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In this episode of BackTable OBGYN, renowned reproductive endocrinologist and minimally invasive gynecologic surgeon Dr. Charles (Chuck) Miller delves into the topic of isthmoceles, a common yet often overlooked complication of C-sections, and shares his best practices for repair.
Dr. Miller shares his extensive experience in diagnosing and treating isthmoceles, discussing various surgical techniques including hysteroscopic, laparoscopic, and robotic-assisted resection. He emphasizes the importance of an aggressive surgical approach for achieving higher success rates in terms of future fertility and resolving symptoms such as abnormal bleeding. Moreover, Dr. Miller highlights the need for standardized treatment protocols and reflects on the mentorship, the ongoing journey of learning and adapting in medicine, and the noble profession of healthcare. The episode offers insightful perspectives on a lesser-known gynecologic issue, underscores the value of experience and mentorship in medicine, and advocates for concerted efforts toward establishing best practices in surgical procedures.
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SHOW NOTES
00:00 - Introduction
07:18 - Defining Isthmocele and the History of Isthmocele
10:00 - The Diagnosis of Isthmocele and Its Impact on Fertility
19:31 - Exploring Surgical Techniques for Isthmocele Repair
27:54 - Understanding Hysteroscopic Resection
30:12 - Addressing C-Section Ectopics and Isthmocele Repairs
36:46 - Adapting the Surgical Approach to Different Patient Scenarios
39:35 - Postoperative Complications and Safety Measures
40:55 - The Future of Isthmocele: Surgical Standardization
50:51 - Closing Thoughts and Acknowledgements
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RESOURCES
Ban Y, Shen J, Wang X, Zhang T, Lu X, Qu W, Hao Y, Mao Z, Li S, Tao G, Wang F, Zhao Y, Zhang X, Zhang Y, Zhang G, Cui B. Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstet Gynecol. 2023 May 1;141(5):927-936. doi: 10.1097/AOG.0000000000005113. Epub 2023 Apr 5. PMID: 37023450; PMCID: PMC10108840. -
Saknas det avsnitt?
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In this episode of the BackTable OBGYN Podcast, hosts Dr. Mark Hoffman and Dr. Amy Park discuss how cultivating an effective team culture in surgery can mitigate complications.
The physicians emphasize that how surgical teams treat each other can significantly affect patient outcomes. They suggest under-promising and over-delivering to patients, their family, and members of the surgical team. The doctors recommend having a care culture, allowing everyone to voice their concerns without fear of reprisals. They also discuss the importance of self-management, leadership, and taking responsibility inside and outside the OR for complications and places where the surgery could have gone smoother. They agree that those who nurture a positive OR culture have higher success rates, noting that complications demand more than technical skills to handle - it takes emotional intelligence, humility, and a good support network.
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SHOW NOTES
00:00 - Introduction
02:07 - Dealing with Surgical Complications
04:24 - The Emotional Impact of Complications on Surgeons
07:24 - The Importance of Patient Communication and Care Post-Complication
08:35 - The Role of Consent and Preoperative Counseling in Managing Complications
11:18 - The Importance of a Supportive and Open Culture in Medicine
15:32 - The Importance of Learning from Mistakes in Medicine
24:28 - The Role of Leadership and Teamwork in the Operating Room
29:56 - The Value of Familiarity in a Medical Team
30:38 - The Importance of Recognizing and Appreciating All Roles in a Medical Team
34:31 - The Role of Care and Empathy in Medical Practice
37:28 - The Role of Preparation in Avoiding Complications
40:53 - The Importance of Scheduling and Time Management in Medical Practice
50:31 - The Impact of Culture on Reporting and Addressing Adverse Events
51:19 - The Importance of Feedback and Self-Reflection in Medical Practice -
In this episode of BackTable OBGYN, host Dr. Mark Hoffman engages in a comprehensive discussion with Dr. Jorge Carrillo, a MIGS specialist at the Orlando VA Healthcare System and Site Director for the UCF/HCA Healthcare OB/GYN Residency Program, about the complexities of chronic pelvic pain from the perspective of a biopsychosocial model.
The conversation dwells mostly on the intricate relationship between pain, trauma, and the patient’s psychological state as it relates to chronic pelvic pain. Dr. Carrillo emphasizes the importance of adopting a trauma-informed care approach that creates a safe environment for patients. The discussion also covers the use of surveys for patient information, the importance of organizing thoughts during patient evaluation, and an outline of the four major categories of pelvic pain: gynecologic, urologic, gastrointestinal, and musculoskeletal. Dr. Carrillo shares valuable insights into managing complex conditions such as pelvic pain, providing an education-first approach for patients with emphasis on shared decision-making, and outlines how he and his team operate within a multidisciplinary framework for patient treatment.
