Urogynecology Controversies: Female Pelvic Medicine and Reconstructive Surgery - Briana Walton

December 16, 2021

In this 2021 LUGPA CME presentation, Dr Briana Walton presents urogynecology controversies, the current landscape of female pelvic medicine, and reconstructive surgery.  She focuses on issues that reconstructive surgeons are facing and how the landscape of treatment for disorders of the pelvic floor is shifting as women are demanding different care.

Biographies:

Briana Walton, MD, Female Pelvic Medicine and Reconstructive Surgeon, University of Maryland Medical System, Baltimore, MD

Discussant: Jennifer Miles- Thomas, MD, Assistant Professor, Dept. of Urology, Eastern Virginia Medical School, Clinical Faculty, Dept. of Gynecology, Riverside Regional Medical Center,  Urology of Virginia

Read the Full Video Transcript

Briana Walton: My name is Briana Walton. I am a female pelvic medicine and reconstructive surgeon out of the University of Maryland. And I have to admit, I feel a little bit out of place here, but my background is also not just medicine. I also have a degree in art and design. So one of the things I've noticed about art is that some of the most interesting pairings come from putting desperate things together. And so I will say this is an artistic application of my own background. All right. I do have a disclosure with Coloplast, I'm a consultant and on their medical advisory board. So everything we do in terms of female pelvic medicine, I feel like we've been assaulted in many ways because of this whole attention and the context of the debate about mesh for urinary incontinence, as well as pelvic organ prolapse. It affects our decision making in terms of our surgical choices.

It affects our ambulatory practices. But I will also say just not just a surgeon, but also seeing myself as a designer I've started to look at things a little bit differently, as well as my relationship with industry has changed over the years. Where I was fairly isolated and did not have a lot of interaction, I find it necessary to collaborate and to understand the landscape in which we work as well. As being much more attentive to the patient experience and really understanding how to curate a better experience for our patients. We all in this room understand that we are not practicing just evidence-based medicine. We're at the interface where our clinical expertise, as well as our patients values and experiences inform our decisions to make a decision for their treatment plans. And that is also really from the world of design and art.

One of the things that I've learned and taken away is that user experience does need to be included to inform people, but also to make a better product, make a better service. So some of the things that we're going to talk about are from both of those vantage points. So let's start off, as I mentioned, this whole mesh controversy. We know the history. I don't have to go through the chronology. It has been really a challenge over the years to continue to have these discussions and have them again. And it was probably in 2018 when the FDA first started removing mesh products from the landscape. And then 2019 with the big update that I started saying, "I think I need to stand up for our patients more. I think I need to stand up for our own civic rights because these are technologies and techniques that we need to speak on and not just the FDA."

We know that we're not alone in this, that there are controversies in other fields as well. Our plastic surgeons have helped to deal with many significant issues in terms of the breast implants. So I'm not here to say that I have all the answers. I'm here to say that I've asked better questions moving forward in the future, and paying attention to things in a very different way than I did in the past. And I hope that that's one of the things you walk away with today. So our first hot topic that Dr. Miles Thomas and I will talk about is the use of mesh products for [inaudible 00:03:33]. We know the evolution over time. I entered this field in the 1980s and was very excited when we were able to offer a minimally invasive technique that had much less voding dysfunction. It was easier to repeat for patients than for trainees, and we've seen some modifications over time, but it's really the same technique with a piece of plastic underneath the urethra.

Well, there's now a migration back, at least in our practices or in our field where people are saying, "Maybe we should go back to our traditional repairs." And I'm not certain that that's the right answer. We'll leave it open for our discussion next. We know that our success rates are high and that window of success is fairly narrow, where as traditional native tissue repair offer in some hands really good repairs, but in other people's hands, not so much. The complications with mesh have really transitioned over time as I think we've limited the providers who actually do these techniques, as well as we've gotten more familiar with the nuances of providing this service to patient. Our mesh erosion rates are down to far less than 1%, which is mainly what our patients have been concerned about.

The voiding dysfunction can still be fairly high for those of us who use retropubic slings as opposed to a trans obturator approach. But nonetheless, we have seen significant improvements as we have, again, narrowed the field, so to speak. We know that the Cochran database has updated the recommendations for utilization of slings and there's... I don't have to go over through all the highlights, but if you watch over time, the main thing is that we know that they offer very similar success rates. We know that there may be a little bit of higher rates of retention as well as injury with our retropubic approach, but both are very great options for our patients. And that the main thing that we need to tell them is that we have good data, but we need to watch over a period of time.

