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Hello, good evening everyone. Hello, and we would like to warmly welcome you in the first joint webinar of European group of trainees in Obstetrics and Gynecology and the European Organology or Gynecological Association. That it is an honor for us to be here and present and support our training. As all everybody knows OC is tries to focus, you know, he is the training and is one of our pathways and we need more knowledge and more training opportunities. I would like also to thank you, professor rate the president of that. He is present here and he's uh welcome us. And also he's very close to the trainees the last two years that I have. The, the great honor to be also in the training committee. He's on our side. He's close to us and he's trying his best in order to offer more opportunities. One of the greatest, the greatest opportunities that he, he was on. One of the biggest supporters is the internship program that please look more information about it because it's now open. The call one cee can give uh can be given a €5000 grant in order to go abroad to a credit center to make a research project in order to know better and to make research. So please look for it and apply. It's a great opportunity. And Professor Serra, again, it's a great honor and thank you very much for being here today and make it that happen. Thank you very much. Your muted. Can you hear me? Yes. OK. Thank you very much. My name. Uh Thank you Sophia. My name is Maurice Sera. I am uh the president, the current president, the outgoing of uh AU uh AOA because uh my presidency will end in three months. It's a pleasure and honor for me to be here and to introduce this joint webinar organized by and the AU if the number of the attendees. So congratulations. Uh I believe that uh one of the most important aims of my pres presidency was to increase the collaboration with the trainees uh and also to increase the visibility and the presence of young Neogyne in our association, our artists, our curses and so on. I believe that this is a relevant part of the uh UGA identity and uh more than in other international society. This is my feeling. Therefore, we included the, the representative in the Y Training Committee. And now Sophia is uh the current co-chair, I hope uh in the future of uh this committee together with uh Alexander Rallo. Uh I believe that also the topic that we have cho for this uh webinar is uh very important because uh the webinar address is uh an all topic, not only for young urogynecologist, but also for all of us, a record prolapse is a complicated condition. And um also the physiopathology of prolapse is more complicated than, than expected. Uh We are a lot of biochemical immuno genetic aspects uh that can be considered as the risk factors uh associated with uh the onset of medical organ prolapse. So, it's important that uh of the prolapse evaluation of uh the recurrence is uh will be really validated and standardized. So only being uh inappropriate terminology and an appropriate diagnostic tool that we can offer a convincing counseling and propose uh a personalized treatment for the por prolapse. It's a pleasure now to introduce uh Professor uh Nicholas. It's correct. My pronunciation. OK. He is Associate Professor in Rix and Gynecology and urogynecology and the leader of uh the Urogynecology unit uh in the university. And uh so I it's a pleasure for me to introduce uh Professor Tamiko, Professor Rate. Thank you very much for the introduction, Sophia. Thank you very much as well for the introduction and enjoying you in this very nice company. You, it's really a pleasure to uh be around. Uh uh So um uh many people uh wanting to learn about uh U in pelvic and prolapse, I will ask for some help in case something doesn't work. Uh well today and I'll try to share my PDF uh and uh OK, here and up here and the no. And uh II don't know what's, what's happening with this. I'm, I'm, I'm sure we're gonna find out uh how to work it out. OK. So, uh the uh the current presentation is uh about a perfect organ prolapse. And uh I have no conflicts of interest for this uh presentation. And uh uh we are going to start with uh some uh uh definitions about prolapse. Uh pelvic organ prolapse. Uh uh is a very common condition and uh uh gynecologist encounter uh cases with prolapse every day. Uh It's a very, very recent statistics uh show that it's uh approximately uh more than uh there is a possibility of uh a woman to get, get operation for polyps up to 20% during her lifetime. Uh This is uh uh state uh statistics uh and uh uh it's very important to uh get uh uh to know exactly how to um uh how to uh evaluate uh cancer and uh treat uh such a common conditions like uh pelvic organ prolapse. Um Sorry for this. This is I'm trying to uh uh get sorry for interruption, but I can, the presentation is not visible for that