All right. Can you guys see me? All right. Are we on? We live? Yep. All right. Welcome, everybody. Let me go back one slide. Whoops. There we go. Welcome, everybody. I apologize. We had some connectivity issues, and we got a few minutes late to start, but we're now here. So thanks for joining us. I know for some of you it's just about it. For other of you, perhaps it's time to hop in the pool if you've gotten home from work. But we certainly appreciate you spending the next approximately 50 minutes with us. So first off, thanks to AUGS for facilitating this discussion. Thanks to Neomedic for sponsoring it. And thanks to my panelists, the speakers, Catherine Matthews, who is a professor of urology and gynecology, fellowship director, and director of female pelvic health at Wake Forest. In North Carolina. And I just made the connection, Mike Cannelli, who's professor of urology and gynecology and director of the Charlotte Continent Center, Carolinas Medical Center, also North Carolina. They're just like an hour and a half apart. So I guess I was the token Midwesterner who was chosen to participate in this. Given that it's so early right now in California, we had a hard time getting someone from there. But anyhow, before we start, and again, thanks to Neomedic for sponsoring this. I just wanted to spend one or two minutes going over Neomedic's products so you're aware of them, and then we'll dive into some of the case discussions. So Neomedic has a number of products that are sold in our area, a number of slings, and something for prolapse. The single incision TOT sling is a unique product of theirs. It's longer than many of the other mini slings so that it can reach both internal obturator muscles. And the area of fixation, which you can see here, is not some kind of anchor or something like that, but it's actually a broader portion of the mesh that allows for better tissue ingrowth. They actually completed their FDA required post-release studies back in 2015. So it's been around for a while and has some data behind it. They also have the Kim sling, which is a full length sling. And it is made in a certain way that there are no knots. Because of that, it is actually the lightest sling out there on the market. It has the largest pore size. And when it's pulled, though it does have a little bit of give, it doesn't really have any elongation. And it's very, very soft to hopefully perhaps minimize other types of problems. The Remix adjustable sling, I think this is what sort of they were known for to me. This is something that's been around now for 20 years, was approved in the United States about 10 or 12 years ago. Many, many publications. And there's follow up out to about 15 years on some of these patients. And the interesting thing here, it's placed just like a traditional transvaginal rectal pubic sling. You pull up the suture. It's got a small area of mesh here. And then the interesting thing is this device is placed right against the fascia. This almost like a little wrench is brought out through the incision or through a separate little stab wound. And then the following day, after surgery, the patient comes into the office and you can actually tension it. It sort of pulls it up like a fishing spool based on what the patient's experiencing. So you fill the bladder up, have the patient cough. If they leak, you give it a few turns until they don't leak. And if on the other hand, it's too tight and they can't void well, you can actually loosen it up. And the nice thing about this is if six months down the line, the patient, and then you just pull that little wrench out. If six months down the line, the patient starts to leak again in the office, you just prep the suprapubic area, make a small incision, find this little area, and then you take a fresh little one of those screwdrivers and you can actually either make it a little tighter or a little looser. So it is something that's very adjustable. And then the final product that they have is something that's used for sacrosymitinous ligament fixation. So it's minimal dissection, and it's a little anchor that goes right through the ligament. And so it doesn't take a bite of the tissue or a bite of the ligament where you perhaps can trap a nerve or something like that. But there's a little bit of a little bit of a little bit of that. But there've been some studies, I think Catherine was, ran one of the studies showing its efficacy and minimal pain. It's actually currently the most utilized anchor for this in the United States. All right. So again, thanks to Neomedic. And now we'll move on with some of the cases. So the way that we're going to do this is I'm going to present the case, and then I'll sort of ask both Drs. Cannelli and Matthews to sort of work through the cases, give their comments, and we'll take it many different ways, different options. As we all know in our field, there are often many different ways you can skin a cat, so to speak. So there are different things you can do. And it'll be interesting to hear what they want to do, why they want to do these things, and we'll sort of go through their thought process. We have three cases to discuss. As we're discussing it, feel free to, on the chat, ask any questions, and I can always relate to them. And if we have time, and I think we, well, we'll see. If we have time at the end of each case, we can open it up. And if anybody has any live questions they want to ask through the microphone, that would be fine. So let's start with the first case. This is a patient who complains of stress incontinence. So she doesn't walk in and say I have stress incontinence. She says, I leak when I cough, laugh, yell at my kids, et cetera. She had a vaginal hysterectomy because she also evidently had some prolapse and an anterior repair. And she had a TOT six years ago. A year later, her partner noted some pain with intercourse. He said it felt like there was some sandpaper in there. And on exam, she was noted to have some extruded mesh in the midline and also in the vaginal fornix. So due to this, the transvaginal portion of the sling was removed. She then had stress incontinence again, at which point they tried a bulking agent. It helped a little bit, but the patient is quite active and having a lot of leakage, which is really bothersome to her. So somebody else went ahead and did a retropubic medirethral sling. But after that, she had a lot of waiting difficulty. And ultimately that sling was incised in the midline. And currently her stress incontinence is worse than ever. So she's had a TOT that was removed. She had bulking. She had a retropubic medirethral sling that was incised. On exam, healthy woman, BMI quite low for Cleveland, abdomen benign, some scarring of the anterior vaginal wall, no prolapse. When you fill her up, she clearly leaks with cough. Her Q-tip is zero to 10 degrees. I guess because she'd had many