 Drug Solutions for 

Incontinence 

1130–1140 Injectables 

Dr. Emmanuel Karantanis 

Dr. Jane Manning 

1140–1150 New Generation Tapes 

Dr. Peta Higgs 


2 New Solutions Pelvic Floor Symposium & Workshop VI

Keynote Lecture 

Chair: Dr. Jim Tsaltas 

1200–1235 Challenges Facing Surgical 

Innovation 


1235–1335 Lunch and Exhibition – 

Foyer and Fairmont Room 

SESSION 4 - DEBATE 

sponsored by Stryker 

1335–1420 Is Graft Reinforcement 

Necessary for Optimal 

Outcome in Pelvic Organ 

Prolapse Surgery 

Chair: A/Prof. Peter Maher 

Affirmative: Dr. Tony Smith 


Negative: 

A/Prof. Alan Lam 

Dr Chris Maher 

Audience Votes: Transponder Session 

SESSION 5 - MULTIDISCIPLINARY 

SOLUTIONS I 

sponsored by 

Johnson & Johnson Medical 

Chair: Dr. Geoff Reid 


1420–1435 Faecal Incontinence 

Dr. Joe Tjandra 

1435–1445 Posterior Compartment 

Prolapse - A Gynaecological 

Approach 

Dr. Chris Maher 

1445–1500 Obstructed Defaecation and 

Rectocele – Colorectal 

Perspective 

Dr. Chip Farmer 

1500–1515 Gems from a Plastic Surgeon 

Dr. Mark Ashton 


1530–1600 Afternoon Tea and Exhibition 

– Foyer and Fairmont Room 

SESSION 6 - MULTIDISCIPLINARY 

SOLUTIONS II 

sponsored by 

Johnson & Johnson Medical 

Chair: Dr. Geoff Reid 


1600–1610 Botulinum Toxin for Bladder 

Dysfunction 

Dr. Caroline Dowling 

1610–1620 Solutions for Painful Bladder 

Syndrome 


1620–1630 Neuromodulation 



SESSION 7 - NEW SOLUTIONS GONE WRONG 

sponsored by 

American Medical Systems 

1640–1725 Chair: Dr. Marcus Carey 

Dr. Anna Rosemilia 

Expert Panel: Dr Tony Smith, 

Prof. Peter Dwyer, Dr Robert 

O'Shea, A/Prof. Alan Lam, Ms 

Helena Frawley, A/Prof. Joe 

Tjandra, Dr Chip Farmer, Dr 

Caroline Dowling. 

Included in the session: 

The Management of Post 

Surgical Dyspareunia; Vaginal 

Stenosis; Voiding Dysfunction, 

Mesh Erosion; Fistula; 

Recurrent Incontinence and 

Recurrent Prolapse. 

Audience Votes: Transponder Session 

1725 Answers to PR&CRM Questions 

Dr Jenny Cook 

1730 Close of Meeting 


PR&CRM Post-Questionnaires to be handed 

in at the close of the meeting. 

1915 for1945 Conference Dinner – 

The Boulevard Restaurant 

RANZCOG PR&CRM and CPD Points 

The Symposium and Workshop have been 

approved as RANZCOG Approved O&G Meetings 

and eligible Fellows of the college will earn 

points for attendance as follows: 

Full attendance 15 CPD points in the 

Meetings category 

Completion of Pre- and Post- 

Questionnaires 5 PR&CRM points 

Pre- and Post-Questionnaires 

The College approved Pre- and Post- 

Questionnaires are comprised of 20 multiple 

choice questions from lectures given on 

Saturday 15 October. 

The Pre-Questionnaire is to be handed in at 

Morning Tea on Saturday 15 October. The Post- 

Questionnaire is to be handed in at the close of 

the Meeting. No exceptions can be made to 

these deadlines. 

Social Program 

WELCOME RECEPTION 

Friday 14 October 2005 1700 – 1830 

Trilogy Room 

Park Hyatt Melbourne 

Relax with friends at an informal gathering 

at the Park Hyatt Melbourne. A fine selection 

of Australian wines and delectable canapés 

will be served while you take the opportunity 

to catch up with colleagues. 

GALA CONFERENCE DINNER 

Saturday 15 October 2005 1915 for 1945 

The Boulevard Restaurant 

121 Studley Park Road 

Kew Victoria 

The Boulevard Restaurant is located in a 

natural bush setting at Studley Park in Kew. 

Its views are framed by Melbourne’s city 

skyline in the distance. The restaurant has 

won many awards for its modern Italian 

cuisine, including the coveted AGE Good 

Food Guide’s Chef’s Hat in 2000. Chef 

Valerio Nucci’s food makes Italophiles 

nostalgic with its fine restraint and 

beautiful flavours – classically Italian but 

simply Australian 

New Solutions Pelvic Floor Symposium & Workshop VI 3


& Workshop VI ABSTRACTS 

PELVIC ANATOMY 

Friday 14 October / Live Operating Session / 

0830-0915 

EIZENBERG N 

Of all regions in the human body, the pelvis is the site where 

most changes in understanding anatomy are currently 

occurring. 

Recent advances in conceptualising the pelvic floor and 

perineal musculature with associated fasciae as well as 

sphincters (urethral, vaginal and anal) and their innervation are 

discussed. 

The anatomy of female genital organs with associated erectile 

tissue, venous plexuses, arteries and autonomic nerves is 

demonstrated. 

Emphasis is placed on an awareness of anatomical variations 

with important clinical, radiological or surgical significance. 

References: 

ANATOMEDIA: Pelvis CD-ROM (to be launched in this lecture) 

Information on Anatomedia: http://www.anatomedia.com 

Author address: Professor Norman Eizenberg, Department of 

Anatomy & Cell Biology, The University of Melbourne, Vic. 3010 

Email: n.eizenberg@unimelb.edu.au 

ASSESSMENT OF PELVIC ORGAN 

PROLAPSE 

Saturday 15 October / Session 1 / 0825-0840 

SEMAN E 

POPQ- Why & for whom 

• Intraoperative assessment - What’s new 

Why POPQ 

• Why measure 

• Why measure with POPQ 

Why measure 

Labour ward registrar scenario: 

New registrar from Chernovia phones with progress report on 

your public parturient. 

Reg: 

You: 

Reg: 

You: 

Reg: 

You: 

Reg: 

You: 

Over the last 4 hours she has progressed from mild to 

moderate dilatation. 

[in dismay] 

Where is she on the partogram 

Sorry Doctor, only one person in Chernovia understands 

the partogram. 

Does she need a Caesarean or not 

No Doctor! 