and this and that. Yes, II know, I know I have not started yet. It, it's, it's uh the slides are the, the, uh the software is processing the slides with a PDF and uh Oh OK. OK. Thank you. Sorry. For. Yeah, this is why I'm uh trying to buy some time speaking. Uh Yes, but so um the definition of the pelvic organ prolapse is the decent of one or more of the anterior vaginal wall, uh posterior vaginal wall, uh the uterus uh including the cervix or the apex of the vagina or the vaginal calf scar after hysterectomy. And uh this is uh something that uh it gives symptoms uh to the woman. Uh It may come to the middle of the vagina and can, can uh it uh may come down to the uh introitus or it can, or it can come out of the vagina and uh usually the two latter conditions. Uh now it's, and I think I will present. Yes. Uh Do you see it? Yeah. Thank you. And uh the, the thing to is to see it and the thing is to change it. Yes. OK. So I think it works, it doesn't go back. So it will be more cautious about. Ok. So, uh this is my hometown, Saloniki. It's a, a coastal uh city in the north of Greece. And uh uh I'm very happy to have uh Sophia Zakki with me uh during the last seven years uh working together uh uh towards uh urogynecology and uh endoscopy lately. And uh uh uh w what we were talking about uh uh really was the definitions of uh pelvic organ prolapse. And uh we talked about the general definition and then we have the uterine or cervical prolapse, which is the observation of the descent of the uterus or the uterine cervix within the vagina or out of the vagina. The uh vaginal vault prolapse, which is the observation of the descent of the vaginal vault. This is the C A scar after the hysterectomy, the anterior vaginal wall prolapse, which is the observation of decent of the anterior vaginal wall. You see, we're not speaking about a cystocele. We are speaking really about anterior vaginal wall and this is most commonly uh due to bladder prolapse. Uh But I make this different because this could be either a central cystocele, a central defect or a paravaginal defect or a combination of these defects. And then we have the uh posterior vaginal wall prolapse uh which is again, what we used to say, posterior rectocele and it's caused by rectal protrusion into the vagina. And uh somebody has to have in mind that the l early in the nineties has very well described that there are levels of atomical support of the uh pelvic organ prolapse. So we have three levels of support according to John de la. And this is the higher level of support. The level one which is up here to the uterus sacral ligaments and the, the cardinal ligaments. And then this level two support, which is mainly into the um middle of vagina in the anterior and the posterior. And then we have the level three support, which is uh about the uh how the urethra support in the perineum is supported. And according to the lesions that we encounter, we have uterine prolapse, vaginal valve prolapse or internal cells. Speaking about uh a loss of level one support and speaking about the middle compartment, and then we have the level to support with the cystocele in the front of the vagina in the anterior vaginal wall or the rectocele in the posterior vaginal wall. And then we have uh when we have level loss of level three support, we have a urethrocele in the front and rectocele uh in the posterior vagina. Again, a little talk about epidemiology. This is from uh the states, the uh thing that I commented before and you see very, very common condi condition. Considering that hypertension diabetes are conditions like that affect up to 10 15% of the population pelvic organ prolapse could be uh responsible for uh people operating, being operated up to 12 13%. Plus the incontinent surgery can reach 20%. What are the risk factors for this condition? Uh We have succeed to uh uh uh to uh assess the risk factor. And uh we can say lately that the uh increased BM I obesity is, is a risk factor for prolapse. The large weight circumference above eight is to centimeter. This lipidemia arterial hypertension constipation, occupational uh risks, heavy lifting, persistent cough, varicose veins are all determinants for pelvic or prolapse and there is a very good work statistical work, um systematic reviews that have been performed towards uh this ends. So, what about the assessment of pelvic organ problems? So we take it the history, we take the interview and uh what we really want to know is the nature of the vaginal bulge symptoms. Uh if uh and the degree of bother that's associated with the bulge. Uh Of course, we ask whether this protrusion is limiting the physical activities or has any implication of the sexual function and is, if it is progressively becomes worse or bothersome. So, we have the prolapse symptoms. And, uh, during this history, we have to investigate about symptoms from the lower urinary