Int Urogynecol J (2014) 25:437–438 DOI 10.1007/s00192-013-2305-6
LETTER TO THE EDITOR
A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Reply to comment R. M. Freeman & K. Pantazis & A. Thomson & J. Frappell & L. Bombieri & P. Moran & M. Slack & P. Scott & M. Waterfield
Published online: 17 January 2014 # The International Urogynecological Association 2014
Dear Editor, We would like to thank Dr Long and colleagues for pointing out the error in our paper [1], i.e. we inadvertently used the word “grade” instead of “stage” for the POPQ. This is a good example of how even those who purport to understand and use the POPQ, still make errors, in our case with terminology. Unfortunately, Dr Long and colleagues [2] have done likewise! In their letter they state that “at least 1 cm above or beyond the hymeneal remnants should be the stage 3 or more of POP-Q”. In fact (as we stated) this is stage II, i.e. leading edge greater than or equal to −1, but less than or equal to +1 [3]. Our baseline data are presented in the results section of the paper [1]: point C was +0.12 for the abdominal and +0.28 for the laparoscopic sacrocolpopexy (i.e. POPQ stage II). At 3 months this was −6.65 (SD 138) and −6.48 (SD 1.50) and
R. M. Freeman (*) : K. Pantazis : L. Bombieri : M. Waterfield Urogynaecology Unit, Directorate of Women’s Health, Derriford Hospital, Derriford Road, Crownhill, Plymouth PL6 8DH, UK e-mail: [email protected] J. Frappell : P. Scott Minimal Access Surgery Group, Plymouth Hospitals NHS Trust, Plymouth, UK A. Thomson : P. Moran Worcestershire Acute Hospitals NHS Trust, Worcester, UK M. Slack Teaching Hospital Trust, Addenbrooke’s Hospital University of Cambridge, Cambridge, UK R. M. Freeman : M. Waterfield Peninsula College of Medicine and Dentistry, Plymouth, UK
the corresponding results at 1 year were −6.63 (SD 1.35) and −6.65 (SD 1.15) for abdominal and laparoscopic sacrocolpopexy respectively. The IUGA/ICS standardization report for the outcomes of prolapse surgery [4] recommends that the leading edge of the prolapse at each site should be reported in detail. This includes all the points as well as the ordinal stage. It could be argued that the points are more meaningful than the stage, but these seem to be reported inconsistently with a recent literature review showing that 47 % of studies used the ordinal stage only and not the points [5]. It is important that there is some form of staging or grading of prolapse and maybe the “simplified POPQ”, which uses the ordinal stage, could be used in routine practice [6], as some clinicians perceive the full POPQ to be “too complex”. The “simplified” system has been validated and shown to have a good association with the full POPQ [6]. However, the latter should be used in all research [4] and those undertaking the examination must be fully trained in the technique to ensure accurate data and reporting. Whether this occurs or not is unclear. It is encouraging to see the improved uptake in the use of the POPQ since our study in 2004, which showed that only 40 % of IUGA and AUGS members used it routinely in their clinical practice [7]. A recent study has suggested that 76 % of AUGS and ICS members are now using the POPQ, but the authors state that the technique “varied considerably” [8]. This raises further concern about training and maybe the reliability of some data. Dr Long’s comments are helpful and allow us to highlight these concerns. The POPQ was originally described in 1998 and maybe now is the time for the ICS, AUGS, SGS and IUGA to revisit it and, more importantly, the training.
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Int Urogynecol J (2014) 25:437–438
References 1. Freeman RM, Pantazis K, Thomson A et al (2013) A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J 24:377–384. doi:10.1007/s00192-012-1885-x 2. Long C-Y, Lin K-L, Wang C-L (2013) A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Comment. Int Urogynecol J. doi:10.1007/s00192-013-2306-5 3. Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17 4. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, Swift S, Whitmore K, Ghoniem G, de Ridder D (2012) An International Urogynecological Association (IUGA)/
5.
6.
7.
8.
