That was like a urogynecology senior seminar. A couple of points of housekeeping before we get to our next item. I so much look forward to the creativity and energy that we bring to our karaoke celebrations. I would ask that we, as we think about what sort of creativity we're going to bring, that we take a moment to be careful. There's no way it could be interpreted that we're making fun of our patients or their conditions. Remember that we live in an age of social media and a snapshot. Depicting such a thing would not go over well for organizations. So make fun of our world and ourselves and me, but thank you for being cognizant of that. A quick message from the coding committee. There was an interesting study presented yesterday regarding the possibility, feasibility of doing post-operative telephonic evaluations. Please remember that the way our coding system is right now, when you bill for a surgery, you have already been paid for an in-person visit. So please consider that an academic discussion, not a piece of advice from your coding committee. Thank you. For the past couple of years, OGS and SUFU have strengthened their relationships by inviting each other's presidents into each other's meetings to present topics and clinical pearls. You'll remember Dr. Gary Lemack's presentation last year in Providence. And I was honored to attend and present at their meeting in Austin this February. Please join me in welcoming the president of SUFU, Dr. Kathleen Kobashi. Thank you. Well, thank you very much. Good morning. I'd like to congratulate Charlie on a really wonderful meeting. And I'd like to thank Charlie and Mimi and Felicia for the kind invitation to be here to talk to you today. Thank you very much. And the privilege and honor of being here. It really is a true honor. Gosh, I can't see. These are really bright lights. So now, this lecture is called the SUFU Update. And I would like to say a couple of words about the state of the state. But I'm not going to really dwell on that. I thought I'd tell you a story instead. And in true transparency, I delivered this lecture recently. And I got a lot of great feedback on it. So I kind of switched gears from what I was originally thinking to talk about here. And thought I might tell you a story. Because I think it's very important for us to reflect upon how we got here. Some of the stuff that is now on the mainstay of our therapies was really the brainchild of somebody who was really of several giants in our field who were willing to really step out of the box and look a little crazy and present some things that no one would have ever thought to try to do. So we'll talk about that in a moment. But I do want to make a couple of comments vis-a-vis Charlie's comments earlier. FPMRS is a really wonderful and unique subspecialty of medicine. And the challenges that it presents are also the most wonderful parts about it. And what do I mean by that? Well, if you think about FPMRS as a little bit, you know, it's a Venn diagram, right? And that middle part of where urology and gynecology come together is FPMRS. And it's really a great privilege to be here contributing to all of that. But what's unique about it is that gynecology brings its own special, unique things to this. And similarly, urology brings a lot of unique things to the Venn diagram. And so those things that don't overlap are the challenges that make this all very wonderful. I can assure you that under Charlie's leadership, the board of OGGS and NSUFU, and for that matter, ABOG and ABU, are really working hard together in conjunction with each other to try to weather the storm and continue to grow that partnership, which is so critical in this climate. So thank you again for this exchange. I think it's a really wonderful way to keep that dialogue going and to really strengthen that relationship. So again, I thought I would tell you a little story, because I think it's important for us to really reflect upon how we got somewhere, to not only respect the process of how we got here, but the people who contributed to it. And of course, the older I get, I must confess, the more interested I get in history. When I was a kid, who wanted to know anything about how we got here? But I think you really start to realize, wow, this is amazing thinking. These are genius people who brought us to this place. So how many of you guys do sacral neuromodulation? So a lot of people. So that's become kind of the mainstay, whereas when you look at things 15 years ago, not many of us were doing it. And now it's become part of the armamentarium that we all sort of expect. As you know, there's a lot of great new neuromodulation techniques and devices that are on the horizon, or not really even on the horizon, they're here. So it's important for us to know a little bit about it. These are my disclosures, and everything goes to Virginia Mason to support our residents and fellows. So what is neuromodulation? Well, it's the concept that electrical stimulation of one pathway, one neural pathway, can modulate another pathway. And for the pelvic floor, that target is sacrum, or sacral. And so how did we get here? I think a little science and history lesson can help us understand neuromodulation and have that much more respect for it. So if we go way back to 600 BC, that was the first description of electricity. And there was a fellow named Tals of Miletus who was credited with rubbing fur on amber, and what we call static now is what he saw. So it's the traction of the fur. And then in 150 BC or so, there was a device that was discovered, and they call it the Baghdad battery