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BackTable / Urology / Podcast / Transcript #4
Podcast Transcript: Management of Pelvic Floor Dysfunction
with Dr. Yahir Santiago-Lastra and Dr. Jose Silva
Dr. Jose Silva talks with Urologist Dr. Yahir Santiago from UC San Diego Medical Center about the diagnosis and treatment of pelvic floor dysfunction in women. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Initial Work-Up of Female Incontinence
(2) Treatment Options: Procedures, Physical Therapy, and Medications
(3) Sling Surgery: TVTs, TOTs, and Mini-Slings
(4) Contraindications and Other Considerations for Sling Surgery
(5) Post-Op Care for Sling Surgery
(6) Cultural Competence
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[Dr. Jose Silva]
Hello everyone and welcome back to the BackTable urology podcast, your source of all things urology. You can find all the previous episodes of our podcasts on iTunes, Spotify, and BackTable.
So, Yahir, let's start with a coThis is Jose Silva, your host this week and I'm very excited to introduce our guest today, Dr. Yahir Santiago. She is the director of Woman's Pelvic Medicine and associate professor of medicine at UC San Diego. Yahir is also a fellow Puerto Rican.uple of things. When you were in residency, you talked about the teaching part of that, and you really enjoyed that aspect of being a urologist. So, how is life as an attending?
[Dr. Yahir Santiago-Lastra]
Pretty awesome. I am an attending at UC San Diego Health. It definitely was what I expected it would be and so far it is interacting with the residents and fellows and getting to teach medical students. But what I also think is quite awesome right now is that I get to interact with a lot of Spanish-speaking patients in San Diego and patients who travel from south of the border in Mexico. I think that was one of the things that I was most worried about when I chose to not return to Puerto Rico for my practice and instead stay in the United States, is that I would miss out on taking care of patients who spoke the same language as me and had a similar background. Definitely, San Diego has given me a flavor of that. You know I'll always miss Puerto Rico. It's home and I haven't been there in a while because of this pandemic-
[Dr. Jose Silva]
Yeah, me too.
[Dr. Yahir Santiago-Lastra]
But definitely that has been a big plus of practicing in San Diego.
[Dr. Jose Silva]
Yes, you always mentioned you wanted to go back to Puerto Rico. There is a big need for pelvic floor specialists. So how did you end up in San Diego? I mean, you went to Michigan for the fellowship and it was mainly that part, the patient population or something else that drove you to San Diego?
[Dr. Yahir Santiago-Lastra]
There are a lot of factors that come into play when people are selecting where they're going to practice. Obviously, heading back home to the Caribbean was really high on my priority list because my family is there, I feel a commitment to the patients and they really definitely could benefit from more female pelvic medicine specialists in Puerto Rico. There were two big challenges. One was that I wanted to retain some funding, some grant funding to be able to do research and that was going to be challenging taking that with me to Puerto Rico. The other challenge was that I'm married, so I have a spouse whose career is also thriving and growing and it was really hard for him to continue that going back to Puerto Rico. We had to have a meeting of the minds and look at our options and San Diego just ended up being the best fit.
[Dr. Jose Silva]
You mentioned that you are a pelvic floor specialist. When we were in residency, I mean you were a female urologist. Is that how you describe yourself, a pelvic specialist?
[Dr. Yahir Santiago-Lastra]
I consider myself a pelvic floor specialist. One of the nice things and a lot of patients will call me their urogynecologist, even though I am board certified in urology, I also have a certification in pelvic medicine and reconstructive surgery. But, one thing that does distinguish urologists like me who practice in this subspecialty, is that we will also often see men. So, men have pelvic floor problems, too. They can suffer from voiding problems, they can suffer from urinary incontinence and so I get to take care of patients like that, as well. The majority of my patients, I'd say about 60%-70% of my practice is in women.
[Dr. Jose Silva]
Okay. So what is a week in your practice? Take me through your day.