International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Urogynecol J 23(5):527–535 Oyama IA, Steinberg AC, Watai TK, Minaglia SM (2012) Pelvic organ prolapse quantification use in the literature. Female Pelvic Med Reconstr Surg 18(1):35–36 Swift S, Morris S, McKinnie V, Freeman R, Petri E, Scotti RJ, Dwyer P (2006) Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system. Int Urogynecol J Pelvic Floor Dysfunct 17(6):615–620 Auwad W, Freeman RM, Swift S (2004) Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS). Int Urogynecol J Pelvic Floor Dysfunct 15(5):324–327 Pham T, Burgart A, Kenton K, Mueller ER, Brubaker L (2011) Current use of pelvic organ prolapse quantification by AUGS and ICS members. Female Pelvic Med Reconstr Surg 17(2):67–69
LETTER TO THE EDITOR
A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Reply to comment R. M. Freeman & K. Pantazis & A. Thomson & J. Frappell & L. Bombieri & P. Moran & M. Slack & P. Scott & M. Waterfield
Published online: 17 January 2014 # The International Urogynecological Association 2014
Dear Editor, We would like to thank Dr Long and colleagues for pointing out the error in our paper [1], i.e. we inadvertently used the word “grade” instead of “stage” for the POPQ. This is a good example of how even those who purport to understand and use the POPQ, still make errors, in our case with terminology. Unfortunately, Dr Long and colleagues [2] have done likewise! In their letter they state that “at least 1 cm above or beyond the hymeneal remnants should be the stage 3 or more of POP-Q”. In fact (as we stated) this is stage II, i.e. leading edge greater than or equal to −1, but less than or equal to +1 [3]. Our baseline data are presented in the results section of the paper [1]: point C was +0.12 for the abdominal and +0.28 for the laparoscopic sacrocolpopexy (i.e. POPQ stage II). At 3 months this was −6.65 (SD 138) and −6.48 (SD 1.50) and
R. M. Freeman (*) : K. Pantazis : L. Bombieri : M. Waterfield Urogynaecology Unit, Directorate of Women’s Health, Derriford Hospital, Derriford Road, Crownhill, Plymouth PL6 8DH, UK e-mail: [email protected] J. Frappell : P. Scott Minimal Access Surgery Group, Plymouth Hospitals NHS Trust, Plymouth, UK A. Thomson : P. Moran Worcestershire Acute Hospitals NHS Trust, Worcester, UK M. Slack Teaching Hospital Trust, Addenbrooke’s Hospital University of Cambridge, Cambridge, UK R. M. Freeman : M. Waterfield Peninsula College of Medicine and Dentistry, Plymouth, UK
the corresponding results at 1 year were −6.63 (SD 1.35) and −6.65 (SD 1.15) for abdominal and laparoscopic sacrocolpopexy respectively. The IUGA/ICS standardization report for the outcomes of prolapse surgery [4] recommends that the leading edge of the prolapse at each site should be reported in detail. This includes all the points as well as the ordinal stage. It could be argued that the points are more meaningful than the stage, but these seem to be reported inconsistently with a recent literature review showing that 47 % of studies used the ordinal stage only and not the points [5]. It is important that there is some form of staging or grading of prolapse and maybe the “simplified POPQ”, which uses the ordinal stage, could be used in routine practice [6], as some clinicians perceive the full POPQ to be “too complex”. The “simplified” system has been validated and shown to have a good association with the full POPQ [6]. However, the latter should be used in all research [4] and those undertaking the examination must be fully trained in the technique to ensure accurate data and reporting. Whether this occurs or not is unclear. It is encouraging to see the improved uptake in the use of the POPQ since our study in 2004, which showed that only 40 % of IUGA and AUGS members used it routinely in their clinical practice [7]. A recent study has suggested that 76 % of AUGS and ICS members are now using the POPQ, but the authors state that the technique “varied considerably” [8]. This raises further concern about training and maybe the reliability of some data. Dr Long’s comments are helpful and allow us to highlight these concerns. The POPQ was originally described in 1998 and maybe now is the time for the ICS, AUGS, SGS and IUGA to revisit it and, more importantly, the training.
438
Int Urogynecol J (2014) 25:437–438
References 1. Freeman RM, Pantazis K, Thomson A et al (2013) A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J 24:377–384. doi:10.1007/s00192-012-1885-x 2. Long C-Y, Lin K-L, Wang C-L (2013) A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Comment. Int Urogynecol J. doi:10.1007/s00192-013-2306-5 3. Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17 4. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, Swift S, Whitmore K, Ghoniem G, de Ridder D (2012) An International Urogynecological Association (IUGA)/
5.
6.
7.
8.
International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Urogynecol J 23(5):527–535 Oyama IA, Steinberg AC, Watai TK, Minaglia SM (2012) Pelvic organ prolapse quantification use in the literature. Female Pelvic Med Reconstr Surg 18(1):35–36 Swift S, Morris S, McKinnie V, Freeman R, Petri E, Scotti RJ, Dwyer P (2006) Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system. Int Urogynecol J Pelvic Floor Dysfunct 17(6):615–620 Auwad W, Freeman RM, Swift S (2004) Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS). Int Urogynecol J Pelvic Floor Dysfunct 15(5):324–327 Pham T, Burgart A, Kenton K, Mueller ER, Brubaker L (2011) Current use of pelvic organ prolapse quantification by AUGS and ICS members. Female Pelvic Med Reconstr Surg 17(2):67–69