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SHOW NOTES
00:00 - Introduction
04:32 - Dr. Carrillo’s Journey in the Medical Field
08:51 - The Importance of Trauma-Informed Care in Chronic Pelvic Pain
14:54 - Understanding the Biopsychosocial Model in Chronic Pelvic Pain
19:49 - The Initial Approach to Evaluating Patients with Chronic Pelvic Pain
25:25 - Understanding Nociplastic Pain and Sensitization
28:00 - Treatment Approaches for Sensitization
29:26 - The Importance of Organized Thinking in Pain Management
30:20 - The Role of Questionnaires in Patient Assessment
35:10 - The Importance of Multimodal Approach in Pain Management
43:00 - The Role of the Provider in Organizing Patient Care
45:37 - The Importance of Education in Pelvic Pain Management
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RESOURCES
International Pelvic Pain Society Handouts for Different Disorders of Chronic Pelvic Pain:
https://www.pelvicpain.org/public/resources/educational-resources/informational-handouts -
On this episode of the BackTable OBGYN Podcast, host Dr. Mark Hoffman is joined by Dr. Arpit Davé, an assistant professor at Penn State Health Milton S. Hershey Medical Center in the Department of Obstetrics and Gynecology. Together, they discuss the importance of surgical education and best practices for teaching new generations of surgeons.
Both Dr. Davé and Mark emphasize TATA, or tools, access, tissue handling, and anatomy, when practicing and teaching how to master surgery. They discuss the benefits of fostering a “sandbox-learning” environment, or a zone of safety where learners can practice techniques on patients. They also delve into systematic approaches for surgical training and the challenges in measuring the progress of trainees. Most importantly, Dr. Davé and Mark explore how to teach trainees not just surgery, but how to learn about surgery so that they feel competent doing new surgeries as their career in medicine progresses.
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SHOW NOTES
00:00 - Introduction
04:34 - The Role of Teaching in Medicine and Lifelong Learning in Surgery
07:15 - The Challenges of Surgical Training Volume
09:22 - The Journey of Learning and Teaching Surgery
17:59 - Understanding TATA: Surgical Tools, Access, Tissue Handling, and Anatomy
27:01 - The Importance of Practice in Surgical Training
30:04 - The Role of Tissue Handling in Surgical Training
31:20 - Creating Zones of Safety in Surgical Practice
33:31 - The Concept of “Sandboxing” in Surgical Training
34:27 - The Importance of Incremental Learning in Surgery
35:22 - The Importance of Breaking Down Surgical Procedures into Steps
42:32 - The Meaning of “Access” in Surgery
47:26 - How to Teach Trainees to Handle Tough Surgeries and the Unknown
50:05 - The Future of Surgical Training and Education -
This episode of BackTable OBGYN features Dr. Matt Reeves, a seasoned OBGYN and CEO/Founder of the DuPont Clinic, and host Dr. Amy Park as they discuss the use of Rh immune globulin (RhoGAM) in pregnancy.RhoGAM is traditionally administered to Rh- women at 28 weeks gestation, within 72 hours of birth, and frequently after an abortion in order to prevent Rhesus alloimmunization in future pregnancies. However, with recent data showing negligible Rh- blood cell exposure in early pregnancy terminations, the need for RhoGAM in such cases is being questioned. Additionally, considering the scarcity of RhoGAM and the reality of smaller family sizes globally, the importance of RhoGAM in Rh alloimmunization prevention might not be as significant as previously thought. However, limited evidence and ingrained medical practices may cause the transition to be slow.---SHOW NOTES00:00 - Introduction03:09 - Understanding RhoGAM: Origin and Development06:06 - The Science Behind RhoGAM and Its Role in Pregnancy08:13 - The Controversy and Debate Around RhoGAM Usage11:52 - The Impact of RhoGAM on Public Health and Medical Practice15:25 - The Future of RhoGAM: Perspectives and Predictions29:24 - Closing Thoughts and Further Resources---RESOURCESHorvath, S., Goyal, V., Traxler, S., & Prager, S. (2022). Society of Family Planning committee consensus on Rh testing in early pregnancy. Contraception, 114, 1–5.https://doi.org/10.1016/j.contraception.2022.07.002Horvath S, Huang Z, Koelper NC, et al. Induced Abortion and the Risk of Rh Sensitization. JAMA. 2023;330(12):1167–1174. doi:10.1001/jama.2023.16953
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In this episode, host Dr. Suzette Sutherland is joined by Dr. Kelly Casperson, a urologist who specializes in women’s sexual health, to discuss the importance of education, therapy, and hormone replacement in female sexual health.
