Thank you. I'm trying to remember now what my father always said, if you're not having fun, it's your own fault, which he always liked to follow with, and if anybody's going to be unhappy in this family, it's not going to be me. I am honored by this award, and I'm grateful for the opportunity to share some of my observations. These are my disclosures. This lectureship is in honor of Dr. Ray Lee, who after completing an OB-GYN and general surgery residency was a beloved attending at Mayo Clinic. He was a founding father of urogynecology, and over the years we have all heard of his devotion to his family, his colleagues, and his patients. The questions that I am asked most often from urogynecologists involve ureteral injuries. There is a sense that the ureter is quite fragile, and this is not what most urologists experience, and that's based on some of our really common surgical procedures. One of the treatments for ureteral strictures, which is a fibrosis of the ureter that results in obstruction, is to dilate the ureter with a, we first go in with a cystoscope. We place a guide wire up into the renal pelvis. This is actually a safety wire for later stent placement. Then we place a second wire, and over that wire we place a balloon with contrast that can be put under very high pressures. And you can see in this image that you have a dilated upper tract pole and ureter, and you can see the dilation. The balloon has been entered on each side of the stricture, and what will happen is we'll continue to apply pressure over a long time until the ureter actually is ruptured. And in fact, we consider this success if we see extravasation following the procedure. And then we place a ureteral stent. And ureteral stents have evolved to now having a hydrophilic coating. With that, along with the cohesive properties of water, allow urine to flow around the stent, and the urine flows based on pressure gradients. But stents, which are used to divert urine away from an obstructed kidney, also allow urine to reflux up the stent, which means that urine increases two to three orders of magnitude over the injury that you are trying to repair with the stent. And it's for this reason that Foley catheters have to be placed and are critical when you're treating someone who has a ureteral injury with a stent. And this may help explain the very low success rates that we see in some series that are trying to repair a ureteral fistula with a ureteral stent. Another great example of ureteral injuries and how ureters heal are work from the early 1940s on open stone procedures. Impacted stones were commonly treated by an open procedure or a nephrectomy. It was Davis who first started describing the Davis open intubated ureteral ureterotomy, or entoyureterotomy. And he described this in a case series in 1943. This was from one of his patients who was actually a colleague's wife. She had stone disease. She had developed a stricture of the proximal ureter. The upper third of the ureter was absolutely constricted and the ureter and the kidney was at risk. And he went in, did an open procedure of abdominal incision, isolated the ureter and the kidney, and with a knife just cut open this very tight stricture which left a very narrow band of ureter, laid down what at the time he used as a ureteral stent, just an open tube, and left the situation just like that, only to find after six weeks that it had healed on its own once the stent was removed. Later Davis and Baker showed that the ureter heals circumferentially around the ureter, not longitudinally. And this helps explain why there always has to be even a small remnant of ureter left in order to have ureteral healing around the stent. This is most likely the mechanism that determines whether or not a ureter or ureteral injury will heal at the time of a stent placement. Our experience with UB fistulas is shown here over 12 years. We've had 18 fistulas. 11 stents were attempted. In the women that we did not attempt to place a stent, it was for very straightforward reasons. These were women who had concomitant vesicle vaginal fistulas, or it was a radiation injury and it appeared later. Or lastly, the ureteral injury was recognized at the time of surgery and a stent was placed and they continued to have a fistula. But in those women who we attempted to place a stent, we were able to do it 92 percent of the time. And in those women who we were able to place a stent, 100 percent of them were dry within 24 hours or 48 hours. In one case, we had placed a stent and after calling the patient the next day, she wasn't dry and we returned to the operating room and just exchanged the stent. And for those of you who work with interventional radiology, I want to let you know that the normal diameter of a female ureter is typically seven French, and yet our interventional colleagues consistently use an eight French stent. If you have a patient that interventional has placed a stent in, then take her back to the operating room. They did their job. It was successful. And exchanged the stent over a wire with a six French. I think you'll be surprised at how quickly they'll be dry. Now at six weeks, we go back to the operating room and we