And that as long as we're using a type one macroporous mesh, we really can say that that's our gold standard. For those who are still offering an open or even a laparoscopic urethropexy, which is what I trained in in my fellowship, it is a really hard procedure to reproduce and I think very limited in the hands of many, very good in the hands of few. And then the autologous fascial slings again, I would say many of the residents that I see in training have never even seen this technique. Let's move on to number two, which is more well, what do we do now. If you believe as I do that slings are the most appropriate repair for incontinence, then doesn't matter. I was one of those that said to myself, "I don't think it makes a difference. Every mesh is pretty much the same," until I started doing a little more investigation with some of the cellular biology with regard to tissue and growth with these meshes, right?

So most of the meshes out there offer pretty much the same footprint, the size, the shape with the variability and the Coloplast mesh, and that it is not as elastic, and that it's a lighter weight when you compare some of the other products to it. I didn't really know that. What I felt and walked away with when I was counseling patients is just to watch the biomechanical properties as that patient touched and held that mesh in their hands and pulled on it. And I said, "Please don't pull it in too much. You don't want to stretch it out of shape. I've got other patients I've got to show it to." So in that I've started to ask more questions about what is the most appropriate sling material to use? Does it make a difference? And trying to pay attention to what's coming out in the literature. Moving forward for hot topic number two.

Also in our field, there was about two years ago, a big debate with the sacrocolpopexy, our main sort of pelvic organ prolapse repair for advanced pelvic organ prolapse. Whether it should be done in the context of a hysterectomy. There are a lot of nuances with these procedures. But the main questions that I wanted to bring forth today is, if we are doing it with a hysterectomy, should that be done vaginally, or should it be done abdominally or laparoscopically? Part of that reason, and there's a star there. We're going to talk about a little bit of the philosophical aspects is, many of the people who are raining residents are choosing the vaginal approach because vaginal surgery has really decreased in terms of uptake with many of the people who teach. Unfortunately, if you take out the cervix and uterus through the vagina, you are going to increase your risk potentially of erosions.

And so the question is, is preservation of the cervix really a key part of the procedure? Again, I'm looking forward to our comments afterwards. And then finally, how do you attach the mesh? If you're going to make a incision in the vagina, should you attach it through the vagina and then push it back up into the abdomen? Which I have been against for some time now. So the recommendations in terms of prolapse utilization of material are fairly similar in that there are wound complications and they've decreased over time with changes in material, changes in suture, as well as again, retention of the cervix versus taking it out completely. There are a few rare complications that we don't see very often with Osteomyelitis or Discitis. But again, in the hands of those who are doing these procedures on a regular basis, you don't see those outcomes.

I think the main concern for us is making sure that we are good stewards of the space. So as we are good stewards over this space that we operate in, and we've really tried to be thoughtful about cost containment. And that these procedures can be costly because of utilization of robotics. And some of the literature, as well as my own personal studies, the key with this is that you can try to decrease the number of arm changes. You can change your products. You can watch how many supplies you have. But the biggest bang for your buck, so to speak, is to make sure those patients are discharged either within the same day, same day discharge or within 24 hours.

Okay. All right. Moving forward. I would give my opinion is that it's our responsibility to really limit the number of people who utilize these procedures, as well as make sure that the complications are limited. And then in order to prevent skill degradation of the team as well as the surgeon, those surgeons need to continue doing those procedures on a regular basis. All right. Our last two hot topics in the ambulatory space, one of the main concerns is the utilization of laser therapy for the correction of genital urinary symptoms of menopause. For years, estradiol has been the gold standard. For those patients who are not candidates for a hormone therapy, we've been using alternative treatments like coconut oil, olive oil, whatever oil you can find on the shelf. But CO2 lasers have proliferated in the market. And using that technology to correct our patients who have vaginal dryness and sexual dysfunction as an opportunity to improve their quality of life has been on the uptake.

We're seeing a lot more in the AUGS, but we've also seen our position statements from several of the society saying these are techniques and tools that we have to be cautious of because they haven't been associated with placebo controlled or sham controlled trials. They're starting to have a lot more. But one of the things that I think we're going to see in the near future is that as we proliferate the field with more of these studies, this is going to be one of our mainstream technologies. The question is though, are you, and should you be using your laser to sculpt the vagina? And the question I have comes about oftentimes when I have a patient who has subjective findings of bulge, but not technical findings of prolapse. And is there a role for our lasers in that to correct some of those symptom for patients who are having sexual dysfunction?

