This latest essay (written Oct. 20, 2019), is not so much an 'exciting announcement, as a 'getting it off my chest' piece. For real 'exciting announcements', please look under the drop-down menus above, especially the 'news' tab. There is a LOT of information on this website, but you might have to work for it just a little bit.
I have been a practicing gynecologist in Canada since 1995, with exclusive focus on urogynecology since the late nineties. I think it is fair to say that I have seen it all. I've been part of every development in the field (and unfortunately, depressingly often the walking back of that) over the last 25 years. When I started my practice, I was doing needle suspensions and Burch colposuspensions for stress incontinence. Later, I did many laparoscopic Burch colposuspensions, and fascia slings when all else failed. I was never completely satisfied with the sometimes high morbidity and relatively poor results, so when the mid urethral slings were first demonstrated, I was one of the very first in Canada to realize the potential of this revolutionary procedure after incidentally seeing a demonstration video at a conference in Cape Town of all places. In fact, I did the SECOND retropubic mid-urethral sling (TVT), that was ever done in Canada after training in Chicago (this was before its launch in either Canada or the US. I did this during the second week of July, 1999, in Cranbrook, BC. The first was done - where else.... Toronto, after which however it took several years before it became relatively freely available in Ontario, during which time I've done hundreds of slings in BC. I will never forget the consternation of the 'father of Canadian urogynecology' at a SOGC meeting in Halifax when I mentioned my experience with these when Ontario was just starting to talk about it for the most part. Very shortly after that I was averaging eight to ten procedures a day, often twice a week. To this day I have done probably the most slings of anyone in Canada, and if not, then certainly close. I was also part of one of the first research groups who pointed out the high complication rate of one particular sling (OBTAPE), in the early 2000s), and remember getting up at a major international conference expressing concern about this particular device - where my concern was brushed aside (but not for long as it was removed from the market within the year). As far as prolapse is concerned, I've done it all, and lived the gamut of developments over the last two decades from native tissue 'site specific' repairs, to biological 'allograft' mesh, to synthetic mesh and all the way back to native tissue repairs. The situation in prolapse treatment is especially depressing. An entire field of research and development that spanned almost two decades has been walked back. Careers were built on research that in the eye of history would be considered a complete waste. Many patients were helped, but many also harmed during the 'go-go' years of expansion of mesh devices and free wheeling access by surgeons who were sometimes wholly unqualified to properly asses, choose the best options as well as perform some of these very complicated operations.
The field of urogynecology is in crises, in my opinion. We've either walked back our own thoughts, access to devices and procedures, or have been forced to do so by pressure groups, beaurocratic governing bodies, or market forces. In reality, we have gone nowhere in the last twenty years. No, it's worse; we've gone backwards. The last IUGA (International Urogynecological Association) meeting in Nashville was a prime example of a subspecialty adrift. Gone is the excitement of new discoveries, new devices, new theories and thoughts, and the associated confidence that what we are doing is effectively treating sometimes devastating pelvic floor conditions. We are left with uncertainty, arguiing about operations that were discredited twenty five to thirty years ago, and a general uncertainty of what to do, tempered further by a grim realization that we can't cure prolapse. At best we can temporize symptoms. Maybe.
There is still research going on of course. Most of it is useless, circular rehashes of what was done already, and done mostly for job security in a 'publish or die' academic world, allowing academics to network and meet on podiums where they lecture and feel elevated above their clinical peers, who do most of the work. But there are some green shoots and interesting concepts taking hold nonetheless, especially in genetics. Then there are also ongoing research among some of the people whom I respect most of all and who are willing to publicly defend the position that mesh has a place, even transvaginal mesh, and that some patients could have no expectation of long term improvement BUT for mesh. These are also for the most part the same people who have the confidence to openly state the prime etiology of most pelvic floor problems: vaginal delivery. Unfortunately the absolute majority of current research is completely depressing in its unoriginality, predictable conclusion, and its obvious intent (filling time instead of actually dealing with patients). Much is a rehash of things done many years ago - when the exact same, inevitable conclusions were reached: 'more research is required'. Blah...
Is it at all surprising that more and more urogynecologists are trying to re-invent themselves as either 'mesh removal' specialists (often those who put the most in - but will never admit to that) - or as 'cosmetic gynecologists', a new field forced into existence by trying to ramp up body image insecurities and offering a fake standard of genital 'beauty'.
Almost the ONLY light in this depressing theatre, is the development of energy devices; lasers, radiofrequency devices, and associated technologies. It is early days yet, and of course companies are falling over themselves to bring devices to market. This creates opportunites, but also risks, including possible complications and injuries to patients, dashed expectations and financial loss, a combination of which led to the FDA putting out a warning a few months ago; not dissimilar to their warning about mesh (for historical interest; read my essay about the impending class action lawsuit against mesh which I predicted in 2008 - a full two years before the first FDA warning). Therefore, given the 'wild west' aspect of this development, it really is a 'caveat emptor' world out there. Be careful whom you trust.
Tell me this: Would you go to your dentist to have your vision checked? Or vice versa? Why then, would you go to a dermatologist, aesthetic clinic, or even a general medical clinic to have your prolapse, urinary incontinence or other genital syndrome of menopause symptoms treated with energy devices? What if the treatment doesn't work? What if the diagnosis is incorrect? What is the next plan, or step? There are many different types of urinary incontinence. There are different degrees of prolapse. And not all vaginal laxity is prolapse. If you only have a hammer, averything looks like a nail, even a screw. And when the hammer effort fails, will you be back at square one?
My office is a complete, integrated and focussed home for urogynecology patients. We offer pelvic floor physiotherapy, pessaries, urodynamic assessment, cystoscopy, the best in class laser treatment, as well as surgery (I operate at the Foothills hospital).
I can offer office based options for most GSM or urogynecology problems, as well as hemorrhoids and skin tags. In fact, I did training in Europe to introduce a first of its kind office based laser treatment for hemorrhoids and am in the process of introducing it. The treatment is highly effective, with less downtime and discomfort as traditional surgical procedures. Also- yes, we can talk about aesthetic gynecology as well. I am not at all against it, unless it is borne out of unfounded insecurities.
We can start at the most conservative options and work our way up, or go straight to surgery, as long as it would be appropriate and if that is what you want. The fact is however that in today's situation which I tried to explain above, it makes absolute sense to try less invasive, office based treatments first, before undergoing surgery, knowing full well that surgery will likely not be a permanent cure. It will most likely only temporize, ameliorize or postpone an almost inevitable recurrence - use whatever term or phrase you want; but a good phrase to wrap your mind around is: "once surgery, always a patient". That is no different for the other treatments of course, but they at least have less, and sometimes no - risk, and no downtime. I'm being overly negative maybe; but I've also been around a long time doing this. Surgical 'cure' of prolapse for instance, is not a cure. The defects are hidden, but still there. Overall long term success rates after surgical intervention for prolapse is closer to 50% or even less, than to 100%. The one bright spot remains the mid-urethral slings (YES with mesh), which is being so vilified at the moment, but even there the long term outcomes depend on the study, the definitions of success, with some studies again finding outcomes less than 50%. At least we now seem to have a very good alternative: Fotona Er-Yag laser.
If you are interested to become a patient of our clinic, ask your family physician for a referral, unless you are interested in going straight to laser treatment: for complicated reasons resulting from the Provincial laws and rules, you do not require a formal referral if the treatment will be outside of Medicare. In this case, please call the office directly to discuss.