[Dr. Yahir Santiago-Lastra]
Sure. So, my practice is unique because I am Spanish-speaking and I am one of the few Spanish-speaking urologists in my department. So, I have a practice that goes to a lot of the places where Spanish-speaking patients live. I have a downtown practice that I am in once a week. I also take care of our veterans at the VA and then I have another practice in La Jolla, which is our largest hospital and, because La Jolla can be difficult to access for some of the patients that I take care of, I end up being in those three locations. On a typical day, I'll either be in clinic with residents and fellows for the whole day and doing procedures like injections and urodynamics and pelvic examinations, etc. Or I'll be in the operating room where I'll do mostly outpatient surgeries but, on occasion, because I take care of patients with complex urinary problems, I'll do bigger cases like bladder augmentations and diversions.
(1) Initial Work-Up of Female Incontinence
[Dr. Jose Silva]
Okay, so I didn't know you were doing those big cases, also. Let's talk today about female incontinence, purely stress incontinence. So, let's say a woman goes to your clinic and tells you that she has incontinence. How is the process of how you evaluate that patient?
[Dr. Yahir Santiago-Lastra]
One, incontinence in women is one of the most common problems that I take care of and, interestingly, it is one of the urinary problems that takes patients the longest to seek care. So, a lot of women will have been suffering with this problem for years or even decades before they seek care for that issue. When women come into my clinic seeking care for urinary incontinence, it can be one of two main types. They either have stress incontinence which is leakage when they cough, laugh, sneeze, or exercise. Or they can have urgency incontinence or what we call overactive bladder and that is leakage that is associated with a strong urge with urinary frequency or incontinence associated with that urgency.
It is really important when I talk to women to do three important things. Number one is to get to know them and to understand how this problem is impacting their life because that factors into my decision making for them. Two is what their expectations are. Some women come into the office already knowing a little bit about what they want or don't want to do, so I don't want to patronize them or give them an option that doesn't fit into what they were expecting. Three, and probably most importantly, honestly, is to distinguish whether their problem is stress predominant or urgency predominant, because those two domains of incontinence are treated completely differently and you definitely don't want to get them mixed up or you're going to have a patient that is quite bothered. Most women have both, but there is usually one that is predominant over the other and so I try to distinguish that in my conversation with the women that I treat.
[Dr. Jose Silva]
And that is based purely on the complaints of the patient, which one you determine is more dominant?
[Dr. Yahir Santiago-Lastra]
Yeah. You know, I'm in an academic center, so one of the things that might distinguish my practice from someone who is in private practice, for example, is that we have really intense questionnaires. Patients don't always love them. They come into the clinic and they could spend maybe 10, 15 or 20 minutes filling out a questionnaire. So by the time I see them, I have a pretty good idea if they have stress incontinence, urgency incontinence, or a mixture of both. But, it is always important to talk to them because sometimes women may not want to fill out all the questionnaires or they may fill them out in a way that is perhaps a little misleading or doesn't answer their concerns perfectly. So, that's what I tend to do is sit down with them and distinguish those two and yes the symptoms are what distinguish one from the other.
[Dr. Jose Silva]
Yes, most of those patients are already frustrated going to other physicians, jumping from medication to medication, and not accurately knowing what they have or treating what they have. So they go to you, the specialist, and they want an answer or a solution immediately. So sometimes that is very tricky and I bet in your case to slow their pace down with the patients and say, "We are going to go through a process and see what's going on." and then offer a solution. Do you find that also in your practice?
[Dr. Yahir Santiago-Lastra]
Yes, that is 100% what I see. I tell my residents this a lot. I tell them it is very common in my practice for me to spend that first visit getting to know the patient and doing a pelvic exam. Whenever they come in with these complaints of urinary incontinence, I will do a pelvic exam. It is not mandated from a guidelines perspective, but most of the time it is going to be something in your toolkit that you will want to do so that you can strategically plan what kind of interventions you want for the patients.
I tell my residents and fellows all the time that, very often, we will have that first visit and the patient gets so much information and options to treat their problem that they can't really make a decision right then. So, I'll often schedule, especially now in the advent of telemedicine, I'll schedule phone calls or telemedicine visits in a few weeks after that initial visit, to go over those options that I talked to them about and to actually schedule either an intervention or therapy or something else. That may not be something convenient to everyone in practice. It really depends what kind of a practice you have, but that works really well for me.
[Dr. Jose Silva]
Okay and will you do a cystoscopy and urodynamics study on everyone? Or is there some sort of, depending on the symptoms and depending on the type of frustration the patient has, would you start a treatment first or... How do you decide?