[3 hours later your Chernovian registrar notifies that the 

parturient has delivered & encountered 2 problems, a 

severely depressed newborn & prolapse.] 

What were the Apgar scores & how severe is the 

prolapse 

In Chernovia we don’t use Apgars. Her POPQ is Aa+3, 

C+10, Ap+3 

Only one person in Australia understands POPQ. Is that 

mild, moderate or severe prolapse 

Reg: POPQ stage 4 is a severe prolapse Doctor. 

Mild, mod & severe are meaningless unless they are based on 

objective measurements eg, Elvis’ interpretation of prolapse 

prePOPQ 

1. Mild = “I don’t think she needs an operation” 

2. Moderate = “I’ve seen this before & I can repair it!” 

3. Severe = “ I’ve never seen one this big ( save it for the 

workshop visitor)” 


Why measure 

Don’t learn anything in medicine unless you measure. 

You look more closely & you see more! 

Why measure with POPQ 

Other methods: Baden-Walker halfway system. 

POPQ: international language of prolapse, analogous to Apgar, 

partogram, etc 

All the hard work has been done! 

Surgical cure is defined. 

Why learn Chernovian when English is the international 

language 

Who should use it & when 

You already know the answers! 

Don’t wait for a medicolegal case, learn it now! 

Quick revision! 

Pelvic floor defects are assessed before & during surgery. 

Critical to see & describe maximum protrusion noted by the 

patient. 

Intraoperatively, up to 32% of patients may have more prolapse 

& 6% less prolapse , than preop (Vineyard et al , 2002). 

POPQ 

Published in Am J Obstet Gynecol in 1996 

2 parts – tandem & ordinal 

Tandem system: 2 sets of parameters 

1. The first is as easy as ABCD – all have A & C, some 

have B & D. 

Hymen is reference point: negative value above, positive 

below. 

Normal 

Aa “urethrovesical crease” -3cm 

Ap 3cm above hymen -3cm 

C ant cervical lip/vault scar -8cm 

Measure B when middle 1/3 prolapses below point A 

D post fornix -10cm 

2. Second set Normal 

Total vaginal length 

10cm 

Genital hiatus 

2cm 

Perineal body 

3cm 

POPQ ordinal system (=staging) 

• Derived from tandem values 

• Stage 0 nil prolapse 

1 to >1cm above hymen (>-1) 

2 to 1cm below, but < TVL-2 

4 vagina completely everted (prolapse = TVL) 

• Stages 0 & 1 define surgical cure 

• Enables each compartment to be staged 

eg vault prolapse 5cm below hymen = stage 3 C 

prolapse 

• Used to describe & compare populations 

What’s new in intraoperative assessment 

Endopelvic fascial defects can be diagnosed & repaired 

transvaginally! 

Combine careful dissection of the ant & post pelvic 

compartments with visualization & palpation. 

“Diagnosing the defect indicates the proper corrective 

procedure” 

Baden & Walker, 1992 

Case examples including videos 

References: 

1. Baden W, Walker T. Surgical repair of vaginal defects. 

Philadelphia: JB Lippincott; 1992. 

2. Bump RC, Mattiasson A, Bo K. et al. The standardization of 

terminology of female pelvic organ prolapse and pelvic floor 

dysfunction. Am J O & G 175:10-17, 1996. 

3. DeLancey JOL. Anatomic aspects of vaginal eversion after 

hysterectomy. Am J O & G 166: 1717-24, 1992. 

4. Vineyard DD et al.A comparison of preoperative & 

intraoperative evaluations for patients who undergo sitespecific 

operation for the correction of pelvic organ 

prolapse. Am J O & G 186: 1155-9, 2002. 

ASSESSMENT OF URINARY 

INCONTINENCE 


LIM Y N 

Urinary incontinence is a disabling and highly prevalent 

condition. With an increase in the ageing population, it is 

inevitable that more women will require referral to a 

gynaecologist. Evaluation of these patients may include one or 

more of the following: 

• History and examination 

• Use of bladder diaries and questionnaires 

• Pad tests 

Simple office bladder filling test 

• Urodynamic investigations: 

• Multichannel or ambulatory cystometrogram 




• Post-void residual estimation 

• Free uroflowmetry, pressure flow studies 

• Urethral pressure profile, leak point pressures 

• Videocystography, fluoro-urodynamics 

• Various forms of imaging technique 

This talk will provide an overview of these evaluation methods 

and discuss their roles in the management of patients with 

urinary incontinence. 

Author address: Dr Yik N Lim, James Cook University, Townsville, 

Queensland 

• Examination findings (stage of POP, short and 

narrow vagina) 

• Urodynamic parameters 

• Evidence base 

• Cost 

• Influence of industry 

Major challenges for POP surgery: 

• Reduction in recurrences and complications 

• Surgical training, prostheses, standardized procedures 

• Ageing population 

• 45% increase in demand for POP surgery 

SURGERY FOR PELVIC ORGAN 

PROLAPSE-CURRENT PRACTICE 


CAREY M 

Each year in the USA, approximately 250,000 women undergo 

surgery for pelvic organ prolapse (POP). Within 4 years, 30% 

undergo repeat POP surgery. Currently there is no consensus on 

optimal surgery for POP. Mesh and biological graft usage is 

increasing and about 18% of POP procedures in US are 

performed with mesh or graft augmentation. 

In the US, cystocele repair accounts for 17% of cases, 

rectocele repair 15%, combined cystocele and rectocele repair 

56% and vault repair 12%. Hysterectomy is performed during 

surgery for POP in 62% of cases and laparoscopy is used in 

only 1.2% of cases. 

Surgery for POP: 

Approach 

Vaginal, Abdominal, Laparoscopic, 

Transperineal/Transanal 

Technique 

Colporrhaphy, site-specific defect approach, mesh or 

graft reinforcement, new surgical kits (Posterior IVS, 

Prolift, Apogee/Perigee) 

Hysterectomy or uterine conservation 

Concomitant anti-incontinence surgery Yes/No 

Which one 

Selection of POP surgery: 

• Training and experience of surgeon 

• Patient factors (age, BMI, sexual activity, medical disease) 

• Previous surgery performed 

Urgent need for improved studies to develop an understanding 

of: 

• Relationship between symptoms and examination findings 

• Indications for POP surgery (including use of prostheses) 

• Impact of surgery on symptoms and examination findings 

Author address: Dr Marcus Carey, Royal Women’s Hospital, 

Melbourne 

MESH AND BIOLOGICAL 

PROSTHESES 


ROSAMILIA A 

The lifetime risk of surgery for prolapse or stress incontinence 

is 11% with 29% of patients requiring more than one surgical 

correction. There is well established efficacy for the use of 

synthetic mesh in groin hernia repair with a 50 to 75 % 

reduced recurrence rate, earlier return to normal activity and 

less chronic pain than pure tissue repairs. The TVT has 

equivalent efficacy and some advantages over open 

colposuspension and rectus sheath sling. Abdominal sacral 

colpopexy using synthetic mesh has cure rates of 90 to 100% 

for the correction of vaginal vault prolapse. Nonabsorbable 

mesh reinforcement placed vaginally has been associated with 

reduced recurrence rate in the anterior compartment. However 

there is an erosion rate of 0 to 13%. Biomaterials are offered 

as an alternative to synthetic meshes with lower erosion rates 

but longterm durability needs to be proven. 


