Int Urogynecol J DOI 10.1007/s00192-013-2314-5
MENTORS IN UROGYNECOLOGY
The long and winding road to urogynaecological subspecialisation Hans van Geelen
# The International Urogynecological Association 2014
After graduation from medical school and 2 years of rotating internships in internal medicine, surgery, obstetrics and gynaecology and a postgraduate course in tropical medicine, I started to work for almost 4 years as a mission doctor in rural Zambia. In 1974 I returned to The Netherlands and started my residency in OB&GYN in a large non-academic teaching hospital, Canisius-Wilhelmina (CWZ) In Nijmegen, The Netherlands (Chief: Dr. A.J.J. de Bruin). The 1970s witnessed great revolutionary developments in OB&GYN, which have completely changed the traditional clinical aspects and image of our discipline. Ultrasound was first introduced into obstetrics and is now a routine diagnostic tool in almost every field of medicine. Fetal heart rate monitoring through the last weeks of pregnancy and at the time of delivery became an indispensable guide for the health of the unborn child, laparoscopy was introduced as a routine procedure for diagnosing and treating gynaecological conditions and in England in 1978, Louise Brown, the first IVF baby, was born.
H. van Geelen (*) Foundation of Pelvic Floor Patients (SBP), Oss, The Netherlands e-mail: [email protected]
These spectacular developments in our discipline overshadowed the great strides being made in the investigation and treatment of lower urinary tract (LUT) disorders. Multichannel urodynamics, based on the studies of G. Enhörning in Sweden and (video-) urethrocystography (P. Hodgkinson, USA) became available for clinical practice and in 1975 M. Asmussen and U. Ulmsten (Norway) presented their findings, performing simultaneous urethrocystometry using a dual micro-tip pressure transducer. John Burch presented his results of the retropubic colposuspension procedure, a technique refined by E. Tanagho to become the gold standard in the surgical treatment of stress incontinence until the late 1990s. The terms “unstable bladder“ (nowadays: OAB), neurogenic bladder, intrinsic sphincter incompetence, detrusor–sphincter dyssynergia were introduced and their underlying pathology identified. These new insights into the function and dysfunction of the lower urinary tract fundamentally altered the traditional approach to and treatment of LUT symptoms. The CWZ hospital was one of the first hospitals in the Netherlands to have multichannel urodynamic equipment, to introduce the Burch colposuspension and to present their results (Dr W.B.K.M.V. de Goey) [1]. In 1977 I obtained a Millar microtransducer catheter with two silicon strain gauge pressure sensors mounted 6 cm apart (Millar Instr. Inc., Houston, TX, USA). This device was very precise, with a high frequency response, but was also very expensive and fragile, and for that reason not suitable in routine clinical practice. In 1979 I completed the last year of my training at the University Hospital of the Catholic University Nijmegen (chiefs: Prof. Dr. J. Mastboom and Prof. Dr. T.K.A.B.. Eskes) and stayed for another 3 years as chief of the outpatient department to finish my research project. The charismatic Tom Eskes suggested that I should focus on urethral function during a women’s life and standardise the method of investigation: reproducibility, rotational variation and postural urethral pressure changes and
Int Urogynecol J
to study the effects of hormonal changes during the menstrual cycle on urethral function. The medical Ethics Committee of the Catholic University consented to a prospective study performing urethral profilometry at regular intervals in healthy women during their first pregnancy—at 8, 16, 28 and 36 weeks—and 8 weeks after delivery. To my knowledge this is the only large study (n=44) providing objective data on the effects of pregnancy and delivery on urethral function. It is highly unlikely that in the future this kind of investigation will be carried out again! I attended postgraduate courses and workshops on urodynamics and other diagnostic modalities in the USA (Th. Stamey 1977, D. Ostergard 1978), in London (R. Turner Warwick 1980) and Sweden (U. Ulmsten 1982). The knowledge and insights obtained from the technological advances opened new pathways in an area, which until that time was hardly explored. In The Netherlands as in many other countries urinary incontinence and urodynamics were considered the unique domain of urology. These developments led to controversy between urologists and gynaecologists. At the farewell