different things done, aerodynamics were performed. Her post-mortem residual was minimal. She filled easily to 400 CCs without really any terrible urgency. She had no issues of activity, normal compliance, and a balsalva leak point pressure of 54 centimeters of water, emptying Q-max of 16, PDET Q-max of 10. So really what we see here primarily is stress incontinence with a low leak point pressure. So let's start with this. Mike, any other tests or any other investigations you'd be interested in getting? Yes. And good evening. It's a pleasure to be here. I'd like to thank Augs for this and Howard for coordinating. It's a pleasure to be on with Catherine. Specific to this case, you know, a thing that I was a little bit interested in is the pressure flow voiding part. I was surprised that she actually had 10 centimeters of water pressure. I would expect it based upon kind of her parameters that she would be more of like a balsalva voider. But regardless, from a testing standpoint, things from in office I would do differently would probably be just trying a incontinence ring or some type of incontinence pessary prior to embarking upon surgical therapy. The rationale that I would say for that is basically because I think this person has probably more of a low voiding pressure, although 10 centimeters of water is not that low. And I would query, she's already had two operations that did not work to her satisfaction. She's seen what happens when you've gone on the other side of having retention or voiding dysfunction just like that. So it's really about adjustability and getting it properly fit. And I think a incontinence ring is in my practice trying to educate them of the scenarios. That would be the only test. Catherine, any thoughts? Yeah. Thanks, Howard. And thanks, everyone. I must say that Dr. Connelly is my new partner, Atrium Health in Wake Forest, and now one big institution. So it's wonderful to have the opportunity to be here with him. Eventually, Howard, you might join us too. You know, I must say a couple of things. I'm super wary of prior voiding dysfunction with a surgical intervention. I really try to ask myself, why did that happen? This woman's got a very low pressure urethra, so she doesn't have to mount much of a detrusor contraction to allow herself to void. But I might be interested on your dynamics if you try to obstruct the bladder somewhat with a catheter or something, or even providing some manual pressure when she's attempting to void, does that change the bladder pressure at all? Is she really a relatively low pressure voider? And I would want to know with any prior records, does she have a staccato avoiding pattern? Does she have evidence of valsalva voiding? Because I'm super nervous about a retropubic sling in that circumstance. The other thing I always try to cover my bases about in someone who's had two prior mesh procedures is, am I missing some injury to the urethra, the bladder neck, or in the bladder itself? And I would do cystoscopy on a patient like this. It's a relatively simple office test. And if it saves me from being wrong about something, I think all of us can tell some crazy story about a fistula that was missed, that was perceived as just severe leaking, or some urethral injury that wasn't determined that was contributing to some of the profound incontinence. So that's the other test I would do. Okay. So let's say, Catherine, let's say you did do a cysto and you didn't see anything. And as you pulled the scope out, she happened to have a cough and you weren't wearing your goggles and you suffered from that cough. And let's say, Mike, let's say you tried an incontinence pessary and it actually helped, but she just didn't like it. She didn't like having something in the vagina. What would be your next step? Right. So the reason I would do the incontinence pessary is basically, can it keep her dry and can she void? And if she can void adequately, then I know that there is a balance, that we should be able to get that somehow. If you had it in place and she was dry, but still had difficulty voiding, we'd have some real discussions about there's going to be, you know, it's going to be hard in that situation. So I use that as a test to kind of see if there's better option for me. Cystoscopy, I think that's an interesting area to do it. I probably wouldn't necessarily do that. In my area, prior to considering a surgical therapy in this patient, though, I would do a perineal ultrasound, even though they said they kind of removed the TOT, even though they said that they incised that area. What I'm interested to find out is what's really in there. And nowadays with 3D and you can even have some 4D ultrasound, it is phenomenal for mesh that you can really isolate and locate the exact location of where the mesh is in relation to the bladder neck, the extramedius. And I think that affords me the opportunity to have a better idea of plan going into surgery because my belief is in these situations, anytime you're going in, I prefer to take out whatever's underneath the urethral area prior to putting in some other intervention. So let's say with the continence pessary, she felt she was voiding pretty well and her post-void residual was minimal and you did 5D ultrasound and there was no mesh immediately beneath the urethra. You could see it sort of going up laterally in each direction. You didn't see any of the trans-opterator mesh because all the vaginal portion of that indeed was taken out, but you could sort of see where the retropubic mesh starts to kind of disappear, but there was nothing right under the urethra. So essentially, you've got someone with pretty significant stress incontinence, nothing in the bladder per se, able to void with your test that you did and nothing directly under the urethra on ultrasound. Catherine, where would you go with this? What are the options that you might discuss with the patient? Yeah, so I mean, I see them as three options. One is to do an adjustable synthetic sling. Second is to do a fascial sling. And third is to do an investigational intervention such as, you know, we're doing stem cell injections, we're harvesting muscle biopsy and regenerating in the operating room and then reinjecting in the urethra, but that is experimental. So I would have offered her that as an experimental therapy. I wouldn't re-bulk her with a standard bulking injection. I wouldn't even offer that. At 56, she's already failed it. I just don't think there's going to be any efficacy. So my real discussion with her would be between a fascial sling and an adjustable mesh sling. I wouldn't offer a birch clipper suspension. I like a birch a lot. I wouldn't offer it in the circumstance because of the lack of mobility of the urethra. And I think in that circumstance, it doesn't work well. And how do you lay out the pros and the cons? So she's not interested in research because