They explore topics such as the role of estrogen and testosterone in women’s sexual desire, FDA-approved medications for hypoactive sexual desire disorder, and the importance of sex education and communication within relationships. They also highlight the topic of gender inequality in sexual health care delivery and the lack of clinical resources specifically tailored to women’s needs. In sum, they aim to provide a deeper understanding of female sexual health and offer strategies for practitioners to provide more effective care.
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SHOW NOTES
00:00 - Introduction
05:53 - The Role of Urologists in Women’s Sexual Health
07:18 - The Importance of Communication in Addressing Sexual Dysfunction
10:23 - The Role of the Clitoris in Female Orgasm
19:52 - Understanding the Hormones Behind Female Sexual Desire
25:32 - The Misconceptions and Gender Bias Surrounding Hormones
26:04 - The Role of Testosterone in Menopause and Sexual Desire
30:02 - The Challenges of Commercially Available Testosterone Products
32:52 - Non-Hormonal Treatments for Low Libido
42:41 - The Importance of Referring to Sex Therapists and Other Resources
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RESOURCES
Dr. Kelly Casperson’s Website
https://kellycaspersonmd.com/
You Are Not Broken Podcast
https://kellycaspersonmd.com/you-are-not-broken-podcast/
“You Are Not Broken” by Kelly Casperson
https://kellycaspersonmd.com/you-are-not-broken-book/
“Magnificent Sex” by Peggy Kleinplatz
https://www.amazon.com/Magnificent-Sex-Lessons-Extraordinary-Lovers/dp/0367181371
American Association of Sexuality Educators, Counselors, and Therapists
https://www.aasect.org/ -
In this episode, Dr. Suzette Sutherland and Dr. Alana Desai from the University of Washington discuss the management of urinary tract stones in pregnant patients, considerations for ureteroscopy, and consequences of radiation exposure in the fetus.
First, the doctors underscore the importance of ultrasound as the first line imaging modality to minimize fetal exposure to radiation. Dr. Sutherland and Dr. Desai also delve into nausea and pain management options, recommended diets for prevention of stone formation during pregnancy, and the necessity of involving a multidisciplinary team in such cases. The episode concludes with a remarkable case study from Dr. Desai’s experience.
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SHOW NOTES
00:00 - Introduction
02:06 - Incidence and Risk Factors of Kidney Stones in Pregnancy
03:29 - Physiological Changes and Stone Formation in Pregnancy
07:04 - Diagnosing Kidney Stones in Pregnancy
13:08 - Expectant Management vs. Intervention
14:41 - Managing Pain and Nausea in Pregnant Patients with Kidney Stones
17:13 - Decompression Methods for Kidney Stones in Pregnancy
23:13 - Ureteroscopy as a Preferred Intervention
26:05 - Case Description from Dr. Desai
30:04 - Considerations for Ureteroscopy in Pregnant Patients
31:14 - Preventing Kidney Stones in Pregnancy
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RESOURCES
Lyon, M., Sun, A., Shah, A., Llarena, N., Dempster, C., Sivalingam, S., Calle, J., Gadani, S., Zampini, A., & De, S. (2023). Comparison of Radiation Exposure for Pregnant Patients Requiring Intervention for Suspected Obstructing Nephrolithiasis. Urology, 182, 61–66. https://doi.org/10.1016/j.urology.2023.09.023
Thongprayoon, C., Vaughan, L. E., Chewcharat, A., Kattah, A. G., Enders, F. T., Kumar, R., Lieske, J. C., Pais, V. M., Garovic, V. D., & Rule, A. D. (2021). Risk of Symptomatic Kidney Stones During and After Pregnancy. American journal of kidney diseases : the official journal of the National Kidney Foundation, 78(3), 409–417. https://doi.org/10.1053/j.ajkd.2021.01.008 -
In this crossover episode of BackTable OBGYN with Urology, Dr. Suzette Sutherland, Director of Female Urology at the University of Washington, and Dr. Anne Cameron, Professor of Urology at the University of Michigan, share their insights on the prevention and management of urinary tract infections (UTIs).
First, they emphasize the importance of dispelling misconceptions about recurrent UTIs being a result of poor hygiene or incorrect behaviors, explaining that they can stem from genetic or hormonal risk factors. Dr. Cameron describes her algorithm for managing UTIs in specific patient populations. She further discusses the impact of factors such as fluid intake, bowel habits, and vaginal health on the incidence of UTIs. Dr. Cameron also highlights the potential for UTIs in diabetic patients on certain medications and the importance of a collaborative approach with diabetic healthcare teams. Additionally, the doctors explore various treatment strategies, such as cranberry supplements and gentamicin bladder installations, cautioning against antibiotic overuse due to the risk of resistance.