symposium in 1984 on the practical aspects of urinary incontinence, where all the great names in urology and (uro-)gynaecology participated, the departing Prof. W. Moonen of the urology department of the University, put the arguments in favour of urology into words [2]: “Until the 1940s stress incontinence was almost everywhere the territory of gynaecologists. Why was there a shift toward Urology? In my opinion there were three reasons for this. In the first place gynaecologists almost never treated stress incontinence according to the principles of suspension described by Goebbell (1910) and Stoeckel (1917). Most gynaecologists resorted to various vaginal operations. These “push-up” operations had only moderate success and then only when performed in skilled hands. In unskilled hands these vaginal procedures led to catastrophes and calamities. Second: The Cavum Retzii had been, for long, a forbidden area. Due to the work of Terence Millin, a urologist performing retropubic prostatectomy, this taboo disappeared. He first applied the retropubic bladder neck suspension (1947). A third factor is that urologists had applied themselves to urodynamics much earlier than the gynaecologists e.g. measurement of pressures in neurogenic bladder disturbances”. In 1983 I presented my PhD thesis on the urethral pressure profile in continent women. I moved to a smaller regional hospital (Oss, The Netherlands ) and continued my urodynamic investigations in the newly established academic hospital of Maastricht (AZM) . The results of my prospective study on the clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension in stress incontinent
women with 5 years’ follow-up were published In 1988 in the American Journal of Obstetrics and Gynecology [3]. The long-term results may reflect suboptimal surgical performance; however, the objective data are in agreement with the results of other investigators of good reputation. The paper evoked much controversy, was appreciated by some and heavily criticised by others. But, at least awareness and discussion on this challenging and increasing health problem commenced. In some hospitals urologists and gynaecologists joined hands and cooperated well; in other clinics the territories were clearly marked and exchange was principally denied. The remuneration system within the Dutch health organisation further contributed to a great extent to this dividing line. In 1990 a few gynaecologists, including de Graaff, Vervest and van Geelen, founded the working party for pelvic floor dysfunction, abbreviated as WBB, and in 1991 this was recognised by the Dutch Society for Obstetrics and Gynecology (NVOG). In the early 1990s the “integral theory” by P. Petros and U. Ulmsten (1993) and the hammock hypothesis by J. Delancey (1994) provided a better understanding of the complex mechanisms by which the pelvic floor muscles control urinary continence. Both theories are complementary, making it clear that the stability of the endopelvic fascia and its intact connection to the arcus tendineus fasciae pelvis and the pelvic floor muscles are essential for adequate urethral closure during stress and for voluntary inhibition of the micturition reflex. It is the stability of this layer rather than the intra-abdominal position of the bladder neck and proximal urethra that determines urinary continence. Don Ostergard (1996) asked me to become assistant managing editor of the IUJ and in the same year I joined the IUGA executive board as second vice president. Mark Vierhout became chairman of the WBB In 1994 and managed to bring together the major care-givers in this field: together with urologists several symposia on different common topics were held and a 2-day postgraduate educational course on urogynaecology was started, attendance at which is nowadays compulsory for all residents in OB&GYN. In 1997, Vervest, Vierhout, C ten Hoope (†) and I organised the 22nd Annual IUGA meeting where U. Ulmsten presented his preliminary favourable results of the TVT. After almost a century of trial and error a rationale for the treatment of stress urinary incontinence seemed to have been found. At the 23rd Annual IUGA meeting in Buenos Aires in 1998 I had the honour of presenting a state-of-the-art lecture on “the urethral sphincter mechanism”. In the year 2000 in The Netherlands a nationwide prospective multicentre study was initiated, including 809 women with validated preoperative and postoperative questionnaires and 2 years’ follow-up (2006). The results of this meticulously conducted study led to the publication of a number of articles presented in this and other prestigious journals [4]. The
