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 Ras 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.

Colo-rectal surgery list

The urogynaecology fellow will assist in major and minor colo-rectal surgical cases. This will include colonoscopy, sigmoidoscopy, abdomino-perineal repair, colectomies and secondary repair of anal sphincter.

Multi-disciplinary team meeting

On a monthly basis, Drs Claire Warden (colo-rectal surgeon), Dr Lisa Kaestner (Urologist) and Dr Kendall Brouard and Dr Lamees Ras meet to discuss complex cases. These are specifically women with pelvic floor pathology involving all compartments with components relating to colo-rectal, urological, and gynaecological issues. A combined management plan is instituted and if necessary a combined surgical procedure is planned.

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 Ras. 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.

Colo-rectal Clinic

The urogynaecology fellow attends this clinic to see patients with the team of colo-rectal surgeons at Groote Schuur Hospital. Skills that will be acquired at this clinic include sigmoidoscopy, endo-anal ultrasound and interpretation of defaecolography and manometry testing.

Wednesday Grand Rounds

This is bedside teaching ward round from 07h30 to 09h30 led by Drs Brouard and Ras. Teaching involves a broad range of topics but the focus is on the pre-operative patients. 70-80% of these are booked for Urogynaecological surgery. 

General Gynaecology Outpatients Clinic

In this general gynaecology 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. The Urogynaecology fellow will focus on the patients with pelvic floor dysfunction. We see 2500 patients a year in this clinic.

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.

Operating Theatre

We perform a broad range of gynaecological procedures. The bulk of our operating comprises surgery for pelvic organ prolapse and incontinence. We perform an average 152 pelvic organ prolapse procedures per year. This includes anterior vaginal repair, posterior vaginal repair, sacrospinous fixation, vaginal hysterectomy for prolapse, laparoscopic sacrocolpopexy and colpocleisis. We also perform a number of vesicovaginal fistula and rectovaginal fistula repairs as well as excision of urethral diverticula. We perform approximately 40 stress incontinence sling procedures per year and a number of urethral bulking 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.

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.

Friday morning journal club

The emphasis here is on recent urogynaecology research.