because it was discovered near present day Baghdad, but it's thought to have served as a battery. And basically what it was is this clay jar inside of which was an iron rod that sat in a copper cylinder bathed in this unknown electrolyte that would help generate the current or transmit the current. And so we call that the Baghdad battery. And then electricus was coined by Sir William Gilbert in 1600. And as you all know, we all learned about this in grade school, Dr. Franklin's experiment with the key on the kite in a lightning storm. And basically he demonstrated the transferability of energy from the lightning. And based upon this, he designed or invented the lightning rod to attract electricity in an electrical storm to protect structures and buildings. Now let's apply this to biology. Luigi Galvani, another experiment we all learned in biology class in probably sixth or seventh grade, was that if you applied dissimilar metals to a frog's leg, you could demonstrate contraction of the frog's leg. And so this suggested that muscles and nerves utilize electricity to function. Now the story goes that Luigi Galvani was a very quiet, reserved gentleman. Down the road was this sort of flamboyant professor in a very prominent university in Italy. And they had sort of, if you read all the accounts, some of them are friendly, and some of them say that it was a little bit contentious. But they had this little rivalry. And Volta, who's credited for designing what is now the modern day battery, actually contested the premise upon which Luigi Galvani thought that electricity created the contraction. And he really thought it was a current electricity that was produced by a chemical reaction. Oh, and what you see here, let's see, right here is the voltaic pile. And basically what that is is a bunch of copper plates between which he had some brine-soaked fabric that was the electrolytes that we saw in the Baghdad battery, right? Now what's interesting is I think maybe the rivalry wasn't so bad after all, because he actually named his experiments galvanic stimulation, even though it was credited to Volta. But what he showed was that if you remove the metal conductors and you eliminate the metal conductors and you loop the nerve back to the muscle, and then you apply the current, you could get a contraction. So basically what that did was confirm that bioelectric forces exist in tissue. So now Michael Faraday, who we still use induction coil stimulators now, but if you run a magnet through a current carrying wire, you can create a force also, a current also. And this, rather than the single twitch contraction of galvanic stimulation, actually creates a more sustained contraction or titanic contraction with the induction coil stimulator. And basically, what's the significance of these findings? It really showed that there is a relationship between electricity, magnetism, and neuromuscular function, which we know is a fundamental today, but they didn't know that then. And what that was able to do was help us really map out the neuroanatomy and neurophysiology. And who was really credited with that was Duchenne of Duchenne's muscular dystrophy. And what he did to these poor individuals is that he stimulated all these nerves and he really mapped out the neuroanatomy using the induction coil stimulator. So in the early 20th century, there was a lot of advance in electric physics, electrical physics, and these theories were used to improve the understanding of synaptic transition, transmission, and functional neuroanatomy. So now moving on, really going towards sacral neuromodulation or going toward neuromodulation, Chaffee and Light were the first to be credited with sort of remote control of the body. And they placed a primary coil outside of the body and they were able to stimulate deep in the body with this sort of thinking. So now let's talk really specifically about sacral modulation or neuromodulation as we use it for pelvic floor. So just a brief history here. We'll run through it in the interest of time without a lot of detail, but notice that it was from back in the late 1800s. So Dr. Sachsdorf was a Danish surgeon and he was the first one who started to try to utilize this thinking to create contraction in patients who have hypotonic bladder and who were in urinary retention. So he placed an electrode in the bladder and then a suprapubic electrode and he stimulated transurethrally to try to get them to contract. And at the same time, a fellow named Dr. Katona was doing similar work in the GI tract. And basically what his thinking was that if you could activate some of the receptors and continue to do it and create small contractions, eventually you could reactivate and depolarize adjacent cells and eventually, hopefully, create a centrally induced, strong, coordinated contraction. And then he applied this to the bladder. Now, I don't know exactly how he measured it because the way things were reported back then were maybe not as precise and as scrutinized as what we do now. But he reported on 420 spinal cord injury patients and had success with conscious micturition control in 314 of these patients. And he termed this vegetative affrontation, this sort of depolarization of adjacent cells. But that, by all accounts, would be quite a successful outcome. So there was a lot of work looking at the ideal electrodes, the ideal configuration of the electrodes, how big they were, how deep they were. They're placed in the bladder. And as you might surmise, multiple pairs was better than just a single pair because you can get a uniform contraction if you place