tract, we have to evaluate for symptoms of stress, urinary incontinence or urge urinary incontinence. And we have to ask if the, uh, patient, uh, use his, uh, her fingers for, to do a splinting. This is something that she puts her finger into the vagina to support the bulging tissue and then, uh, try and succeed to, uh, pass her water and then, uh, we investigate same symptoms about bowel function. And, uh, if again, uh, she splints, uh, she does splinting and if she strains and if she use laxative about fecal incontinence and deplete rectal emptying. Whereas, uh, as important is the sexual history about dysuria, coital incontinence and sexual dysfunction that could be related to prolapse. Lately, we have concluded that there are very good instruments like questionnaires that uh they are not only used in research but they can be used in everyday clinic, uh which can be really, um not long questionnaires and can be very helpful. And they are uh uh uh listed as great they recommended, which means that they have been very thoroughly investigated and they have evaluated and they are really useful in the uh in the clinical uh using uh the evaluation and the of pelvic floor control laps. You see here, the pelvic fold distress inventory, the pelvic floor impact questionnaire, the prolapse quality of life questionnaire, the uh questionnaire about sexual questionnaire, the, the uh uh sexual uh the sexuality and prolapse and the, the International Continence Society, the IC uh questionnaire. All of these are great uh recommended questionnaires and they are used during the evaluation of pelvic organ prolapse. Then we proceed to physical examination. We check the external genitalia about atrophy skin irritation or ulcerations we examined with a split speculum. If we don't have the seams, we can very easily break the plastic speculum that most of um the gynecological offices have and they can use it and you can use it to uh isolate the uh the department that you are not looking to see the BS and use, ask from the lady to uh strain and then or to do a valsalva maneuver. And then you evaluate the most distal site of vaginal descent in the uh department. The vaginal department that you are looking at and then if the symptoms are not confirmed, then you have to repeat the same evaluation in standing position. We're looking for stress incontinence, either overt or occult stress incontinence, occult incontinence is when you uh push the anterior compartment and you ask the lady to uh do valsalva or cough and then uh appears that she's leaking at the the in increase of the abdominal pressure. And finally, you have to evaluate the uh integrity of pelvic sort of muscles and the strength of the contraction. And you have to note it as well. And of course, you have to uh measure the prolapse. So how do we do that initially? Many decades ago, that was what was really in use was systems like the button walking system that you uh uh the the clinician was evaluating the prolapse uh using uh how further into the vagina or outside the vagina, the leading end of the pros was protruding. So, if so, if the prolapse was coming to the middle of the vagina, we're talking about a, a small cystocele and then we're talking or a grade one cystocele. And then if it was reaching the introitus was a grade two cystocele. If it was beyond the introitus, it was a grade three cystocele. And then if it was all averted, it was a grade four cystocele or uterine prolapse or rectocele. Today, we suggest strongly that somebody uses the pelvic organ prolapse quantification system. And this is um this grid that we um put some uh distances measured in centimeters. Uh I will show you in the next slide and then we have stages of prolapse depending on the protruding department of the vagina compartment, sorry of the vagina. So why do you pop Q, pop Q? Because it's a, a objective evaluation. It allows a baseline measurement before surgery. And so you can compare if you have a recurrent prolapse and you can uh compare how the uh prolapse is uh ev evolves through the time. If somebody uses an expectant management, it incorporates measurement of vaginal length, genital hiatus and perineal body. And it is converted to stages based on the most severely prolapsed vaginal segment. It facilitates communication between clinicians but it facilitates the clinician himself or herself because he, it's uh uh objective evaluation and it's recommended from the uh most of the modern urogynecological societies. So, uh how does it work? It? You have to take points of the vagina. You see here, it's the uh nine measurements. The uh upper line is about the uh posterior post, the anterior compartment. And the, the uh lower line is the about the posterior compartment. And the, the first two measurements is about the anterior vaginal wall. The first two measurements of the uh third line is about the posterior vaginal