Int Urogynecol J
favourable outcomes of the TVT procedure, the good host response to this synthetic tape and the publication by Olson et al. [5] in the USA on the high prevalence and recurrence rates after conventional repair of pelvic organ prolapse (POP) led to the accelerated introduction and marketing of new, mostly synthetic grafts for the treatment of pelvic floor dysfunction. The preliminary published reports on mesh use by the French TVM group were encouraging and within a relatively short period of time many gynaecologists decided to introduce this technique into their practice. In 2005, M. Vierhout became the first Professor in Urogynecology and started a structured project to carry out RCTs with sufficient power on the use vaginally inserted mesh and prospective observational cohort studies. It was decided to bring together and to coordinate all studies on the management of pelvic floor (dys)function into a consortium (J.P. Roovers 2006). This initiative has proven a very effective way of enhancing medical research and has inspired more than 100 publications in peer reviewed journals and 20 PhD theses. The greater interest in the impact of pelvic floor dysfunction on an increasing and ageing population, and the introduction of new diagnostic and therapeutic modalities, have led the Dutch Society for Obstetrics and Gynecology (NVOG) to recognise urogynaecology in 2009 as being the 4th subspecialty in OB&GYN. At present, there are four officially recognised institutes for training as a urogynaecologist. The membership of the WBB grew from 16 members at the beginning to almost 240. It is gratifying to observe that the recommendations presented in my lecture in Prague (2002) on “The Future of Urogynecology” have been fulfilled: urogynaecology is now recognised as a subspecialty by national and international societies and guidelines for training as a urogynaecologist are generally accepted. Pelvic floor reconstructive surgery with meshes became popular, but also the subject of concern, leading to lively and heated discussions, not only among medical specialists, but also in the public domain. The FDA update on serious complications associated with the transvaginal placement of surgical mesh also has also had repercussions in the Netherlands and since a TV program was broadcast where the adverse effects and serious complications of mesh use were covered in detail, mesh use in The Netherlands has been reduced to almost zero. In spite of efforts by the WBB to provide guidelines for surgical training, to register all mesh procedures and all Patient Registered Outcome Measures (PROMs), the pendulum wavers to the other side and women for whom a mesh procedure could be the last remedy recoil from this intervention. From 2000 to 2002 I was IUGA president and the International Urogynecology Journal became the official IUGA journal with a new editorial board. In the following years (2004)
the office of the secretary-treasurer moved from Chicago (Peter Sand) to Florida (Willy Davila), the by-laws were revised and initiatives for a joint ICS/IUGA working group on the terminology and standardisation for pelvic floor dysfunction were taken. In 2003, because of health problems, I retired from practical work, but remain active today on the side-lines as a consultant, member of a supervisory board and chairman of the foundation for pelvic floor patients. In this latter position I am often on the patient’s side of the doctor’s desk and have participated in discussions with the Dutch health care inspectorate (IGZ), leading to creation of a document issued by the health authorities calling upon gynaecologists to exercise caution in prescribing and fitting transvaginal mesh. However, the inspectorate’s report concludes: “very few alternatives are available for the conventional surgery without use of mesh. Therefore a ban on mesh, as required by a group of patients suffering from serious complications after mesh implant, is considered not to be in the interest of patient”. Last but not least, my mentors. Dr. Wilfried de Goey, who taught me in his enthusiastic way how to perform urodynamics, the late Prof. Tom Eskes who inspired me to continue in this field and the IUGA family whose good friendship, dedication and sound competition have achieved so much. However, urogynaecology is an everchanging science, with new techniques constantly being tried, the most recent mesh POP repair. We are still in the midst of this ”perfect “ storm [6]. There remains much more to be done. Conflicts of interest None.
