Speaker 1 (00:00:00):
Hi everyone. It’s me, Dr. Shirin Towfigh. Welcome to Hernia Attack Live, our weekly q and a. As many of you know, my name is Dr. Shirin Towfigh. I’m a hernia laparoscopic surgery specialist. Thank you for following me on Twitter and Instagram at Hernia Doc. Many of you’re joining me on Facebook Live at Dr. Towfigh. At the end of this episode, I will make sure you have access to review this and share it on YouTube. We have an amazing guest today, Dr. Susan Rusnack. She is a urologist who I’ve gotten to know since she came to Los Angeles or came back to Los Angeles, I should say, at Cedar Sinai. She is one of the elite urologists at Tower Urology, which you’ve seen many guests from that group on my webinar because they are very involved in the care of my patients. You can follow Dr. Susan Rusnack at Susan MD on Facebook and at S Rusnack on Instagram. And let’s say quickly say hi to her. Hi. Hi, how are you?
Speaker 2 (00:01:11):
I’m good. How about yourself?
Speaker 1 (00:01:13):
Good. Thanks so much for joining us. Thank
Speaker 2 (00:01:15):
You for having me.
Speaker 1 (00:01:17):
So we’ve had a couple of guests from Tower Urology. You guys are the best. You’re just amazingly talented urologists. I have a very unique practice which overlaps a little bit with urology because of the groin stuff. And in addition, hernia patients, I always ask them about urologic problems, whether it’s like how many times a night do you urinate because I want to make sure that I address any prostate problems or sometimes they have bladder spasm from hernias and they have a lot of problems that are urologic that are secondary to their hernias. So also we’ve had urologists because of sexual dysfunction that we see with hernias and testicular pain from hernias. So even though during residency we don’t really get expo, I got one month of urology. I feel like over time I’ve learned so much from you guys.
Speaker 2 (00:02:16):
Well, we’re always willing to teach and help. So
Speaker 1 (00:02:21):
Thank you for joining us. So maybe before we start, you can quickly tell us your journey into urology and how your practice is different than maybe a general urologist.
Speaker 2 (00:02:32):
Sure. Just really quick background raised here in Los Angeles. Went to RICE for my undergrad and off to Jefferson Medical College, which is now known as Sydney Kimmel Medical College. And then did my residency at Columbia and a minimally invasive robotic fellowship at Mount Sinai. Prior to moving back to Los Angeles, I actually worked in Paramus, New Jersey for six years where I was actually one of three urologists who were women in all of Bergen County. So that really accelerated my learning curve of bladder dysfunction, prolapse, incontinence care, especially since one of the three women had absolutely no interest in women’s care and wanted to concentrate on oncology. So I did a lot of that I made sure coming out of residency that I had a really good understanding of the pelvic floor from a cervical standpoint. I spent a lot of time with one attending who did exclusively women’s urologic healthcare, who happened to have been a UCLA fellow in that specialty, and finally made the decision to come back to la. But in terms of my journey into urology, I was one of those weird kids in high school and even earlier that knew that they wanted to do be a doctor and became pretty obvious that I wanted to do surgery because I liked doing the animal labs.
Speaker 1 (00:04:22):
Yeah. Did you ever dissect your goldfish or dissect your goldfish?
Speaker 2 (00:04:26):
Yeah, yeah. Or fetal pig or frog or whatever it was. I know it maybe a valuable commodity in that class.
Speaker 1 (00:04:35):
Right. So I know are very involved in robotic minimally invasive surgery and applying your interest in a lot of, the female urology issues using minimally invasive surgery. Can you explain the difference between you as a urologist versus urogynecologist that are baseline training is gynecology and then they get involved in the urologic standpoint. So there’s a lot of overlap in those two specialties. Is there fundamentally a difference?
Speaker 2 (00:05:12):
I think the way that we approach things as urologists, there’s a fundamental difference because the concentration is on, our entire training has been concentrated on the urinary tract.
Speaker 1 (00:05:27):
Speaker 2 (00:05:28):
So I think inherently there’s a better understanding of any sort of bladder pathophysiology. The general bladder anatomy, we have a lot less fear of bladder injury or your veal injury because we spent five or six years learning how to fix that most before the You’re a gynecologist would. They did primarily gynecology. So more female reproductive tract, not doing a lot of anterior vaginal surgery where you are dealing with the bladder directly. And then they do a fellowship where it’s kind of starting all over because you have to learn different surgical techniques.
Speaker 1 (00:06:22):
And that’s a one year for them.
Speaker 2 (00:06:25):
Actually. It’s usually two or three.
Speaker 1 (00:06:27):
Two or three. Oh, okay. Good. Yeah.
