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The Current Dire Need for Training in Uro-Gynaecology and Pelvic Reconstructive Surgery in Pakistan [EDITORIAL]

Author(s) Name:

Dr. Raheela Mohsin

Address of Correspondence
Assistant Professor
Obstetrics and Gynaecology department
Aga Khan University Hospital
Stadium Road, Karachi
 

Urinary Incontinence is a social and hygienic problem in many affected women, restricting their daily activities.1 About 50% of women suffer from some form of urinary incontinence2 which is estimated to affect 17-55% of community-dwelling women.3 Furthermore it is estimated to cost 10 billion US$ each year.4 About 11% of women have to undergo surgery for pelvic floor problems and 29% of those have to be operated, at least one more time.5 There are no data regarding prevalence of urinary symptoms in our population. A study on Urinary Incontinence Prevalence in rural Pakistan has been completed by Obstetrics and Gynaecology (Obs/Gyn) department of Agha Khan University (AKU) and its results are being compiled for publication.
The treatment options for both urinary incontinence and pelvic organ prolapse are increasing not only in number but also in complexity with the use of synthetic mesh and minimal invasive surgery. The number of women reporting pelvic floor defects and urinary incontinence are increasing in our country perhaps due to various public awareness programs. As these symptoms greatly affect the women’s quality of life hence they seek for treatment at an early stage. Our tertiary referral centers cater to these patients. Considering the advancements in treatments, Uro-Gynaecology (UG) has now become a sub-speciality of gynecology recognized and promoted by Institutions of higher professional training, worldwide. It thus becomes our obligation to develop the capacity of our Gynaecological Surgeons. Therefore Obs/Gyn department of AKU has introduced a Fellowship program in UG to develop skills of our Gynaecologist in this sub speciality. The faculty itself needed to be well skilled in UG as well as had special interest in Medical Education so that the residents could be trained by the surgical experts to deal with complex cases of Urinary Incontinence and Utero-vaginal prolapse. This program is approved by postgraduate medical education (PGME) department of AKU.
UG is a rapidly expanding sub-specialty of Obs/Gyn. There is a rising trend of training in sub-specialty and many universities in the western countries have developed pelvic floor units to offer training in UG. Countries like US, Australia and Great Britain have introduced 3 years certified Fellowship Program for UG. There are limitations for training residents in this field in our country as there are few formerly trained pelvic surgeons to tutor them. Even the best residency program with a dedicated UG rotation cannot offer this training to residents as pelvic surgery demands a strong background of pelvic anatomy and not only extensive but also appropriate surgical experience.
There are few studies that address the problem of training in UG. Schimpf found that 46%, of 205 residents surveyed in the United States, were unsatisfied with UG residency education program.6 Only 23.9% of the respondents had received training in female pelvic medicine and reconstructive pelvic surgery, they however were more satisfied with their education if they did a rotation in UG also.6 Similarly, Dunn et al. described that most of the respondents, 51 in number, among gynaecologists working in the United States Air Force reported inadequate training in advanced pelvic surgery techniques during residency even though 48% of them treated patients with incontinence and prolapse.7
The European Board and College of Obstetrics and Gynaecology (EBCOG) and the European Urogynaecology Association (EUGA) have published guidelines for a sub-specialist training program in UG. Currently there are no recognized training programs for UG in our country, due to which our graduates travel abroad in order to gain hands-on experience of training in this sub speciality, bearing heavy costs. Hence there is a dire need to provide sub-specialty advance training for UG in Pakistan. We need to develop our own curriculum based on need assessment. The curriculum should cover both the educational and research component in UG. Teaching rotations should cover diagnostic radiology, physiotherapy, urology and colorectal surgery. Fellowship Program should include formal assessments and program evaluation to ensure the quality of training. More over there being general lack of UG training in South East Asian Countries, introducing fellowship in this subspecialty would become a hallmark for Pakistan. We look forward for the stake holders to approve and introduce a structured UG Fellowship Program in near future.

References

    1. J.F. Wyman, S.W. Harkins, S.C. Choi, J.R. Taylor and J.A. Fantl, Psychosocial impact of Urinary Incontinence in women. ObstetGynecol 1987;70: 378–381.
    2. G.L. Harrison and D.S. Memel, Urinary Incontinence in women: Its Prevalence and its Management in a Health Promotion Clinic. Br J Gen Pract 1994;44:149–152.
    3. Burgio K, Matthews K, Engel B .Prevalence, Incidence and correlates of Urinary Incontinence in healthy, middle –aged women. J Urol 1991;146:1255-1259.
    4. L. Cardozo, Urinary Incontinence in women:Have we anything new to offer?BMJ 1991; 303:1453–1457.
    5. A.L. Olsen, V.J. Smith, J.O. Bergstrom, J.C. Colling and A.L. Clark, Epidemiology of surgically managed Pelvic Organ Prolapse and Urinary Incontinence. ObstetGynecol1997; 89: 501–506.
    6. Schimpf M, Deborah M, David F, SullivanO,Lasala. Resident education and training in Uro-Gynaecology and pelvic reconstructive Surgery: a Survey Int Urogynecol J 2007;18 (6):613-617.
    7. J.S. Dunn, D. Gruber, J. Broberg, J.R. Fischer and J.A. Thornton. Uro-Gynaecology practice patterns among Air Force obstetricians and gynecologists: survey results. Int Urogynecol J Pelvic Floor Dysfunct,2006;17: 598–603.