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Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/2P5fzK
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SHOW NOTES
00:00 - Introduction
02:13 - Understanding UTIs: Definitions, Symptoms, and Prevalence
04:39 - Recurrent UTIs: Definitions, Causes, and Treatment Challenges
12:00 - Understanding Asymptomatic Bacteriuria
15:00 - Cystitis vs. Pyelonephritis vs. Urosepsis
20:57 - Antimicrobial Resistance and Antibiotic Stewardship
24:36 - Treatment Guidelines for UTIs
31:13 - Self-start Antibiotic Therapy for UTIs
34:37 - Preventing UTIs: Hydration, Lifestyle Factors, and Bowel Health
38:33 - The Connection Between Vaginal Health and UTIs
42:40 - The Role of Supplements in UTI Prevention: D-Mannose and Cranberry, and Methenamine Hippurate
57:18 - Identification and Treatment of UTIs in Patients with Indwelling Catheters
01:00:04 - The Role of Gentamicin Bladder Installations in UTI Prevention
01:04:27 - The Impact of Diabetes Medications on UTIs
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RESOURCES
AUA Guidelines for UTI Treatment:
https://www.auanet.org/guidelines-and-quality/guidelines/recurrent-uti -
In this episode of BackTable OBGYN, Dr. Mark Hoffman is joined by Dr. Sarah Rassier, a minimally invasive gynecologic surgeon and Director of the Fibroid Clinic at Mayo Clinic, to discuss the multiple treatment modalities of fibroids with a focus on laparoscopic myomectomy.
Drs. Hoffman and Rassier discuss the various factors they consider when deciding on the most suitable approach for a myomectomy. Specifically, they touch on pre-surgical patient optimization, the use of laparoscopic techniques in surgery, and the significance of efficient incision planning and closure. Dr. Rassier also highlights the practice of using preventative measures, such as iron infusions and Lupron, in certain patients to manage fibroids before surgical intervention. The conversation wraps up with a discussion about how future developments could potentially revolutionize fibroid management.
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SHOW NOTES
00:00 - Introduction and Overview of the Podcast
03:32 - Discussion on Fibroids and Their Different Treatment Options
06:40 - The Future of Fibroid Treatment
09:17 - Patient-Centered Decision Making in Fibroid Treatment
11:40 - Preparation and Approach for Myomectomy
13:18 - Discussion on the Use of MRI in Fibroid Treatment
15:55 - The Role of Laparoscopy in Myomectomy
29:00 - Umbilicus vs. Suprapubic Approach
32:04 - Cosmetic Considerations in Surgery
32:27 - - C-sections After Myomectomies?
34:51 Instruments and Techniques for Fibroid Removal
36:28 - Minimizing Blood Loss in Surgery
38:47 - The Importance of Efficient Closure in Surgery
44:46 - Tissue Extraction Techniques
49:02 - The Future of Myomectomy -
In this episode of the Backtable OBGYN Podcast, host Dr. Suzette Sutherland (University of Washington) and Dr. Tamsin Greenwell (University College London Hospitals) discuss surgical treatments for incontinence and their comparative efficacies.
They focus mainly on midurethral slings and a new urethral bulking agent called Bulkamid. They further analyze how conditions like product expectations, surgeon expertise, data availability, patient preferences, and financial costs influence the choice of procedure. Additionally, they discuss the impact of mesh-related complications and how they affected the usage of synthetic slings in the UK. Finally, they touch on the role of shared decision making in choosing treatment strategies.
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Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/p4RNfi
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SHOW NOTES
00:00 - Introduction
03:48 - Discussion on Midurethral Slings
11:05 - The Mesh Controversy and Its Impact
22:21 - Shared Decision Making in Treatment Options
26:47 - The Role of Urethral Bulking Agents
32:51 - Comparative Trial and EAU Guidelines
42:12 - Conclusion and Closing Remarks
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RESOURCES
Bulkamid Injections
https://bulkamid.com/en-US -
In this episode of the BackTable OBGYN Podcast, Dr. Princess Urbina shares her experiences with medical mission trips to underserved areas in the Philippines, where she was born, and the logistical challenges and rewards that come with this work. She also emphasizes the importance of providing sustainable healthcare solutions that empower local healthcare providers and meet the long-term needs of the community. The discussion further explores how these trips shape her perspective towards healthcare delivery.