she doesn't want to end up in the placebo arm. So how do you counsel her as fascia versus an adjustable? Yeah, you know, I'll tell you in part, two prior complications related to mesh, I would push her towards a fascial sling. You know, she's worried about voiding dysfunction. But I think that, you know, we've learned that you don't need to over tension fascial slings. I would make sure that she could cath and that she would be okay. And I would want to know, are you really going to prioritize your continence over the voiding dysfunction? If she said to me, look, I'm not concerned about a mesh complication. I really just want my incontinence fixed and my voiding dysfunction minimized. You know, then I think the adjustable sling would be probably what she would choose. But in my hands, I feel like I would, in this patient who's had the two prior issues, different issues with the synthetic sling, I would go for a fascial sling. Mike, so let's back up to the question that I asked Catherine. So assuming the scenario that was laid out, what would you advise this patient? I think a lot of the same scenarios are there. Certainly research is part of it. We're part of that trial also, but I think in reality, a bulking agent is certainly on the table. She has minimal hypermobility. She fits the criteria. Some of the new hydrogel agents are a little bit different because they're non-particulate, but she's 56. So really the long-term durability, we really don't know. It's kind of a, it gets them through. So I think a more, if you want the longer term solution, it really comes down to an adjustable synthetic sling, remix, or a fascial sling. Now I would really ask her about how did she feel when she had voiding dysfunction with the retropubic midurethral sling? Because that drove her to get it incised. And I do think that, you know, I trained on fascial slings. There will be voiding dysfunction. And so that takes time and it may take, could be a week, could be three months, but you've got to be ready for that voiding dysfunction afterwards. I think when it boils down to it for these types of patients is that it's really about when is the adjustability being made? The adjustability is done at the surgeon operative time where you do the adjustability and you're done or postoperatively where the patient now has a shared decision-making along with it. And it makes very sense. This is the type of person that we, that I see within the practice. And when you put those two things together, I much prefer to have a patient involved in their post-surgical adjustability than intraoperatively. Because we all know, we're all surgeons, we all get in the situation where you do a fascial sling or a retropubic midurethral sling, even under monitored anesthesia, intraoperative cough, and et cetera, there's still going to be that kind of unknown. So I guess boiled down to it, fascial versus a remixed adjustable sling, how does she feel about mesh or not? And then what does she feel about voiding dysfunction? So if the patient's question to you was, I've been through a lot of surgery, I've already had a lot done and I want my best chance of having one operation, not having to go back to the operating room. I don't want a calf. I'd like to hopefully avoid normally, but be dry. Mike? In my hands, I would probably say this person, a remixed adjustable sling, because I think she would be more, it's more involved for her in the postoperative period. But I think together we would have the best opportunity to meet her need that balances voiding function and continence. So do you want to tell us a little bit about how you do the adjustment? Right. So basically what tends to happen intraoperatively, it's actually very nice because normally for midgerital slings, I have patients under monitored anesthesia. So we do intraoperative adjustability. For the remix, it's all about postoperative. So it's actually a faster operation because they are put to sleep either an LMA or a general spinal, your choice, but positioning it is in place. Usually I use about a four centimeter suprapubic incision, depending on their suprapubic adiposity. You do try to really mobilize down to the rectus fascia as the device is then placed. You want to leave at least about six centimeters of freedom between, because you want it to be loose. And one of the key things that you're doing as you're adjusting down on the device, the varitensor, one of the sort of areas that you may forget about is you accidentally can pull up on the sling underneath. You want to make sure you've kept sort of something below the urethra and the suburethral portion of the remix sling when you're doing that initial sort of loose adjustability. Close it, leave the key or the screwdriver stick in place. And then I normally will have them come back, it depends on the time of day we did the surgery and where they live, usually one to two days later. And then when they're coming to the office, what we tend to do is we will catheterize them. We'll fill their bladders based on, we usually know prior urodynamics what their bladder capacity is. So getting not to total capacity, but usually about three quarters capacity. Having them stand at that point in time, having them do cough strain maneuvers, they clearly will leak because you really want this, you're not adjusting it intraoperative, it's total postoperative. And as you're doing it, should you say, as they cough and leak, usually as you'll turn it three turns, they really don't, it doesn't mind, it's a different feeling that they have, but as you do the adjustability, and it may take several turns to get it where it's close and you can't get them disappointed, but it's almost like when you get kind of close, it's really quick. It's like, whoa, that just happened. And then when I'm close, I basically will have them walk around the office, kind of do jumping jacks, kind of feeling where they're comfortable. And then I actually have them go to the restroom and do a uroflow. And with that uroflow, I'm just sort of vetting to see how their flow pattern is. We know what we put in their bladder, so we know what their PVR is. And after that time, if they think that they're close, we have a discussion. And if they live close by or others, I might say, you know what, this is your body, your choice. If you wanna go home, see how things are and come back tomorrow, we can do that. And some people are like, nope, this is it. I've got it, great. We disconnect the key and they're gone. Other people are like, okay, well, let me see. I mean, I had a lady fly in from Utah and she stayed and worked on this probably about a week to 10 days until she was absolutely satisfied. She was the lady that had a little more operations than what you predicted here. But because of that patient-shared decision and having her ability, she actually did her self-adjustment with where things are