Information regarding in vitro characteristics, behaviour in 

animal models and clinical trials is presented. The “ideal 

prosthesis” should be biocompatible, inert, have minimal 

shrinkage, be durable, noncarcinogenic, have good tensile 

strength, low suture pull-out, lack allergic response, sterile, 

handle well, of uniform thickness, convenient, with no limit on 

size, good remodelling, low infection and erosion risk and 

affordable. The ideal synthetic mesh to date is monofilament, 

large pore, low weight polypropylene. The allografts available 

are derived from donor dermis or fascia lata. Xenografts 

available in Australia are porcine crosslinked dermis or 

submucosal small intestine. 

Experimental data confirm monofilament polypropylene has the 

strongest initial inflammatory response and is the strongest 

product. Porcine derived collagen materials provoke a milder 

and more “tolerant” host response. The crosslinked nonporous 

dermis encapsulates and is weaker early on; adding pores of 

2mm improves integration but relative weakness persists. Non 

cross linked collagen matrix tends to develop seroma within its 

layers early on and is weakest (all values higher than breaking 

strength of healthy tissue). 

New innovations include collagen coating of polypropylene 

which attenuates acute inflammation, produces less adhesion 

and has same long term response as polypropylene. 

BILATERAL EXTRAPERITONEAL 

UTEROSACRAL SUSPENSION FOR 

POST-HYSTERECTOMY VAGINAL 

VAULT PROLAPSE 


DWYER P 

The post-hysterectomy vaginal vault is normally suspended to 

the pelvic wall by the ligamentous complex of the paracolpos 

and lateral cervical-uterosacral complex. In post-hysterectomy 

vaginal vault prolapse there is detachment of these ligamentus 

supports. The sacrospinous ligament and the iliococcygeal 

fascia have both been used as anchor points to suspend the 

vaginal vault but both procedures have been found to have a 

high rate of recurrence particularly of the anterior compartment. 

The uterosacral ligament complex can be used for vault 

suspension and can be approached either transperitoneally as 

described by Shull or extraperitoneally. These ligaments provide 

strong natural support for the vault and give the vagina a 

normal axis. 

The transvaginal extraperitoneal uterosacral ligament vault 

suspension has been our main operation for post-hysterectomy 

for vault prolapse over the last 4 years. In women with 

complete vaginal eversion a midline incision is made extending 

from the urethra anteriorly onto the vault and down the 

posterior wall to the perineum. Little or no vagina needs to be 

excised. The bladder, enterocele sac and rectum are dissected 

off the vagina and the uterosacral ligaments are identified, and 

are usually present high on the lateral pelvic side walls. Midline 

fascial repairs are performed on the anterior and posterior 

compartments, reinforced where necessary with polypropylene 

mesh. Two sutures of 0 PDS are placed into each ligament 

bilaterally and the vagina to suspend the vault. 

Our experience using this procedure over the last 4 years will 

be discussed. 

LAPAROSCOPIC PELVIC FLOOR 

REPAIR – IS THIS APPROACH A 

VIABLE OPTION 


O’SHEA R, SEMAN E, COOK J, 

BEHNIA-WILLISON F 

The laparoscope has offered a unique approach to this surgery. 

Technique: 

• Anterior compartment – Paravaginal Repair ± Anterior 

vaginal repair compartment with Graft 

• Posterior compartment – Supralevator Repair ± Posterior 

vaginal repair 

• Apex – Vaginal vault suspension to uterosacrals ± 

Enterocoele sac excision 

From February 1999 to September 2005, we present a 

prospective observational study. All patients were assessed 

using POPQ, pre and postoperatively, and on an annual basis 

thereafter. Overall, 386 patients are under follow-up, with 

average age 61.5 (31-89), parity 3 (0-11), weight 71.1 kg (47- 

124). Mean operating time (mins). was 137(30,390), 

estimated blood loss 95 (0-2000) and hospital stay (days) 4.3 

(1- 16). 

With follow-up up to 5 years, success rates up to 90% have 




been achieved. At this stage, the laparoscopic approach for 

pelvic floor repair, although technically difficult appears to be 

successful and holds its own against other approaches. 

Author address: Flinders Endogynaecology, Flinders University 

and Flinders Medical Centre, Adelaide, Australia. 

PROLAPSE SURGERY WITH UTERINE 

CONSERVATION 


MAHER C 

In women wishing uterine preservation a variety of surgical 

options are available including the Manchester repair, 

sacrospinous hysteropexy and mesh hysteropexy vaginally, and 

uterosacral hysteropexy and sacral hysteropexy abdominally. 

The Manchester repair has largely been abandoned due to 

recurrence of prolapse in excess of 20% in the first few 

months, decrease in fertility, pregnancy wastage as high as 

50% and future sampling of the cervix and the endometrium 

can be difficult due to vaginal re-epithelialization or cervical 

stenosis. 

The sacrospinous hysteropexy is a safe and effective procedure 

as compared to vaginal hysterectomy and sacrospinous 

colpopexy for uterine prolapse 1, 2 . Only limited data is available 

on pregnancy outcome following sacrospinous hysteropexy. 

Seven pregnancies have been reported with 2 (29%) 

undergoing further prolapse surgery, one each following vaginal 

and caesarian delivery 1, 3 . 

Alternative abdominal approaches include laparoscopic suture 

hysteropexy and sacral hysteropexy. We described the 

laparoscopic suture hysteropexy where the plicated uterosacral 

ligament and cardinal ligaments are re-sutured to the cervix4. 

The objective success rate was 79% at mean 12 months. The 

operation is simple, effective and utilizes native tissue. 

Several authors have reported objective success rates of over 

90% with sacral hysteropexy 5, 6 where mesh secures the cervix 

to the sacrum. Roover’s et al in a randomized control trial 

compared sacral hysteropexy and vaginal hysterectomy and 

repair7 reported a significantly higher re-operation rate for 

prolapse in the hysteropexy group. Cosson has advocated 

uterine preservation as part of the total vaginal mesh repair as 

hysterectomy was an independent risk factor for mesh 

complications. 