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EARN CME
Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/jq41GW
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SHOW NOTES
01:14 - Introducing the Guest: Dr. Princess Urbina
01:46 - Dr. Urbina's Background and Journey
02:44 - First Mission Trip to the Philippines
05:23 - Logistics and Challenges of the Mission Trip
07:47 - Sustainability and Impact of the Mission
16:54 - Patient Selection and Care in the Mission
19:03 - Cultural Competence and Professional Culture
21:12 - Sustainability and Education in Surgical Teams
21:41 - Leaving Behind Equipment and Training
23:08 - Addressing Health Issues: HPV Vaccination and Cervical Cancer
28:59 - Patient Follow-up and Communication
30:59 - Support from Academic Institutions
38:09 - Getting Started with International Medical Missions -
In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park invite Dr. Jocelyn Fitzgerald to discuss the relationships among chronic inflammatory pelvic diseases, focusing on painful bladder syndrome / interstitial cystitis (IC) and endometriosis. Dr. Fitzgerald is a urogynecologist at Magee Women’s Hospital in Pittsburgh, PA.
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SHOW NOTES
The episode begins with Dr. Fitzgerald describing her pathway into urogynecology, including training with MIGS physicians. This allowed her to make the connection between many young, reproductive-aged women with painful urination who also have endometriosis. She then goes into how to define IC, which can be difficult. Officially, it is bothersome urinary symptoms lasting more than 6 weeks without other identifiable causes. It is almost always a diagnosis of exclusion after negative urine cultures and other tests. Cystoscopy is no longer needed for diagnosis as it is often normal. However, the best understood phenotype of IC is bladder-centric IC, and these have Hunter lesions seen with cystoscopy. This type responds very well to fulguration, Kenalog, or steroid injections with 85% of patients experiencing improvement.
Dr. Fitzgerald further discusses treatments for IC. Behavior modification is essential, and she advises that patients avoid alcohol, coffee, tea, soda, spicy things, acidic things, and any other dietary triggers. She is also doing trials of giving patients an “IC bundle” which includes neurogenic medications like amitriptyline or gabapentin, vaginal estrogen, scheduled Pyridium, Hiprex, and aloe vera tablets. For some patients, she offers bladder instillations (comprised of heparin, lidocaine, bicarbonate, kenalog, +/- gentamicin), pelvic floor injections of bupivacaine and kenalog, and pelvic floor PT.
Next, Dr. Fitzgerald discusses the basic science research she has done that connects pain pathways throughout the pelvis. Chronic pelvic inflammatory disorders cross-talk through central sensitization. The lumbosacral plexus nerve roots receive pain signals from the bladder, colon, and other pelvic organs, explaining the relationship between IBS, endometriosis, and IC. The pathways are well understood, but we don’t yet know how to reverse central sensitization.
Finally, Dr. Fitzgerald ends by describing the multidisciplinary clinic for endometriosis at Pittsburgh: MIGS, urogynecologists, pelvic floor PT, and behavioral health teams all work together to care for these complex patients holistically. She stresses the importance of teamwork and great administrators who have made this happen. She finishes by discussing how researching more about mast cells, especially through COVID patients, can help us learn more about these chronic inflammatory disorders of the pelvis.
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RESOURCES
Fitzgerald JJ, Ustinova E, Koronowski KB, de Groat WC, Pezzone MA. Evidence for the role of mast cells in colon-bladder cross organ sensitization. Auton Neurosci. 2013 Jan;173(1-2):6-13. doi: 10.1016/j.autneu.2012.09.002. Epub 2012 Nov 24. PMID: 23182915; PMCID: PMC3715122.
AUA Guidelines for Diagnosis and Treatment of IC:
https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-treatment-interstitial-of-cystitis/bladder-pain-syndrome-(2022) -
This week on BackTable OBGYN, Drs. Mark Hoffman and Amy Park are joined by Dr. Barbara Levy to discuss the latest advancements in endometrial ablation using cryotherapy. Dr. Levy, a professor at George Washington University and a volunteer at the University of California San Diego OBGYN and reproductive sciences department, has dedicated her career to gynecological advancements.
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CHECK OUT OUR SPONSOR
Cerene Cryotherapy
https://cerene.com/healthcare-professionals/
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SHOW NOTES
Initially, the physicians delve into the history of endometrial ablation, originally conceived as an alternative to hysterectomy for severe menstrual bleeding. The early method involved using a fiber to ablate the entire cavity, followed by electrosurgery using a roller ball, which has various control-related challenges. This approach necessitates operating room time, anesthesia, and prolonged recovery with significant pain. As techniques advanced, complications, including burns and bowel injuries, emerged. The introduction of cryotherapy marked a significant breakthrough in ablation. However, it initially had a steep learning curve.
Barbara then details the new Cerene handheld cryoablation device, highlighting its advantages over traditional rollerball electrocautery. The primary benefit of cryotherapy is the improved healing pattern of the uterus compared to electrocautery. Electrocautery often results in Asherman's syndrome, leading to scarring and adhesions, making visualizing the uterine cavity for concern of future pathologies very difficult. Cryotherapy offers over 90% visibility into the cavity, making assessment for uterine or endometrial cancer much easier.
