I'm going to talk about today will complement what Dr. Carter Brooks has gone over. So I'm going to talk about surgery, a little bit how to talk to patients about it. We'll look at a few pictures, and then I'm kind of packing several lectures into one. Here we'll talk about complications as well. Okay, so you have a 66 year old woman with prolapse. You've been managing her pessary for two years. It's all going really well until she comes in and she says, I'm ready for my surgery. What do you recommend? And this is a time where you might want to back out of the room and maybe send her on to see someone else. So let's talk a little bit about how you're going to go through this with patients. So most of you in this room are not going to be the one doing the surgery. So you want to think about how you're going to explain surgical options to patients without actually making the decision about their surgery. Because I think in most practices where people are working together, usually the surgeon works together with the patient to determine what surgery they're going to do. But the patient is going to want to hear from you. You've been caring for her pessary for two years. She knows you. She trusts you. So she wants your opinion. So the important things that I think are really key are that you want to keep it simple, right? There's so many different procedures for prolapse and they can be nuanced. And as was just mentioned, we all do things a little bit differently that you could go through this for hours with a patient and then there's only more confusion at the end. So you want to keep it simple, know the basics, don't do an extensive counseling and know what your surgeon does, right? You don't want to offer procedures that your collaborating surgeon does not do. So I put some buckets here because I think it's important to just create some simple buckets in your mind to be really straightforward and organized of how you're going to talk to patients about this. So this is kind of how I do it. So I think of my buckets as first being, are we doing an obliterative or reconstructive surgery? How are we going to do the surgery? Are we going through our abdomen or through our vagina? And lastly, is there a uterus? And if there is, am I leaving it in or am I taking it out? Okay, so let's go through each category. So I start out with obliterative versus reconstructive. So obliterative surgeries essentially close or extremely foreshorten the vagina and reconstructive surgery is trying to recreate normal anatomy. And so the questions in my mind when I come to this first bucket is what's feasible and what's appropriate. So we said obliterative surgery is essentially vaginal closure or shortening. The patient ends up with a shortened vaginal canal that's maybe a couple of centimeters, normal external genitalia, and this can be done with or without a hysterectomy. And in these pictures, you can see on the left, looking at the patient on the exam and from the side, the prolapse coming all the way down. And then on the right, at the top, the external genitalia looks normal. There's no more prolapse. But if we're looking from the side, you can see that the vaginal walls are closed down together so that they can't prolapse. So when I think about what's feasible and what's appropriate, these are the things going through my mind. How old is this patient? I don't typically offer copal clases to women under 70, right? So she's 45. This bucket's already done. You're not gonna offer her an obliterative procedure. How severe is her prolapse? Milder forms of prolapse, even though they're bothersome to the patient, can make copal clases really challenging. So it's more appropriate with advanced prolapse. If she's sexually active with penetration, not a good candidate for copal clases. And does she have a uterus or vaginal bleeding? In those cases, we wanna be really thoughtful in a woman who has a uterus with postmenopausal bleeding or abnormal bleeding that a copal clases with leaving the uterus in place is not appropriate. So if you look at your patient and they're 45 or they are sexually active or their prolapse is not severe, copal clases is done. You don't even have to think through this bucket, right? This is a pretty quick thing you can figure out whether or not this is something you're even gonna bring up to the patient. Okay, so you've figured out whether or not she's a candidate for obliterative surgery versus reconstructive surgery. The next thing I think about is how are we gonna do the surgery? Through the abdomen or through the vagina? And I kind of pair this together with whether or not we're gonna use any implants. So again, here's where it's really important to know your surgeon. You don't wanna talk about procedures that they don't do. And you wanna think about when mesh is appropriate. We don't place mesh through the vagina. It's only an abdominal procedure. So if