Australian and New Zealand Continence Journal

Introduction The Australasian Pelvic Floor Procedure Registry (APFPR) was established in 2019 to monitor safety and efficacy of pelvic floor procedures (PFP) that use prostheses. This followed increased international and Australian regulation of mesh for PFPs, resulting in an overall reduction in PFPs and changes to the procedure profile. The aim of this study was to determine contributing factors and clinician responses to clinical practice trends, and implications for the APFPR.

Methods An online clinician survey was developed and distributed between July and October 2022 to APFPR contributing clinicians and USANZ and UGSA members. Descriptive statistics were calculated and stratified analysis performed.

Results Seventy-nine valid responses were received. Approximately two-thirds of respond-ents reported a decline in procedures to implant mesh slings; forty percent reported a decline in mesh sacrocolpopexy; and 40% and 50% reported an increase in explantations of mesh used for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) respectively. Contributing factors for SUI procedure changes were patient preference (83%) and litigation concerns (59%), for POP procedures it was mesh non-availability (81%). Clinician responses included changing to other procedures (SUI 54%; POP 71%); conservative management (SUI 17%); and upskilling and onward referral (14%, 10%) for POP. Responses varied by specialty group. A majority recommended adding native tissue SUI procedures to the APFPR.

Conclusion The survey provides insights into the impact and implications of the reduction in pelvic prostheses over the last 5 years. The addition of native tissue SUI procedures to the APFPR will ensure it maintains clinical relevance in a changing landscape.

Pelvic health physiotherapy care is considered best practice for managing many pelvic health conditions. However, access to pelvic health physiotherapy varies greatly, and may be lacking in rural and remote areas of Australia. This study reports an evaluation of a new pelvic health physiotherapy service model in the Kimberley region of Western Australia, undertaken from July–December 2021. The objective of this evaluation was to document patient and service outcomes, consumer satisfaction and key stakeholder feedback, to guide ongoing need and development of such a service. A total of 113 referrals were managed by the new service, resulting in over 199 appointments and involving 77 patients. Many of the 60 patients who attended their booked appointments had significant symptoms and most (76.7%) had experienced symptoms for more than one year. Consumer feedback was positive, and all key stakeholders reported it was either moderately, very, or extremely important that the new service continue. This evaluation demonstrated a clear need and support for pelvic health physiotherapy services in the region, and documented a successful model of care, working alongside the existing generalist physiotherapy model. Future priorities are to implement culturally-informed models of pelvic health care to improve access for Aboriginal and Torres Strait Islander people with pelvic health conditions, and to examine other service models that improve access to pelvic health physiotherapy in under-served regions.

For management of mesh complications relating to full-length midurethral slings, a number of techniques for total excision of mesh have been reported. Surgical excision is invasive due to scarring and anatomical location, requiring effective techniques to avoid complications, such as neurovascular injuries or incomplete excision of mesh when total mesh excision is planned.

Detailed surgical technique descriptions of total excision of retropubic midurethral mesh slings and transobturator midurethral mesh slings are presented, including surgical points. In addition, illustrations provide an accurate view of the path of midurethral mesh slings in relation to anatomic considerations.

The described techniques have been utilised for the total excision of over 150 midurethral mesh slings, with the authors avoiding any unplanned incomplete mesh excisions.

For total excision of retropubic midurethral mesh slings, an open retropubic technique combined with vaginal dissection, allows for effective access to the vaginal, retropubic and subcutaneous potions of the sling, without the addition of risks related to intraperitoneal access with pneumoperitoneum and Trendelenburg positioning. Transobturator midurethral mesh slings can be located and completely excised through vaginal and inner thigh/groin incisions, with good cosmesis.