Speaker 2 (00:06:28):
Yeah. I mean, for instance, the Cedars fellowship is they just took on a gynecologist and she’s doing three years just because her instead of two years, which is what the urology fellows do, because she doesn’t have any of the same experience that we have. So her learning curve is much greater or
Speaker 1 (00:06:58):
Speaker 2 (00:06:59):
Speaker 1 (00:07:00):
There’s so much overlap. So for example, I’m a general surgeon, don’t really in general surgery, we are supposed to know for our boards a lot about gynecology, how hysterectomies and deal with ovarian cancers and so on. But practically speaking, no one does. Right. Gynecology in the United States. Back in the day, urologists were really general surgeons that were in urology. Yeah. So Dr. Roz, he’s actually was a general surgeon,
Speaker 2 (00:07:33):
A lot of the guys that were at the tail ends of their careers all started as general surgeons when I training.
Speaker 1 (00:07:43):
And now there’s the urologic specialty. So for me, I do a lot of groin stuff, which the bladders nearby and all this spermatic,
Speaker 2 (00:07:53):
Sometimes it goes into it,
Speaker 1 (00:07:57):
No, and then the bicycle. But I feel like I probably could do a vasectomy if I had to, but I choose not to because there’s always the risks with vasectomies. So I always bring the urologist in. We are taught to fix the bladder injury if it’s during trauma or something, but usually we choose not to. We ask the urologist to come to be able to handle all the repercussions of whatever exactly that involve. Exactly. So I feel that gynecology and urology are also one of those where you all are very familiar with the bladder and the ureter, which is very close to intimately involved with the uterus and the fallopian tubes and the ovaries. Well,
Speaker 2 (00:08:45):
But at the same, it’s a little different though, because in one of the things that’s done for a radical cystectomy in women is you’d actually, if they’re still have the uterus, you’re actually taking the uterus tubes in part of the anterior vaginal wall, which
Speaker 1 (00:09:03):
Oh, for cancer, for bladder cancer. Oh, really? So the neurologist does that part?
Speaker 2 (00:09:10):
Yeah. At least in academic institutions they do. I dunno if they do in the community, but that was part of my training, at least for open surgery, which was the vast majority of my training until my chief year when we became much more heavily.
Speaker 1 (00:09:27):
And I think because urologists by definition treat women and women are often, they’ve had pregnancies, et cetera. So they have the uterus drops that’s like a lab’s term, basically a bladder prolapse or other prolapses because of labor and delivery and all that. So they see that part. But so the women have stress urinary incontinence, which is really a urologic problem, but it became so that gynecologists were treating it, they were, because their patient population has it, number one. And then I think all these transvaginal meshes were marketed. Were they marketed to the gynecologists or to urologists and GYNs?
Speaker 2 (00:10:12):
Both. And now it’s really rarely going to find a gynecologist who will do a mid urethral sling because they’re all so frightened of the Mesh repercussions. Even though at least the American Urologic Association clearly states that Mesh is still considered the gold standard for surgery for stress.
Speaker 1 (00:10:40):
Well, let me ask you this. So from her hernia surgeon standpoint, we’re putting Mesh against muscle usually, which is much more hardy. We’re not putting it on bowel. We know not to do that. We used to do that back in the sixties and fifties and people were getting fistulas. So we shouldn’t put Mesh on bowel, but putting against muscle, we can argue about safety of Mesh in general, but putting it against muscle has been shown to be tolerable. But what are your thoughts of putting Mesh or any inflammatory product on the
Speaker 2 (00:11:18):
Speaker 1 (00:11:18):
Speaker 2 (00:11:19):
But the urethra is a muscular structure,
Speaker 1 (00:11:24):
But it moves. It’s okay
Speaker 2 (00:11:26):
Because the fascial supports have failed. The fascial and other muscular supports have failed. But the tube itself,
Speaker 1 (00:11:36):
Speaker 2 (00:11:37):
Is a muscular tube.
Speaker 1 (00:11:40):
So if you have, I’m just saying hypothetically, if you have a product, I’m going to call it Mesh, but it’s no inflammation, no. Like impurities, totally tolerable. Would that have a risk of having these erosions and stuff that we see or
Speaker 2 (00:11:59):
Of course. I mean the difference between doing a fascial sling where you harvest the patient’s own tissue versus using an artificial thing like a polypropylene sling. Yeah. Is that the honest about only difference is that there’s a slightly highly higher failure rate with the autologous fascia. Yeah. So your own tissue, and with the artificial material, there is a risk of erosion of mat, the material honestly, much more often into the vagina,
Speaker 1 (00:12:42):
Speaker 2 (00:12:42):
Isn’t that big of a deal and much, much less often through the urethra. And the reason for that is because the urethra is that is a really party muscular two. I mean, otherwise we’d be in big trouble with childbirth, with intercourse, with all that kind of stuff because it could actually hurt the urethra. Whereas with vaginal childbirth, it, it’s actually damaging the supporting structures, but not the urethra itself.
Speaker 1 (00:13:12):
I always wondered that because what you hear is Mesh eroding into the vagina and painful intercourse and you can feel the filaments and sandpaper and all that. But I, I’ve haven’t seen this onslaught of urethral injuries, which is very complicated, that will require reconstruction not to discount what’s happening in the vagina, but relatively speaking, one’s like brain surgery and one’s not. One’s more like hernia surgery.