at because she was knowledgeable about it. It came to the point where she was satisfied. We made sure the voiding was fine and the key was sort of taken out. So that's a long-winded answer. But the one thing I would say is that for a surgeon standpoint, there's more involved post-surgery. So you have to be ready in your office and your schedule to kind of work these people in. But ultimately, these complex patients, you can get great results with this. And I think for people who aren't as familiar with this device and this technique, it's important to realize the length of mesh that's forming the actual sling is actually very small. So as opposed to most of the other slings that we work with where it's a much longer length and the whole thing scars in, here you just have this little area under the urethra and that's why at a later date, even months, years later, you can come back and by tightening this, you sort of pull the suture into this device here and it just kind of pulls it up and puts a little more tension on it. Catherine, any other thoughts before we go on to something else? Yeah, and I think just in terms of consent, in terms of litigation, people will forcefully state that there is no evidence for tripeat mesh slings and such. And so I think it's just important to, in that circumstance, just make sure that the patient is very clearly informed, that we don't know cumulatively mesh load under the urethra, what the potential risks would be just so that you're not burned down the road. Any, so for some reason, I'm not seeing the other chat. Any chats here? I think I saw a question about using the Sarah balloon from Solace Pharmacy device that is currently being trialed. Would that be something to consider? So apparently there are 30 study sites around the country for that, but it sounds like another good research opportunity for a patient like this. Some of the challenges with research is that patients who have actually had prior surgeries, and especially if they've had certain complications that are oftentimes excluded for some of these type of device studies, because they're trying to pick the ideal patient in that scenario. One other option I would bring out, Howard, is that I've done this on occasion, is that you do have the ability, if someone is, quote, mesh averse, to utilize fascia. You can, you saw that image that you showed, you can actually put a small piece of fascia, autologous or biologic, use the proline suture that is there, and then put it through the barotensor and have that same adjustability. Now, honestly, you really have, it's a postoperative adjustability that probably is within that short postoperative period of maybe three to four weeks. I don't believe that it would be something come a year later or five years later that you could really come and adjust it. So if you're trying to tweak it to get it to where it is, that is one option I've utilized. The cabinet also, there's still the implant, meaning the barotensor, which is that adjusting device above the fascia, that is an implant, so that's not going away. But it's certainly very simple and easy to remove, and the proline suture, as you know, does not encase. So that's very easy to remove if something were to happen. Okay, good. Yeah, I know some of our colleagues in South America and some other areas actually are doing that a lot. All right, let's go on, let's switch gears. I think we may just open it for more questions at the end. So let's switch gears to prolapse. So this is a 64-year-old woman who comes from Greensboro, North Carolina. She has bothersome vaginal prolapse. She had a vaginal hysterectomy and a utero-sacral vault suspension a few years ago, but something is back, and she sometimes has to splint to defecate. She's never had stress incontinence, has a little bit of urgency, but nothing to write home about. She's sexually active, no dyspareunia, and she's bothered by this bulge and the fact that she just can't move her bowels easily. On exam, healthy woman, BMI 30, empties relatively well, abdomen is benign, vaginal tissue, some mild atrophy, but overall looks pretty good. On her POPQ, BA is minus one, C is zero, so the apex is pretty much to the hymenal ring. BP is two centimeters beyond that. Her general hiatus is five, and total vaginal length is eight centimeters. You just did a simple little, simple systemetrics in the office, filled her bladder up, pushed the prolapse, kind of reduced the apex, reduced much of the prolapse, and she coughed and did not leak at all. So this is what it looked like. This is obviously, you could tell by the drapes that we're getting ready for surgery here, but pretend this is in the office. This is kind of what it looked like when you first took a look, and then when you put a half speculum in, you can see this is posterior, and again, this is in the OR, so she's asleep, so she's not straining. So you'll have to take my word for it that when she strains, it came out about two centimeters. So what we've got here is somebody with a C point of zero, BA minus one, BP plus two, and a general hiatus of five centimeters. So let's start with Catherine. Anything else you wanna, any other tests or investigations? Just with the intermittent need to splint, there's no other investigation that I would need to offer her surgery. If she was a chronic obstructive defecation patient, I would, but not for the scenario that you've provided. Mike, anything else? I would tend to agree. I don't think any definitive tests are needed. Certainly would not do a defecography, would not do anal manometry, would not do urogynamics in this situation. Well, good, I wasn't anticipating you guys would think exactly like me. So I guess there are not any other tests you really must have. I was gonna try to get you to commit, but you've already committed. So let's move on then. So back to Catherine. So what really requires treatment here? What's, which portion or portions of the prolapse seem to be- To me, yeah, to me, the apex and the distal posterior vaginal wall, if someone's actually having to splint it, I do think that there is a benefit of doing a distal repair. So to me, she needs apical support and a reduction in size of a genital hiatus and reduction of the distal rectocele. Mike, any different thoughts? I would say, if you went back to that image, one of the things that you notice is that you've got clear rugations that are there all on the posterior vaginal wall, which means to me that the rectovaginal fascia is still all intact. And so when someone has this amount of prolapse, that it's got to be apically to there, and I'm sure the apex has really minimal rugations. The other part is, just as Catherine said, it's really the key is gonna be the genital hiatus. You've got to narrow that down and sort of rebuild up the perineal body to actually sort of provide the shelf and have a good apical