them all over the bladder. And this was direct stimulation of the detrusor. Also, if you placed it on the lateral walls, you'd get a more effective contraction. So just kind of skipping over the details of all of this. When they first started to apply it to the human, again, realizing that right now, at this point in time, they were directly stimulating the detrusor. And you'll see that the thinking really evolved over time. The first go at it wasn't all that successful. So one patient was successful, one sort of middle, and one wasn't successful at all. But this was the first foray into all of this. In dogs, they were able to get complete emptying that was sustained for 14 months. Not quite as successful in the human, but they still got two patients to empty completely who were not emptying at the onset of this. So in the 50s and 60s, the big question was, well, where do we stimulate? Do you stimulate the detrusor directly? Do you stimulate the sacral plexus? Where do you stimulate? So some of the work and the thinking and going that went into this is really very fascinating. Pelvic floor stimulation, the first implantable stimulator was actually for fecal incontinence. No surprise. We use it for fecal incontinence now. But they realized that patients who were being treated for fecal incontinence also had help with their urgency incontinence. Now, I've switched gears a little bit. As you know, we use it both for overactive bladder and underactive bladder now. And so these experiments kind of went back and forth as the literature evolved. And it will make sense, hopefully, when we finish talking about this. But they found that patients who they treated for fecal incontinence also had this sort of nice side effect of success with the urinary leakage as well. And they stimulated. So what they also found, interestingly, was when they were just stimulating the pelvic floor, what you would get is not only an inhibition of the detrusor muscle in patients with detrusor overactivity, but also you got increase in outlet resistance. So that's good if you've got someone with mixed incontinence, stress incontinence, and urgency incontinence. But if you're just trying to get someone to empty and you stimulate that outlet, the problem, of course, is that they're not going to empty, right? So we'll talk about that. And the mechanism of detrusor inhibition was really very based upon basic physiology. It's an activation of the sympathetic inhibitory neurons and a central inhibition of the parasympathetic excitatory neurons. Remember that the afferents are part of this as well. Oops, that went backwards. About this time, by the way, Dr. Ed McGuire from the University of Michigan was actually way ahead of his time. And he was doing some stuff based on acupuncture theory that I think has really evolved into what we call posterior tibial nerve stimulation now, right? PTNS, PTNE. But he was doing these experiments on non-human primates based on acupuncture literature. So about this time, though, there were a lot of people working on this stuff in parallel. And the NIH approached several of the leaders in our field. Dr. Tanago at UCSF was doing really elaborate, excellent neuroanatomic and physiologic studies. And he brought together Dr. Nasholt, who had successfully implanted an electrode in the sacral spinal cord at Duke, and Dr. Jonas and his fellows from Europe. And he brought this team together to really put more effort into this. So again, pelvic nerve stimulation. That was a no-go. And the reason why, again, was because when you stimulate in the pelvic nerve, the pudendal nerves are activated as well. So what you end up with is sort of detrusor-sphincter dyssynergia, basically, or dysfunctional voiding. But the bottom line is that you would get contraction of relaxation of the bladder. Sorry, I misspoke. You get relaxation of the bladder and contraction at the sphincter at the same time. So you could not facilitate emptying. What they found was that the parasympathetic fibers were, it was a broad plexus and a big target, so it was hard to separate things out. So you couldn't just control exactly what pathway you wanted to affect. How about the detrusor directly? Now, some of the early studies were detrusor directly. And there was variable success on this. But though it's theoretically a good thought, it's a very high target specificity, the problem, of course, is as the bladder contracts or moves around, you dislodge your electrodes. The other problem was erosion of the devices into the bladder or fibrosis of the bladder wall over time. So the detrusor didn't fly as a target. How about spinal cord stimulation? So again, you can see the group, the names down in the corner there were the group that was convened to really look at this. And they tried direct stimulation in the micturition center. Again, same problem. What they got was detrusor contraction and sphincter contraction simultaneously. When working on patients, you were trying to get to void who had hypotonic bladders. Again, they were looking at different depths of placement of the electrodes. They found that only the depth produced void. If you did surface stimulation, you really got this dyssynergia picture. And again, different types of electrodes. I mean, it became very sophisticated. When you look at the literature, you think how many hours of thinking. And then to actually construct that research, all of you who do research, clinical or basic science, you know how toiling it is. But this is years and years of hours upon hours of things that you just, they were really just, trying one thing