Speaker 2 (00:13:44):
Yeah, your referral injury is far more complicated than something into the vagina, which can be sometimes you can even fix it in the office.
Speaker 1 (00:13:52):
So you may actually, even with a biologic or your own vaginal with
Speaker 2 (00:13:58):
A biologic, it should not go into, it should not erode. You can have, if you are exceedingly dry and you have significant postmenopausal changes in the vaginal tissue, it may not heal properly. And that’s pretty much the only way that you’re going to get that fascia into the vagina.
Speaker 1 (00:14:26):
Speaker 2 (00:14:28):
So otherwise you really don’t see that.
Speaker 1 (00:14:32):
Okay, got it. There’s a question related to just prolapse and so on. If you can just for our audience, describe what does prolapse even mean, and then how is that related to bladder issues like urinary incontinence and so on?
Speaker 2 (00:14:50):
Sure. So recently, actually, one of the ways that I’ve been describing prolapse to my patients is to actually use the word hernia. Yay.
Speaker 1 (00:15:02):
It’s all the same. It’s all the same. Oh,
Speaker 2 (00:15:04):
I know. It’s not just that. It’s because that’s a more commonly used term that people understand.
Speaker 1 (00:15:15):
Speaker 2 (00:15:15):
To say that your bladder dropped or your bladder fell down or you have prolapse, some people just don’t know. Or if you tell them that, then they’re afraid that their bladder’s actually going to fall out of their body, which it won’t.
Speaker 1 (00:15:31):
Speaker 2 (00:15:31):
Whereas if I tell ’em that their bladder is herniating through the vaginal wall, which it pretty much is, that tends to turn on the light where they understand that. And the same goes for the uterus, herniating or the top of the vagina herniating into the vagina or the rectum coming in. I mean, they’re all just different versions of hernias. And it’s the same idea where I want to go back and either reconstruct where that tissue is or sometimes put in Mesh from above, not from the vagina, and reinforce that reconstruction.
Speaker 1 (00:16:20):
So I tell my patients this is all related. So from hernia research, it shows that it’s usually collagen deficit. You have less mature collagen, plus the pelvic floor has so many stressors on it, especially with labor and delivery. And I heard actually some specialists in your field, the females choose not to have labor and just electively deliver because they know that there’s so much damage to the pelvic floor just from that action. Is that true?
Speaker 2 (00:16:54):
I know people who have done that. Yes. But the thing is, you also still have to realize that carrying a child to term, you’re still going to go through all the hormonal changes. You can still end up with tissue laxity because of things like relaxin that help you to accommodate the fetus in the pelvis. And sometimes people don’t get that same muscle strength back. So even just carrying a child’s term, even if you have an elective C-section, you can still have prolapse. And there are genetic factors that go into it. As you said, there are people with collagen and connective tissue disorders have a right much, much higher risk. But also people who’ve had pelvic surgery, women who’ve previously had hysterectomies, especially if they had a hysterectomy because of prolapse, their likelihood of having recurrent prolapse is somewhere on the order of 4 to 500 times more likely than anybody else. I mean, it’s enormous. Whereas if you had a hysterectomy for non prolapse reasons, it’s still increased, but not nearly to that degree.
Speaker 1 (00:18:10):
Why does a hysterectomy promote prolapse?
Speaker 2 (00:18:15):
Because you are limiting some of the supports. I mean, you’re taking away the round ligament, broad ligament, all of that stuff that helps to support everything that, aside from supporting the uterus, also help to support the vagina so that all of those structures are gone. So you just lose, I mean, it’s pretty simple. Yeah.
Speaker 1 (00:18:43):
Wow. We have a question is, I don’t know if you can answer this. What is a tipped to uterus? Before my last child in 1988, I had to hold my vagina up to poop. After the transvaginal tape and rectal sling, I could not poop without prepping and physically unpacking my rectum. I had many polyps removed. This sounds like enterocele or rectocele? No, maybe a rectocele. Wait,
Speaker 2 (00:19:11):
So after her second child, she had a sling. And then what?
Speaker 1 (00:19:16):
So before her last child, she had to hold her vagina in to poop her
Speaker 2 (00:19:22):
Vagina. Yes. She had
Speaker 1 (00:19:23):
a rectocele. That’s a rectocele. Yeah. Which is your colon herniating into your vagina.
Speaker 2 (00:19:28):
Speaker 1 (00:19:29):
So instead of it emptying straight out through the anus, it goes, it does a little loopy loop.
Speaker 2 (00:19:35):
Speaker 1 (00:19:36):
It really difficult
Speaker 2 (00:19:37):
To get it out. And what she was doing is called splinting, which is a classical sign of somebody with a rectocele that’s causing obstruction.
Speaker 1 (00:19:48):
So you get obstruction.
Speaker 2 (00:19:50):
Speaker 1 (00:19:50):
And sounds like she also had transvaginal tape and rectal sling, which probably is multiple different levels of prolapse. Maybe she had the prolapse.