wall. C implies the vaginal cuff or the cervix. And D is the pouch of ductus and the middle line is about the genital hiatus that you can see here and the perineal body and the total vaginal length. So, with nine numbers, you can really describe what you're looking at the uh a woman who has prolapse. And you see how a cytosine described very, very well here when you have this point which is approximately three centimeters. And then if you have a bulge, you have the leading edge of the bulge and you write down in centimeters how far is from the introitus. And uh then uh you don't have any rectal cell here, which is uh written down with uh minus uh numbers and, and uh vice versa. Speaking about an uh rectocele, you have the uh plus two, speaking about the uh posterior compartment and plus five, it's not plus five, it's less here. But uh it's uh you can see how is the difference between the first line, the anterior compartment and the last line with the posterior compartment. And the way you can describe the uh prolapse. And in case that there is a uterine um inversion, the c the cervix you can see and that is written here with uh the, all the distance uh the distant point from the introitus and uh uh respectively that uh various uh sites of the vagina you can put down. So you have the whole uh picture of uh uh that moment that uh the uh the prolapse, how big is the prolapse and you compare it later. What about other investigations? Urodynamics? Urodynamics is not necessary, usually can help get information about counseling the patient and maybe consider if it is bothersome incontinence together with grade two stage two prolapse or bigger. And there are many times that physicians, urogynecologist need urodynamics, preoperatively, mainly in cases of occult stress urinary continence. So it's not necessary, but it's something that could help the evaluation of uh the woman with prolapse. And then we have other diagnostic modalities like cystoscopy, which again is not necessary, but we could use it in case we have hematuria and we have previous operation with a mesh. Whereas pelvic floor ultrasound again is not necessary for the first evaluation or the uh first time that somebody comes with a prolapse. But it's really useful in cases of pelvic recurrence and uh um detecting and differentiating among inter cystocele or rectocele with the ultrasound. We can uh really investigate the levator revulsion injuries and hiatal ballooning. The same, we could use the MRI in order to assess and detect any ulcer injuries. And uh uh of course, with the ultrasound, we could use it to investigate uh mesh in cases that we have um that we have the uh previous uh mesh operation with mesh. When we complete the evaluation of the patient, we have to conclude what are we at? What are our therapeutic targets. So we have to uh define what is our aim about the symptoms of uh uh uh the patient who has the prolapse and we should treat or limit the symptoms. Uh What are the expectations of the patients? So, we have to uh ask and investigate and to identify and uh to uh reach and fulfill this expectation. We have to improve the quality of life of the patient. We have to treat and to control the comorbidities we have to avoid and we have to minimize new morbidities and if possible, we should prevent future disease. So how we're going to decide what sort of management we're going to do. We have to decide upon conservative or surgical management and the base. The first steps is to think about the patient's preference. The future fertility, we're talking about young women, family condition and suitability for surgery for a woman with no symptoms. We have to educate and reassure appropriately. We know that the natural history of is not very well investigated, but it appears that women who do not want treatment for the pelvic organ prolapse, they probably will have no change or only a small increase in the size of prolapse within the next year. So we can reassure them and we can if they don't want and we can uh advise them appropriately how we can uh advise noninterventional treatment, avoid heavy lifting. We should advise pelvic floor exercises, quit smoking, vaginal estrogen and correct defecatory dysfunction. All these they are going to control the symptoms and they are going to prevent the deterioration of pelvic organ prolapse. What about conservative treatment? Apart from pelvic floor exercises, we have energy devices or pessaries, pelvic floor exercises. Sorry, pelvic floor exercises appear not to be very um effective. Uh Speaking about the uh the studies that have been performed on prevention during the postpartum period, but there is a very high level evidence from our cities that pelvic floor uh exercises could uh work as first line treatment for prolapse in the general female population. Unfortunately, the kegels do not work pre and post operatively and uh