support. Okay. So, Catherine, you've sort of, you've mentioned the general things that have to be repaired. What are the options for actually performing the repair, these repairs? Yeah, in my hands, it would be limited to two options. And I don't think that, by the way, that she would be well-served by a pessary. It's interesting, these people with wide hiatus, relatively short vaginal length, and some distal symptoms, I don't think do really well with pessaries. So for surgery, my choices would be a robotic sacral copepaxi with concomitant distal posterior repair, or a posterior sacrospinous ligament fixation with posterior coporaphy. My reluctance in offering this patient a native tissue repair is that, in my mind, she's failed a native tissue repair just four years prior, and she has all the identified risk factors for occurrence. And so I tend not to believe that my native tissue repair is gonna be so much voluminously better than someone else's. And so I would definitely offer her a copepaxi. Now, there are some circumstances where someone's prior surgical history or comorbidities may push me towards not following that recommendation. If she'd had diverticulitis nine months before or something like that, I would not recommend that. If she'd had diverticulitis nine months before or something like that, I would go with a native tissue option. But if she's not had that surgical history, I would definitely recommend that she have a copepaxi. And I would say the two options, those are the ones, I think it comes down to what she's gonna value more. Is it durability, longevity, which we know the sacral copepaxi has the evidence, has the data? Or is she wanting something that isn't native? It's how does she feel regarding kind of transabdominal mesh? I think that she's already had one failure to that area, which we know. And we know the data on sacral spinous. But if I were to do a sacral spinous, I still like trying to do based on pelvic anatomies for bilateral sacral spinous to try to give her better support. Because I think apically is what's missing there. And then definitely narrow down the jama haze and rebuild up the perineum body. So she's, let's just say she's terrified of having anything in her abdomen. Her daughter had a tubal ligation, had a bowel perforation, and she would like to avoid at any way going abdominally. So Catherine, let's go back to you. How would you do this? Yeah, then, you know, look, I'm a huge fan of extraperitoneal prolapse repair. I feel like it's really important for trainees to have a robust confidence in doing extraperitoneal repairs because you can never really hurt someone with an extraperitoneal repair. And so that is a very important thing to recognize. Whereas there's plenty of damage you can cause with intraperitoneal repair. So, and I like sacrospinous particularly for the posterior compartment because we do know that the anterior compartment is more vulnerable to recurrence in post hysterectomy prolapse. If you're, you know, if you're having to do it with from an anterior abdominal prolapse. So as her prolapse is posterior dominant, if she was really mesh averse or had again a contraindication to an abdominal approach, I would feel fine about doing an extraperitoneal sacrospinous fixation unilaterally or bilaterally, depending on how wide the apex of the vagina is. Some of these people have conical narrowing from their prior repair, in which case I would do it unilaterally. If she's a wide apex, I would do it bilaterally. And specifically, how would, let's just say you were gonna do it unilaterally, how specifically would you do it? Yeah, so, you know, one of the things I love my trainees to be able to demonstrate to me is accessing the sacrospinous ligament from the anterior, the apical and the posterior approach. And you need to have good versatility. It's like entering a kitchen from the front or the back door. You gotta be able to get there both ways. I just need to get to the fridge. Yeah, so for me, in a case such as this, you can see that she's got some distention of the posterior vagina. I feel like she's gonna need some reduction in the size of the genital hiatus. So I would approach this through a diamond-shaped wedge from the distal posterior vaginal wall and extend up the incision as far as I feel like I would need to reduce that epithelium in terms of trimming it. I feel like you shouldn't open that epithelium unless you know that you're gonna trim it. You can unroof the posterior vaginal epithelium from the underlying vaginal muscularis without any difficulty if you don't need to actually trim it. And then I would gain access to the sacrospinous from the apical posterior compartment, making sure that you have enough room to easily fit the vagina into the dissection. So if you still have a cervix present, sometimes that space needs to be a little wider than in a case such as this where you don't have a cervix. Mike, what about you? Anything different or? No, it would really be that same approach. And certainly, as Katherine said, accessing it from the posterior compartment is really, it's safer, it's easier, it's simpler for where things are at. And I think from a training perspective, really knowing where to navigate and how to get to the ischial spine and then kind of going off of that. Using sacrospinous, we've had such great advancement within the tools that have been there as opposed to the Mia hook that started the aspect of things that really it's made it easier. And when you're talking about with trainees is that they have the opportunity of placement and then you can really self-evaluate and others can evaluate the proper placement. And if you don't like it, if you're not satisfied, oftentimes you can remove that portion of things. So it really should be a reproducible approach. And remember, the whole key to the operation is your fixation. If you're not satisfied with where you placed it, then stay in the operating room and make sure you're happy with it. From a standpoint of putting it in, I normally like to have two supports within that area. We can talk about sutures. I'd be interested to see what Katherine does. But I've really, based on the data that's come out, I used to do a permanent ethaban plus a PDS. Now I've really gone to just two PDS. And I do like the fact that I try and take it through and through the vaginal epithelium. We do talk to the patient about having the suture there for upwards of six months, so they need to know that. But I found that that gives me a little bit more better support look, at least at the time. Katherine, what suture are you using? Yeah, so it depends on if they still have a uterus. You know, I'm a big fan and a postmenopausal woman who's got a small uterus and small cervix not to do a concomitant hysterectomy. In that circumstance, I like to use one permanent stitch that goes through the heart of the cervix, I like