Uterine preservation at prolapse surgery is feasible, safe and 

effective. The reconstructive gynecological surgeon has a variety 

of surgical options available that can be individualized to meet 

the needs of the patient. 

References: 

1. Maher CF, Cary MP, Slack MC, Murray CJ, Milligan M, 

Schluter P. Uterine preservation or hysterectomy at 

sacrospinous colpopexy for uterovaginal prolapse Int 

Urogynecol J Pelvic Floor Dysfunct 2001;12:381-4. 

2. Hefni M, El Toukhy T, Bhaumik J, Katsimanis E. 

Sacrospinous cervicocolpopexy with uterine conservation for 

uterovaginal prolapse in elderly women: an evolving 

concept. Am J Obstet Gynecol 2003;188:645-50. 

3. Kovac SR, Cruikshank SH. Successful pregnancies and 

vaginal deliveries after sacrospinous uterosacral fixation in 

five of nineteen patients. Am J Obstet Gynecol 

1993;168:1778-83. 

4. Maher CF, Carey MP, Murray CJ. Laparoscopic suture 

hysteropexy for uterine prolapse. Obstet Gynecol 

2001;97:1010-4. 

5. Leron E, Stanton SL. Sacrohysteropexy with synthetic mesh 

for the management of uterovaginal prolapse. BJOG 

2001;108:629-33. 

6. Barranger E, Fritel X, Pigne A. Abdominal sacrohysteropexy 

in young women with uterovaginal prolapse: long-term 

follow-up. Am J Obstet Gynecol 2003;189:1245-50. 

7. Roovers JP, van der Vaart CH, van der Bom JG, van Leeuwen 

JH, Scholten PC, Heintz AP. A randomised controlled trial 

comparing abdominal and vaginal prolapse surgery: effects 

on urogenital function. BJOG 2004;111:50-6. 

Author Address: Dr Christopher Maher, Wesley, Royal Women’s 

and Mater Urogynaecology, Brisbane, Queensland, Australia. 

www.urogynaecology.com.au 


OUTCOMES OF PROLAPSE SURGERY 

– IMPACT ON QUALITY OF LIFE 


COOK J 

Pelvic floor dysfunction (PFD) is a general term that describes 

conditions which adversely affect the female urinary and faecal 

continence mechanisms, together with genital prolapse. It is 

not uncommon for several pelvic floor disorders to coexist in the 

same woman or to develop sequentially over time. Disorders of 

the pelvic floor rarely result in severe morbidity or mortality. 

Rather, they affect the quality of a woman’s life and it has long 

been assumed that sexual function and satisfaction are 

compromised by these disorders. Over a 12 month period, 61 

women underwent laparoscopic Pelvic Floor Repair (PFR). Four 

questionnaires were administered pre-operatively. These were 

the Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact 

Questionnaire (PFIQ), Pelvic Organ Prolapse-Urinary 

Incontinence Sexual Function Questionnaire (PISQ) and the 

WHOQOL-BREF, which is a general health related quality-of-life 

instrument. Follow-up questionnaires were administered six and 

12 months following surgical intervention. Results showed that 

quality of life, urinary symptoms, and bowel symptoms were 

significantly improved following surgery to equal levels of the 

non-clinical comparison group (N = 50). Surprisingly, however, 

sexual satisfaction remained unchanged from pre-operative 

levels and did not differ from the comparison group. It may be 

concluded that neither the condition of PFD nor the 

intervention of Laparoscopic PFR impact on sexual function 

and satisfaction, despite the otherwise debilitating aspects of 

the condition and benefits of the operation. 

Author address: Dr Jennifer Cook, Flinders Medical Centre, 

Flinders Endogynaecology, Flinders University 

LYING, SITTING, STANDING – DOES 

ASSESSMENT POSITION MAKE A 

DIFFERENCE 


FRAWLEY H 

Symptoms of pelvic floor dysfunction (incontinence, pelvic 

organ prolapse) are commonly provoked in the upright position. 

However assessment of pelvic floor muscle (PFM) function 

traditionally occurs in the recumbent position, which may not 

reflect the physiologic and functional demands on the PFM 

required for continence and organ support. Pelvic organs and 

PFM do not work in isolation from each other, so both aspects 

shall be considered with reference to effect of body position. A 

summary of the differences in the continence mechanism and 

organ support – detected using urodynamic investigations, 

ultrasound imaging, dynamic MRI, defecography and POP-Q 

assessment – shall be presented, highlighting the variations 

identified between lying and upright assessment positions. 

Various factors affect PFM function, including factors intrinsic 

to the muscles, neuro-motor control strategies, intra-abdominal 

pressure changes and specific patient attributes, however it is 

not known whether these factors affect muscle function in the 

same way in the upright position. Results of studies measuring 

PFM activity in lying and upright positions using clinical 

observation, digital muscle testing, manometry, dynamometry, 

real-time ultrasound and electromyography will be presented. 

Validity and reliability of the measurement tool in the upright 

position is an important consideration, before accurate 

interpretation of the results can be accepted. Where statistically 

significant differences have been found between PFM 

contraction in lying and upright positions, the clinical 

significance of these differences will be assessed. Finally, 

clinician and patient preference for assessment of PFM 

function will be discussed. In summary, body position does 

make a difference to measurement of PFM function. 

Recommendations for clinical practice will be presented. 

References: 

1 Altomare DF, Rinaldi M, Veglia A, Guglielmi A, Sallustio PL, 

Tripoli G. 2001. Contribution of posture to the maintenance 

of anal continence. Int J Colorectal Dis 16(1):51-54. 

2 Arunkalaivanan AS, Mahomoud S, Howell M. 2004. Does 

posture affect cystometric parameters and diagnoses Int 

Urogynecol J Pelvic Floor Dysfunct 15(6):422-424; 

discussion 424. 




3 Aukee P, Immonen P, Penttinen J, Laippala P, Airaksinen O. 

2002. Increase in pelvic floor muscle activity after 12 

weeks’ training: a randomized prospective pilot study. 

Urology 60(6):1020-1023; discussion 1023-1024. 

4 Aukee P, Penttinen J, Airaksinen O. 2003. The effect of 

aging on the electromyographic activity of pelvic floor 

muscles. A comparative study among stress incontinent 

patients and asymptomatic women. Maturitas 44(4):253- 

257. 

5 Barber MD, Lambers A, Visco AG, Bump RC. 2000. Effect 

of patient position on clinical evaluation of pelvic organ 

prolapse. Obstet Gynecol 96(1):18-22. 