Speaker 2 (00:20:02):
Well, I mean it’s … I think she, I’m going to guess because I’m going to assume that she’s calling it a rectal sling. The same way that someone would call a bladder prolapse repair a bladder sling,
Speaker 1 (00:20:16):
Speaker 2 (00:20:17):
Is that she had a posterior repair probably with Mesh, and it may have been overly tightened so that it was causing, instead of holding everything up and aligning it correctly, it actually may have been causing obstruction because so
Speaker 1 (00:20:40):
Everything is falling in and they’re pulling everything up and they
Speaker 2 (00:20:43):
Pulled everything up, but then they pulled it up too far.
Speaker 1 (00:20:45):
Yeah, yeah, I get it. It’s a very complicated area. The pelvis, I mean, there’s so many surgeons, general surgeons that are very uncomfortable with the pelvic anything. Yeah. We’re just not trained except for the rectum and colon
Speaker 2 (00:21:02):
Speaker 1 (00:21:02):
Yeah. We really don’t. Even friends of mine are like, dude, I don’t know how you do these hernia things in the groin, these revisions, because there are nerves and all this stuff. And that’s
Speaker 2 (00:21:13):
Why I love doing robotic approach because you can just see everything.
Speaker 1 (00:21:17):
Yes, I agree.
Speaker 2 (00:21:18):
These see everything. It’s great doing that.
Speaker 1 (00:21:22):
All these perineal hernias, which are very complicated. I love doing those. I don’t get too many of them, but I enjoy doing them because very few people understand the anatomy and how everything relates and where you can and cannot put sutures and what’s safe to place and what’s not safe to place. So it’s complicated, but because it is, it’s also fun. If you’re weird like me,
Speaker 2 (00:21:49):
A challenge. You would like a challenge.
Speaker 1 (00:21:51):
I do. Okay. So bladder prolapse is when the bladder, let me get this right. Bladder prolapse is when the bladder just herniates down, correct?
Speaker 2 (00:22:01):
Speaker 1 (00:22:02):
It’s not herniating into any organ?
Speaker 2 (00:22:04):
No. I mean theoretically the other hollow viscus is the vagina. So it’s just, it’s herniating basically almost outside of the body, but the vagina is between the actual organ and the outside wall. And the outside wall. Got it.
Speaker 1 (00:22:21):
So that’s what they call cystocele.
Speaker 2 (00:22:23):
Speaker 1 (00:22:24):
So is that usually a surgical problem or No,
Speaker 2 (00:22:29):
Not always. There are certain things that can be done. Certainly one of the nonsurgical treatments is using something called a pessary, which if you imagine what a diaphragm is, which it’s kind of a firm, so firm ring, usually plastic or silicone or something along those lines. But instead of there being kind of a cup there, there’s either a flat diaphragm that acts as a support or it’s actually just hollow and it goes into the vagina and lifts everything up using the pubic ramus as well as assuming that you have good support at the top of the vagina and it’s just the front pocket that’s failing, you can use that and it just holds it up. Understood
Speaker 1 (00:23:31):
Pessary. So someone figured out that you can stick some plastic cup like cap,
Speaker 2 (00:23:39):
That’s the most common type of pessary used.
Speaker 1 (00:23:43):
It just stays in there and by it stay there, it locks it in and therefore pushes a bladder up higher the goes. Correct?
Speaker 2 (00:23:51):
Yeah, it pushes it reduces it. Yeah.
Speaker 1 (00:23:55):
When I first saw that, I was like, it’s a very cheap way of fixing a very difficult problem
Speaker 2 (00:24:02):
And what’s really nice is that if the patient is comfortable enough with their own body and they have enough dexterity, they can actually manage it on their own. Whereas I also have several older women who just cannot do it. So they come into the office anywhere from one to three months and I take it out, clean it, check the tissue and put it back in.
Speaker 1 (00:24:26):
So yeah, I’ve only seen all in elderly patients. I haven’t seen it in younger patients,
Speaker 2 (00:24:32):
Speaker 1 (00:24:33):
Speaker 2 (00:24:35):
Yeah. So that’s one non-surgical way to manage it. Another non-surgical way to manage it is similar to what the woman asking the question regarding splinting, you can actually splint the bladder to urinate as well, so you can push it in and pee.
Speaker 1 (00:24:54):
Oh, right, because it strains it out and then it empties.
Speaker 2 (00:24:57):
Speaker 1 (00:24:58):
Yeah. Sometimes hernias in include the bladders, so bladder is stuck in the hernia. They either push the hernia in and then they can pee.
Speaker 2 (00:25:04):
Yeah, I know. I’ve seen those images
Speaker 1 (00:25:08):
So interesting. Yeah, the body is so interesting, but especially the pelvis, there’s so many things going on. There’s
Speaker 2 (00:25:14):
So much in such a small space. But yeah, I mean aside from that, everything else is really surgical management.
