Doctoral Degrees (Obstetrics and Gynaecology)
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Browsing Doctoral Degrees (Obstetrics and Gynaecology) by Subject "Non-inferiority"
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Item Open Access Evaluation and management of a rectocele in a resource limited setting(University of the Free State, 2017-01) Henn, Etienne Wilhelm; Wessels, P. H.English: INTRODUCTION: A rectocele can be expected in approximately 11-19% of women and is present in 40-85% of women requiring pelvic floor surgery for other disorders. There is considerable international variation in the evaluation and management of these women, particularly in regards to surgical treatment. The healthcare environment of the Free State is one with limited resources and innovative clinical approaches are often required to allow for optimal service provision to continue. OBJECTIVES: The objective of this thesis was to research the assessment and management of women who presented with rectoceles in a resource limited setting through innovative and frugal methods, whilst maintaining a pragmatic clinical inclination. METHODOLOGY: The methodologies included the linguistic and cultural psychometric validation of pelvic floor questionnaires, the randomized assessment of the clinical impact that transperineal ultrasound has on patient management, the randomized evaluation of the value which a rectopexy might add in combination with a sacrocolpopexy, the retrospective review of a rectocele plication and description of this novel surgical technique, the retrospective review of the benefit which a perineal body repair in combination with a posterior repair might confer as well as the randomized assessment for non-inferiority of a rectocele plication compared to a defect-specific repair in women with rectoceles. RESULTS: The PFDI-20, PFIQ-7 and PISQ-12 pelvic floor questionnaires were validated in South African women for the languages of Afrikaans and Sesotho and shown to be responsive to clinical change. The integration of transperineal ultrasound findings resulted in an alteration of the definitive management plan in 37.6% of women and this was most evident for those with posterior compartment disorders. A rectopexy was not found to add significant clinical benefit in women with advanced multi-compartment pelvic organ prolapse who underwent an extensive sacrocolpopexy. The rectocele plication procedure, which involves the repair of the anterior rectal wall though a vaginal approach, was found to result in anatomic success of 88.6% after a mean follow-up period of 27 months with an associated significant improvement in symptoms and quality of life. The addition of a perineal body repair in those women who underwent a rectocele plication was not observed to be of any clinical benefit in this population. The randomized assessment of a rectocele plication compared to a defect-specific repair demonstrated that the new procedure was not inferior to the existing operation in regards to anatomic outcome. The anatomic success rates were 92.3% and 76.9% respectively (p=0.2485, 95% CI -13.6; 42.5). The rectocele plication did however demonstrate significantly superior symptomatic and functional outcomes compared to a defect-specific repair after 1 year. A significant observation was that of voiding dysfunction in this population of women with isolated rectoceles. This was the second most prevalent initial complaint and it was significantly improved (p= 0.0011) after surgical correction of a rectocele in both the retrospective and prospective evaluations. CONCLUSION: This research compilation demonstrated that a thorough assessment of women with posterior compartment disorders through the use of validated instruments and standardized investigations in combination with innovative surgical procedures resulted in clinical outcomes not inferior to those reported elsewhere in the literature. It emphasized that pragmatic innovation in a limited resource healthcare environment can produce internationally equivalent clinical results.