[Dr. Yahir Santiago-Lastra]
That is an excellent question as well and really important. For me, in the treatment of pure stress incontinence, there is no need for a cystoscopy or for a urodynamic evaluation, if the patient has some objective signs of incontinence on your exam. The best way to demonstrate that is a cough stress test. A cough stress test is just that. The patient will cough while you're examining them and you look for visible signs of urine leaking when they cough and you can also see urethral hypermobility. Women who demonstrate that on an exam are going to absolutely be candidates. As long as they don't have contraindications otherwise, they are absolutely going to be candidates for surgical therapy for their incontinence. If they have urgency incontinence, they also don't need cystoscopy or urodynamics; however, a lot of these women will also have hematuria, either gross or microscopic, and then I start to think about a work-up.
The other times that I think about urodynamics is that some of these women will have an elevated residual urine volume after they empty their bladder and if there is any suspicion that their incontinence may also be related to incomplete emptying of their bladder, I will consider doing either a bladder diary or a urodynamic study, but I try as hard as I can to not do a urodynamic study right off the bat because it can be really uncomfortable.
In fact, just a small plug... That's one of the foci of my research. I have a clinical trial looking at a noninvasive method of monitoring the bladder like urodynamics, but without needing the catheters that can be so uncomfortable for women.
(2) Treatment Options: Procedures, Physical Therapy, and Medications
[Dr. Jose Silva]
Oh, wow. That is interesting. Let's say you have a patient with stress incontinence, a young patient in their 40s, and that patient has a little bit of urge and frequency, but no leakage, so no urge incontinence, will you start a treatment for overactive bladder? Or would you just go straight into a sling treatment or some treatment for the stress? And, will you counsel them on the overactive bladder after you do that treatment? How would you go through that?
[Dr. Yahir Santiago-Lastra]
That's another great question, because it is something that people who take care of a lot of women with incontinence are going to see on a daily basis. So, I actually have a really nice visual aid that shows patients the two main types of urinary incontinence, the urge and the stress and it lists the treatment options, starting from the least invasive to the most invasive. I basically have women prioritize for themselves what bothers them the most. I tell them, "Hey, if your stress incontinence is what's bothering you. If you really want to get back to doing CrossFit without having to wear a diaper or, if you just want to be able to carry your kids without having to worry that you are going to leak, then treatment for stress incontinence is what is indicated for you."
I will go over all of the treatments from pelvic floor exercises to a pessary to a bulking agent to a sling, either made out of their own tissue or made out of synthetic polypropylene or mesh and let them decide for themselves. If they are really bothered by the urgency component and, for me, the women who have really bothersome nocturia, those women will really want to try to treat their overactive bladder first. I've really let the patient decide where they want to start. If I think they are going to be better off with one treatment or the other, I'll choose it for them and I'll explain to them why. But I ultimately let them decide for themselves.
[Dr. Jose Silva]
Those patients that might have an overactive bladder, but they need to go, for example, you said back to CrossFit, would you do a procedure and also give them Ditropan or any other anticholinergic or any medications or would you just try to treat the stress and see what happens with the urge?
[Dr. Yahir Santiago-Lastra]
I choose the latter. I typically will recommend that women treat their most bothersome component and then, within 12 weeks of their initial intervention, will circle back with the patient and then see how they are doing with their symptoms. One of the great things about clinical trials like the SISTEr trial which looked at outcomes of treating stress urinary incontinence in women is that a lot of women who had a lot of urgency symptoms found that those symptoms also improved after having a sling. In fact, there is currently a randomized controlled trial that we are recruiting for at UC San Diego where we are comparing first line sling treatment versus Botox for women who have mixed urinary incontinence. So, those women, through that clinical trial, will undergo urodynamics to confirm that they, in fact, have both of those parameters present and they don't have a contraindication to either of those two procedures. Then, we will randomize them to either a sling, which is a treatment for stress incontinence, or to Botox, which is a treatment for urgency incontinence. Those results, I think, will answer your question even better, but in my experience, a lot of women who have mixed incontinence and undergo a sling will find that a lot of their symptoms have improved enough that they don't need to try anticholinergics.