a patient is interested in a mesh augmented surgery, that's not a vaginal procedure for most surgeons. So when we think about these surgeries, if we're talking about abdominal surgery, most of the time that means a laparoscopy that includes a mesh placement to treat prolapse. Some surgeons do suture repairs through the abdomen, but that's less common. Going through the vagina, that's usually a uterus sacral or a sacrospinous suspension using the patient's own tissue. So what I say to patients is there are different ways we can fix your prolapse. We can go through the vagina using stitches in your own tissue or through the abdomen using a mesh graft. And I just keep it really simple like that for patients. If you start talking to her about copepaxi versus hystropaxi, your patient has no idea what any of those terms means. You have to keep it very simple for the patient. And then my last bucket, which Dr. Carter Brooks gave me a nice lead into this, is whether or not the patient is gonna undergo a hysterectomy or a hystropaxi if she has a uterus. Some women just shouldn't have a hystropaxi. Maybe she's postmenopausal bleeding that's recurrent. Does she have a genetic predisposition to cancer? Does she have high-risk HPV, ongoing abnormal pap smears? These are not good candidates for hystropaxi. So this is another moment where you kind of wanna look at the patient's exam, look at her chart and her history, and think about whether or not you should even bring this up to the patient. Maybe this is a situation where you say, given your history, we recommend including a hysterectomy in your surgery and don't even bring up the option of keeping the uterus. So you wanna put all of this together. Other considerations, as mentioned earlier, if the cervix is very long, no matter how high we suspend the uterus, she may still have symptomatic prolapse. If a patient desires future fertility, obviously we shouldn't remove her uterus. So this is part of the reason we do a comprehensive history when we meet these patients, to understand their childbearing history, their future plans, how bothered are they, and what other symptoms they're having, like bleeding or abnormal pap smears. So you need to review GYN history and surgical history with these patients as well. So to kind of put all of this together, when we go through our buckets, reconstructive versus obliterative, what's appropriate, what's feasible. We can do your surgery through the abdomen using a mesh graft or through the vagina using stitches and your own tissue. And you're also gonna keep in mind if there are reasons to avoid mesh. Remember this morning, our patient who had a sling and then got an erosion and it got excised, you probably don't wanna offer that patient a mesh-based procedure. And then does she have a uterus? If she does, is it appropriate or reasonable to leave it in place? And through all of this, even though I only have it listed on the right here, you need to know your surgeon. So immediately post-operatively, what do things look like? I don't know if you guys are getting to spend any time in the operating room, but I'm gonna show you just a couple of pictures of what things look like at the end of surgery. I'm sorry, my picture for copephalysis didn't come through, so we'll keep going. So here we have two images of what it looks like at the end of a uterosacral ligament suspension. So on the right, there are retractors in the vagina, one anteriorly and one posteriorly. And you can see at the top of the vagina all of these sutures and a suture line. So this patient had a hysterectomy and a uterosacral suspension. So those stitches at the top of the cuff, the way that I do this surgery, those are stitches that are going through the cuff, through her uterosacral ligament and back out the cuff. So when we tie it down, it elevates the top of the vagina up to those ligaments and then it scars down there. So that's what that looks like at the end of the surgery. The photo on the left is the same procedure but leaving the uterus in place. The sutures haven't been trimmed yet either, that's why they're so long. But you can see where those sutures are going. Just anterior to that, there's a little bulge of tissue, that's her cervix. So I bring those stitches out through the posterior cervix and that's why they're kind of hiding. But this is what it looks like at the end of the surgery. These sutures, as they dissolve over time, they'll lose their color. So when you see them in the office at six weeks, those sutures might be clear. They might also feel brittle or kind of sharp and stiff. And that's because those sutures typically, at least in my practice, are called monofilament. It means they're just a single strand, like if you think almost like dental floss rather than a braided, like shoelace. So they lose their coloration over time and they're a little bit stiff. So if you wipe it and they kind