6 Bertschinger KM, Hetzer FH, Roos JE, Treiber K, Marincek 

B, Hilfiker PR. 2002. Dynamic MR imaging of the pelvic 

floor performed with patient sitting in an open-magnet unit 

versus with patient supine in a closed-magnet unit. 

Radiology 223(2):501-508. 

7 Bø K, Finckenhagen HB. 2003. Is there any difference in 

measurement of pelvic floor muscle strength in supine and 

standing position Acta Obstet Gynecol Scand 

82(12):1120-1124. 

8 Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, 

Klarskov P, Shull BL, Smith AR. 1996. The standardization 

of terminology of female pelvic organ prolapse and pelvic 

floor dysfunction. Am J Obstet Gynecol 175(1):10-17. 

9 Chen GD, Lin LY, Gardner JD, Yeh NH, Wu GS. 1998. 

Dynamic displacement changes of the bladder neck with the 

patient supine and standing. J Urol 159(3):754-757. 

10 Deindl FM, Vodusek DB, Hesse U, Schussler B. 1993. 

Activity patterns of pubococcygeal muscles in nulliparous 

continent women. J Urol 72(1):46-51. 

11 Devreese A, Staes F, de Weerdt W, Feys H, van Assche A, 

Penninckx F, Vereecken R. 2004. Clinical evaluation of 

pelvic floor muscle function in continent and incontinent 

women. Neurourol Urodyn 23(3):190-197. 

12 Dietz HP, Clarke B. 2001. The influence of posture on 

perineal ultrasound imaging parameters. Int Urogynecol J 

Pelvic Floor Dysfunct 12(2):104-106. 

13 Dodi G, Bogoni F, Infantino A, Pianon P, Mortellaro LM, Lise 

M. 1986. Hot or cold in anal pain A study of the changes 

in internal anal sphincter pressure profiles. Dis Colon 

Rectum 29(4):248-251. 

14 Dorflinger A, Gorton E, Stanton S, Dreher E. 2002. Urethral 

pressure profile: is it affected by position Neurourol Urodyn 

21(6):553-557. 

15 Frawley HC, Galea MP, Phillips BA, Sherburn M, Bø K. 

2005a. Reliability of pelvic floor muscle strength 

assessment using different test positions and tools. 

Neurourol Urodyn (in press) 

16 Frawley HC, Galea MP, Phillips BA, Sherburn M, Bø K. 

2005b. Effect of test position on pelvic floor muscle 

assessment. Int Urogynecol J Pelvic Floor Dysfunct (in press). 

17 Gufler H, Ohde A, Grau G, Grossmann A. 2004. 

Colpocystoproctography in the upright and supine positions 

correlated with dynamic MRI of the pelvic floor. Eur J 

Radiol 51(1):41-47. 

18 Haslam EJ. 1999. Evaluation of pelvic floor muscle 

assessment: digital, manometric and surface 

electromyography in females Master of Philosophy Thesis. 

Manchester, UK: Manchester University. 

19 Laycock J. Comparison of vaginal electromyography (EMG) 

in lying, sitting and standing. Abstract # 325; 1999; ICS 

Denver. p 403. 

20 Morgan DM, Kaur G, Hsu Y, Fenner DE, Guire K, Miller J, 

Ashton-Miller JA, Delancey JO. 2005. Does vaginal closure 

force differ in the supine and standing positions Am J 

Obstet Gynecol 192(5):1722-1728. 

21 Mouritsen L, Bach P. 1994. Ultrasonic evaluation of bladder 

neck position and mobility: the influence of urethral 

catheter, bladder volume, and body position. Neurourol 

Urodyn 13(6):637-646. 

22 Nguyen JK, Gunn GC, Bhatia NN. 2002. The effect of 

patient position on leak-point pressure measurements in 

women with genuine stress incontinence. Int Urogynecol J 

Pelvic Floor Dysfunct 13(1):9-14. 

23 Parkkinen A, Karjalainen E, Vartiainen M, Penttinen J. 

2004. Physiotherapy for female stress urinary incontinence: 

individual therapy at the outpatient clinic versus homebased 

pelvic floor training: a 5-year follow-up study. 

Neurourol Urodyn 23(7):643-648. 

24 Sapsford R, Maher C, Richardson C. Pelvic floor muscle 

activity in different sitting and standing postures - a pilot 

study; 2001; CFA 10th National Conference, Melbourne, 

Australia. 

25 Sapsford R, Maher C, Richardson C. The effect of sitting 

posture on pelvic floor and abdominal muscles activity at 

rest and during functional activities; 2005; Excellence 

Down-under, 2nd Biennial Conference Melbourne, Australia. 

p 52. 

26 Santiesteban AJ. 1988. Electromyographic and 

dynamometric characteristics of female pelvic-floor 

musculature. Phys Ther 68(3):344-351. 

27 Schaer GN, Koechli OR, Schuessler B, Haller U. 1996. 

Perineal ultrasound: determination of reliable examination 

procedures. Ultrasound Obstet Gynecol 7(5):347-352. 

28 Shafik A, Doss S, Asaad S. 2003. Etiology of the resting 

myoelectric activity of the levator ani muscle: 

physioanatomic study with a new theory. World J Surg 

27(3):309-314. 

29 Shafik A, El-Sibai O. 2000. Levator ani muscle activity in 

pregnancy and the postpartum period: a myoelectric study. 

Clin Exp Obstet Gynecol 27(2):129-132. 


30 Staskin D, Hilton P, Emmanuel A, Goode P, Mills I, Shull B, 

Yoshida M, Zubieta R. 2005. Initial assessment of 

incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A, 

editors. Incontinence. 3rd ed: Health Publications Ltd. p 

497. 

31 Swift SE, Herring M. 1998. Comparison of pelvic organ 

prolapse in the dorsal lithotomy compared with the standing 

position. Obstet Gynecol 91(6):961-964. 

32 Visco AG, Wei JT, McClure LA, Handa VL, Nygaard IE. 

2003. Effects of examination technique modifications on 

pelvic organ prolapse quantification (POP-Q) results. Int 

Urogynecol J Pelvic Floor Dysfunct 14(2):136-140. 

DRUG SOLUTIONS FOR 

INCONTINENCE 

oestrogen has been shown to alleviate stress incontinence 

symptoms in some studies. Combined HRT can worsen stress 

incontinence, but oestrogen-only HRT may cure or improve 

leakage. 

INJECTABLES 

Saturday 15 October/ Session 3 / 1130-1140 

MANNING J 

Injectable agents have been used to treat urinary incontinence 

for over 50 years. This review covers agents in current use and 

new developments. 


KARANTANIS E 

Medical treatments are important in the management of urinary 

incontinence. Treatment options vary depending on the type of 

incontinence. 