uh it needs so in the, the s really need thorough instruction and supervision. So unsupervised KS are not really helpful, energy devices like lens or radio frequencies, they have been lately very uh thoroughly investigated. And uh it seems although the evidence is accumulating that there are no good quality studies to evaluate the use of laser for women with vaginal laxity. Here you see in um a randomized study from uh the team of uh uh Athens, they concluded that uh there was no difference between the laser group and the nonintervention group between uh uh in terms of uh prolapse um improvement during that study. And there are studies that may give better results. But the well performed studies, they will conduct studies, studies are really give uh results like this. Finally, we have conservative speaking, the pessaries, pessaries are a very uh historical uh treatment for prolapse. And uh we can use it in uh uh many circumstances that they are not uh us usual like pregnant women, this prolapse. Uh And generally, we expect that the 92% of women can be fitted successfully with a pessary. The, the uh feeling of pessary needs experience, um smaller prolapses are managed better with the ring pessaries, whereas a bigger prolapses can be uh managed with uh pessaries like the gel horn. Uh And uh the downside is that uh in case that women do not, cannot change them independently, uh women have to come back to the clinic every 34 months for a change. And uh you see here, you should start with a ring for uh for beginning when you see the for the first time in clinic and you want to fit the pessary. And then if this doesn't work, you uh continue to the gel horn and then to the donut pessary. And then you could either do combination of pessaries until you reach the one that fits better. And finally, we are talking about the surgery. When we talk about surgery, we talk when the treatment, uh it's that is a good treatment for women who are bothered by their problems and have failed or declined non surgical treatments. And uh how do we uh select the type and the route of surgery based on the patient's experience, the sorry preferences, the surgeon's experience and the expertise, the location, the severity of prolapse, the patient's general health and the nature of the symptoms. If it there is coexistent urinary bowel or sexual dysfunction and the type of prolapse as well. And you see, there are plenty of operation that somebody has could perform. And what we really have to evaluate and make clear from the beginning is the stage and the type of prolapse that we are talking about because we have surgery for anterior vaginal wall prolapse surgery for posterior vaginal wall prolapse surgery for middle compartment prolapse. We have reconstructive surgery and obliterative surgery and most of the times what we have to do is a combination for of these operations. So how do we choose operations or combinations of them based based on the success and the recurrence rates of each procedure? Sorry, the age and the general health of the patient, the presence of sexual activity of the patients, complications from of any operation, whether we can perform them uh with a minimally invasive wave way. The cost the surgical expertise, the risk of malignancy if there is any and the patient's preference, along with all the above, what could we do about the anterior compartment prolapse. We could perform a material called py, which seems that it works 6 to 1060 to 100% the vaginal paravaginal repair again, 55 to 100% abdominal paravaginal repair, 76 to 97%. And then we have uh support with a mesh or uh sling type support, which is not very common operation. Uh But again, it's up to 98%. And uh uh you uh uh I'm sure everybody has uh seen or performed uh this type of operation. Uh Similarly about the posterior compartment, uh we could do the midline application, the traditional Corp or the site specific posterior vaginal repair with success reaching 83% for each of these operations along with the urography. When we're speaking about the middle compartment, there is the um option of performing a hysterectomy. We really not perform only hysterectomy for middle compartment prolapse. But we uh are doing a suspension procedure. Usually a uterus sacral ligament suspension or a sacrospinous ligament fixation uh of the vault prolapse. And uh this can have a success up to 77 or 88% in three or seven years for each of these uh uh options. And then we could preserve the uterus either with the sacral sacral hysteropexy or a sacrospinous hysteropexy or we could either perform an anterior abdominal wall hysteropexy. So there are options preserving the uterus. And when we have a vault prolapse, we could perform sacral spinous ligament fixation of the vault, the uterus sacral ligament suspension of the vault. We could do a mass sacral called pexy or a transvaginal pa. Uh I'm not