Barbara emphasizes that cryotherapy minimizes or avoids complications such as abnormal vaginal discharge, prolapsed fibroids, dyspareunia, persistent bleeding, and post-ablation pain syndrome when compared to heat-based methods.She outlines various patient-centric advantages, notably in pain management. Cryotherapy numbs nerves before ablation, allowing in-office procedures without sedation or anesthesia. Patients can tolerate the procedure well, typically requiring only NSAIDs for comfort during device insertion through the cervix. The accessibility of this procedure through telehealth and brief in-office appointments reduces the impact on patients' daily lives and costs, eliminating the need for operating room time and anesthesia. Instead, patients only pay a copay in the office.
Barbara highlights specific patient populations that can benefit from this therapy, including those with heavy menorrhea leading to iron deficiency anemia. It is also suitable for women unable to use additional hormones due to breast cancer concerns or those who prefer not have an IUD but suffer from heavy menorrhea. Patients facing barriers to healthcare, such as those in rural areas, those with time constraints due to work, or financial constraints, may significantly improve their quality of life. Additionally, women in their forties, no longer in their childbearing years, with heavy periods and an alternate form of long-term contraception, can particularly benefit from this therapy. -
In this episode, host Dr. Amy Park interviews co-host Dr. Mark Hoffman about laparoscopic hysterectomies.
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SHOW NOTES
The episode begins with Mark describing his journey to becoming a minimally invasive gynecologic surgeon, with more exposure to traditional laparoscopic surgery (“straight stick”) throughout his career, but with a recent revival of robotic surgery as well. Overall, Mark still prefers traditional laparoscopy. However, there are certain instances where robotics is especially helpful – namely in patients with a high BMI and in myomectomies where robots make the extensive suturing more manageable. Additionally, robotic surgery is easier to do in a situation where students and residents are not available to assist. Most importantly, he likes to get an MRI, look at the anatomy, and decide what the best approach is for each individual patient. And of course, the doctors emphasize the importance of having a strong team to operate with.
Next, Mark discusses his tips and tricks to a successful laparoscopic hysterectomy. He likes to be in the operating room before the patient is there to ensure it is set up correctly. Once the patient arrives, he stresses the importance of proper patient positioning on the bed, with the arms always tucked at the patient’s side, and then inserting the Foley catheter after draping. The doctors then discuss incision locations and sizes, with Mark preferring all 5 cm incisions. Mark continues with the steps of the procedure – he starts with the fallopian tubes, then gets the utero-ovarians and carries around the round ligament to move the ovaries laterally. He then emphasizes skeletonizing the uterines/posterior peritoneum. He saves the anterior incisions for last as they can get complicated with adhesions from prior C-sections, for example. Mark highlights the “critical view,” which is the anterior cup, posterior cup, ring, and vessels on the other side. The doctors go on to discuss colpotomy, barbed sutures, visualization, antibiotics, and more.
The physicians end by expressing the importance of asking for help, knowing your limits as a surgeon, and ensuring patient safety.
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RESOURCES
ACOG: Choosing the Route of Hysterectomy for Benign Disease
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease -
In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park have an in-depth discussion on the topic of vaginal hysterectomy. Amy, who handles a substantial caseload of vaginal hysterectomies, takes the lead in this conversation as she walks through the procedure and its intricacies. In Mark's practice as a Minimally Invasive Gynecologic Surgery (MIGS) surgeon, he typically deals with cases involving candidates for laparoscopic hysterectomies, while many vaginal hysterectomy cases are referred to urogynecologists.
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SHOW NOTES
Both Amy and Mark stress the critical importance of selecting a surgical approach that aligns with a patient's medical history and anatomical considerations. Amy asserts that a patient is a suitable candidate for a vaginal hysterectomy when they possess a tall and mobile uterus, with ample vaginal space, and a pelvic outlet of sufficient width. Furthermore, she highlights that patients with a cervix located within 6 cm from the hymenal remnant are good candidates for vaginal hysterectomies.
The physicians delve into the topics of competency and confidence within the operating room. They agree that the volume of surgeries, repeated practice, pattern recognition, and experience in managing complications are pivotal factors contributing to a surgeon's growing competence with each case. Both doctors concur that it typically takes approximately three to five years to achieve confidence and a reduction in anxiety levels regarding surgical cases.
