I have yet to meet an individual who was not nervous heading into surgery. We all hope our health concerns will be addressed and resolved when having surgical repair; we all hope procedures will be complication free. Every surgical procedure has risk factors, thus the importance of looking for the best clinician for our surgical needs and the best type of surgery to optimize results.
“Success for one woman may not MEAN the same for another.”
~Roger Dmochowski MD
A common topic in APOPS support forum is the safety of mesh procedures for pelvic organ prolapse (POP) repair. Much has been addressed to improve outcomes of mesh procedures, yet fear factor remains for many women who read stories of mesh complications online or see lawsuit commercials on television. Seldom do women who’ve had successful mesh procedures talk about them, they simply get on with their lives. Every week women newly diagnosed with pelvic organ prolapse find APOPS forum; frequently they reach out for guidance on mesh. Let’s revisit the purpose and value of mesh treatment for pelvic organ prolapse as well as share insights on best practice techniques utilized by properly trained Female Pelvic Medicine Reconstructive Surgery (FPMRS) urogynecologists and urologists.
Every woman navigating POP would like to have a magic list of "the best of the best" when it comes to pelvic floor clinicians; it's unfortunately not that simple because needs differ significantly from woman to woman. Some women prefer a clinician who's the most qualified surgeon, with little concern about bedside manner. Some women prefer great bedside manner, but may be disappointed if the surgical outcome is not perfect or the heal curve takes longer than first indicated. Surgeons are as individual as we are ladies, they are after all human. Skill set of clinicians will vary with time, experience, continuing education, and new innovations and tooling.
It truly takes a specialist to repair the intricate female pelvic cavity, a diverse mass of organs, soft tissues, muscles, ligaments, tendons, boney structures, and nerves pushing against each other in a very compact space. To complicate matters, women with POP typically have more than one type of prolapse in need of repair and each POP type shifts organs from their normal positions. Kind of like putting an assortment of large cooked vegetables into a Ziploc bag lying flat on the cupboard-when you hold the bag upright or shake it around, everything squishes together and shifts position. As much as you love your gynecologist, it is imperative you see a specialist for POP repair.
“Urogynaecology is a sub-specialty in its own right- The literature and clinical experience have both clearly shown that the best results of POP surgery are obtained when the attending surgeon is a urogynaecologist rather than a general gynaecologist/obstetrician.“
~Diaa Rizk MD
If considering mesh surgery, it is important to find a clinician with extensive mesh experience. Have the questions you want to ask your doctor written down before your appointment to make sure you don’t forget any. Let your practitioner know you have mesh surgery fear if that is the case. Ask your surgeon what he/she does to avoid mesh complications. Small incisions, proper mesh insertion location, preparation of mesh insertion site, use of estrogen cream pre and post surgery, degree of mesh tension, and a two layer closure are important considerations for a quality mesh procedure, whether your doctor performs mesh surgery through a transvaginal, robotic, or abdominal incision.
“Mesh surgery is not a magic cure. Proper pre-operative evaluation of women with POP who need surgery will dictate the best surgical approach whether mesh or native tissue repair”
~Roger Dmochowski MD
When clinicians or industry magnify the benefits only of a product or procedure, it is a red flag. You should hear both sides of the story, risks and benefits, in order to be fully informed to better enable you to make the most appropriate decision whether to move forward with surgery. My POP procedure in February 2008 was transvaginal and a consult with my urogynecologist at the seven year point in 2015 confirmed that my tissues remain healthy, the mesh is in proper position, and there is no erosion. The value of finding the right specialist is priceless; I am grateful mesh was an option for my surgery. There is never a 100% guarantee of success with any surgery, but if all of your questions are answered, it will give you peace of mind heading into a procedure.
” It is important to counsel women pre-operatively about the efficacy and complications of mesh repair to enable them to make an informed choice.”
