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Gold, incentives and meh

Urogynaecological procedures

The primary care tsar wants GPs to get more involved in postoperative care. Professor Linda Cardozo and Dr Rufus Cartwright outline what GPs can expect when urogynaecology patients are discharged

The primary care tsar wants GPs to get more involved in postoperative care. Professor Linda Cardozo and Dr Rufus Cartwright outline what GPs can expect when urogynaecology patients are discharged

In urogynaecology, as in many other areas of surgery, there has been a gradual trend towards less invasive procedures. Burch colposuspension and conventional slings for stress incontinence are being supplanted by the use of mid-urethral tapes, which can be offered as day case or even outpatient procedures. The reduced inpatient stay and increased use of these operations means that GPs have a greater role in the management of problems that can arise in the early postoperative period.

Prolapse and continence procedures form the majority of surgical practice in urogynaecology. Serious complications are fortunately rare. However when complications do occur, prompt intervention helps to minimise morbidity.

Vaginal hysterectomy and pelvic floor repair

Vaginal hysterectomy is often performed together with pelvic floor repair for the correction of symptomatic pelvic organ prolapse. Either procedure may be performed alone, but regardless, the postoperative course and complications are similar. These procedures can be carried out either under general or regional anaesthesia.

Postoperative pain is much reduced compared with abdominal hysterectomy, usually requiring only simple analgesia, such as paracetamol, tramadol or diclofenac after the immediate postoperative period. Patients may be discharged home at any time after 24 hours once they have resumed normal voiding.

Following discharge – what to expect

Patients may mobilise freely but must avoid heavy lifting and constipation, to minimise the risk of recurrence of prolapse. Movicol may be an appropriate prophylactic laxative.

• Some light vaginal bleeding is normal, and may continue until the absorbable sutures have entirely dissolved. Heavy bleeding should, however, prompt reassessment in hospital.

• A non-offensive vaginal discharge is also common during the first three weeks, and does not normally require antibiotics.

• Women may experience increased urinary frequency and urgency initially, which should resolve spontaneously.

• Urinary tract infection is a common postoperative complication, which can be treated in the community with a seven-day course of an appropriate antibiotic.

Complications – what to look for

Most gynaecologists review patients routinely at six weeks following a hysterectomy or prolapse repair, but some serious complications may require earlier review.

A pelvic haematoma is associated with increased postoperative pain, and sometimes a low-grade pyrexia. It may be suspected on vaginal examination by the presence of bogginess in the pouch of Douglas.

It can usually be managed conservatively with antibiotics, as long as it is not associated with florid infection or severe anaemia.

In the long term, around 30% of women will suffer recurrent prolapse. This had led some surgeons to experiment with synthetic or biological meshes to help support prolapse repairs. These meshes are associated with their own specific complications, including dyspareunia and erosions. Any patient with suspected erosion of mesh should be referred back.

There are other very rare serious complications that may also be recognised on vaginal examination (see below).

Getting back to work

Most women return to work after the six-week hospital review, however patients with relatively sedentary jobs may be able to resume employment earlier.

Continence procedures

The commonest procedure performed in the UK for stress incontinence is the tension-free vaginal tape (TVT). A Prolene mesh is inserted vaginally either side of the urethra. It is passed on two trocars through the retropubic space, emerging in the mons pubis. Alternatives to the TVT have been actively promoted, including transobturator tapes, in which the tape is passed from a sub-urethral incision through the obturator membrane and out of the inner thigh. These procedures can be performed under general, regional or local anaesthesia.

Following discharge – what to expect

Postoperative pain is usually minimal so patients can return home as soon as they resume voiding.

• Early voiding difficulties are common, and may require patients to either learn clean intermittent self-catheterisation, or manage at home with a temporary indwelling catheter.

• If patients go into complete retention, the tape may need to be adjusted or divided in the early postoperative period.

Complications – what to look for

Following any continence procedure, urinary urgency and frequency may initially worsen. A few women have persistent overactive bladder symptoms, or persistent voiding difficulties. These symptoms merit urodynamic evaluation three to six months postoperatively.

Rare complications that GPs need to be aware of are shown in the box (above left).In some centres, bladder neck bulking procedures are available as a less invasive alternative to a sub-urethral tape. These procedures are performed under local anaesthesia. They are associated with lower long-term success rates, but may be suitable for women with multiple co-morbidities or those who do not wish to risk complications.

Getting back to work

As for pelvic floor surgery, women are usually reviewed in hospital at six weeks. Most women can return to work by two weeks.

Professor Linda Cardozo is a consultant gynaecologist and head of the urogynaecology department at King's College Hospital, London

Competing interests None declared

Dr Rufus Cartwright is senior clinical fellow in gynaecology at King's College Hospital, London and current joint International Continence Society 'Young investigator of the year'

Competing interests None declared

Complications that need hospital attention

Vaginal hysterectomy and pelvic floor repair

• Vesico-vaginal fistula, causing continuous dribbling incontinence.

• Dehiscence of the vaginal vault closure may lead to bowel obstruction if a loop of small bowel prolapses into the vagina.

• Dehiscence of the perineal sutures following a posterior vaginal repair incorporating a perineorrhaphy occurs rarely, usually secondary to a wound infection. Such dehiscence is typically managed with antibiotics and delayed secondary closure.

• Ureteric injuries are rare with vaginal surgery, but may present with ileus, oliguria, or urine leak via the vagina.

Continence procedures

• The development of retropubic haematoma or an unrecognised intra-operative bladder or urethral injury.

• The obturator tapes are associated with increased thigh pain, and there have been case reports of thigh abscesses.

• As when mesh is used in prolapse repair, the vaginal mucosa may be eroded.

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