Urogynecology Post-Graduate Course

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Roberta Speyer: "This is Roberta Speyer, Publisher of OBGYN.net, I'm reporting live from the AAGL in Atlanta. Today we're talking to Dr. John R. Miklos, Urogynecologist and Reconstructive Pelvic Surgeon in the Department of Obstetrics and Gynecology at Northside Hospital here in Atlanta, Georgia. Thank you for taking the time to talk to us, Dr. Miklos."

Dr. John Miklos: "Roberta, it's certainly my pleasure to be here at the AAGL meeting. We are certainly looking at some new innovative and non-invasive forms of reconstructive pelvic surgery, and it's actually been quite enlightening to the participants here today."

Roberta Speyer: "You were doing a post-graduate course in urogynecology here at the AAGL. Could you tell us a little bit about that - what was covered and the attendants?"

Dr. John Miklos: "Actually, it was probably one of the better, well attended post-graduate courses with over two-hundred participants. Doctors from around the world who specialize in reconstructive pelvic surgery, urinary incontinence, and minimally invasive surgery - meaning laparoscopic surgery in small incisions - produced the course to instruct and help educate our fellow obstetricians and gynecologists in minimally invasive reconstructive surgery for women."

Roberta Speyer: "And doing this laparoscopically - that is unique and fairly new, is it not?"

Dr. John Miklos: "Yes, it's actually been developed probably over the last five years with great emphasis and great advances in the last twenty-four months. We've actually been able to take these surgeries from abdominal incisions of anywhere from 6" to 12" and have minimized the surgical incisions to ¾" to as little as ¼" incisions on the belly. And we've actually reconstructed complete vaginal walls and given support to the bladder, rectum, and the urethra so the patients can have good physiologic function."

Roberta Speyer: "So what does that mean to me as a woman? If someone is suffering from incontinence or stress incontinence, and there are many forms - why would I be more likely to want to have laparoscopic surgery?"

Dr. John Miklos: "What it really means to you is getting out of the hospital early. The average hospital stay for my patients is 1.2 days, and 90% of my patients go home in less than twenty-four hours. There's minimal blood lose for a bladder suspension, and on the average less than a tablespoon of blood is lost to these surgical procedures. There's minimal pain and discomfort, and the capability to resume a normal life as soon as possible."

Roberta Speyer: "As opposed to - how is it done prior to this, and how long was the recovery time then?"

Dr. John Miklos: "Abdominal incisions can be anywhere from four to five inches, and as I said before, up to twelve inches due to the same surgical procedure. Quite often these patients are losing quite a bit of blood and requiring at least a hospital stay of two, three, or four days, and as much as a week."

Roberta Speyer: "This certainly sounds exciting for the patients. It's a great improvement over what they had to face in the past - the disruption of their life. So I assume most women would like to have this procedure. What are the indications and contraindications?"

Dr. John Miklos: "Most importantly, women will experience symptoms usually of urinary leakage when they don't anticipate to have urinary leakage. Along with urinary leakage they may have symptoms of pelvic pressure, discomfort, dyspareunia - which means painful intercourse, and actually relaxation of the vaginal lining. Those are the major indications, and after a thorough physical examination in an appropriate diagnostic work-up, they may have definitive indications for surgical intervention."

Roberta Speyer: "Would other things be tried before surgery or is it usually best when you have a surgical solution to go directly to that?"

Dr. John Miklos: "No, we believe that urinary incontinence and vaginal relaxation is a quality of life issue. Only the woman should make that decision whether or not her condition is severe enough that she feels she needs surgery. That's probably one of the most important questions. No physician should ever tell a patient they need surgery for something that is not life threatening."

Roberta Speyer: "I understand. So if a woman had maybe just a small amount of leakage, she might say - "I'm uncomfortable with this, I don't like this" - but she'll put up with it. But if it starts to become something that is inhibiting their lifestyle, their ability to go to work, or wear certain types of clothes, then this starts to become a problem. Is that when they usually go and seek out urogynecologists?"