to say. And the second suture I use as a PDS is going to go through the vaginal fornix. If they still, of course, have a uterus and cervix, I'm going to just be taking it up unilaterally, usually to the right sacrospinous ligament. If we have a vault prolapse, like in this case, I will use two PDS sutures. I want them through and through. I don't want to have me dealing with granulation tissue. I think that braided suture in the vagina is a thing of the past. And so definitely would use PDS in that circumstance. Catherine, you've looked at some different ways of attaching suture to the ligament. Can you tell us a little about that? Yeah, so we are presenting at SGS in June, our randomized trial of the CAPIO versus the AnchorSure. Neomedic was very gracious in providing us with an institutional grant for doing this trial. The primary outcome was for pain. And we didn't find any significant difference in pain between the two devices, but we overall had a very low rate of pain. So I was very proud of that. Our hypothesis was obviously that if you have an anchor that's going into the ligament, you're not going to entrap the levator ani nerve. There is still a significant number of patients that have pain at one week, but the pain level declines dramatically by six weeks. And so that helps us with counseling. So in my practice, the way that I typically do this is, you know, the AnchorSure device, I don't like to use that if I've got a young, a new trainee, because Mike, as you say, I love to be able to readjust their placement if it's in the wrong place. And once the anchor is deployed, it's in the ligament and I'm not going to be able to take it out. And my great fear is that it's put through the inferior gluteal artery or something, and then it's really an issue. And so I just, you know, if somebody that showed me they know where they're going, I love to use the anchor system, but I won't use that for somebody new. For somebody with a uterus, we love to use the AnchorSure system because it comes with two bullets that's loaded with already proline. So we use the first bullet that goes into the sacrospinous that's going to go through the internal cervix. And then we replace the second bullet with a zero PDS suture. You know, the AnchorSure comes with, you can have as many bullets as you want, but the kit comes with two anchors. And of course, if you use something like the Capio device, you can load either a proline or a PDS suture onto that, and those are separately packaged. Okay, good. We didn't find any difference in outcomes in terms of prolapse repair either. So they worked equally as well, but the pain was no different. Okay, well, let's move on. We have one more case, I don't see anything in the chat, but once we're done with this case, we can have anyone who wants to ask questions come on forward. So this one is gonna mix it up with both prolapse and incontinence. So it's a 66-year-old woman with bothersome prolapse and incontinence. She's got even a more complicated history than the prior patients. She's had a hysterectomy, an A&P repair, Kelly placation years ago. She had a number of collagen injections right after that. She then had a fascial sling for stress incontinence, that worked for a few years, but then the stress incontinence recurred. She then had a TOT and had no improvement. So she now comes to, she's got a recurrent vaginal bulge and bothersome mixed incontinence. She leaks a lot with cough bending exercise. She also has urgency and urge incontinence and goes through a number of thick pads per day and both components of her incontinence bother her. The prolapse is not horrible, but it bothers the patient, particularly at the end of the day. She did try a pessary for this, but she found that she had a lot of irritation, a lot of discomfort and the leakage was actually worse. Her past history is significant for hypertension, diabetes, AFib, diverticulosis, and a past history of endometriosis. She did have an appendectomy after a ruptured appendix many years ago. She also had a bowel resection after one of her episodes of diverticulitis and she had a number of laparoscopies to deal with her endometriosis in the past. She's an obese, healthy appearing woman, a BMI of 33, abdomen, multiple surgical incisions, empties relatively well. Her BA and BP points are zero. C is plus two, GH is six, TVL is eight. And when you reduce the prolapse and she coughs, she leaks. Her Q-tip is zero to 10. So in summary, multiple abdominal operations, prior native tissue prolapse repairs, multiple treatments for stress incontinence, now has stress, urge and prolapse. What would you like to do? Mike? I think this lady obviously has had many, many therapies where things are at. I've been a believer based on where things are at that even though the patient doesn't think the prolapse is as bothersome as the leakage, I think to optimize your organs, you should put them in the perfect position. My concern with her BA at being zero, if you're gonna do any sort of suburethral component, the prolapse is gonna make an artifact to that. So I like to actually reduce everything, sort of re-put her vault in place, reposition the anterior and posterior compartment. And that would be my number one priority and tell her that this is gonna be multifaceted approach to things. She's now had three operations for stress incontinence. I think by putting the prolapse back, it has the best option for her OEB to be stabilized. I think we would then work on a secondary component of stress incontinence management of which there's different options. But I think I would go towards the prolapse first. Is there any further evaluation, I'll throw that to Catherine or to Mike, before you operate that you perhaps wanna do? Yeah, well, first of all, I would check if there was a bus from Winston-Salem to Charlotte and see if she would like to get on the bus. No, I'm kidding. Yeah, these are people, this is the problem with seeing these people that are living a lot longer and then we're managing these pretty complicated situations in their 60s and 70s. A couple of questions just to clarify in history, is this woman sexually active? Yes. Sexually active, okay. And for me, the first investigation, I definitely wanna get your dynamic study. I feel like in this circumstance, I've definitely, definitely had patients with profoundly worse incontinence after fixing their prolapse. And these are the people in the office when you manually just push up the bladder base, the urine just starts to come on out. It's almost like reducing the prolapse starts to precipitate some sort of bladder spasm and it just comes on out. And those people terrify me because they seem to have no bladder capacity. They've got a non-functional urethral sphincter. And while they thought they were bothered by the urinary incontinence before, they really are bothered after surgery. So I'm