[Dr. Jose Silva]
Sometimes, even though you mention it to the patient that they could continue with the frequency, they say "Well, I'm not leaking but I'm still the same." So, definitely you treat one part but you still have the frequency so it is difficult. Depending on the patient, I usually give her the Ditropan and treat both at the same time to see how that goes.
[Dr. Yahir Santiago-Lastra]
That's a great idea. I don't usually do that but I think it is great to be proactive.
[Dr. Jose Silva]
Because then you don't want them to say, "Hey, it didn't work." So, it depends on the patient and some patients you know are understanding more than others. So, maybe those really understand you can treat one at the same time and they are more patient but I guess it depends on the patient.
[Dr. Yahir Santiago-Lastra]
Totally and I will say my sling patients are some of the happiest patients that you can encounter. But, when a patient with a sling does not get a good result or when you have a patient who undergoes a sling who develops more urgency as opposed to less, and, that can happen sometimes, where their urgency is worsened by a sling, so they have more urinary urgency after they undergo the surgery. Those patients require a lot of counseling and reassurance to understand that, in most cases, things get better. But I have had patients come to me very upset after having had a sling with another surgeon because they developed this very bothersome urgency and, when we evaluated the patient with urodynamics, what was happening was that the sling was too tight. So, it is tricky with slings. I think if patients have really bothersome urgency after a sling surgery that is not to be expected, then they will need, like you said, some proactive measures with either a medication or even looking to a third line of therapist for overactive bladder like a Botox or even sacral neuromodulation.
[Dr. Jose Silva]
You mentioned pelvic floor exercises. Do you send everybody, prior to the procedure if they have stress incontinence, everybody has to go to pelvic floor or there are patients that you decide "Hey, it might not work, let's just go into more invasive procedures or something else."
[Dr. Yahir Santiago-Lastra]
I'm a big believer in pelvic floor physical therapy. I think that it is really nice for women to learn to take care of their pelvic floor and to understand the muscles that are there. I think it can be really helpful, not just for incontinence, but also for their sexual function. But, I leave it up to the patient and I explain to the patients that, if you really want pelvic floor exercises to work, you have to dedicate yourself to that really for the rest of your life and you have to be committed to it. It is like undergoing any sort of therapy or exercise program, the more you put into it, the better results you are going to see. Some women are really honest with me and they will tell me, "Look, this is not something that fits in with my lifestyle." and that's totally fine. Some women do it and prefer to do that as opposed to going straight into surgery and they come back after the therapy, feeling like their symptoms have improved to the point where they don't feel like surgery is in the cards for them any longer and I consider that a success, as well.
[Dr. Jose Silva]
Yeah, definitely and also access to the pelvic floor. Not everybody... I'm in a community hospital and we don't have one, so they have to drive half an hour or 45 minutes to their appointments sometimes. Younger patients do tend to go. I have tried to push them that way first, but definitely older patients that might have problems driving and all that. I mean, I mention it to them and see what they think but most of the time, I end up doing a procedure.
[Dr. Yahir Santiago-Lastra]
Yes, I think my practice would be in line with that, too. Access to care for pelvic floor physical therapy is really problematic. I take care of a lot of minority patients and under-served patients and usually there's only one pelvic floor physical therapy location that's contracted with that insurance and so it can be really limiting for women who might be interested in doing it, but their insurance either won't cover it or won't offer them a location that's close to where they live. I am fortunate that now my institution has set up some internal pelvic floor physical therapy, but for now it is only in La Jolla. So, patients that live 45 minutes away in Bonita or in Chula Vista or somewhere else are limited to that location and it doesn't always work for them. I do get patients who end up choosing something else, just because they don't have that access which is definitely a disparity.
(3) Sling Surgery: TVTs, TOTs, and Mini-Slings
[Dr. Jose Silva]
Let's talk about sling surgery. Are you doing TBTs, TOTs, mini-sling? What are you doing? Are you doing different procedures depending on the patient and also for residents to learn? What are you doing?
[Dr. Yahir Santiago-Lastra]
I have trained to do TVTs, TOTs, mini-slings from bottom up, top down... all different kinds of slings, I've seen them all. My preferred route for sling is the retropubic sling. The reason that I like the retropubic sling, again this sling surgery is the most common surgery that I do and so, for me, the retropubic sling has the best results and it also keeps the arms of the sling within the retropubic compartment, which I think is the urologist's domain.