really um uh uh analyzing these techniques. We, if we have time, we could really speak about them more, all the abdominal operations could be performed endoscopically, meaning laparoscopically or robotically and the trend is not to open. So all the operations that involve um a all the previously abdominal procedures are should be performed endoscopically today. And finally, we have the obliterative techniques and uh definitely have some place in the uh uh surgery of the uh the surgical armamentarium of prolapse uh like uh culpo classes and uh uh somebody could uh combine them with uh incontinence procedures as well. Of course, what are you talking about? Uh, surgery? We have to talk about complications and there are complications from prolapse surgery like dyspareunia, chronic pelvic pain, vaginal stenosis, de novo, urge incontinence, fist, lower urinary tract symptoms, mesh erosions where we put mesh or infections. And uh, of course, there are uh European countries that meshes have been stopped because of complications. Uh This is, there is not a uniform approach to the use of mesh and uh uh this is something that hampers the homogeneity of the uh procedures along the continent. Another question that uh um is very important is whether somebody uh should remove or preserve their uterus. And there are indications for not preserving the uterus. In case we have uterine pathology, cervical pathology, mineral postmenopausal bleeding, uh gene of uh mutation carriers, uh uh women on tamoxifen and the women who are unfit for routine. Well, woman's check. And uh compared to uh vaginal hysterectomy, it appears that hysteropexy according to the latest literature, uh has many advantages uh that mainly because it can perform with a minimally invasive way. And um, it could be, uh less uh expensive and, uh, it, uh generally it can preserve the sexual activity and it generally can be performed, definitely can be performed in uh increased age and in women of poor general health, a big discussion about meshes and, uh, uh, if we should use them or not, uh, definitely somebody should, uh very cautiously use mesh uh through the vagina if at all. And uh uh doing laparoscopy or uh abdominal procedure, uh, it seems that um, it has a more, uh it's more appropriate. And uh another question is whether we should do combined surgery or not and uh, it appears that really shouldn't do combined whereas there is no um uh preoperative stress incontinence. And uh uh it's so there is no place for prophylactic procedure here. But whether there is occult incontinence or overt incontinence, then the patient really, uh gains from a prophy from, from a uh combat surgery. And uh, so we should think about it. You see here the, or here in the overt incontinence, which is 5.5%. Is there a need for specialist? Is there a need for better training? Yes. And this is why a yoga exists. And uh uh I think everybody of you is welcome and uh uh to join us to uh uh work with us to uh learn and to spend time with us in this uh very uh important issue of pelvic organ prolapse. And uh there's also a need for guidelines. Guidelines depend on the current uh available literature. And uh uh according to the latest uh uh well contact trials. And uh here is a um a su a sum up of the guidelines of uh a major organization and uh they changed through the time and they have already removed hysterectomy from the um from the algorithm of prolapse management. And uh this is something that, of course, uh many societies uh declared that there is no, still a lot of data. Uh But uh then again, uh we don't really have um a guideline from that is agreement from all the societies. So in conclusion, when we see a prolapse, we evaluate and uh really should PTU it, we should learn this uh instrument. It's very helpful. And uh this is the way that uh we uh help both patients and physicians. We should identify coexistent lower urinary tract symptoms or co comorbidities. We should set therapeutic goals and respect patients'. Wish we deliver the management as appropriately. It doesn't matter if it's surgical conservative, but we have to uh choose the right uh uh option for this. The uh each lady and uh very important to follow up uh and audit our results. So, thank you very much. And uh we really uh very, very uh want to see you in our annual congress in pre in the beginning of December. And uh I'm uh welcome and uh I'm very happy to accept any questions. Thank you. Thank you a lot, Professor Romis for this comprehensive and complete presentation. I think that for all the it was a great opportunity to give this full detailed presentation about pelvic prolapse even has no previous knowledge about pelvic prolapse. Now, with your presentation, with the opportunity to get to get a big picture for everything from the assessment to management. Uh Thank you very much and the professors any comment uh from you before we