of break off, that's okay, that's normal because they're losing their strength. These sutures, most surgeons use what we call a delayed absorbable suture at the top of the vagina so it stays around longer so we get really good scarring and healing there. So sometimes I still see these sutures if I exam a patient for some reason at three months post-op. So don't be alarmed if you see sutures there for a long time. Always ask your surgeon just so you understand the materials they're using. But sutures can hang around. And these pictures, these are a little harder to get because of shadowing, but on the left side, we have kind of a curved retractor in the posterior wall of the vagina and a short retractor on the anterior wall. So that's a suture line from an anterior colporaphy. And then on the right, there's a shadow there, but there's another suture line there from a posterior colporaphy. So this is at the end of surgery. And then these are just photos of external anatomy after an exam. And so you can see for most patients, the prolapse is reduced after the surgery. And if you look on the posterior foreshad, the posterior portion of the vagina, you can see there's a small area there where an incision was made and things were put back together. So let's move on to talk about complications, unless anyone has any comments about the surgical buckets or anything before we keep going. Okay. So most of our urogyne patients thankfully do really well and they go home the same day of surgery. So the things that can go wrong after surgery are pretty extensive, but what I'm really gonna focus on today are the things that you're probably gonna get the phone call for. I'm not really gonna touch on things like post-op hemorrhage and all of that that's happening in the hospital. So we're gonna focus on things that are gonna come to you. And these are things you would see in the office. So let's start off with a patient. So a 66-year-old patient calls on post-op day three and she's urinating frequently and she has urgency. She had a vaginal hysterectomy with a utero-sacral suspension, anterior-posterior colporphy, a sling, and a cystoscopy. On the day of surgery, everything went smoothly. She woke up. She had a void trial passed. Her catheter was removed and she went home the same day. All right, so what are we thinking about in a patient with frequent small voids after surgery? We're thinking about UTI, urinary retention, maybe her detrusor's a little overactive and that's making her go more frequently, or maybe, thankfully uncommon, she could have a bladder injury. So what you're gonna start with is you need more information. So since almost everyone's going home on the day of surgery, almost all these complaints come in over the phone. So every patient, when a phone call comes in, you just need more information. You wanna know for any post-op patient, so she's voiding frequently, does she have any other symptoms of UTI? Is there blood in her urine? So you want more information about that. Is she leaking? Is she getting up at night? You want to know about all the things that are associated that could be impacting why she's having this trouble, right? Is her pain well controlled? How is she feeling? Is she taking pain medications? Is she walking around? Has she had a bowel movement? I would hope that this patient doesn't have a catheter in, but patients report complaints to us sometimes and not the words we would choose, so you want to know if she has a Foley in place. Is she bleeding? Okay, so what could be the etiology for her? She could have a UTI. This is common up to six weeks after a urogyne surgery, and anyone with urgency frequency after a urogyne procedure needs to be evaluated for a urine culture. Depending what she tells you over the phone, and if she seems totally fine otherwise, it may be a situation where you just send her to get a urine culture if she's having symptoms of a UTI. For most people who have frequency and urgency, they probably need their PVR checked as well, but on a rare occasion, if it's simple, straightforward symptoms of a UTI, you could even just send her to the lab to get a culture. But it's okay to treat her empirically. We know these patients are at high risk for a post-op UTI, so they can give a culture and you can treat them over the phone empirically for a UTI while you're awaiting results. The only time I wouldn't do this just so easily is if the patient's having fever, flank pain, CVA tenderness, you want to see that patient in person if they have these complaints. Another common cause of this could be urinary retention. Now it's uncommon. Probably only about 5% of the time would a woman pass her void trial at the hospital and then come home and go into retention. That's pretty uncommon, but it can happen. Retention is common after surgery up to 50% of the time, and so you may need to just repeat the void trial and consider a