TOT, on the other hand, involves placement of the sling through the obturator and involves the groin and I do think that, when patients develop really severe groin pain after a TOT, it can be really debilitating to their quality of life. For me, that is prohibitive and places the TOT in a category of a type of procedure that I prefer not to perform.
That said, there is also the mini-sling, which is similar to a TOT except that the mesh arms don't go all the way through into the groin. A lot of my colleagues in pelvic medicine place mini-slings and do think that the recovery from the mini-sling is a lot easier for women, especially for younger women. I, again, have not had any difficulty with the retropubic sling and its recovery and so that tends to be my sling of choice. But I also think that a TOT, especially for example a robotic procedure or a pelvic organ prolapse procedure when you are doing these things in combination, can be a really nice short bookend to a long case. I don't disavow it or think that it is not a great option. TOTs, however, I'm slightly biased again, just because of that potential for the groin pain.
[Dr. Jose Silva]
Yeah, I personally have the same side. I haven't done mini-slings, especially for big women that have a big pelvis. Sometimes you struggle putting the trocar in. I don't know but for now I continue using the TVTs. Is there any specific brand name you are using?
[Dr. Yahir Santiago-Lastra]
I have used many different brands. I don't have a preference. My institution is contracted, so full disclosure. We are contracted with Caldera, because we need to go for the lowest cost option and that was what the lowest cost options were when we looked into pricing. But, for example, at the VA, I use Boston Scientific Advantage and they have their Advantage Fit, as well, and I think they are both really good slings. The differences, I think, for people who are thinking about what to choose is that Caldera has a reusable trocar and the reusable trocar for Caldera, that's nice, right? Because you can process it, you always have it on hand, but it can get a little dull after many uses. Boston Scientific's trocar is much easier to deploy and I think it is nice to use in resident education and, obviously, Boston Scientific's commitment to resident education is really hard to beat as well. So, I think if people are thinking about choosing between the two, they are pretty equivalent. They are both nice and blue so that if anyone has to have a mesh excision for retention, for example, it can be easy to locate in order to do that as opposed to some earlier slings that were a color that didn't permit that easy localization.
[Dr. Jose Silva]
Yes, I have used the Advantage Fit and, for now, the results have been good. Also, they are very small so, if you... I have had two perforations of the bladder, which I have retracted, and you are able to see it and, luckily, the patients have been okay.
[Dr. Yahir Santiago-Lastra]
Great.
(4) Contraindications and Other Considerations for Sling Surgery
[Dr. Jose Silva]
When do you have trouble with a case?
[Dr. Yahir Santiago-Lastra]
The nice thing about the sling surgery is that it really is the kind of surgery where you can do it the exact same way each and every time and it is very easy to become an expert and master the technique because there is very little variability in what you do. That said, I can think of two instances in which I would not proceed with the surgery. One would be if the urethra is injured during the dissection or also if you injure the urethra with the trocar when you're trying to pass the trocar. So those two instances... There's a third instance, actually, that is extremely rare and, full disclosure, I've never actually witnessed it in my career, but it has been reported in the literature, is if you have a bowel injury during trocar passage, for obvious reasons. So, those two scenarios, urethral injury or bowel injury, I think would be a moment to abort the surgery. Another thing that can happen with the sling operations, more so with the autologous slings but also for the synthetic slings is bleeding, especially if you are operating on a very young woman. I have had very young women who have very well estrogenized vaginas, where they have lost a significant amount of blood during the surgery. So whenever I'm thinking of a patient that is younger who is interested in undergoing the surgery, I definitely keep that in the back of my mind, because some of these patients will bleed quite a bit before the incision is closed.
[Dr. Jose Silva]
Do you do anything different in those cases? I mean, after you close, do you do any ultrasound or do you just wait and see how it goes.