nervous about those people. So I would do your dynamics and get an understanding about her capacity, her urethral function. Is this really a very profound DO and how does she empty? Let's just, for argument's sake, let's say the urodynamics showed she had a capacity of 200. She had DO and she had a stress incontinence with a leak point pressure of 55 and emptying, she emptied completely without any evidence of obstruction. Yeah, you know, capacity of 200 with this very low leak point pressure, it's going to become very problematic, right? Because you're going to have to provide some pretty significant urethral resistance to deal with that. And that's going to be a problem with that capacity. So, you know, it's, have to understand from this patient, you know, I would enter a deal with this patient. She's going to have to lose a significant amount of weight before I'm going to engage with her. Like there's two people on this equation, right? So otherwise you're doomed for failure with the scenario that you've provided me. Sometimes you can't fix it, right? So I would be super nervous with the BMI and with her diabetes. You haven't told me what a hemoglobin A1C is, but I'm imagining it's not very good. And a capacity of 200, you're up against a lot. So let's just say for argument's sake that she loses 70 pounds, her BMI is now 28.34. Okay. Let's say her sugar, her non-insulin dependent diabetes is much more stable, better control. You did a cystoscopy, you didn't see anything. What are the, let's just go back to her POPQ. What are the things that, and she wants to lead an active lifestyle. She wants to be fixed. Yeah. So, I mean, I would never go into this woman's abdomen. I think that we can all pretty much agree that that would be a bad idea. So then we're talking about, we're going to optimize the native tissue repair. And so, I would, again, do my extra peritoneal sacrospinous fixation. I would really reduce the size of the genital hiatus six centimeters. And I think that in a case like this, the idea of an adjustable sling makes a lot of sense to me. And she's probably going to need some Botox along with that. When you do that in the sequence of events, it's hard to know, but with a capacity of 200 and DO, that's going to be a major source of leaking for her. Mike, what about you? So you're at the point, she's tuned herself up as best as she possibly can and really wants and needs something done. How are you going to approach it? Yeah, I think I would vaginally approach the prolapse just as Catherine said. But a unique thing about this is really your decision point with her is to say, do you need this staged approach to say, well, we're in the OR one time, let's just fix your prolapse. Let's see what happens to your OAV. We know the SUI is going to get worse and then come back and treat it after that. Or could you put in a adjustable sling, but I would actually not keep the key in place or the stick, keep it in loose, close everything in place, let the prolapse stabilize, and then have that as a secondary. And I would actually probably, if the OAV is still there, I would probably stabilize that the best I can with either beta threes or anticholinergies, possibly Botox. And then when things have settled down, say, okay, now let's adjust the sling with the Remix sling. So if you're, let's just say you were going to work on the prolapse first for argument's sake, what would you specifically do? So I would do a sacrosance vaginal vault suspension, anterior and posterior repair. And that's the discussion would be either I would try and do a hydrogel Vulcan agent at the time, or I would put in the Remix sling. And whether or not I'd leave the key in or not is really depending on her and what she's wanting. But I do know that there's many other factors such as your OAV, her voiding function, that I could probably sway her one way or the other to leave the key in or not. I don't think a Vulcan agent is really going to be the end all be all, but I think it temporizes her enough to maybe see a little bit light at the end of the tunnel. What do you think the chance of improvement in the OAV and maybe even in the capacity once the prolapse is fixed? I've been remarkably surprised at what the effect is. And I think that you should try to do everything in your power to do it because if you don't fix the prolapse, what are you going to do for a SUI treatment? Anything underneath it's going to make the OAV potentially worse because you're going to kink. If you're tightening a Q-tip that's on zero to 10 degrees, you've got to put pressure on that area, which means it may augment or worsen the voiding function. I think that, and honestly, this is where, you know, the pessary experience of the patient is going to be very predictive of what they're thinking about after you fix the prolapse. This woman had adequate vaginal length to hold in a pessary. If she leaked a lot more with the prolapse reduced, I really think that you have to be fully prepared that her incontinence is going to be significantly worse. You know, these are women oftentimes that have funneling of the bladder neck. They have stress-induced DO as well. And so in large measure, you know, managing something at the mid urethra also doesn't necessarily deal with their big problem, which is this funneling of the bladder neck. So, you know, it's interesting how, the fact that she was really bothered when the pessary was in, I would use that as my predictor to hers as what her degree of bother would be for the incontinence. And so I would really be focusing my efforts on this woman's incontinence more so than I would be for a prolapse. So we have a question on the chat and I'll just read it directly for this patient. What is your talk track when you see her in clinic? She comes to you and says, I've heard you, Dr. Matthews or Dr. Connelly, you're the best and I want to be fixed. How do you set the expectations and prepare her for the process that she faces? Mike, why don't we start with you? You be honest and say, I'll be honest with you. You have a really difficult situation and you've already been through three other surgeries. It's going to be challenging. This is not the first time through. So, you know, I'm going to do my best to try to really help you, but it's going to be a process and let's work together on them. You know, as I loved, Catherine said it earlier, there's two here or something to that effect. What'd you say, Catherine? There's two factors that we've got to consider. Yeah, and it's interesting, you know, because patients, you know, when you're a junior faculty member, you love hearing that, oh, I'm the best. And now I'm like, I say to my trainees, you know what that is? That's set up for failure, right? Because that's all it can be. No one's going to, no one is going to make this person dry. Let me just put it out there, okay? Nobody. Okay, maybe