distention injury. If a woman goes home without her catheter and is having trouble peeing for days and she's got a really full bladder, she's probably got a stretch injury, which means her bladder is not going to work very well if you have her come into the office and just teach her how to straight cath, right? She needs full bladder rest. And if she's peeing frequent small amounts and something's not adding up, so you come in, she does another void trial, you instill 300 and she pees 50 and your bladder scan says 0 or your cath is 0, that fluid's going somewhere else, right? It's not in her bladder. She may have a bladder injury. This is an uncommon scenario to happen. But if the fluid is unaccounted for, then you need to talk to your collaborating surgeon and figure out there may be something else going on. So intraoperative injuries, as we said, manage with your collaborating physician. Another thing that can happen after surgery is detrusor overactivity. It can be transient after surgery, right? The patient has had their tissue manipulated, their nerves have been impacted, their sensation has been impacted with anesthesia. And it's okay to use short-term overactive bladder medications in post-op patients to help them deal with these symptoms. Let's move on to another patient who is a 42-year-old who has severe pelvic pain who's Day 2 from a vaginal hysterectomy, utero sacral suspension and posterior colporaphy. She's using her Tylenol and ibuprofen as instructed. And she took one tablet of oxycodone on post-op Day 1. She's Day 2 now. So what are we worried about? Why does she have this pain? Is it uncontrolled pain because she only took one tablet of oxycodone, or is there something else more concerning going on? She could have infection. Post-op Day 2 is a little early for infection, but these are the things you want to be thinking about. She could have wound breakdown, pelvic floor spasm, constipation, she could have a blood collection somewhere, a hematoma, or nerve entrapment. So again, when this patient calls in, just like we talked about urinary complaints, you want more information. You're trying to call her and figure out, can I treat her over the phone, does she need to come in for an exam, or am I sending her to the ER right now? So what's the severity of the pain since surgery? Is it overall getting better, just not well controlled? Or was she doing great and all of a sudden pain is worse? What has she done to treat it so far? If she's had no pain medications whatsoever, her pain may just be consistent with untreated post-operative pain. Is she peeing? If she's in a lot of pain, her pelvic floor may be very tight. She can't relax. And so a complication of the pain is now she may be having urinary retention or trouble voiding. We want to know if she's pooping, right? If she has a lot of pain, that also may be impacting her bowel function. Or severe constipation could be causing pain and discomfort. You also want to ask about bleeding and discharge. We've gathered some information over the phone to decide what to do. And if you bring this patient in for an exam, you're going to look at their vital signs and say, do they have a fever? Are they tachycardic? Is there anything worrisome? These patients all should probably have a PVR and a UA check if they're having severe pain. Just look at your patient. Is she sitting like over on one side, crying and writhing in pain? Is she pacing around the room because it hurts way too much to sit down? Or is she resting comfortably? So just look at her. How does she look? Does she look like a patient who's okay? And when I exam these patients, I use a lot of caution. When you have an early post-op patient, exams can be challenging, especially for the patient. They're terrified it's really going to hurt. So you want to, as we talked about earlier, get consent from her, explain to her what you're about to do, and that you're going to make any measure you can to decrease her pain during the exam. Make adjustments if something hurts to let you know. And I tell them what I'm going to do. I'm going to inspect on the outside. Patients who have pain, I typically start my exam with a digital one-finger exam rather than using a speculum first because I don't know if she has a hematoma or something. I don't know what pain she's going to have. So I just sort of get the lay of the anatomy with a one-finger exam before using a speculum. And I assess for exam findings. So if she had a hysterectomy, I feel the cuff, the top of the vagina where we saw that suture line. Do I feel fullness there? Is it tender? If there's a mass there, she could have a hematoma or an abscess. I feel the cuff. Does it have any defects? Is it separated anywhere? I palpate the pelvic floor to see is it in spasm? Is it tender? I feel the posterior wall. Is it full of hard stool in the rectum? If she had a sacrospinous ligament fixation, I press