start with this? No, my general comment is excellent presentation. Uh I have uh some minor comments. Mhm The S one is that I really appreciated the the comment and uh and the evaluation and assessment of the urodynamic role because I am traditionally a convinced supporter of uh uro in general in urogynecology. So it's clear that uh on the basis of the available evidence, uh it is not at all mandatory to propose urodynamics in all women before the surgical treatment of prolapse. But uh I believe that this is the only way that we have to improve our counseling cause some patients. Uh uh Not really mm Sure to correct their prolapse because the anatomical defect is not uh severe, but they can have uh a relevant uh symptom of oac bladder for instance. And uh we can predict maybe, maybe we can predict the evolution of these symptoms only if we perform a preoperative urodynamics. Some studies we have recently published a study with, showed that in case of uh preoperative detrusor varity, the symptoms of a bladder can continue also after the anatomical repair. WW, what is your opinion about it? Thank you for a and do you and do you per dynamics before your surgery? Uh Generally speaking, I think urodynamics are really necessary in our job. But the thing is we don't have the evidence to support it in all patients. So we have to uh uh walk to uh the midline, let's say, uh speaking with evidence, we could not suggest, you know, urodynamic everybody. So definitely, I would use urodynamics in case there are lower urinary tract symptoms. I think both the patients and the clinician have broke evidence of what's going on both pre and postoperatively. So generally I agree with you, but the evidence does not support very strongly this notion. I completely agree. This is one of our problems. Hm, as you can see and all that goes conducted during the presentation for the trainees. If they can interpretate a report for Adynamic study and they can apply to their counseling and uh management options. You can see that. One third, they don't use it urodynamics, unfortunately. And uh 42% they don't know how to interpret it. The report of foams. So there is a lack of training, there is a gap that we should fulfill from training opportunities that already have organized some courses about foams in order to get more familiar the new generations with foam study, because it's a tool, it's a very useful tool for pelvic in LAS in general. So maybe we need to more to do for the gynecologist in the future in order to know more about dynamics about the PQ. Let me ask about the classification to that. It's the global terminology, global language of private las. Also th 30 34% they don't know it, they don't use it. So what's your comment about it? How we can make people use more popular in order to be more una unanimous in every center? Uh Yeah. Mm My opinion is uh is that uh it's uh negatively surprising that uh only the 50% of uh a fast uh usually use the PQ because uh this is the only objective way that the anatomical defect maybe we can try to use it or to mm share a simplified version of the PQ. We can indicate only the most uh prolapsed anterior point, the most prolapsed posterior point. But uh we need to objectively describe the anatomic situation and we are always to remember that uh also the other measurements of the PAP Q can be very important. In particular, the total vaginal length can, could be very important to predict the sexual function of our patients. After surgical treatment. In general, the surgical repair of the P uh is able to improve the sexual function because we move uh the, the mechanical uh um dysfunction. But uh there is sometimes the, the, the risk to have a too short vagina. But if we don't know at the baseline, what, what is the total vaginal length? We cannot predict or to or and we cannot interpret it after the surgical procedure, the sexual function and the sexual dysfunction of our patient. So, urodynamic maybe can be not uh proposed to all our patients. But uh the PQ should be used in all patients with P with P. This is my personal opinion. Y yes, II would totally, totally agree with that. Uh I think whoever doesn't use PO Q does not really follows up his patients or her patients. OK. It's really, really important. You cannot uh to compare what's going on before and after operation. This is the only instrument that will tell you exactly what's going on. And it gives plenty information for many, many, many um for all the pelvic floor conditions. So, uh I think it's a matter of training, it's a matter from a yoga to uh embedded into the uh training of the um uh of the trainees I is in. So it's something that it has come to stay. And I think it's the only way to go ahead and to offer better service for our patients without you without evaluating thoroughly what's going on before and after surgery. I don't think we can go very far. OK. I'm