~Roger Dmochowski MD
It is important to understand that in the hands of a qualified practitioner, mesh is typically used to prevent additional POP surgery down the road. Without mesh, surgery often fails in one to five years because our tissues are not strong enough to hold the repair long term. Considering the multitude of POP causes, it’s no shock that lifestyle and the aging process increase the risk of surgical failure when mesh is not used. While childbirth is absolutely the most common POP cause, most women have a multitude of risk factors. Menopause (estrogen loss impacts muscle tissue strength and integrity), heavy lifting (every mom and grandma I know loves picking up babies and toddlers can get pretty heavy), athletic activities with downward pounding (many women like to run and jog but a water filled balloon jerked up and down gives you an idea what you organs are going through), chronic constipation (we seldom know which comes first, constipation causing rectocele, or rectocele causing constipation) are common causal concerns. Additional causes stacking the risk factor list are chronic coughing, DRA (the long abdominal muscle splits down the middle during pregnancy), genetics, hysterectomy, neuromuscular diseases such as Ehlers-Danlos (hypermobility), MS (multiple schlerosis), or Marfan (connective tissue disorder), the list of causes goes on and on. Show me a woman with one cause alone and I’ll show you a woman who is the exception to the rule.
“Obesity is also an important risk factor for failure of mesh repair because the accumulation of fat in the abdomen increases the intra-abdominal pressure similar to straining.”
~Diaa Rizk MD
“Know your symptoms and be able to identify the most bothersome.”
~Roger Dmochowski MD
All things pelvic organ prolapse will evolve considerably over the coming years. While APOPS pushes the envelope behind the scenes to generate broad-spectrum awareness, research is simultaneously exploring multple layers of the POP dynamic while clinicians evolve skill-set and treatments. There is little doubt, pelvic organ prolapse will generate the next big shift in women’s health. Women with POP, practitioners, and research are all learning side by side.
“With ageing of the female population, the prevalence of POP will significantly increase creating a greater demand for services worldwide.”
~Diaa Rizk MD
There are multiple links to clinicians who specialize in surgical and nonsurgical POP treatment on the APOPS website Practitioner Locator page. Try to find a few practitioners in your area and Google them individually by name to see what information you can find regarding experience, location, length of time in practice, etc. Several physician review websites such as vitals.com, healthgrades.com, and ratemds.com will give you basic information to start with, but are not a 100% guarantee of practitioner quality. It is in your best interest to meet the doctor in person to decide if your unique needs will be met, an clinician referrals from other women walking the walk are helpful. Pelvic organ prolapse is a condition that absolutely warrants a second opinion if you are not comfortable with the first specialist you see. Surgical skill should be a top priority. How well your practitioner answers your questions and understands your specific needs is priceless. Some women prefer a doctor with top surgical skill, some prefer good bedside manner-the ideal is a mixture of both.
“The health care providers responsible for treatment of POP, besides urogynaecologists, include: pelvic floor physiotherapists, nurse continence advisors, and women's health urologists.”
~Diaa Rizk MD
As patients, it is our responsibility to do our homework. Check references, get referrals, consider second opinions. Pelvic organ treatment is diverse, complex, and continually evolving. Ladies, I can’t say it enough-get all of your questions answered and do not move forward with surgery until you are sure you are ready.
APOPS Mesh page: http://www.pelvicorganprolapsesupport.org/mesh-updates/
APOPS Practitioner Locator: http://www.pelvicorganprolapsesupport.org/healthcareconnections/
A heartfelt thank you to Dr. Roger Dmochowski and Dr. Diaa Rizk or their contributions to this article.
Urologist
Roger Dmochowski, MD
Vice Chair of Surgical Sciences
Vanderbilt University Medical University
Nashville, Tennessee, US
Urogyenecologist
Diaa E.E. Rizk, MSc,FRCOG, FRCS, MD, Dip BA,
Professor and Chairman,
Department of Obstetrics and Gynaecology,
College of Medicine and Medical Sciences,
Arabian Gulf University
Manama, Bahrain