if she has bladder augmentation and like a tight fascial sling or something, maybe she's going to be dry. She's not going to be voiding. So no one's going to have a perfect balance in a patient such as this. So you have to then manage expectations. And I think that one of the things about being good is being honest. And I think the patients are typically not so much frustrated. If you don't meet their expectation that you've set erroneously by being the best and promising, then, you know, they're going to be frustrated in that circumstance. But I think if you say, look, let's aim for a 50% reduction. Let's see if we can achieve that goal. I tell you, I would try to achieve that goal in this patient without fixing a prolapse and concentrating a lot of OAB management. You know, that's how I'd manage that. So let's change it up. Let's say she said, I'm not sexually active and I have no intention of ever being sexually active again. It doesn't change the fact that doing anything to unkink the urethra is going to make her incontinence worse. So look, if she's not sexually active, well, then you're just going to improve the chances if she's really bothered by the bulge and you want to go and fix the bulge transvaginally that you'll be successful in that in the long-term. We do a lot of really aggressive hyperneurophys even if you're not able to completely obliterate the vaginal canal. But it doesn't change the fact that it's still going to affect the bladder neck. And I think it's still going to affect her leakage. I think one of the issues when you're doing a coprochliasis, be careful because the tendency is to pull down that anterior compartment and consequently you funnel the bladder neck and you don't leave yourself much room to manage. So I actually try to prefer more of a native repair. Sometimes it's easier in these types of situations to give myself some option because you know the incontinence is going to be worse. Yeah, and that's why I specifically use the word hyperneurophy, not coprochliasis. And I think that that's a very important subtle point to bring forward that if one really reduces the size of the hiatus, you're going to achieve a lot of the same benefits of a coprochliasis without having to pull down the bladder base. So Mike, let's say either case, let's say you fixed the prolapse and you had decided to wait on incontinence. And now that you've fixed the prolapse, the OAB was a little better, but not much better. You went ahead and gave her Botox and now she has far fewer urgency symptoms but she still has a lot of stress incontinence. What are your thoughts there? Yeah, so this person, if her bladder capacity increased and she's doing well, I think at this time it would be part of that plan. And we would have set that plan up to the beginning as a multifaceted. So here I would recommend, she's already had a fascial sling. I would do a remix adjustable sling, giving her the ability. And as I said, I might've put it in already at the very first time. That way it's there. And then we just would adjust it at this point as an outpatient. Catherine, any thoughts? I really would challenge the assertion that somehow her bladder capacity is going to improve because if she's really got bad stress incontinence, I just don't understand how we're going to improve her bladder capacity by fixing the prolapse. But if that is what you're really seeing, the magic has happened, then- Botox, she had Botox also. Well, Botox may well have helped the situation. I think that then I have to talk through, she's already had the fascial sling for sure. I either would consider bulking again or doing an adjustable sling. I think that that's a good circumstance for it. Okay, we have one question on the chat line here and I'll throw it to Mike. The question is for patients with prolapse and urgent incontinence. Do you have a threshold for attributing the OAB symptoms to the POP, stage two versus stage three, et cetera? Well, normally I would say it's if it's stage three, but I do like the fact of trying a PESRI, meaning a trial of PESRI, not only for the prolapse reduction, but really for OAB symptoms. And that's all about counseling. Just as Katherine said, it's proper counseling and expectations. So if they have resolution of improvement in OAB with the PESRI in place, I tell them typically that will tend to happen during the prolapse repair. But if it's not, then I expect that we're going to need to go ongoing treatments afterwards. Okay. Now, Howard, if I can just quickly say, Kim Kenton's provided so much literature on so many different facets of female pelvic medicine. And one of the papers that I quote of her so often is about the most common reason patients are frustrated after prolapse repair is because of lack of improvement in OAB symptoms. We of course know that there are so many women who've got overactive bladder, who've got perfectly normal pelvic support. So I think that that's one of the areas that are really under-promised and say, gosh, if you've got incomplete emptying and have got a low functional capacity, I'm going to fix that. And I'm very excited to fix that. And those women are the ones that are just, you know, getting up four times at night because they go to bed with 250 CCs in the bladder and you fix their anterior prolapse and they're perfectly better. The woman with, you know, garden variety OAB who had that before her prolapse, I just don't think that those people tend to respond with just prolapse repair. Okay. So this was a great discussion. And actually I know we are now going over, but I see pretty much all the participants are still on. So why don't we open up the mics? And if anyone wants to ask any live questions, they can feel free if we have that option. Are the mics open? Anyone want to cough? It's pretty intimidating, Howard. You know, you're a force up there at the clinic. It's hard to ask you a question. They're asking questions to North Carolina. All right, we'll give it a few more seconds here. The participants are still there. So I don't know. Well, while we give it a few more seconds and see if anyone comes on. And again, if you have any questions, now's your chance, so feel free. But if not, I just want to end by once again, thanking Augs for facilitating this, thanking Neomedic for sponsoring it. And of course, thanking our North Carolinians, Doctors Matthews and Canelli for really an informative discussion. And I guess that the questions have already been asked and I see the participants are starting. The number is dropping. So at this point, I guess we'll say good night and Catherine or Mike, thanks. Hope to see you live soon. Thanks so much, everyone. Thank you, have a good night. Have a good one. Thanks, Augs. Bye-bye.

prolapse

incontinence

patient cases

stress incontinence

treatment options

adjustable slings

fascial slings

native tissue repairs

urodynamic studies