[Dr. Yahir Santiago-Lastra]
That is a great question. I have thought about that a bunch and really what I do and it is the same for each case. For those young women, this would definitely be a case where I am not teaching during the case and I am really the one that is taking it from point A to point B completely independently. But, in addition, for all of my cases, when the vaginal incision is closed, I will actually take a lap or a Raytec and I will hold pressure while the suprapubic perforation sites are closed with Dermabond and everyone is getting the patient cleaned up and extubated in order to go to the recovery area. That will probably be about five minutes of pressure in the vagina with a Raytec or a lap sponge and then they go to the recovery with a Foley. I don't do an ultrasound. I don't necessarily admit them for observation. I definitely would if I were concerned about a lot of bleeding or if the patient were unstable, but luckily that has been a very rare occurrence.
[Dr. Jose Silva]
You always hear that the sling has to be retained to be tension-free. What does that mean?
[Dr. Yahir Santiago-Lastra]
The mesh does have to be placed in a tension-free manner, which means that you don't want it to be abutting the urethra directly. You want it to have some space between the urethra and the sling, where it is located. That can mean different things to different people. Everyone has their style of tensioning. I tend to use the style that was used back when the mesh was described, the first sling cases were described, which was a placement of an 8 Hegar dilator in between the sling and the urethra, while you're tensioning. So, I'm always, whenever I'm tensioning and pulling the sheaths off the sling, I have the 8 Hegar and I take it out and put it back in and make sure that it fits there snugly but without putting any undue pressure on the urethra and I do this tensioning with the 16 Fr Foley in place, I don't take it out. That has tended to go pretty well. I have only had three cases of retention in my career and those three women were all women who already had some incomplete bladder emptying, so I suspect that they had some intrinsic properties of their bladder that already predisposed them to being in retention. I actually haven't had a woman have a sling be placed too tightly who did not have some predisposition.
[Dr. Jose Silva]
I also use the Hegar but some people say that it needs to be not touching the urethra, so it is a little bit floating around. I mean it is interesting that is the same thing that I do but what would be the difference, I'm not sure. Do you know if there is a difference between letting it a little more loose. Definitely, the important part is to not strangle the urethra, but in terms of how loose is too loose. So you don't want to just not do anything.
[Dr. Yahir Santiago-Lastra]
One of my colleagues, Charlie Negar. He is this wonderful urogynecologist. He was the chair of OB/GYN when I started my career. He always tells us that you can almost never make a sling too loose. I think that that's true. It is always better to err on the side of making it more loose and it is very difficult to actually make it so loose that the patient doesn't get a good result and the reason for that is that you still have to close this very small incision. So, if the sling is a little too loose, then it is going to be really hard for you to close the vaginal epithelium over the sling, so it always ends up being in that sweet spot where it is easy to close but not too close to the urethra is what I've seen in my experience.
[Dr. Jose Silva]
That's great. That definitely makes sense and I feel better now. Because sometimes, even though I do four or five a month... I mean you are probably doing four or five a week or one day at least. But, you never know. I never had that reassurance that what I was doing was correct.
[Dr. Yahir Santiago-Lastra]
I think you're doing the perfect. I mean, just the fact that you are using the Hegar and not using a tonsil or any sort of other instrument, I think keeps you where the evidence can be replicated in your own practice. All the trials were done in that way and so you are replicating what you know has excellent data. I mean, looking back, four to five slings in a week is a lot and so I think you are definitely high volume enough that you-
[Dr. Jose Silva]
No, four or five a month.
[Dr. Yahir Santiago-Lastra]
Even so, that means you're doing about 60 slings a year. That's a lot. That's a really good amount and super solid and if you are getting really great results with that technique that already has a lot of evidence behind it, I would not change anything. There's always going to be... You know women don't read the textbook and all their bodies are different and special. Definitely, if I continued to place slings the way that I'm doing, I'm bound to get somebody that goes into retention at some point. Like I said, I've already had three women. It just so happens they also had some other characteristics that predisposed them but there will be a day when somebody goes into retention and I have to divide the sling and I think that is how anatomy is.
[Dr. Jose Silva]
It happened to me once back in Puerto Rico, we were doing a combined procedure, an AP repair and then my part and what I started doing afterwards when I did combined procedures is to just leave it looser and that helped. A friend of mine, he is a urogynecologist and he told me, "Hey, you need to leave it a little bit looser." Sometimes, when they are closing... the way we did it was that I put in the sling and then they would continue with the repair, so they were the ones actually closing everything and that pushed everything upwards and it made it tighter. So, I learned from that.