shoot a retrograde. And one of these women, she had a stricture that required a robotic ureteral re-implant. Two of these women developed pyelonephritis, one requiring oral antibiotics and one requiring IV. And similar to previous studies that demonstrated a 64 to 76% success rate, our series was similar to that. Our current approaches and my recommendations to my colleagues are take women who have a UV fistula to the OR. Do an exam under anesthesia and shoot a retrograde. Place a ureteral stent if possible. And if it's unsuccessful, send her to Antigrade. It's sent her for an Antigrade stent placement by our colleagues in interventional. They have a good success rate because they're using a straight shot down to where the fistula is and making a turn. And they also have some techniques and a table that moves in three dimensions that we don't have. Once it's placed, be sure to place a Foley catheter. And then call the woman the next day and see if she's dry. And if she's not, take my advice and take her back to the operating room and just exchange the stent over a wire, which is a straightforward procedure. At this time, I recommend oral antibiotics. I have no data for that, just this experience of pyelonephritis, which is severe. I give a daily prophylactic antibiotic while the stent and the Foley are in. When I remove the Foley, I give a three-day treatment dose. And before I shoot the retrograde and remove the stent, six weeks later, IV Ampingen. Now I'd like to take an opportunity to, I'd like to share with you some of my experiences of being in an integrated FPMRS program. But before I do, I want to introduce you to two thought leaders I admire. And probably before I do that, I better tell you a little bit about my background because it's going to sound weird. I graduated from high school and became a registered nurse. I did have a passion for medicine. I just didn't know what I wanted to do all the way. During my nursing career, I was kind of mouthy and I got in trouble a lot. It was not a good fit, I just got to tell you. And so, they thought so too, by the way. But I continued to work as an ICU nurse and I went to engineering school. I have a bachelor's in mechanical engineering and a master's in fluid dynamics. But when I left engineering, I missed being around people. I went to work with Procter and Gamble. I was a manager for them for six years in a production environment. And at the age of 34, I decided to go to medical school. And from there, I went into urology and I was, I had the opportunity to do a fellowship in female public medicine. I need to tell you that because I wanted to introduce you to two thought leaders that I admired over my other experiences outside of medicine. During my engineering school, I had an opportunity to work in a semiconductor manufacturing facility. And I was exposed to this concept of statistical process control. And that is when you use statistics to make decisions in the manufacturing process. Edward Deming is credited with the precision and quality that we associate with Japanese manufacturing. Before World War II, the idea of made in Japan was actually a very low quality product. But along with his statistics and his ability to put this in manufacturing environments, he believed that all people, whether we are working in the soap factory or working in the operating room, come to work to do the right thing. But that there are barriers that keep us from doing this work. And interestingly, which I always found compelling, he held leaders accountable for working on the system and removing those barriers. And he did, though, believe that that kind of work, it belongs to everyone. I met Stephen Covey when I was at Procter & Gamble. I had the opportunity to spend a week training with him. And it was during that week that I made the decision to go to medical school. He believed deeply that leaders work on their character. And he outlined the skills to develop your character and his seven habits. The ones that motivated me the most were beginning with the end in mind, thinking win-win, and the concept of synergy. I believe deeply that these are the factors that made our program at Loyola successful. Linda Brubaker and her team, along with the chairs of urology and OB-GYN, deeply believed in the concept when they moved to Loyola that our organization, that the research, that fellows and patients would benefit by this new endeavor. In fact, my colleagues made a point when they asked me to join them to make sure that every issue was taken care of so that we were seen as similar and equal and on equal footing. From the mundane things like the color of our lab coats, which is really a thing in Chicago, I got to tell you, everyone, every specialty has a different lab coat, to the belief that we could all do the same procedures, or if we couldn't in the beginning, that we aimed towards that goal. Over the decade and a half that we worked together, I was continually mentored and encouraged to expand my surgical skills in vaginal hysterectomy, anal sphincter repair, and I did likewise. My colleagues learned urologic procedures, stent placement, and ureteral re-implants. And I can say proudly that Kim Kenton