sorry for that. But this is my opinion and any comment because you are also professors and uh you are also our mentors. How easy is for a trainee to start using it in order to motivate more trainees to start using um Sophia if you remember your young age. OK. Uh I if there are uh clinics dedicated for prolapse and somebody comes and takes 10 measurements of hope you, it's uh each week or twice a week. Uh by the 2nd, 3rd week, it is easy to uh do it. Hope you everybody. So it's a matter of, you know, established clinics, clinics using these instruments and then uh using to for their follow up as well and follow up uh into uh you know, for a long, for a long time. So uh it's not that uh difficult, it's a matter of organization mainly. Mhm A and I believe that the, the outcomes of our surgery strictly depend on the, the quality of our clinical evaluation before surgery. So if we are in current evaluation before surgery, also our outcomes will be poor and not satisfying. Yeah, this is we have a, a question from the audience. That's the form of vaginal estrogen. Uh for example, tablet cream mattress and help in further tissue atrophy in those using pessaries. Have you shared recently, I think will be more useful by available than price limits user. Uh I would generally say that. Uh it's uh um I don't think there is so much difference between uh what sort of preparations you use. Uh The difficult is to use the preparation. They are very, very wide variation among countries. So, uh it's really uh the guideline to use it. And uh if you can, uh if you have a personal, you can use what you prefer most, but I don't think there's any difference between and, and about the pessaries about the trainees can, a trainee can and also apply a pessary for the patient. It's an easy thing because some uh trainee, they have not ever see a pessary because there are several cancers that you have shown, but some for trainees trained enough do. Uh Yes, this is another thing. II think it depends on the uh health system. If there is a, a co these are countries that they can operate widely and uh a lot then the need for pessaries is much uh smaller. Uh uh So uh somebody cannot really gain experience in pessary feet because uh there are no so many people who use it. Uh all the other way, it's a, it's a good instrument, it's a good uh uh tool uh for uh ladies and that uh they simply don't want to rush into the theater. And uh uh I think it's uh every, every gynecological clinic should have um a dedicated session for a pessaries that I think again, it's really, really easy to do it. Mhm. And Sara uh one member of a training committee also she asks about, asks a question about what instrument is used across Europe for measurement in, in Slovenia. We don't have anything should make, should I make my own wooden spatula in order to make the popular, for example. Um Yes, this is very, very, very easy, very basic. Uh but ideally, uh you could use some uh uh ready rulers that uh they are sterile and can be used for every uh person for any new patient. But uh this could be expensive at the end of the day. And uh we have to think of this as well. Uh So it's uh much more clever to do it by yourself. Uh Kind of a custom made a ruler for the Pope. You, yes, sir. And uh I don't want to take more of your time because I asked for one hour webinar. I would like to deeply thank you both of you and all the trainees that are attending this webinar. I would like to remind to all end of trainees and all European trainees that CC all and the fellowship grant in order to go to attend three months abroad. So you can visit professor ga training as a certificate and accredit center or Professor Mico Center in order to gain more information, more knowledge, more training in uh Rogan. The call is still open in o so take the opportunity and get in touch with uh these center or any other center. For example, for uh for Rogan, you can see all the list, all the accredited hospitals, departments in AU a a official website and also in website in order to apply for three months and get training in organ ecology. And also don't forget junior program that's about €5000 in order to go to Organ Special Center in order to conduct ser uh results. And uh we are welcome you all to join the U training committee se session in the upcoming because professor U Officer are very close to young or and uh train. So we do have our own session and we're going to discuss and to raise our voice, our concerns and please, you're all welcome to join. Thank you very much. All, thank you very much. All, thank you very much. And I would like to invite all of you to the next uh au meeting in Prague and to become a new members of our association. Thank you very much. Thank you so much. Both of you and all the trainees for attending. Thank you very much. All, good night. Good evening and see you. All right. Bye. Yeah.