References 1. De Goey WBKMV (1976) Incontinence of urine in women. A urodynamical and roentgenological study. K.U Nijmegen, The Netherlands, PhD thesis 2. Moonen WA (1986) A review of 35 years experience in the management of urinary incontinence. In: Debruyne FMJ, van Kerrebroeck Ph EVA (eds) Practical aspects of urinary incontinence. Nijhoff, Leiden, pp 312–320 3. Van Geelen JN, Theeuwes AGM, Eskes TKAB, Martin CB (1988) The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol 159:137–144 4. Schraffordt Koops SE, Bisseling TM, van Brummen HJ, Heintz PM, Vervest HAM (2006) What determines a successful TVT? A prospective multicenter cohort study, results from the Netherlands TVT database. Am J Obstet Gynecol 194:65–74 5. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clarl AL ( 1997 ) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–505 6. Brubaker L, Shull B (2011) A perfect storm. Int Urogynecol J 23:1–2
MENTORS IN UROGYNECOLOGY
The long and winding road to urogynaecological subspecialisation Hans van Geelen
# The International Urogynecological Association 2014
After graduation from medical school and 2 years of rotating internships in internal medicine, surgery, obstetrics and gynaecology and a postgraduate course in tropical medicine, I started to work for almost 4 years as a mission doctor in rural Zambia. In 1974 I returned to The Netherlands and started my residency in OB&GYN in a large non-academic teaching hospital, Canisius-Wilhelmina (CWZ) In Nijmegen, The Netherlands (Chief: Dr. A.J.J. de Bruin). The 1970s witnessed great revolutionary developments in OB&GYN, which have completely changed the traditional clinical aspects and image of our discipline. Ultrasound was first introduced into obstetrics and is now a routine diagnostic tool in almost every field of medicine. Fetal heart rate monitoring through the last weeks of pregnancy and at the time of delivery became an indispensable guide for the health of the unborn child, laparoscopy was introduced as a routine procedure for diagnosing and treating gynaecological conditions and in England in 1978, Louise Brown, the first IVF baby, was born.
H. van Geelen (*) Foundation of Pelvic Floor Patients (SBP), Oss, The Netherlands e-mail: [email protected]
These spectacular developments in our discipline overshadowed the great strides being made in the investigation and treatment of lower urinary tract (LUT) disorders. Multichannel urodynamics, based on the studies of G. Enhörning in Sweden and (video-) urethrocystography (P. Hodgkinson, USA) became available for clinical practice and in 1975 M. Asmussen and U. Ulmsten (Norway) presented their findings, performing simultaneous urethrocystometry using a dual micro-tip pressure transducer. John Burch presented his results of the retropubic colposuspension procedure, a technique refined by E. Tanagho to become the gold standard in the surgical treatment of stress incontinence until the late 1990s. The terms “unstable bladder“ (nowadays: OAB), neurogenic bladder, intrinsic sphincter incompetence, detrusor–sphincter dyssynergia were introduced and their underlying pathology identified. These new insights into the function and dysfunction of the lower urinary tract fundamentally altered the traditional approach to and treatment of LUT symptoms. The CWZ hospital was one of the first hospitals in the Netherlands to have multichannel urodynamic equipment, to introduce the Burch colposuspension and to present their results (Dr W.B.K.M.V. de Goey) [1]. In 1977 I obtained a Millar microtransducer catheter with two silicon strain gauge pressure sensors mounted 6 cm apart (Millar Instr. Inc., Houston, TX, USA). This device was very precise, with a high frequency response, but was also very expensive and fragile, and for that reason not suitable in routine clinical practice. In 1979 I completed the last year of my training at the University Hospital of the Catholic University Nijmegen (chiefs: Prof. Dr. J. Mastboom and Prof. Dr. T.K.A.B.. Eskes) and stayed for another 3 years as chief of the outpatient department to finish my research project. The charismatic Tom Eskes suggested that I should focus on urethral function during a women’s life and standardise the method of investigation: reproducibility, rotational variation and postural urethral pressure changes and
Int Urogynecol J
to study the effects of hormonal changes during the menstrual cycle on urethral function. The medical Ethics Committee of the Catholic University consented to a prospective study performing urethral profilometry at regular intervals in healthy women during their first pregnancy—at 8, 16, 28 and 36 weeks—and 8 weeks after delivery. To my knowledge this is the only large study (n=44) providing objective data on the effects of pregnancy and delivery on urethral function. It is highly unlikely that in the future this kind of investigation will be carried out again! I attended postgraduate courses and workshops on urodynamics and other diagnostic modalities in the USA (Th. Stamey 1977, D. Ostergard 1978), in London (R. Turner Warwick 1980) and Sweden (U. Ulmsten 1982). The knowledge and insights obtained from the technological advances opened new pathways