and I did all of these at Loyola, and she's carried that work forward at Northwestern. We encouraged the same interactions with our fellows and residents. And for those of you who've trained fellows from other specialties, you know what a gift this new perspective and skill set is. Residents and fellows had a deep appreciation for how everyone could be a teacher. And junior learners returned to their departments with new ideas. And from that experience, I learned a few things. Department leadership sets the tone for how departments will interact. And I came to believe that a program where residents and fellows are interacting daily with both urology and OB-GYN specialists allows for a deeper understanding and appreciation of a different perspective. I've also come to believe that we need to teach skills that may go beyond the scope of what our fellows will do in practice, whether it's complex pelvic pain and muscular skeletal issues, colorectal issues, or ureteral re-implants. The exposure that they have will develop thought processes and skills that will advance our field for years. Because I live in both worlds, I do hear consistently from both of my colleagues. I hear from urologists about being denied privileges or being proctored for hysterectomies, that they were asked to join in joint practices to work up hematuria, IC or UTIs, and are not getting the prolapse cases. I hear from gynecologists about block referrals for microscopic hematuria are being denied privileges for stent placement or retrogrades. I believe it's time for leaders in our field to work out these systemic barriers that are not the responsibilities of our trainees. These issues belong to us. We should and can find a way to address these concerns. The first is to expand the curriculum of FPMRS. We need to address the knowledge and skill gaps in our programs and find new ways to mentor attendings or colleagues. Nothing that any of us does is so sacred that we have to hold on to it. And the reason is actually quite simple. Together, we really do take better care of women. For a long time, the care and the research of pelvic floor disorders has been fractionated between specialties. Our shared fellowship is a win-win opportunity for all of us. I believe in the synergy of our specialties. I believe in the unending talent and the goodwill of the men and women I've met in both fields. I would like to take a moment to thank the people who have been so influential in my life. Bob Flanagan, the chair of urology, who was now president of the AUA. Linda Brubaker, who has deeply valued principles and has the ability to build infrastructure. Ron Potko, my current department chair. My friend and the woman who has challenged me the most to get my message out and has given me opportunities, Mary Pat Fitzgerald, who was a dear collaborator and friend. I want to thank Dr. Steinhardt, who yanked me out of ER, which was my planned intent when I was in medical school and got me into urology. Leslie Rickey followed me at Loyola. She was the year behind me, and we have been working together ever since and following in each other's steps. I'd like to thank Colleen Fitzgerald, who is a PM and our specialist who works with us at Loyola, and also my two colleagues, Titi Pham and Marion Acevedo-Alvarez. And of course, I'd like to thank the fellows who trained me, worked with me, and I've had the opportunity to train. Every year around April and May, I get that sick feeling that someone I've trained for three years is about to walk out the door. And thank God, someone new comes in who just restores my faith that all of this is supposed to go this way. I'd like to acknowledge the fellows and the teams that I currently work with, the nurses, my research nurse Mary Toki, who's with us, and I'd also like to call out to Dr. Wolf, who's brought a deeply collaborative environment at Loyola, and works with us on our microbiome research. Our fellows' interaction with his postgraduate students has been nothing short of phenomenal, and has included the residents in our program. Lastly, I want to thank my wife, Dori. Today is our 24th anniversary, and I'm pleased to say she's here. I am the daughter of two parents who loved each other, and they loved their children. I have five sisters, I'm the oldest of six girls, and my sisters have been a deep, they have a deep sense of self, and they not only am I inspired by them, but they've been my good friends. And lastly, again, Dori, she brought into the world our twins, John and Mia, who've added dimension to my life I did not know was something I could dream of. Thank you so much. Oh, I meant to say, I am so grateful to AUGS. Consistently, even when I was a fellow, they were so welcoming to me. I've had the opportunity to be on the executive committee, to be on the membership committee, to be given opportunities to lead. So many of the people here have pulled me aside, they've taught me, they've coached me, they've given me feedback, they've invited me to lectures. I think one of the dearest things in my life is being part of this society, so thank you.

ureteral injuries

ureteral strictures

ureteral stent

urology and OB-GYN integration

FPMRS curriculum