The last three things I wanted to talk about is labioplasty in that there has been an increase uptake in the office setting. One of the things Dr. Miles and I talked about in our discussion beforehand is, could it be done in the setting and what are some techniques that you could utilize to make it an office procedure for those patients who are looking for feminine rejuvenation? That's a big bag, right? So everybody knows that feminine rejuvenation can mean a lot of things. But for some women, it is more about their anatomical finding and wanting to correct some of the changes that they are seeing or feeling in either relationship to their sexual function or just aesthetically. And then finally on this topic, that should we and can we use lasers in the setting of a patient who has already had a mesh procedure? And that's something we can talk about too.

All right. Finally, I think this is where I really wanted to focus and leave you with these thoughts. And I don't have a lot of answers for this, but I do want to bring it up in that as we've seen in this pandemic, there been some modifications in the landscape of who's providing this care now. Many of our senior physicians have decided to retire, and there's been some limitations in our trainees' ability to do these procedures on their own. And one of my concerns is, is that going to put an increased burden on those of us who do these surgeries? How do we do give that sort of knowledge transition when a lot of our surgeries actually happen either in the office setting or in a surgery center where the residents aren't exposed to it? Dr. Holden and I actually work in an area where there are a few gynecologists who are operating... Who are utilizing her services significantly for repeat [inaudible 00:14:45] with very large hysterectomies.

And so that can be a very disruptive request from a colleague to come out of your office and help another colleague do a repair. Well, is that going to increase as we have seen the diminished training for our residents over time? And then finally, the triple aim really focuses on three things, right? From IHI, we have tried to curate a high quality, low cost environment that's patient centric, but that quadruple aim has added into it the need for the team and the need for preservation physician, and as that burden is increased on us. And over time, one of the things that I've started looking more at is just this human factors, the ergonomics and our own personal wellbeing as that quadruple aim really doesn't really focus that much on this aspect. We are really going to have to sort of pay attention to this for ourselves.

Ergonomically, we've started to be more concerned about how do we interface with machine, with systems to make sure that we have that sort of best fit? In the operating room, there has been a migration towards robotics for that very reason. We are seeing more and more surgeons have problem with work related musculoskeletal injuries and impact our ability to deliver care over time. So what is the best tool technique that we can actually have that interaction between man and machine? But I think we are also missing a large part of our workflow is actually in the office, sitting in front of a computer. Particularly as all of us have had to do more telemedicine visits and sit and talk. And that one of the concerns is that sitting is the new smoking, that sedentary [inaudible 00:16:54] where we're having to sit in front of a computer for long periods of time to talk to patients. And its relationship to work related injuries is starting to sort of pan out for many of us.

Jennifer Miles-Thomas:  thank you, Dr. Walton.

Briana Walton: No, thank you.

Jennifer Miles-Thomas:  That was a great overview of quite a few of the issues that we as reconstructive surgeons deal with. I think in urology, it's a very exciting time because I think it's really opening the eyes of many of our urologists that women are an integral part of the urology practice. Our female patients are coming and they're demanding different care. I think in the past there's been a lot of, "Okay, go ahead and do the kegels or the kegels and come back." And now these patients are like, "No, we know what our options are. And we're demanding care." If we start talking about the slings, just a few questions.

Briana Walton: Mm-hmm (affirmative).

Jennifer Miles-Thomas:  I think your point was very well taken. The procedure should be done by the highest volume surgeons. Generationally, the urologist has typically been the one who does everything, right? They'll do your prostate, your nephrectomy, and then also put your sling in. Now, the next generation, most people are fairly specialized. They want to do one or two things and be the best at that. So it's very difficult for our next generation, our residents to get the adequate numbers. Should we really be funneling? Should we prevent certain people from dabbling so that we don't come through this next debacle of mesh and injuries, or should we just really expand it and make sure that the residents are by multiple people?

Briana Walton: I don't have a good answer for that, but I think it's definitely something to consider if we even compare ourselves to some of the orthopedic surgeons, correct? Many of them have streamlined their practices in which they focus on. Either hand or hips and knees. So I think it makes sense for us to think about potentially streamlining some of the practices, but the question is how do you enhance the exposure for the trainee? And that's the part I'm struggling with. Because again, much of what we do has left the hospital where these trainees are and it's in a world where they don't really have access to on a regular basis. The nuances of training is mostly technical aspects of the procedure, right? But our trainees also learn from our adaptive leadership styles. How do you interface with the staff? What is the right way to talk to the patient? And that's the other piece that I'm a little nervous about the trainees missing. In that they're missing the package and not just the... They can learn the technical aspects later on-

Jennifer Miles-Thomas:  That's right. Yeah.