right on those sutures to see if that's the tender spot. One potential cause of postoperative severe pain is nerve entrapment in a suture. And that typically doesn't get better with time. We need to remove those sutures. So if your patient is in agony and can hardly tolerate an exam, that's a time where you really want to find your collaborating surgeon, pull them into the room so you can figure out is this a patient that needs to go back to the OR right now to have some sutures removed. So I take this all really slow. If I find those tender sacrospinous sutures and you think she needs to go to the OR, she probably doesn't need a speculum exam right there in the office. You're going to cause a lot of agony and not change the outcome. So everything we do, we should be doing for a specific purpose. And if you're doing a speculum exam in the office for someone going to the OR, you're probably doing unnecessary pain. But say you get through the exam and you think she seems okay, now you need to look at the cuff. So you felt the cuff to make sure there's no mass, no defect, but now you need to look at the cuff. Maybe it's tender and she has an infection in the tissue, a cellulitis, you can palpate that it's tender there, but you may not be able to feel a mass. So then if you've gotten through everything else, now you're ready for your speculum exam. That's appropriate. You just have to think about whether or not you really need it. So hematoma or abscess, thankfully for our patients, not common. More common with a hysterectomy. We can have an abscess less than 1% of the time. If you think your patient has a hematoma or an abscess, she needs to go to the hospital, she needs imaging and labs and you definitely want to let your collaborating surgeon know. A cuff cellulitis or a wound infection typically is going to have some discharge in the vagina. The tissue may look a little bit abnormal or pale and it may be tender. In that situation, if your patient is okay otherwise, you can probably treat her with oral antibiotics. You see a wound break down, a suture line opening up. If it's small and superficial, it may be able to heal by secondary intention. But I think any of these situations that you think you're having, always reach out to your collaborating physician. So you've done all of this. Let's say you have a pretty benign exam. She doesn't have an abscess. She has pain, but there's nothing on your exam that's making you worried. So now you need to consider about controlling her pain a little bit better. What is she taking? Is she taking enough? Do we need to add more things like neuropathic pain agents, muscle relaxants? Do we need to optimize her dosing? Is she taking her Tylenol and Motrin around the clock or just as needed and now her pain has just gotten out of control as she's waiting to take her next dose? If she's having severe constipation, we should treat that and try to avoid an enema if possible. Sometimes you don't have a choice, but that shouldn't be our go-to. And again, the voiding trial. She could be having discomfort because of inability to void. Okay. Third case, 57-year-old, five months from a hysterectomy, utero sacral, anterior posterior colporaphy, sling and cystoscopy for prolapse and incontinence. She resumed intercourse eight weeks post-op. So this is after all her post-op checks. She came to all her post-op checks. She was doing fine and was clear to resume intercourse. So she goes back to her life, resumes intercourse at eight weeks post-op, but has pain. She did not have pain before the surgery. And she's only coming to us now five months later because she resumed, she didn't have any more appointments and she was hoping that this would get better with time. So now we have a patient who has post-operative dyspareunia. So you definitely want to examine this patient and see if you can understand her pain a little bit better. So things I think about on this exam is, what's the vaginal length and caliber? Is her vagina really narrowed or foreshortened? What's happening with her muscles, are they tight or tender? Other things that could be going on are things that have nothing to do with her surgery, like atrophy in the vagina from low estrogen. She also could have a mass, endometriosis. All of the other things that can cause dyspareunia in our patients can happen even if they're post-op. So we want to look for surgical etiologies but also assess some of these other things. In women who do have issues related to their surgery, such as vaginal narrowing or foreshortening, physical therapy and vaginal dilation can be really helpful. I've seen this also sometimes. I've just given patients dilators to practice on their own at home, and in some instances that alone will be successful. They don't always need PT. And then if it's muscle function, then PT may be helpful. Occasionally if I see muscle spasm after surgery that I think is