in an area, which until that time was hardly explored. In The Netherlands as in many other countries urinary incontinence and urodynamics were considered the unique domain of urology. These developments led to controversy between urologists and gynaecologists. At the farewell symposium in 1984 on the practical aspects of urinary incontinence, where all the great names in urology and (uro-)gynaecology participated, the departing Prof. W. Moonen of the urology department of the University, put the arguments in favour of urology into words [2]: “Until the 1940s stress incontinence was almost everywhere the territory of gynaecologists. Why was there a shift toward Urology? In my opinion there were three reasons for this. In the first place gynaecologists almost never treated stress incontinence according to the principles of suspension described by Goebbell (1910) and Stoeckel (1917). Most gynaecologists resorted to various vaginal operations. These “push-up” operations had only moderate success and then only when performed in skilled hands. In unskilled hands these vaginal procedures led to catastrophes and calamities. Second: The Cavum Retzii had been, for long, a forbidden area. Due to the work of Terence Millin, a urologist performing retropubic prostatectomy, this taboo disappeared. He first applied the retropubic bladder neck suspension (1947). A third factor is that urologists had applied themselves to urodynamics much earlier than the gynaecologists e.g. measurement of pressures in neurogenic bladder disturbances”. In 1983 I presented my PhD thesis on the urethral pressure profile in continent women. I moved to a smaller regional hospital (Oss, The Netherlands ) and continued my urodynamic investigations in the newly established academic hospital of Maastricht (AZM) . The results of my prospective study on the clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension in stress incontinent
women with 5 years’ follow-up were published In 1988 in the American Journal of Obstetrics and Gynecology [3]. The long-term results may reflect suboptimal surgical performance; however, the objective data are in agreement with the results of other investigators of good reputation. The paper evoked much controversy, was appreciated by some and heavily criticised by others. But, at least awareness and discussion on this challenging and increasing health problem commenced. In some hospitals urologists and gynaecologists joined hands and cooperated well; in other clinics the territories were clearly marked and exchange was principally denied. The remuneration system within the Dutch health organisation further contributed to a great extent to this dividing line. In 1990 a few gynaecologists, including de Graaff, Vervest and van Geelen, founded the working party for pelvic floor dysfunction, abbreviated as WBB, and in 1991 this was recognised by the Dutch Society for Obstetrics and Gynecology (NVOG). In the early 1990s the “integral theory” by P. Petros and U. Ulmsten (1993) and the hammock hypothesis by J. Delancey (1994) provided a better understanding of the complex mechanisms by which the pelvic floor muscles control urinary continence. Both theories are complementary, making it clear that the stability of the endopelvic fascia and its intact connection to the arcus tendineus fasciae pelvis and the pelvic floor muscles are essential for adequate urethral closure during stress and for voluntary inhibition of the micturition reflex. It is the stability of this layer rather than the intra-abdominal position of the bladder neck and proximal urethra that determines urinary continence. Don Ostergard (1996) asked me to become assistant managing editor of the IUJ and in the same year I joined the IUGA executive board as second vice president. Mark Vierhout became chairman of the WBB In 1994 and managed to bring together the major care-givers in this field: together with urologists several symposia on different common topics were held and a 2-day postgraduate educational course on urogynaecology was started, attendance at which is nowadays compulsory for all residents in OB&GYN. In 1997, Vervest, Vierhout, C ten Hoope (†) and I organised the 22nd Annual IUGA meeting where U. Ulmsten presented his preliminary favourable results of the TVT. After almost a century of trial and error a rationale for the treatment of stress urinary incontinence seemed to have been found. At the 23rd Annual IUGA meeting in Buenos Aires in 1998 I had the honour of presenting a state-of-the-art lecture on “the urethral sphincter mechanism”. In the year 2000 in The Netherlands a nationwide prospective multicentre study was initiated, including 809 women with validated preoperative and postoperative questionnaires and 2 years’ follow-up (2006). The results of this meticulously conducted study led to the publication of a number of articles presented in this and other prestigious journals [4]. The
Int Urogynecol J