Amy proceeds to describe each step of a vaginal hysterectomy and shares her preferred practices in the operating room. To ensure patient comfort and safety, she positions her patients in the dorsal lithotomy position, taking special care to avoid exerting pressure on the peroneal and femoral nerves. While providing sacral support, she positions the remainder of the perineum as close to the edge of the table as possible to maximize vaginal access. Amy initiates the procedure with a posterior colpotomy using a 10-blade after administering lidocaine. Gradually, she progresses anteriorly, retracting the vaginal epithelium until the peritoneal folds become visible. She tags the uterosacral ligaments and proceeds to access the pelvis anteriorly, paying careful attention to avoid injuring the ureters. She systematically advances to the utero-ovarian ligament and artery, concluding by addressing the fallopian tube and ovary. Amy emphasizes her preference for two-handed knotting in all vaginal cases to achieve optimal tension and mentions her infrequent use of energy devices.
Finally, Mark and Amy discuss the evolution of training within the operating room over the years, acknowledging the changing landscape due to advancements in technology and varying case volumes. They underscore the significance of mastering technical skills outside of the operating room, which enables trainees to dedicate the necessary time to enhancing their operative abilities. -
In this episode, hosts Dr. Mark Hoffman and Dr. Amy Park invite Dr. Linda Bradley to discuss advanced hysteroscopy. Linda is a professor of OB/GYN and Reproductive Biology at Cleveland Clinic as well as the Director of Center for Menstrual Disorders, Fibroids, and Hysteroscopic Services.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/9tWZ3D---SHOW NOTESThe episode begins with Linda describing the utility of hysteroscopy: it is a great option to visualize the endocervix, endometrium, uterine healing after complicated surgeries, foreign bodies, broken IUDs, and hyperplasia. It should be used for uterine bleeding, retained products of conception, evaluating women for Asherman’s, and evaluating why the endometrium is thick on ultrasound. Hysteroscopy has two main roles: diagnosis and therapeutics. Hysteroscopic surgery allows for the uninterrupted visualization and removal of pathology, as opposed to other measures like D&C where the uterus is scraped blindly. It is also great for visually-directed, targeted biopsies and treating pathologies like fibroids and polyps. Linda emphasizes that it is a disservice to women to go in blind because fibroids or cancer can be missed with blind biopsies--in fact, pipelle biopsies picked up zero polyps in their study. Hysteroscopy surgery has a faster recovery, is less invasive, has less risks of bleeding or damaging other structures, and has low risk of infection.The physicians then discuss techniques involving hysteroscopy. Linda prefers using a flexible hysteroscope that is 3.2 mm wide because dilation isn’t needed. She also explains that there isn’t a need for a paracervical block (just oral ibuprofen) as the patients have minimal pain when the walls of the uterus are appropriately avoided.Linda focuses on the need to believe women when they are bleeding. It takes 3-5 doctors and 3-5 years for many women to get their bleeding appropriately treated instead of trying the same medicines without success. We have the technology to do something different, and hysteroscopy is the best option to look into the uterus and understand what is going on. Mark asks about the training of physicians in hysteroscopy, and Linda responds that simulators are key in addition to having courses and mentors to teach the technique properly. Finally, the doctors finish by talking about future applications of hysteroscopy.---RESOURCESOrlando, Megan S. MD; Bradley, Linda D. MD. Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology. Obstetrics & Gynecology 140(3):p 499-513, September 2022. | DOI: 10.1097/AOG.0000000000004898
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This week on BackTable OBGYN, Dr. Suzette Sutherland and Dr. Rachel Rubin discuss the diagnosis and treatment of genitourinary syndrome of menopause (GSM) with vaginal estrogen.
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SHOW NOTES
GSM is not only a condition of "vaginal dryness", but rather a multi-faceted symptom set including pain with sitting, urinary frequency and urgency, bladder pain, opioid use, and recurrent UTIs. First, the doctors discuss the myths and misconceptions about the use of estrogen creams, suppositories, and rings to treat GSM . However, Suzette and Rachel also discuss the importance of advocating against the misrepresentation of vaginal estrogen in box labeling. They conclude that the benefits of using a low-dose vaginal estrogen far outweigh the risks, and doctors should advocate for better labeling and understanding of this treatment.
Suzette and Rachel also discuss the American Urologic Association (AUA) guidelines for GSM and its importance. Systemic hormone therapy is rarely enough to address GSM symptoms, so screening for GSM symptoms is essential. They also talk about estrogen therapy for special patients, such as those on hormone replacement therapy (HRT) and cancer survivors. Suzette and Rachel emphasize the importance of understanding the general hormone fluctuations of patients particularly oral contraceptives, those with disordered eating, those who are breastfeeding, and those who are transgender. They end the episode by encouraging the production of more research and data to back up treatment options for GSM in premenopausal women.
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RESOURCES
WellPrept
https://wellprept.com/
Femring
https://www.femring.com/ -
This week on BackTable Urology, Dr. Suzette Sutherland (University of Washington) and Dr. Olivia Chang (UC Irvine) discuss reasons for uterine preservation and hysteropexy techniques for prolapse repair.
