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Urogynaecology

Weekly Programme

Structure of Service

Weekly timetable

Monday

Morning

Pre-operative operative assessment clinic

Afternoon

Alternate Weeks

-Pelvic Floor Assessment Clinic

-Perineal Clinic

 

Tuesday

Morning

Hysteroscopy Clinic

Afternoon

 

Wednesday

Morning

Grand Rounds

General Gynaecology Outpatient’s Clinic

Afternoon

Urogynaecology Clinic

Thursday

Morning

Operating Theatre (2 lists)

Afternoon

Operating Theatre (1 list)

Friday

Morning

Teaching ward round

Afternoon

Departmental Teaching

 

Specifics of individual activities

 

Pre-operative operative assessment clinic (Monday Morning)

The patients that are booked for the operating list on Thursday are seen by the students, registrars and fellows. This is followed by a detailed teaching round where the patients are presented to either Dr Jeffery or Dr Brouard. The patients are usually examined by the consultant with an emphasis on clinical signs. Each patient’s clinical picture is used to integrate a broad range of teaching points on the pathology and rationale behind procedure selection. This is done with for students at both under and post –graduate level. 

Pelvic Floor Assessment Clinic

This is a Urodynamics-based clinic run by Dr Brouard. Our complex urogynaecology patients are usually referred here. Indications for referral include: persistent or worsening urinary symptoms after surgery for stress urinary incontinence (SUI) – especially if we are planning repeat surgery, symptoms of voiding dysfunction after surgery for SUI, before prolapse surgery if symptoms the women has symptoms of voiding dysfunction, before surgery in women with SUI and if there is a clinical suspicion of detrusor overactivity. Women with complicated urinary symptoms are also seen here. This clinic is usually attended by a registrar and one of the fellows and this opportunity is used to teach them how to approach complex urogynaecology patients.  

Perineal clinic

This clinic is run by Dr Jeffery. The indications for referral to this clinic include:  all women who have sustained a third or fourth degree vaginal tear, any woman with severe perineal trauma where there are concerns regarding healing, women with perineal pain following delivery, post-partum voiding dysfunction and defaecatory dysfunction, post-partum dyspareunia, pregnant women who have a history of a third or fourth degree tears for advice regarding mode of delivery following clinical assessment and endo-anal ultrasound. This is an important opportunity for the registrars to be educated on the management of these patients.

Hysteroscopy Clinic

In this weekly clinic, which is run on an alternating basis by Drs Jeffery and Brouard, we perform outpatient hysteroscopy, using a vaginoscopy technique, on between 10 and 12 women per clinic. We are well-equipped with a Bettochi scope system and the appropriate graspers, scissors, twizzle and biopsy instruments that enable us to perform a range of minor procedures. This includes removal of small polyps and fibroids, biopsy of lesions, treatment of Ashermanns Syndrome and division of uterine septa. The principle in this clinic is that every patient is seen and managed by the registrar under consultant supervision. After a 6 week rotation each registrar would have performed between 60 and 70 hysteroscopies. They are all competent in this technique on completion of the rotation.  The indications for referral to the clinic include post menopausal bleeding with ET>4mm, persistent post menopausal bleeding with ET<4mm, abnormal uterine bleeding with an ultrasound suggestive of an endometrial polyp or submucous fibroid, secondary amenorrhoea with a suspicion of Ashermanns syndrome, recurrent pregnancy loss with suspected uterine anomaly and lost IUCD strings.

 2.3.2.5 Wednesday Grand Rounds

This is bedside teaching ward round from 07h30 to 09h30 led by Prof Roos. Year 6 undergraduate students present the patients but post-graduates are in attendance and are also a major focus of this session.  Teaching involves a broad range of topics to include general under- and post-graduate gynaecology. Some of the teaching also involves aspects of pelvic floor dysfunction, but the focus of this session is general gynaecology.  

 2.3.3.6 General Gynaecology Outpatients Clinic

In this general gynecology clinic, a broad range of patients is seen. Registrars and consultants see the patients individually. Drs Brouard and Jeffery encourage an environment of openness to consultation by the registrars if they are unsure about the management plans. Undergraduate students sit in on the consultations and are allowed to perform supervised gynaecological examinations in this clinic.  We see 2500 patients a year in this clinic.

 2.3.2.7 Female Continence Clinic

This clinic is staffed by four gynaecology consultants, two urogynaecology fellows and the urogynaecology registrar. A urology consultant and a number of urology registrars are also in attendance. The aim of the clinic is to provide a multidisciplinary approach to women with urinary incontinence. Referral criteria include: all women with stress incontinence prior to undergoing surgery; women with urgency and urgency incontinence not responding to 3 months of oxybutynin and fluid reduction; women with voiding difficulties i.e. hesitancy, poor stream, double voiding, incomplete emptying, post-micturition dribbling; any woman with a suspected neurological cause of urinary incontinence; women with painful bladder syndrome / interstitial cystitis; all women booked for prolapse surgery who have not been seen on the urogynaecology unit; women with previous prolapse or continence surgery who now have symptoms of pelvic floor dysfunction and all women who are considered to require urodynamics. We see 500 patients a year in this clinic.

 We have recently commenced Posterior Tibial Nerve Stimulation as a new treatment strategy for women with OAB in this clinic. In order to make this cost-effective, we have purchased an electroacupuncture machine to provide this service.   We have modeled this technique on the high cost commercially available “Urgent-PC” device. This is a 12 week course of weekly electrostimulation of the posterior tibial nerve lasting 30 minutes. Our results this far are encouraging. 

 2.3.2.8 Operating Theatre

We perform a broad range of gynaecological procedures. The bulk of our operating comprises surgery for pelvic organ prolapse and incontinence.  In 2013 we performed approximately 152 pelvic organ prolapse procedures. This included anterior repair, sacrospinous fixation, vaginal mesh insertion, vaginal hysterectomy for prolapse, laparoscopic sacrocolpopexy and colpocleisis. We also performed a number of rectovaginal fistula repairs and we excised a few urethral diverticula. We performed approximately 40 stress incontinence sling procedures.

 Our general gynaecology procedures included about 50 laparoscopic cases including Total laparoscopic hysterectomy, myomectomy, cystectomy, tubal ligation. We performed 30 operative hysteroscopies, mostly for excision of polyps and fibroids. Due to the focus of our unit being pelvic floor and minimally invasive surgery, we perform relatively few TAH’s, but we did do a number of these last as well.

 2.3.2.9. Friday morning teaching ward round

The essence of this ward round, which occurs on our post-operative patients as well on the acute admissions of the previous day, is to teach students and registrars the basics of the ward management of patients. We try to focus on the treatment of PID, miscarriage, ectopic pregnancy, Ca Cervix, menorrhagia, hyperemesis gravidarum and post-partum sepsis. The other emphasis on this ward round is to teach students to recognize important post-operative complications. For the registrars, we regularly emphasize medico-legal issues.