Speaker 1 (00:25:28):
We have several questions about Foley catheters. If you can quickly just explain what a Foley catheter is. Dr. Foley invented it, so that’s why it’s called Foley catheter, but it
Speaker 2 (00:25:39):
Is a long either latex or silicone tube that basically goes through the urethra. The urethra is where your urine goes from your bladder to the outside world and goes into the bladder. And I wish I had one I used when I worked in Paramus, I had a lot at home because I would go to the Paramus veterans home and do catheter rounds once or twice a month. So I always had a bag of catheters.
Speaker 1 (00:26:09):
My nurse has, I think my nurse has a couple in her trunk or something. But
Speaker 2 (00:26:13):
Anyway, they vary in size, but they’re about 30 centimeters long, regardless of if it’s used for men or women. And approximately two centimeters from the end, there is a balloon that you put water into and once the catheter’s in the bladder, you inflate that balloon with sterile water and it holds it in place so it can’t fall out.
Speaker 1 (00:26:40):
Speaker 2 (00:26:42):
Yeah. Just a drain. And it passively drains the bladder so that you don’t have to worry about getting up to urinate or if you have difficulty urinating. It is, it’s really helpful in the postoperative patient when they can’t get out of bed. But there are a lot of issues that go with it in terms of risks of infection or long-term use with erosion of the urethra. So I mean it’s not without its own issues.
Speaker 1 (00:27:13):
So for surgery, so we use it for hernia surgery, for two purposes. One the main purposes. If it’s a long operation, then you don’t want the bladder to fill with urine during the 4, 5, 6, 7, 8 hours that you’re going to be operating. And that has repercussions, which I’d like you to describe shortly. And then this. So you’re constantly allowing the urine to kind of flow out. And plus the anesthesiologist understands that your hydration status is okay because you’re still urinating. So that’s helpful. And the second purpose, which I think is very important and is not done enough in general surgery, is anytime we do pelvic surgery, so hernias including revisional surgery, the bladder is there and there’s always a risk of not on purpose but accidentally injuring the bladder. In fact, I had one, oh my god, you may know this patient. I had one lady who had just a routine laparoscopic inguinal hernia repair with mush. And you can read in the opera report that we kind of didn’t understand what plane we were in. It got kind of bloody and we thought we were in the right plane and then we put the Mesh in and fixed her hernia. Well, that plane was bloody because they were in the wrong plane. They were not outside the bladder, but in the wall of the bladder. Oh gosh.
Speaker 1 (00:28:44):
So they put Mesh not into the bladder. No,
Speaker 2 (00:28:47):
But in one of the
Speaker 1 (00:28:48):
Layer, the wall
Speaker 2 (00:28:49):
Speaker 1 (00:28:50):
Yeah. So of course she had a problem. So I went in there and took out the Mesh and we were in the bladder and she’s had repercussions from that, which I believe she’s fine now. But the point is for even those routine case, I always put a catheter to move the bladder out of the way of the way. I learned that from urologists, you guys would never do surgery in the pelvis without first putting a catheter to protect the bladder. General surgeons do it all the time. Appendix surgery and hernia surgery are the two most common ones. And when I tell them that I put catheters in, which is not considered standard. It’s not also not standard, but
Speaker 2 (00:29:37):
Especially if you’re going to do laparoscopic, my at least my understanding was that emptying the bladder was standard of care. If you’re going to introduce the veris needle in,
Speaker 1 (00:29:48):
Yes. So yes, that’s very correct. What they say is, oh, I just have my patient urinate the right before we go to the OR. But there are patients that don’t completely empty their bladder. Right?
Speaker 2 (00:30:00):
Very much so.
Speaker 1 (00:30:02):
And they think they did, but they don’t.
Speaker 2 (00:30:05):
Yeah, I definitely had men. It’s usually men, but it can be women also who have chronic either just bladder dysfunction or enlarged prostate where slowly over time their ability to actually empty the bladder becomes worse and worse. And they may not realize it. And more often than you would think, there are men who show up in the ER who suddenly can’t urinate, and they’ve got over a liter in their bladder and they said, I don’t know. I was doing fine. I never had any issues before this. And they probably have been walking around with a residual four or 500 milliliters in their, their bladder chronically. And it happens.
Speaker 1 (00:30:50):
Yeah. I had a lady a long time ago, she was a stewardess, which will be relevant shortly. She was a stewardess by training and she had a hernia, kind of lower abdominal hernia. She had a laparoscopic Mesh repair. And then ever since then she’s had these horrible bladder pain, horrible bladder pain. She’d be like on the floor on her knees in pain. Oh gosh. She would urinate every half hour to an hour because the minute the bladder expanded, she would just couldn’t tolerate it.
Speaker 2 (00:31:21):
So she added some sort of adhesion of the Mesh to the bladder.