[Dr. Yahir Santiago-Lastra]
Yes, so that's a really great point. That's a huge pearl for people who are doing prolapse cases and also sling surgery. So, the point Aa on a POP-Q, if you use the POP-Q when you are measuring prolapse, you may not but, the urethra is one of the levels of support of the pelvic floor. So, when you have a pelvic floor specialist who is doing an anterior colporrhaphy or a sacral spinous ligament suspension or a sacral colpopexy, when that procedure is finished, then that vagina is going to be elevated towards the sacrum in all probability and that is going to take with it the urethra because the urethra is one of the levels of support of the pelvic floor and the vagina inserts right there, right in the distal vagina. So, if you do your sling, and you tension it at the beginning of the case, before that elevation portion of the procedure has happened, then you're definitely going to change the dynamics of the tensioning and it is probably going to be too tight.
[Dr. Jose Silva]
That is exactly what happened.
[Dr. Yahir Santiago-Lastra]
One other thing you could consider doing is you could be there when they select their tissue for their anterior repair and when they are done tensioning and tying down and finish their portion of the procedure, then you can come in at the end and place your sling without an interruption.
[Dr. Jose Silva]
So, next time I will have that in mind. Since I came from Puerto Rico here to Orlando, I haven't done combined cases. So, for now, I don't need to do that, but at some point when I have to do a combined case, I will definitely note it. So, do you always leave a catheter afterwards or any vaginal packing afterwards... if everything runs smoothly, what do you do?
[Dr. Yahir Santiago-Lastra]
If everything has gone textbook and I am really happy with the case, I will hold that vaginal pressure with that lap sponge or Raytec right as the staff or my co-surgeons are putting their Dermabond on and cleaning the patient and taking off the drapes and getting the patient extubated. Then, once the patient is going into the recovery area, we will remove that Raytec or the lap sponge. All of the patients go to the recovery area with a Foley and they all have a void trial in the recovery area where the nurses will backfill their bladder with 150-300 mL of saline and then the patient will void before home and, if they can't empty, then they'll go home with a catheter and come back in one or two days to void trial again. Even in the setting of a perforation during trocar placement, because the trocars now are so small, I typically will have them void trial in the recovery area anyway.
[Dr. Jose Silva]
So, for my cases, I always leave the catheter and the vaginal packing because that was how I trained. For now, I haven't had any problems. But, definitely, I know from a friend of mine, and a friend of yours also, Danny Hoffman, he told me he didn't do it, so. So, maybe at some point, I'll start moving towards that way and not leaving the catheter but doing the voiding trial. For younger patients, do you still do a sling? I will say like a 20-25 year old who already has three kids and their incontinence is... is there any special consideration in terms of what to expect afterwards?
[Dr. Yahir Santiago-Lastra]
Yeah, that is another population that requires a little bit of thought. So, again, I try to follow my algorithm of looking to see what the patient's expectations are. In general, younger women will choose to have more conservative therapies first. On occasion, you will see that type of patient that you described. A young woman, who has already had her family or who does not have the intention of having a family or who is very, very bothered by the stress incontinence and they will choose to undergo a sling because it has the highest effectiveness of all of the options to treat stress incontinence and I don't have a problem with that.
I have very rarely done sling surgery on women who are still planning to get pregnant and what I explain to those women is that the sling and the presence of the sling, should not make it any harder for them to get pregnant which is fine, but the sling's effectiveness may change if they get pregnant and have a delivery. Even if they choose to have a C-section because a C-section alone can put pressure on the pelvic floor and so that may change the dynamics of the urethra and definitely if they have a vaginal delivery, even though we have data that shows that the incontinence rates are not very different after that vaginal delivery. What I have found is that it can increase their bother from incontinence, even if they have had a sling before. No reconstructive surgery is going to last forever, so that is also coming into play. Now, you can expect the sling, I think the longest data that we have for sling effectiveness is about 17 years, which is amazing. But it is not always going to be that way for every woman.
(5) Post-Op Care for Sling Surgery
[Dr. Jose Silva]
In terms of post-operative care, what do you tell a patient about when they can start doing exercise, lifting, having sex... What do you tell a patient or what do you do?