after another and amazingly got to where we are now. But again, the biggest problem was this simultaneous contraction of both the sphincter and the bladder. So how about stimulating at the root? The problem again, as I keep mentioning, is the simultaneous contraction of both. Dr. Tanago did these very elaborate, very elegant radio tracer studies with horseradish peroxidase and was able to really map out the anatomy. What was important was that he found two nuclei that are very critical in voiding and found that they exist within each other. So you couldn't really separate them, at least on first glance. You couldn't separate them, the parasympathetic and the pudendal nuclei exist within each other. So he explored the root and he found that you could actually trace the root. And again, if you think about it, now he did laminectomy and if you think about it, the nerves come out and there's a ventral root and there's a dorsal root. So they separate the motor and the sensory pathways. He really, this is how he did it, was unilateral, bilateral, intact dorsal and ventral roots. He separated them and divided them in different places and stimulated the proximal and distal aspect to really map this out. So again, we're talking about this in 15 minutes and I've got 58 seconds to tell you the rest of this story, but this is years and years of hours and hours of amazing genius work with all of these individuals. What they learned basically is that you could actually, just skipping in a little bit, if you use different stimulation, different voltage and different frequency, you can fatigue the muscle. Okay, so if you do low frequency, low voltage, you get good sphincter contraction. If you do a high frequency with low voltage, you fatigue the sphincter. So what you can do is high frequency, low voltage and fatigue the muscle, followed by high voltage stimulation and what you get is a void. So with all of these things, again, all this thinking at a level much higher than my understanding, they were able to actually get to the end of the story, which is fascinating because I don't know how many places along the way I would have gotten discouraged if I even had the brain to think about all of this, but thankfully they did because it's become something very successful in our armamentarium. Histologically, no damage to the nerves, even with repeated stimulation. So bottom line is, let me just move along here, you can target the nerves. That's the huge significance of this and you can control the detrusor and the sphincter separately and as you know, we've also now utilized it not only for overactive bladder, but we use it for underactive bladder as well and fecal incontinence as well. So Pacemaker was born. As you know, the FDA approval was about 20 years ago. It's really come a long ways and as you know, also there are other players on the field now and so a lot of advance, that always is a catalyst for further advance, but you know, and globally it's been accepted in many countries it was fecal incontinence before bladder, but be that as it may, it's come a long way from where we used to cut down. Has anybody been doing it long enough that you used to cut down? I remember when I first joined Virginia Mason and I said, put the patient on their belly and I was cutting down and they were like, who is this young person? What is she doing? And I kind of got in a little bit, I got a little dirt on me for that at the beginning, but thankfully it's panned out and now we've got these great percutaneous techniques and not only the percutaneous techniques, but I will say we used to come out of the OR and I'd be satisfied if I got two electrodes that were at 7.0 and now we don't come out of the OR unless all four are under two and it's very doable and when I first heard that, I'm like, that's impossible, but it's not. We've improved things with the curved stylen and radiographic landmarks and things that we can do that you can dependably get there and I think that that's been, you know, keep the faith and I think that's been a huge advance. So again, high success, low complication rate, they get to take it for a test drive, you know, everything about it is kind of nice. The future is, you know, the future, part of the future is here, but we continue to advance the technology and the indications keep increasing. I think that my point about giving you a lecture on this was it's interesting to have that appreciation of how we got here, but I think it's important for all of us to reflect on that sort of thing across the board and the things that we do on a daily basis and to respect the people that helped many, you know, your leadership here in this room and a lot of people here, hopefully one of you is gonna be doing something that 40 years ago, you know, out of the box today is gonna be the standard in 30, 40 years, but this, what we do here is a real privilege because it has a huge impact on quality of life for our patients and we should always consider, you know, the thinkers and the giants amongst us and not forget that. When I talked to Dr. Chanago, he said, this is just the tip of the iceberg. He said, this is so powerful, there's so much more, there's a lot of disease processes that we haven't even touched with this technology yet, so that's super exciting to me. And with that, I just wanna say thank you, I wanna say thank you to Charlie for the privilege to be here. Thank you very much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

sacral neuromodulation

treatment technique

overactive bladder

underactive bladder

fecal incontinence

history and development