related to acute pain, sometimes I'll try a skeletal muscle relaxant, especially if it's related to pain and it's short-lived. I don't typically treat long-standing pelvic floor dysfunction with a muscle relaxant, but for acute post-op pain it can be really helpful. So mesh complications can occur after surgery as well. You can find this incidentally, a mesh exposure in the vagina on a routine exam on a patient. She doesn't have any symptoms. Or it could be that they have vaginal bleeding or their partner reports that they feel something in the vagina during intercourse. So here you want to do a physical exam. If the exposure is small, you could treat with a trial of vaginal estrogen to see if you could get that to heal. But if there's a large exposure and the patient has symptoms, typically surgery is indicated. Thankfully these exposures are not common, but you will see them. So what questions do you have? What things have you seen in post-op patients that you want to talk about? Can you come up to the mic or can we pass her a mic way over there in the corner? So the question is about post-operative complications with a suprapubic catheter. Are you talking about like patient discomfort and that kind of thing, or what specifically? Yeah, so everyone manages post-operative voiding dysfunction a little bit differently. Suprapubic catheters I think aren't used now as much as they used to be, but there's still a reasonable way to provide bladder drainage. You can get leaking around it for several reasons. One is just the fact that there's space there, right? That's one thing. If the patient's having bladder spasms, you could use an overactive bladder medication to try and calm that down if they're getting spasms and that's causing leakage. Sometimes if the opening is much bigger than the catheter, you could potentially size the catheter up to try and close that space, but I would avoid that as like a solution to just keep sizing up. Usually this kind of thing gets better with time. For discomfort, again, you can use your normal things you would use like finazopyridine for bladder discomfort. Sometimes tugging and pulling lidocaine jelly at the area can be helpful for discomfort, but hopefully they're not using it too long. If it's just for post-operative voiding dysfunction, hopefully getting it out is gonna be your solution to most of that. Yeah. Yeah, my question is just if you suspect an infection, what antibiotics do you recommend using? And does that differ if there's mesh involved or not? So if we think there's infection involved, I think typically if you feel like that's a superficial infection like a cellulitis, there are nice guidelines that you can use. I tend to use Bactrim because it has MRSA coverage. Doesn't mean that's the only answer, but that's kind of my go-to. There's some patient considerations that can go into that. So I personally often look it up every time I do it because thankfully I'm not doing that all the time. So I'd look that up. And then I don't think there's any recommendation to change the antibiotic if there's mesh involved. But if you have infected mesh, especially over time, removal may be the solution. Like what about flagell? So the docs that I work with sometimes are like, oh, Bactrim and flagell or doxy and flagell. So I don't think that there are great guidelines to tell us. I think that's reasonable though. Okay, and then so I also feel like my exam is so limited when the patients have a copolysis. So would they come in with bleeding or pain? Do you have any good tips of how to figure out exactly what's going on in those circumstances? Yeah, I mean for bleeding, I think you can exam them in lithotomy, really spread the labia, look at their site. Are they having bleeding from the tunnels? It's emanating from the side of the tunnel. Depending how brisk it is, they may potentially need to be re-examined in the OR and that may need to be addressed. I've never done this, but there are hemostatic agents we use in the office. So there may be a role for squirting some hemostatic agent in those tunnels. I think it depends on how much they're bleeding. If the bleeding is active, then they may need to go to the OR to address that given that you can't really see the suture lines. But if you're worried about a mass or a hematoma, you can do a rectal exam. You can feel that area, you can feel muscles that way too. You can feel the pelvic floor through the rectal exam as well. Sorry, so if it's a hematoma, what do you do about it? Well, I think if a patient has a hematoma with a copolysis, I'm happy to hear what other people would do, but I would take her back to the OR. Because if she has a hematoma inside her copolysis, the surgery's gonna fail. It doesn't just rip? No, because the way the copolysis works is where you oppose the vaginal walls, that scars together to keep the prolapse from coming back down. So if that has a collection