Dr. John Miklos: "Yes, when they have this type of problem and if it is minimal, we may recommend a minimally, non-surgical approach to treatment. However, some patients we find have already gone the route of non-surgical treatment, and they are quite frustrated because the cure rates are not very high. At that time, they want a more definitive therapy, and they will come to our office looking for a final cure. Now obviously we know surgery is not 100% successful but…"

Roberta Speyer: "What is the success rate with your procedure?"

Dr. John Miklos: "With the laparoscopic Burch urethropexy - meaning minimally invasive skin incisions - the surgical success rate is no different than that of a open procedure, and that's roughly 85%-90% five years after surgery."

Roberta Speyer: "That's quite high."

Dr. John Miklos: "Yes, in the past a lot of the surgical procedures that have been done had cure rates of only 50-60%, and these were surgeries that were only performed two and three years ago. In fact, some of those surgeries are still being performed today, and I feel unnecessarily so."

Roberta Speyer: "What would some of the names of those surgeries be? If a woman was looking into this, they'd want to know that these are some of the ones that have the lowest success rate, and they might want to look further."

Dr. John Miklos: "Needle urethropexy procedures which have names such as the Raz procedure, Pereyra, Gittes, and Stamey procedures have success rates that fall between 45%-70% five years after surgery. The other surgical procedures which are less invasive - even then what we are doing today - are the anterior repair and Kelly plication but their cure rates are only 25% at five years. It certainly doesn't make any sense for a woman to have an operation that only has a cure rate of 25% and 30%, and then need the second surgery within two or three years and to under go all that trauma, complications, and possibly a potential second surgery."

Roberta Speyer: "What's the average age of women that are experiencing this problem or perhaps I should say - age range? Is it related to the number of children they have or are there other things in a woman's life that make her more susceptible to having these types of urinary incontinence problems?"

Dr. John Miklos: "Absolutely, Roberta, most people feel that urinary incontinence is a typical condition of aging, and it indeed is not something that is typical. We have patients from the ages of twenty to ninety-five years of age who have received surgery at Northside Hospital for this condition. The majority of patients tend to be a little older and are actually past reproductive years - meaning post-menopausal patients. Once they hit menopause and they've had a number of children, which seems to be a precursor for this condition, we see that there's an increase rate of urinary incontinence and vaginal relaxation."

Roberta Speyer: "Some diseases, like endometriosis, you find there's a great deal of time a person who suffers from that before they get a diagnosis. I wonder though, this isn't actually a disease; it is a condition that is developed over a period of someone's life. Are some women embarrassed so they avoid seeking treatment, and is it something that women should be aware of? How prevalent is it in the population? Should they really be embarrassed?"

Dr. John Miklos: "The condition is very prevalent, above the age of sixty-five 20%-40% of women in America today have some form of urinary incontinence. What's interesting is that as our society develops mentally, psychologically, and emotionally, women have demanded a greater awareness for their needs. And they're demanding a greater amount of education, as well as treatment for their conditions, and rightfully so. Because of that, women are finding that they no longer have to be embarrassed, and they can feel free to voice and express their thoughts concerning this type of condition. So they're much more readily to talk about problems with urinary incontinence and sexual dysfunction. It's a great merit to our women today that they are seeking advice and seeking treatment for this condition. They should not have to live and suffer in silence, they should seek out the physician of need so that they can improve their quality of life, live a normal life, and have this condition treated."

Roberta Speyer: "Then my last question to you, Dr. Miklos - and we appreciate your giving us this insight - would be if we have a woman listening to this tape that is suffering from this problem, what steps should she take? How should she go about finding the proper care and know that she's getting the opportunity to get an operation that is really in all likelihood going to solve this problem for her? What would your recommendation be?"

Dr. John Miklos: "I think it's always appropriate to ask your family physician, and maybe they can give you some insight and give you a referral to a physician who can treat it more definitively. However, they may also recommend that somebody in your condition may be treated with some medications that are now on the market. If that does not work, then look for a urogynecologist or a urologist in your area who has specialized in female anatomy and who understands the problem. One way of doing that is to call the American Urogynecologic Society or the American Urological Association and finding somebody who specializes in female incontinence."

Roberta Speyer: "Thank you very much for sharing this with us. I think it's going to be a big help to OBGYN.net women everywhere."

Dr. John Miklos: "Thank you, Roberta."