Briana Walton: ... but they don't... That adaptive piece of it is going to be really important. And just to kind of carry out, part of the reason I, I started to increase my sort of knowledge of some of the rejuvenation techniques, was because I felt like we were missing a population of patients who really wanted intervention but didn't really want to have sling. That didn't really want to have the recovery that we would tout as standard of care. So I think as our patient are asking different questions, we need to respond as well.

Jennifer Miles-Thomas:  I agree. And if we go ahead and touch on the laser therapy and the rejuvenation, I think a lot of us are... Probably a few years ago, we all had the marketing of bringing those instruments in and creating women's centers and things like that. One of the major limitations is we were still mostly focused on men.

Briana Walton: Mm-hmm (affirmative).

Jennifer Miles-Thomas:  And so we really didn't have the marketing or the language or the communication or the entire process in place. And the other issue was it's not really covered by payers yet. And so it's really a therapy that we've researched and does provide significant benefit, but it's not covered. So how do you think that we should address that, or is there a language we can start using?

Briana Walton: Yeah, that's another tough one in that as you look at the interface between reconstructive and cosmetics, right? In one person's eye, you are seeing some minor prolapse and that could be covered by insurance. And in others it's more subjective. "Well, you just have a minor bulge. Does it really need to... You have to have surgery for this, or is this something we should look at with another technique?" That challenge, I think, is the one that we are going to need to answer. And part of our responsibility as experts in this space is to start to delineate that for patients and figure out what's a right application. But in the process of delivering that care where we are utilizing these machines that are very expensive, as you know, I think we've got to think of ourselves more like our plastic surgeon colleagues, which are very different. No one argues about the cost of your tummy tuck or your rhinoplasty. They know walking in the door that this is a cosmetic procedure. So how do you tease it out, separate it so that you apply these things ethically? And that to me is the harder part.

Jennifer Miles-Thomas: Yeah. That's going to be a challenge, but I think that's something that's going to... I think as additional therapies come out for other disease processes, it's going to be the same. We're going to have to learn how to have those conversations about money, about payment, because everything won't be covered in the future.

Briana Walton: Right.

Jennifer Miles-Thomas:  And if we were to just quickly talk about prolapse, everyone's region's a little bit different.

Briana Walton: Mm-hmm (affirmative).

Jennifer Miles-Thomas: Quite a few FPMRS fellows are coming out, and so hopefully it'll be more accessible for a lot of patients, but I've found, especially in our community, there's still a lot of gynecologists who are self declared as you're urogynecologist who have been doing open sacrocolpopexies, which is no longer really the standard of care, unless it's in complex. How would you recommend that we kind of evaluate our region and make recommendations and referrals because I personally I'm concerned if people are making referrals to things that maybe are not still the standard of care?

Briana Walton: Mm-hmm (affirmative). Good question. I think some of it comes with transparency, right? Transparency about our outcomes. Not just the set outcome of the repair, but the outcomes around that. The time in the hospital, the time back to get to work, when you have an open repair versus some of these minimally invasive techniques. The whole really point of doing a minimally invasive surgery is to cut down on some of the things that are important to a patient. So I think if we can be more transparent about our own success and their own concerns about why we offer this technique versus an open, you don't have to have the argument. It kind of speaks for itself, if that makes sense.

Jennifer Miles-Thomas: Exactly. And then the last thing. Just what's recently happened is AUGS kind of came out with a survey and so did SUFU regarding the terminology used. So we're both FPMRS. I'm urology, you're Urogyn. And whether or not Urogyn should be used across the field so that there's not patient confusion.

Briana Walton:  I think there's going to be patient confusion no matter what.

Jennifer Miles-Thomas: We've got to sell what we do.

Briana Walton:  That's been part of the issue, is that there are very few providers. Not just patients, providers that really even understand what it is we offer. What is it in terms of the role of that FPMRS specialist? What do they do?

Jennifer Miles-Thomas: Mm-hmm (affirmative).

Briana Walton:  I've had to explain to a number of people, "No, I don't treat men. No, I don't treat [inaudible 00:24:52]." Whereas some will.

Jennifer Miles-Thomas: Yes.

Briana Walton:  Right? So I think as we push forward, we're utilizing the FPMRS honestly, to me, better defines what we do in that there's part of our role of medical, in part surgical, and that the nuances of it will just happen as we sort of self-select what is it we want to practice within our sort of own wheelhouse?

Jennifer Miles-Thomas: Thank you.

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