Speaker 1 (00:31:24):
So she, no one figured this out for years. But what she had was the Mesh was the Mesh was sewn onto the bladder then onto the hernia. Oh, no. So the Mesh was sandwiched in the hernia repair, but every time it was perfectly sandwiched to the point where every time they went in with a cystoscopy to look inside the bladder, it looked like a normal bladder, just maybe a little bit smaller because the rest was tacked up by the Mesh and they misread the imaging. So I read the imaging, I’m like her bladder’s in the repair. And of course what happened was she was a stewardess, so she said, old school says kind of like surgeons don’t take bathroom breaks. Yeah. They’re discouraged from using the bathroom. We’re in the OR all day. We don’t leave.
Speaker 2 (00:32:13):
Don’t leave bathroom.
Speaker 1 (00:32:15):
Right. I mean, I’m going to be one of those people with enormous bladders by training. So she says, you train yourself to have to tolerate an enlarged bladder. And probably she was asked to urinate before surgery as routine, but she never emptied her bladder and the surgeon didn’t know and tacked up the Mesh to bladder.
Speaker 2 (00:32:40):
Well, I mean that goes with all the Pelvic, the vast majority of pelvic pain or chronic pain in pelvis is due to some sort of scarring. And so she had a section of her bladder that was immobile. And so when it was filled and it tried to stretch because the bladder is a very elastic
Speaker 1 (00:33:04):
Speaker 2 (00:33:05):
Couldn’t stretch it couldn’t stretch. And that caused pain.
Speaker 1 (00:33:08):
Yeah, that’s exactly what happened. Poor thing. Yeah, poor
Speaker 2 (00:33:11):
Thing. Yeah. I mean that was one of the big issues 10, 15 years ago with the whole vaginal Mesh group. Aha. Is that a lot of times? It was either not put in correctly or put in too tightly and it created this her or there was just the really old school Mesh kits. The amount of Mesh that they used was obscene.
Speaker 1 (00:33:39):
Speaker 2 (00:33:40):
And it would literally go from front to top to back, and so the entire vagina would get immobilize
Speaker 1 (00:33:51):
Speaker 2 (00:33:52):
And it’s not that a hundred percent’s going to cause pain.
Speaker 1 (00:33:57):
It looked like an octopus.
Speaker 2 (00:33:59):
It was horrible. And then it had all these little, oh god, it frightened me.
Speaker 1 (00:34:04):
Yeah. Crazy. So what question that’s proposed is are there risks to open anterior hernia surgery and injuring the bladder? Or is it just laparoscopic and robotic procedures where the bladder is at risk? Well, every so often uncommon, but the bladder can be in your hernia.
Speaker 2 (00:34:24):
Yeah, that’s what I was mentioning earlier. Or you’re like, no,
Speaker 1 (00:34:29):
That’s the only time when you can injure the bladder with an anterior approach. Agreed. So it’s uncommon, fortunately. So here are the foley catheter questions. What’s your recommendation regarding management of a foley catheter for someone that already has, well, it sounds like prior surgery and injury. So mid urethral stricture and bladder neck contracture after a turp. So TURP is a prostate like Roto-Rooter surgery.
Speaker 2 (00:34:56):
Speaker 1 (00:34:58):
Speaker 2 (00:35:00):
I mean it following a
Speaker 1 (00:35:02):
TURP undergoing hernia repair. Now with general anesthesia,
Speaker 2 (00:35:07):
I mean if they’re urinating normally on their own, unless there is a reason for them to have a catheter, it’s being done laparoscopically or robotically. I would treat it like anything else. I mean, if you’re urinating and your stricture and bladder neck contracture are managed, you have a slightly higher risk of having an inability to urinate after the surgery. But it’s minimal in terms of, so whatever the indicated procedure is that’s or the indicated use of catheter is for that. I would follow that just with an understanding that there’s a slightly higher risk of urinary retention after the procedure.
Speaker 1 (00:36:01):
But if they’re
Speaker 2 (00:36:04):
Avoiding fine on their own, it’s not going to change anything.
Speaker 1 (00:36:09):
So the TURP is trans urethral resection of the prostate? Correct. You guys go through the urethra, correct to the prostate and you burn it or something?
Speaker 2 (00:36:19):
It depends on what method’s being used. The classic TURP is actually using, there’s an instrument that goes around the cath or around the camera so that you can see, but you’re working either below or above, depending on how you move it. And it has an electrocautery loop. So you’re literally just scraping out strips of the prostate and they go in the bladder and then when you’re done, you evacuate all of it out of the bladder, take it out.
Speaker 1 (00:36:53):
And that process can make the area narrow as you’re part of. It
Speaker 2 (00:36:57):
Can, if you are overly aggressive at the bladder neck or there’s too much cautery or sometimes it just happens for no good reason, but there are
Speaker 1 (00:37:10):
More than others.
Speaker 2 (00:37:12):
There are definitely reasons for it to happen. And then sometimes with the, because the instrument that’s used to do the TURP is significantly larger than a normal catheter say would be used. Sometimes we have to dilate the urethra. Some people will get strictures afterwards or scarring, but it’s very uncommon.