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SHOW NOTES
First, Suzette and Olivia discuss the value of keeping the uterus in place for women undergoing prolapse repairs, as well as the indications for apical suspension surgery. They also note the historical context of hysterectomy and why it has been the go-to treatment for so long. Next, the doctors discuss the advantages of hysteropexy over hysterectomy for prolapse repair, such as a shorter operative time, less bleeding, and a quicker recovery. The doctors then go into more detail about the best approaches for prolapse repair, like weighing the options of permanent sutures versus delayed absorbable sutures. They also analyze recurrence rates after prolapse surgery, specifically in the anterior compartment.
Then, they explore the data on how the choice to keep the uterus in place can stem from a woman's personal and cultural views. Olivia shares about the Value of Uterus questionnaire, a six-question survey instrument that can quantify how a woman values her uterus. It can streamline clinic visits and help to predict whether a woman would choose a uterine-preserving procedure. The doctors note that there is research demonstrating a correlation between valuing the uterus and sexual activity.
Finally, Suzette and Olivia contraindications for leaving the uterus in place. They emphasize the importance of assessing for abnormal uterine bleeding and cervical pathology before recommending uterine preservation. They suggest that listeners review the current guidelines around preoperative workup and consider transvaginal ultrasound or endometrial biopsy first. Lastly, they emphasize the importance of symptom and risk stratification and shared decision making when it comes to uterine preservation.
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RESOURCES
Chang OH, Walters MD, Yao M, Lapin B. Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus. Am J Obstet Gynecol. 2022 Jun 25:S0002-9378(22)00483-5. doi: 10.1016/j.ajog.2022.06.029. Epub ahead of print. PMID: 35764134.
https://pubmed.ncbi.nlm.nih.gov/35764134/ -
In this episode, Dr. Mark Hoffman hosts Dr. Jan Baekelandt, a gynecologic surgeon from Mechelen, Belgium, to discuss a novel gynecologic surgery approach known as vaginal natural orifice transluminal endoscopic surgery (vNOTES).
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SHOW NOTES
This technique involves entering the pelvic cavity through the vaginal lumen, eliminating the need for abdominal incisions and promoting a less invasive procedure. Dr. Jan Baekelandt explains that during his career this approach originated from the single-side surgery technique, gradually evolving into a fully transvaginal procedure. He highlights that the advanced tools required for vaginal surgeries now offer equivalent visualization and hemostatic control as laparoscopic techniques, while providing the added benefit of reduced invasiveness.
The benefits of vNOTES for patients are discussed, including findings from two randomized control trials comparing vNOTES hysterectomy and adnexectomy to laparoscopic approaches. The results indicate non-inferiority, reduced postoperative pain, decreased analgesic use, and shorter hospital stays for vNOTES. Complications were also lower in the hysterectomy trial. Notably, the vNOTES technique especially benefited patients who were obese, had undergone prior abdominal surgeries, or had large uteruses. Jan underscores the significance of technique standardization to facilitate teaching and complication avoidance. He acknowledges vNOTES-specific complications, such as a higher cystotomy rate, but notes a lower ureter damage rate. However, he cautions that vNOTES might not be suitable for certain patients, like those with endometriosis, prior pelvic inflammatory disease or pelvic abscesses.
The potential impact of vNOTES on non-hysterectomy surgeries, future deliveries, and sexual function is briefly discussed, though data in these areas remain limited. Dr. Jan Baekelandt is hopeful that more evidence will emerge to guide physicians. He shares that, based on available data and his own experience, vaginal deliveries following vNOTES have generally proceeded without complications, without a notable increase in cesarean sections or vaginal tears. He notes that to protect sexual function, surgeons should take care to make incisions away from the posterior cervical fornix to avoid subsequent dyspareunia for their patients. The episode concludes with Jan emphasizing the importance of formal training and starting with simpler cases to build proficiency and confidence. He asserts that the best technique for a surgeon is the one that instills confidence in keeping patients safe.
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RESOURCES
Baekelandt J, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BW, Bosteels JJ. HALON-hysterectomy by transabdominal laparoscopy or natural orifice transluminal endoscopic surgery: a randomised controlled trial (study protocol). BMJ Open. 2016 Aug 12;6(8):e011546. doi: 10.1136/bmjopen-2016-011546. PMID: 27519922; PMCID: PMC4985989.
Baekelandt JF, De Mulder PA, Le Roy I, Mathieu C, Laenen A, Enzlin P, Weyers S, Mol BWJ, Bosteels JJA. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial. BMJ Open. 2018 Jan 10;8(1):e018059. doi: 10.1136/bmjopen-2017-018059. PMID: 29326183; PMCID: PMC5780723. - Visa fler