Urge Urinary Incontinence and other irritative lower urinary 

tract symptoms are commonly caused by detrusor overactivity. 

Along, with bladder retraining, medical treatments are 

important in the management of women with such symptoms. 

Traditional medications have anticholinergic properties. These 

include drugs such as Propantheline and Oxybutynin, together 

with some tricyclic antidepressants such as Imipramine, and 

Amitriptyline. Recently Tolteradine has become available, 

having fewer dry-mouth side-effects than existing drugs in 

Australia but is not yet listed on the PBS. Other anticholinergic 

medications such as Darifenacin, Trospium, and Propiverine are 

not yet available in Australia. Some of these have topical or 

intravesical applications. Desmopressin has been trialled in 

some centres with successful outcomes. Topical oestrogen may 

have a role to play in decreasing the severity of overactive 

bladder symptoms and is a useful first-line treatment for 

postmenopausal women. The role of HRT is variable. Leakage 

may worsen with combined HRT, while oestrogen-only HRT 

appears to have a significant cure. 

Stress Urinary Incontinence is usually treated with pelvic floor 

training, intravaginal devices or surgery. Duloxetine is an oral 

medication that has been shown to significantly decrease the 

frequency of incontinence episodes in women with stress 

incontinence, but is not yet available in Australia. Topical 

NEW GENERATION TAPES 


HIGGS P 

The transobturator approach was first reported in 2001 and is 

rapidly gaining popularity. The aim of the new approach is to 

provide mid urethral support in more horizontal plane compared 

to the traditional mid urethral slings. By avoiding the 

retropubic space, the transobturator approach may lessen 

complications of bladder and bowel perforation and 

haematoma, however all of these complications have been 

reported. The transobturator approach was hoped to result is 

less post operative voiding dysfunction but this has not been 

demonstrated in comparative trials. 

At present there are short term reports success rates of 80- 

95%.[1,2] 

Gynaecologists and urologists who use the transobturator 

approach should understand the anatomy of the obturator fossa 

and the position of the obturator nerve and path of the vessels 

relative to the path of the tape. The transobturator tapes pass 

through five muscles in the thigh, the obturator internus, 

obturator externus, abductor brevis, abductor magnus and gracilis. 

This may result in post operative groin pain in some women. 




The long term efficacy of the transobturator slings remain to be 

established. They may offer a safer approach, especially in 

women who have undergone previous retropubic surgery. 

References: 

Costa P et al. Surgical treatment of female stress urinary 

incontinence with a trans-obturator-tape (TOT®) uratape: short 

term results of a prospective multicentric study. Eur Urol 

2004;46:102-107. 

Lim J, Cornish A, Carey M. Short term Clinical and Quality of 

Life Outcomes in Women Treated by the TVT-O Procedure. 

Poster presentation, ICS 2005, Montreal. 

POSTERIOR COMPARTMENT 

PROLAPSE - A GYNAECOLOGICAL 

APPROACH 


MAHER C 

While over 10% of women undergo prolapse surgery, and 

approximately one third have significant obstructed defecation 1 

the efficacy of a posterior colporrhaphy in the management of 

symptomatic prolapse and obstructed defecation is poorly 

reported. Obstructed defecation has been reported to persist in 

23-64% of women following posterior colporrhaphy 2, 3 . The 

midline fascial plication has been demonstrated to be effective 

in correcting prolapse and impaired defecation in those with 

and rectoceles and obstructed defecation 4 . Abramov reported 

similar findings in case control series 5 . The transanal approach 

to rectoceles and obstructed defecation is effective and well 

reported in retrospective case series 6, 7 . 

Recent RCT’S comparing the transanal and have demonstrated 

the efficacy of the vaginal approach as compared to the 

transanal approach for the management of posterior 

compartment prolapse 8, 9 . A recent Cochrane meta-analysis 

concluded the vaginal approach was more effective than the 

transanal approach but warned that more trials were required 

on this topic 10 . 

References: 

1. Weber AM, Walters MD, Ballard LA, Booher DL, Piedmonte 

MR. Posterior vaginal prolapse and bowel function. Am J 

Obstet Gynecol 1998;179:1446-9. 

2. Porter WE, Steele A, Walsh P, Kohli N, M. K. The anatomic 

and functional outcomes of defect-specific rectocele repair. 

Am J Obstet Gynecol 1999;181:1353-9. 

3. Kenton K, Shott S, Brubaker L. Outcome after rectovaginal 

fascia reattachment for rectocele repair. Am J Obstet 

Gynecol 1999;181:1360-3. 

4. Maher CF, Qatawneh AM, Baessler K, Schluter PJ. Midline 

rectovaginal fascial plication for repair of rectocele and 

obstructed defecation. Obstet Gynecol 2004;104:685-9. 

5. Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, 

Sand PK. Site-specific rectocele repair compared with 

standard posterior colporrhaphy. Obstet Gynecol 

2005;105:314-8. 

6. Arnold MW, Stewart WR, PS. A. Rectocele repair. Four 

year's experience. Dis Colon Rectum 1990;33. 

7. Tjandra JJ, Ooi BS, Tang CL, Dwyer P, Carey M. Transanal 

repair of rectocele corrects obstructed defecation if it is not 

associated with anismus. Dis Colon Rectum 1999;42:1544- 

50. 

8. Nieminen K, Hiltunen KM, Laitinen J, Oksala J, Heinonen 

PK. Transanal or vaginal approach to rectocele repair: a 

prospective, randomized pilot study. Dis Colon Rectum 

2004;47:1636-42. 

9. kahn MA, Stanton SL, Kumar D, SD F. Posterior 

colporrhaphy is superior to the transanal repair for treatment 

of posterior vaginal wall prolapse. Neurourol Urodyn 

1999;18:70-1. 

10.Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. 

Surgical management of pelvic organ prolapse in women. 

Cochrane Database Syst Rev 2004:Cd004014. 

Author address: Dr Christopher Maher, Wesley, Royal Women’s 

and Mater Urogynaecology, Brisbane, Queensland, Australia. 

www.urogynaecology.com.au 


Communications 

“Strykers Endosuite Operating 

Room is a fully functional 

surgical suite, designed to 

perform and transition between 

cases more efficiently and 

ergonomically than the traditional 

cart system. The Endosuite 

Operating Rooms offer 

opportunities for significantly 

improving both procedure and 

turnover time across virtually 

all specialties by enhancing 

efficiency and ergonomics through 

integrated technology.” 