[Dr. Yahir Santiago-Lastra]
So, I think this paradigm may change, but currently what I and a lot of my colleagues will recommend is six weeks of no heavy lifting more than 10 pounds, nothing in the vagina during that time, so no intercourse for six weeks, and no soaking or bathing or bathing in the ocean, etc.
There are currently some clinical trials that are actually looking at whether we need to be having those restrictions present for the patient. I think that some restrictions are going to be necessary whether it is six weeks, or maybe less, I think remains to be seen. I bet you it is probably not necessary for it to be six weeks, but I don't want to take that chance. Most women are pretty happy doing that because they want their sling to work. If you think about how the sling works, since it is tension-free, it actually has to scar at the endopelvic fascia right in that position and you don't want it to stretch out because then it is not going to be effective for them when they have moments of effort or coughing or sneezing. So I think it is a good investment of their time to follow the restrictions, but I bet maybe in a few years, we'll be counseling them that maybe it needs to be four weeks or three weeks instead of six.
[Dr. Jose Silva]
Yes, I usually do two months just to be on the safe side and definitely in diabetic patients and people who are still smoking, I tell them it is going to be a lot longer, just because the healing will be less. Anything else you want to add for our listeners?
(6) Cultural Competence
[Dr. Yahir Santiago-Lastra]
I think that one really important thing, especially for people who take care of women who have urinary complaints, is to definitely listen to the patients. Women are so different and their perspectives are so varied. You will find that some women are open to having surgery and they really want that and some women are really afraid. The great thing about treatments for stress incontinence is that none of the treatments burn any bridges, so you can have a bulking agent and then in a few years, you can have a sling. You can always do pelvic floor physical therapy if you want to and some women are going to need various treatments throughout their lifetime. So if you are going to offer one of these procedures, you should feel comfortable counseling patients about all of them because that way you are delivering the best care for your individual patient.
[Dr. Jose Silva]
I totally agree. I mean, like you mentioned, communication and listening to the patient will definitely give you better results. I'll bet you see a lot of patients that they complain of frequency or stress and they had the wrong treatment.
[Dr. Yahir Santiago-Lastra]
Yeah.
[Dr. Jose Silva]
That was it. Maybe they put a sling for an urge incontinence, the patient is still the same, the sling is perfectly fine, no revulsion or anything, but still it was the wrong treatment. So, definitely talk to the patient, listen to them, ask the right questions.
[Dr. Yahir Santiago-Lastra]
Yeah, asking the right questions is actually really important. I had a woman who came to see me who was really upset because she had seen a urologist and she felt like the urologist was telling her that the incontinence was all due to the fact that she was too emotional and it was because he was using an interpreter that was literally telling her that she had stress incontinence or that her incontinence was happening because she was really stressed out and she was pissed because he was interpreting stress as estres, like emotional distress and not esfuerzo, which is effort which is how we would translate it in Spanish and she was mad. She really wasn't stressed out, she just had stress incontinence.
[Dr. Jose Silva]
Yeah, definitely, and that is a completely different conversation, the translation and all that with all the different ethnicities that we see and languages and that really poses a problem. I think that is an entirely separate podcast, but definitely something very important that we are dealing with. We need to provide better care.
[Dr. Yahir Santiago-Lastra]
For sure and definitely we need to give more opportunity to Spanish-speaking trainees and people that can actually go to these communities and speak to women in the language that they know and understand.
[Dr. Jose Silva]
Good. Excellent. So, Yahir, thank you again for your time and thank you for being here. We will definitely talk more. We have neurogenic bladder and urge incontinence and a bunch of other topics. I know you are into women in urology and women in surgery, minorities in surgery and urology, so definitely all of those topics will be touched along the way of this podcast.
[Dr. Yahir Santiago-Lastra]
Awesome, happy to be here. Thank you so much for inviting me.
[Dr. Jose Silva]
Okay, take care Yahir. Bye.
[Dr. Yahir Santiago-Lastra]
Bye.
Podcast Contributors
Dr. Yahir Santiago-Lastra
Dr. Yahir Santiago-Lastra is an associate professor of urology and the director of the Women's Pelvic Medicine Center at UC San Diego in California.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 21). Ep. 4 – Management of Pelvic Floor Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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