Speaker 1 (00:37:38):
Speaker 2 (00:37:39):
See. So this guy unfortunately had a double whammy of a occurrence, but again, if I think I’m understanding him correctly in that he’s had some procedures or dilations to allow him to be without a catheter and he’s urinated fine, emptying is bladder adequately. Yeah, I would not treat it any differently than any other patient.
Speaker 1 (00:38:05):
So the recommendations I would give is you can undergo open surgery, which does not require a catheter. It’s really the laparoscopic and robotic ones that require a catheter.
Speaker 2 (00:38:19):
And if you’re really concerned, just have your urologist place the catheter.
Speaker 1 (00:38:23):
And you would do that, just use a narrow catheter or you’d do it under visualization with the,
Speaker 2 (00:38:30):
I mean, if it’s my patient, oh, I would do what I feel is appropriate. So if I think I need to have visualization, I would use a flexible camera and look in and then place a guidewire so I could pass the catheter over that. If I know that he’s generally open, but there might be a little lip somewhere, I might use a specialized catheter to bypass that area.
Speaker 1 (00:39:00):
The next question has to do with anesthesia and what can affect bladder function. So one of the things that we always worry about is we do a great surgery and then the patient can’t urinate after surgery. And so there are different things we can do to help prevent that. So this is asking that, what’s your opinion about different anesthetics, drying agents, glycol, antiemetics, et cetera, which may impact bladder function after surgery? A lot of things affect it, right?
Speaker 2 (00:39:31):
Yeah. I mean, more than anything else it’s narcotics.
Speaker 1 (00:39:35):
Speaker 2 (00:39:36):
Which are a huge part of general anesthesia.
Speaker 1 (00:39:41):
Doesn’t have to be though.
Speaker 2 (00:39:43):
I’m sorry. No, it doesn’t. But I generally, aside from getting something along the lines of propofol or gas, they’re going to get some sort of pain relief. And typically that comes in the form of
Speaker 1 (00:40:00):
Speaker 2 (00:40:05):
So it really depends. Some people are much more sensitive and they have more of a likelihood of having some sort of issue with retention. It’s hard to say. The best measure is what’s happened previously with surgeries.
Speaker 1 (00:40:29):
So is there, in the general surgery literature, we tend to think that using a catheter fully catheter increases your risk of urinary retention after surgery, whereas the urology literature says the reverse,
Speaker 2 (00:40:44):
I don’t think it makes that much difference. Oh, okay. I mean, unless somebody has a known history of enlarged prostate and placing the catheter created an inflammatory response in the prostate, thus narrowing the urethra opening through the prostate,
Speaker 2 (00:41:07):
I think it’s six or at one half dozen. I don’t think that some people tend to retain and some people don’t tend to retain. And if you know that that’s how you are, then it’s helpful to know that ahead of time so that you can set up proper expectations of, you may have to go home with a catheter, we’ll have you in the office the next day and fill your bladder and take it out and see if you can go. So it is an inconvenience, certainly, especially after undergoing surgery. And it’s the last thing you want to have is an extra thing to deal with, but it’s almost, it’s always temporary unless you’ve had some sort of really huge major pelvic surgery or spine surgery
Speaker 1 (00:41:52):
And it’s more, much more common among men than women by a lot.
Speaker 2 (00:41:57):
Speaker 1 (00:41:59):
So for hernia surgery, I prefer to have, they give Toradol and Tylenol and and so on and local as opposed to in the hospital where everyone gets Dilaudid, the narcotics. And then fluid restriction has been shown to reduce urinary retention after hernia surgery. So don’t give too much IV fluids during surgery.
Speaker 2 (00:42:25):
I don’t know. Now I haven’t heard
Speaker 1 (00:42:27):
That, especially for open surgery, 400 ccs was a number that one study kind of showed. And then some people put heat packs over the bladder. Have you heard of that? They’re doing a trial of that at the hospital to see if that helps get people to urinate. I don’t know. But there’s a lot of things you can do. There’s good, there’s some reversing agents for general anesthesia. Right. That can maybe reduce the risk of urinary retention. I think the best is to know ahead of time how much prostate issues there may be and treating it aggressively before surgery so you don’t have to deal with it after surgery.
Speaker 2 (00:43:07):
Speaker 1 (00:43:09):
We have another question about what’s the amount of post voiding urinary residual that would single a need for catheter? My residual is about 200 milliliters.
Speaker 2 (00:43:23):
If you’re not having infections and it’s not causing you to have to go much more often. And with a lot of urgency, I leave that alone. Mean when you start getting into the three 400 s, I start to worry because that’ll increase your risk of bladder infections, bladder stones. The other thing is not only is an increased residual showing me obstruction, but it can also be a signal that the bladder muscle itself is failing. So if you continue to have that obstruction, the one, so with enlarged prostate, one of the things that you can commonly see is that the bladder wall, because the bladder’s, a muscle will thicken because it has to work extra hard. So it’s basically like
Speaker 1 (00:44:20):
Speaker 2 (00:44:21):
Yeah, it’s basically lifting weights to the equivalent of lifting weights to get the urine out because it’s pushing harder and harder and harder against more resistance.