Unit 58, 2A Herbert Street 

St Leonards NSW 2065 

P: (02) 9467 1000 

E: dean.fuller@stryker.com 

Brent Scott 

Managing Director 

South Pacific 

Stryker 

Stryker Corporation makes the 

Endosuite operating theatre the ideal 

environment to perform endoscopic 

surgery. It provides clear lines of sight 

for communication amongst the 

operating team, and the uncluttered 

floor space eliminates unnecessary 

movement. Voice activated equipment 

and external live video links to other 

specialists mean the operating team 

can concentrate on the patient. 

This new innovative operating suite is 

now available in St Leonards, Sydney, 

close to Royal North Shore Hospital. 

“We can teach, educate and train on a 

world-wide basis out of this 

facility. We can link into any hospitals 

that have a Stryker’s Endosuite .” 

For more information on Stryker 

Endosuite please contact Dean Fuller 

at Stryker on (02) 9467 1000.



OBSTRUCTED DEFECATION AND 

RECTOCELE – COLORECTAL 

PERSPECTIVE 

WHAT ABOUT BOTOX UROLOGICAL 

APPLICATIONS OF BOTULINUIM 

TOXIN A 


FARMER K C 

The Obstructed Defecation Syndrome (ODS) is a recognised 

colorectal entity that is often (but not always) associated with 

the presence of a rectocele. Obstructed defecation can be 

defined on the basis of symptoms when the following three 

criteria are present: 1) an inability to initiate defecation 

following the urge to do so, or difficulty with stool evacuation; 

2) excessive straining at stool more than 25 percent of the time 

or self-digitation to facilitate defecation more than 25 percent 

of the time; 3) a feeling of incomplete evacuation after 

defecation. 

Colorectal signs include anismus, perineal descent, internal 

rectal intussusception and a rectocele. Investigations consist of 

a colonoscopy, colonic transit time, defecating proctogram, 

anorectal physiology studies and a transanal ultrasound. 

The colorectal surgeon is more likely to see a patient with 

isolated posterior pelvic floor compartment symptoms only 

compared to those consulting a gynaecologist with a global 

pelvic floor dysfunction. 

Recent theories of the aetiology of this syndrome surround the 

concept of a sensory-motor dissociation in the colon and 

rectum and highlight the complexity of the normal defecatory 

process. The precise role of a rectocele in this condition 

remains unclear and explains the difficulty in patient selection 

for surgery. 

The management of ODS includes specialist pelvic floor 

physiotherapy including biofeedback, dietary modification and 

consideration of rectocele repair. Colorectal surgeons will either 

refer patients to a urogynaecologist for rectocele repair or 

perform their own transanal repair. Transanal rectocele repair 

may be performed by suture or staple plication techniques 

depending on surgeon preference. 

Author address: Dr K Chip Farmer, Melbourne Gastrointestinal 

Investigation Unit (MGIU), Cabrini Hospital, Melbourne 


DOWLING CR, KURCZYCKI L, SANJEEVAN KV, 

O’CONNELL HE 

Botulinium toxin was first identified in 1897 and its first 

clinical use was in treatment of strabismus. Botulinium toxin 

Type A (Botox A) now has wide clinical applications. Current 

approved therapeutic indications in Australia include the 

treatment of cervical dystonia, muscular spasticity in Cerebral 

Palsy and VII nerve disorders. 

Administration of Botox A results in the blockage of 

neuromuscular conduction by binding to receptor sites on motor 

nerve terminals. The toxin enters nerve terminals and inhibits 

acetylcholine release at presynaptic cholinergic junctions. This 

results in a localised partial but reversible chemical denervation 

of muscle resulting in local muscle paralysis. 

The use of Botox A in urological management began in patient’s 

with spinal cord injuries who had developed detrusor-sphincterdyssynergia 

(DSD). It is now being widely applied in the 

treatment of both neurogenic overactive bladder and nonneurogenic 

overactive bladder. We present the early results of a 

twenty patient pilot study using Botox A (Allergan) in the 

treatment of DSD, neurogenic overactive bladder and nonneurogenic 

overactive bladder and discuss the potential 

magnitude of the impact this agent may have in the treatment 

of lower urinary tract dysfunction, for which the traditional 

therapeutic options carry significantly greater morbidity. 

Author address: CR Dowling, L Kurczycki, KV Sanjeevan, HE 

O’Connell NeuroUrology and Continence Unit, Royal Melbourne 

Hospital, Parkville, Victoria 


SOLUTIONS FOR PAINFUL BLADDER 

SYNDROME 


ROSAMILIA A 

Painful bladder syndrome/ Interstitial cystitis remains for the 

present a diagnosis requiring the exclusion of all other possible 

causes of bladder discomfort or pain and frequency. The workup 

includes a urinary diary, urine microscopy and culture and 

usually a cystoscopy. If indicated urine cytology, urodynamics, 

imaging, bladder biopsy or laparoscopy may also be required. A 

symptom questionnaire can be helpful to monitor progress. The 

etiology is most likely multifactorial with epithelial dysfunction 

and neurogenic inflammation being the most studied and 

proposed mechanisms. An exciting development is the recent 

identification of a urinary biomarker, antiproliferative factor. 

Prevalence estimates are of the order of 0.5 % of the female 

population in the United States and the impact on a person’s 

life is similar to many other chronic pain states. Management 

options include information regarding the condition, direction 

toward self-help strategies, oral, intravesical and the possibility 

of surgical treatment. Evidence based on randomised trials to 

date support the use of amitryptyline, Elmiron® , and 

intravesical DMSO. There are many treatments including 

analgesics, anti-inflammatories, physical therapies including 

electrical stimulation, oral medications, intravesical 

instillations, neuromodulation and major urological surgery 

which are used widely and require continuing evaluation. 

NEUROMODULATION 


CAREY M 

Sacral nerve stimulation (SNS) has become established therapy 

in the US and Europe for the management of severe and refractory 

over active bladder syndromes (urge incontinence, urgencyfrequency 

syndrome) and idiopathic urinary retention. More 

recently, SNS has been used for interstitial cystitis and 

neuropathic faecal incontinence. The implanted sacral nerve 

stimulator device comprises a pulse generator, extension cable 

and lead with quadripolar electrodes. Recent lead modifications 

have seen a tread towards a two staged implant procedure using 

small skin incisions. These recent modifications allow for surgery 

to be completed under local anaesthesia. This new minimal 

access surgical approach to SNS implantation is likely to result in 

more accurate patient screening and reduced wound morbidity. 