favourable outcomes of the TVT procedure, the good host response to this synthetic tape and the publication by Olson et al. [5] in the USA on the high prevalence and recurrence rates after conventional repair of pelvic organ prolapse (POP) led to the accelerated introduction and marketing of new, mostly synthetic grafts for the treatment of pelvic floor dysfunction. The preliminary published reports on mesh use by the French TVM group were encouraging and within a relatively short period of time many gynaecologists decided to introduce this technique into their practice. In 2005, M. Vierhout became the first Professor in Urogynecology and started a structured project to carry out RCTs with sufficient power on the use vaginally inserted mesh and prospective observational cohort studies. It was decided to bring together and to coordinate all studies on the management of pelvic floor (dys)function into a consortium (J.P. Roovers 2006). This initiative has proven a very effective way of enhancing medical research and has inspired more than 100 publications in peer reviewed journals and 20 PhD theses. The greater interest in the impact of pelvic floor dysfunction on an increasing and ageing population, and the introduction of new diagnostic and therapeutic modalities, have led the Dutch Society for Obstetrics and Gynecology (NVOG) to recognise urogynaecology in 2009 as being the 4th subspecialty in OB&GYN. At present, there are four officially recognised institutes for training as a urogynaecologist. The membership of the WBB grew from 16 members at the beginning to almost 240. It is gratifying to observe that the recommendations presented in my lecture in Prague (2002) on “The Future of Urogynecology” have been fulfilled: urogynaecology is now recognised as a subspecialty by national and international societies and guidelines for training as a urogynaecologist are generally accepted. Pelvic floor reconstructive surgery with meshes became popular, but also the subject of concern, leading to lively and heated discussions, not only among medical specialists, but also in the public domain. The FDA update on serious complications associated with the transvaginal placement of surgical mesh also has also had repercussions in the Netherlands and since a TV program was broadcast where the adverse effects and serious complications of mesh use were covered in detail, mesh use in The Netherlands has been reduced to almost zero. In spite of efforts by the WBB to provide guidelines for surgical training, to register all mesh procedures and all Patient Registered Outcome Measures (PROMs), the pendulum wavers to the other side and women for whom a mesh procedure could be the last remedy recoil from this intervention. From 2000 to 2002 I was IUGA president and the International Urogynecology Journal became the official IUGA journal with a new editorial board. In the following years (2004)
the office of the secretary-treasurer moved from Chicago (Peter Sand) to Florida (Willy Davila), the by-laws were revised and initiatives for a joint ICS/IUGA working group on the terminology and standardisation for pelvic floor dysfunction were taken. In 2003, because of health problems, I retired from practical work, but remain active today on the side-lines as a consultant, member of a supervisory board and chairman of the foundation for pelvic floor patients. In this latter position I am often on the patient’s side of the doctor’s desk and have participated in discussions with the Dutch health care inspectorate (IGZ), leading to creation of a document issued by the health authorities calling upon gynaecologists to exercise caution in prescribing and fitting transvaginal mesh. However, the inspectorate’s report concludes: “very few alternatives are available for the conventional surgery without use of mesh. Therefore a ban on mesh, as required by a group of patients suffering from serious complications after mesh implant, is considered not to be in the interest of patient”. Last but not least, my mentors. Dr. Wilfried de Goey, who taught me in his enthusiastic way how to perform urodynamics, the late Prof. Tom Eskes who inspired me to continue in this field and the IUGA family whose good friendship, dedication and sound competition have achieved so much. However, urogynaecology is an everchanging science, with new techniques constantly being tried, the most recent mesh POP repair. We are still in the midst of this ”perfect “ storm [6]. There remains much more to be done. Conflicts of interest None.
References 1. De Goey WBKMV (1976) Incontinence of urine in women. A urodynamical and roentgenological study. K.U Nijmegen, The Netherlands, PhD thesis 2. Moonen WA (1986) A review of 35 years experience in the management of urinary incontinence. In: Debruyne FMJ, van Kerrebroeck Ph EVA (eds) Practical aspects of urinary incontinence. Nijhoff, Leiden, pp 312–320 3. Van Geelen JN, Theeuwes AGM, Eskes TKAB, Martin CB (1988) The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol 159:137–144 4. Schraffordt Koops SE, Bisseling TM, van Brummen HJ, Heintz PM, Vervest HAM (2006) What determines a successful TVT? A prospective multicenter cohort study, results from the Netherlands TVT database. Am J Obstet Gynecol 194:65–74 5. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clarl AL ( 1997 ) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–505 6. Brubaker L, Shull B (2011) A perfect storm. Int Urogynecol J 23:1–2