of blood in the middle, eventually it's just gonna come back down because the scarring is not gonna happen appropriately. So I would take that patient back to the OR. Would anyone do anybody different? Okay. Your lecture was great. Thank you. Quick question, copolysis, is there ever a time that you, are there patients you can't do that with? I have a couple, like 90-year-olds that aren't resurgical candidates, and I've referred them to the Urgine, and sometimes they're like, well, no, they need a full surgery. And I'm trying to wrap my arms around like, why can't we do that? Is there? So some of it is exam considerations. If the prolapse is milder, then it's hard to do. These are severe. If it's like real, legit prolapse. I mean, one of the things I would think about is does she have unexplained bleeding that? There are 90-year-olds with three to four grade prolapse. And I've had different physicians have said, well, if they have a uterus or they don't have a uterus. I just didn't know if there's some. Yeah, so I think my advice would be to maybe probe your collaborating physicians just a little bit more of like, what is it about this patient? Or if that doesn't get you the answer, I would say maybe, if she's not appropriate, tell me who would be. And that might help you tease it out, because it sounds like a good copolysis candidate to me. That's what I was thinking, but I wasn't sure. Like, if they have a uterus, it's still okay. If they don't have a uterus, it's okay. If they have a uterus, it's okay. If they don't, it's okay. The procedure's slightly different, but it's okay. It's okay, and even if there's a lot of anterior support issues. Yeah, I mean, really a good copolysis is support problems everywhere. Well, these are them, okay. We want all loss of support. I'm a little more confused, but great, thank you. Sure, all right. And we'll just take one more question, and then the rest can go on that chat box. I just wanted to know your opinion. I'm new in urogyne. I've been in it for about eight months. And I've seen, we've had a couple of complications where the patient falls after surgery. And recently, I had a patient last week where I did their post-op, and she said, oh, I had fallen, and I had horrible pain, and a little bit of vaginal bleeding, but she never called to report it. And when I took a look, she had good anterior and posterior report, but her cervix was all the way down to zero, and she had a sacrospinous ligament fixation, and I was like, no. So I'm not quite sure of the approach. If she's asymptomatic, because she didn't, she's like, I feel great. Do you leave alone? Do you offer to go back in? And then those patients who have had a mid-urethral sling, when they cough, they get sick right after surgery, and they're coughing, coughing, coughing, and then all of a sudden, the stress incontinence is just back because their sling has moved. Like, what would be your approach to those things? Sorry, another two different scenarios. So going, starting first with the patient who fell and has the apical prolapse recurrence, I think the bottom line is, we don't really know why she recurred. It could have been the fall, or it could have just been that, like, we didn't get a good bite on the suture that day. But at any rate, I would say if she's asymptomatic, then I would explain the exam findings to the patient, it's the exam findings for that patient, they deserve to know what you see. But I would provide reassurance that if you feel good, that was the goal of the surgery, we don't have to go back and fix this. So you still wanna use those same principles of treating only bothersome prolapse. So in that situation, I would explain the exam findings and say, we can do another intervention in the future if that's what you want when this becomes bothersome, and just explain that I don't know if it's that you failed quickly because of the sutures or because of the fall, we don't know. When it comes to the patient who gets a terrible cough after the sling is placed and then has recurrent stress incontinence, I think we have the same options that we'd have for any patient who has recurrent stress incontinence, is to talk to them about why this might have happened, and it's tough because in that situation, we don't have great data to say, if this happens to you, we can replace your sling and it'll be great. So I think that's a situation where we talk through with the patient, have they had any improvement? If they're 80% better, then maybe they would be a good candidate for some, add some physical therapy or for bulking. So you always wanna go back to the patient's symptoms and how bothersome it is to her and what treatment is reasonable. Thank you very much. Thank you. Thank you, Dr. Probst.

surgical options

prolapse management

obliterative surgery

reconstructive surgery

patient communication

post-operative care

surgery complications