Anatomical Considerations 

The third sacral nerve root is the target for SNS. This sacral nerve 

root has a width of 3 to 4 mm and exits from the third sacral 

foramen. Occasionally, needle insertion into S3 can result in 

vascular and nerve damage. This damage can be minimized by 

employing a lateral entry into foramen and by ensuring the 

needle enters the foramen at an acute angle rather than 

vertically. The sacral nerves provide many branches to the pelvis 

and lower limbs. The pudendal nerve, which is the main sensory 

and motor nerve to the pelvic floor, receives contributions from 

S2, S3 and S4. Stimulation of S3 results in both a motor and 

sensory responses. The motor response includes contraction of 

the levator ani muscle complex (“bellows response) and flexion of 

the toes via stimulation of the tibial branch of the sciatic nerve. 

The sensory response includes a sensation of “tingling” in the 

vagina, rectum and labia majora. In clinical practice, accurate 

placement of electrodes into the third sacral foramen is 

confirmed by the appropriate motor and sensory responses and by 

fluoroscopy (if available). 

The most easily identified surface anatomy landmark of the S3 

foramen is the greater sciatic notch. The S3 foramen is located 

medial to the upper edge of the greater sciatic notch and a 

middle finger’s breadth from the spine of the sacrum (midline). 

Mechanism of Action of SNS 

The precise mechanism of action of SNS is unclear and a number 

of theories have been advanced. Sacral nerve neuromodulation 

stimulates the afferent somatic nerve fibres responsible for the 

modulation of sensory processing and the micturition reflex in the 

spinal cord. It has been postulated that SNS depends on the 

electrical stimulation of afferent nerve fibres in the spinal roots 

that, in turn, modulate voiding and continence reflex pathways in 

the central nervous system. 

SNS may cause suppression of bladder over activity by the 

neuromodulation of several reflex mechanisms. Firstly, direct 

inhibition of bladder preglangionic neurons suppresses unstable 

bladder contractions. Secondly, inhibition of unstable bladder 

contractions by suppression of interneuronal transmission in the 

afferent limb of the micturition reflex. SNS does not interfere with 

voluntary voiding mediated by descending excitatory efferent 

pathways from the brain to the sacral parasympathetic 

preganglionic neurons. 

Efficient bladder emptying relies on the ability of brain pathways 

to turn off urethral sphincter guarding reflexes. SNS may act by 

switching off excitatory outflow to the urethral sphincter, thereby 

promoting bladder emptying in patients with urinary retention. 


Clinical Indications for SNS 

In the United States, SNS has FDA approval for urge 

incontinence, urge-frequency syndrome and voiding difficulty. 

The cost of SNS is around $15,000 and surgical revisions are 

required in about 30% of cases. SNS is therefore reserved for 

refractory lower urinary tract dysfunction. 

Thorough clinical assessment, including neurological 

evaluation, is mandatory prior to considering SNS. Appropriate 

investigations are also required prior to SNS to establish a 

precise diagnosis and exclude neurological disorders (e.g. 

multiple sclerosis). Often urodynamic studies, cystoscopy and 

various imaging techniques (MRI; MRI scanning is 

contraindicated once SNS has been implanted) are performed 

prior to SNS. Psychiatric assessment is appropriate in some 

cases. 

SNS should be considered as an alternative to major urology 

procedures such as augmentation cystoplasty and urinary 

diversion. 

Results of SNS 

Recent studies by Schmidt et al (J Urol 1999), Hassouna et al 

(J Urol 2000) and Jonus et al (J Urol2001) reported the results 

of SNS for refractory lower urinary tract disorders. These 

studies demonstrated SNS to be effective, safe and reversible 

therapy for the treatment urge incontinence, urgency-frequency 

syndrome and voiding difficulty. 

Surgical revision is reported in 6% to 50% of cases. The largest 

RCT evaluating SNS is the MDT-103 study. This study involved 

633 patients: 210 with urge incontinence; 229 with urgencyfrequency 

syndrome; and 194 with urinary retention. 

Repositioning of the electrode or extension lead was required in 

24.4% of patients. A further 21.1% of patients required 

repositioning or replacement of the implanted pulse generator. 

Recent lead modifications and the trend towards a two staged 

implantation procedure with a minimal assess surgical approach 

are likely to improve the outcomes for patients undergoing SNS. 

Conclusion 

SNS is effective therapy for refractory over active bladder 

syndromes and idiopathic urinary retention. Emerging 

indications include interstitial cystitis, perineal pain syndromes, 

and neuropathic faecal incontinence. Currently, the high cost of 

SNS and its restriction to refractory lower urinary tract disorders 

limits the use of SNS to specialist tertiary centers. 

Author address: Dr Marcus Carey, Royal Women’s Hospital, 

Melbourne

ANNUAL SCIENTIFIC MEETING 

AGES 2006 

Managing Common 

Gynaecological Challenges 

ART & SCIENCE 

OF ENDOMETRIOSIS 

WCE 2008 

4, 5 & 6 May 2006 ADELAIDE 

Chairman: Dr Robert O’Shea 

Co-Chairman: Dr Elvis Seman 

International Guest Speaker: 

Prof. Charles Koh, Milwaukee, USA 

AGES Focus Meetings 

AGES SYDNEY 2006 

in association with APAGE 

August 2006 Sydney 

Chairman: A/Prof. Alan Lam 

Scientific Chairman: Dr Geoff Reid 

Workshop Chairman: Dr Greg Cario 

AGES Pelvic Floor Symposium & 

Workshop VII 2006 

17 & 18 November 2006 Brisbane 

Chairman: Dr Chris Maher 

Co-Chairman: Dr Anusch Yazdani 

International Guest Speaker: Prof. John DeLancey, Michigan, USA 

World 

Endometriosis 

Society 

Chairman: 

Prof. David Healy 

Deputy Chairman: 

A/Prof. Peter Maher 

Scientific Chairmen: 

Dr Luk Rombauts 

Dr Jim Tsaltas 

Organiser: 

Mrs Michele Bender 

Conference Connection 

Phone + 612 9967 2928 

Fax + 612 9967 2627 

Australian 


Endoscopy 

Society 

Email conferences@ages.com.au 

MELBOURNE AUSTRALIA 

11-14 MARCH 2008 

TH 

10 

WORLD CONGRESS 

ON ENDOMETRIOSIS 

Artwork: Fiona Hall born Australia 1953 | Paradisus Terrestris Entitled: 

Miwulngini (Ngan’gikurunggurr) / Nelumbo nucifera / lotus (1996) | 

aluminium and tin 24.6 x 12.1 x 3.6 cm | Purchased through The Art 

Foundation of Victoria with the assistance of the Rudy Komon Fund, 

Governor, 1997 | National Gallery of Victoria, Melbourne.

AGES gratefully acknowledges the following companies which 

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Platinum Sponsor of AGES 

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Major Sponsor of AGES Pelvic Floor 

Symposium and Workshop VI 

Sponsors 

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