Speaker 2 (00:44:30):
And unfortunately there is an end point to that where the bladder eventually just gives out and you end up having a poorly contractile bladder even though it’s thickened. So it doesn’t do the squeeze to get the urine out. So when you have a residual, it’s important to understand how well the bladder muscle is working versus how much of it is caused by obstruction from the prostate. And then there are also other factors that can also affect the bladder function. Things like diabetes. Are you having neuropathy in the bladder where it is just not working because of nerve damage from chronically elevated blood sugars? Is there a spinal issue? Was there previous pelvic floor surgery that whether it’s a colon resection or whatever it might have been, that’s leading to decision as well.
Speaker 1 (00:45:33):
What is a normal residual? If I were to your less than a hundred, I’m not normal. Less than a hundred. Okay. And then what number?
Speaker 2 (00:45:40):
I mean honestly, less than 50.
Speaker 1 (00:45:42):
Less than 50.
Speaker 2 (00:45:43):
I really don’t get too upset as long as it’s less than a hundred.
Speaker 1 (00:45:48):
And then what’s the number where let’s say after surgery, they haven’t urinated yet. What number do you start thinking, I should probably drain this bladder because you’re not, it’s going to get so distended that you won’t be able to urinate. Is it 300?
Speaker 2 (00:46:06):
I usually wait until the patient has actually had an urge, because some people’s normal signaling is at 400 or four 50. A full bladder can be honestly on, in normal circumstances anywhere the literature says about three 50 to 500. And then there are people like you or me where we probably void six or 700 ccs when we go because
Speaker 1 (00:46:34):
Speaker 2 (00:46:35):
I just hold it all day. So if I always let people go, if they’re not uncomfortable, they’re not having pain, they’re not having significant urgency or feel like they need to go and they can’t, I’ll let them go until they get that urge. And then if they get an urge and they’ve tried and they can’t, I’ll give them another half an hour or so, maybe 45 minutes with the understanding that if they’re unable to urinate the plans to put in a catheter
Speaker 1 (00:47:09):
And just people know it’s a one-time thing. This is not like you’re not going to urinate for the rest of your life. Correct. Early after surgery you have, you’re relaxed, you’ve got narcotics on board, you have anesthetic on board,
Speaker 2 (00:47:21):
So many different medications that they turn off a lot of the normal nerve signaling in your body temporarily.
Speaker 1 (00:47:29):
I remember as a resident, one of the more common orders was please call the house officer the doctor. If the U patient hasn’t urinated in six hours, we expect every six hours for our patient to urinate. And I would walk around and be like, I am not, it’s been 12 hours. I am not on urinated, I’m still working. There
Speaker 2 (00:47:50):
Was one day during residency, I don’t even remember how far along I was. It was before my chief, maybe it was my chief year. I think it was before my chief year where I went into work and had a, grabbed a coffee at the cart outside, went and rounded, had our conference. Everything started at about five 30 and I got home somewhere between eight 30 and nine and realized that I had not used the bathroom all day.
Speaker 1 (00:48:20):
Been there. Absolutely. And so I was always had this fear that if I end up in the hospital, I may have to get fully catheter and I have to explain, no, you don’t understand. My bladder has been trained. No catheter, I swear. Well, we were just chronically dehydrated too.
Speaker 2 (00:48:40):
Oh yeah. Well, I also really hadn’t drunk anything else that day. Yes. So what came out was not, it was very concentrated.
Speaker 1 (00:48:50):
Yes, I remember that. Okay, next question also about catheters. Okay, we kind of a answered this. How do you decide whether to insert a foley catheter during surgery or or allow for voiding trial after surgery and only insert if the voiding trial fails? Sounds like they’re very afraid of the catheter.
Speaker 2 (00:49:12):
Yeah, it’s not the end of the world. It’s inconvenient, it’s uncomfortable. I get all of that. But you know, and I were discussing this briefly beforehand, and I am, I’m more than happy to let people try and urinate. But the last thing I want to do is send somebody home who hasn’t yet urinated with the thing of, oh, this always happens, I can urinate. And then somewhere around midnight, they’re in the ER because they’re completely in retention and they’ve got 750 ccs in the bladder and they’re going to die because they’re in pain. So does
Speaker 1 (00:49:53):
The bladder ever burst?
Speaker 2 (00:49:55):
No, not spontaneous. You’ll overflow before you burst.
Speaker 1 (00:50:00):
Okay, good to know.
Speaker 2 (00:50:02):
Yeah, unless there are some few exceptions. People who have bladder augments, so people who have had pieces of their intestine that has either been put on their bladder or their entire bladder has been replaced by intestine because usually because of bladder cancer, but it can occasionally be other things. Those can perforate and that is a surgical emergency. But in terms of somebody with a normal healthy bladder who doesn’t have diverticula in the bladder or anything like that, it’s not going to, it doesn’t perforate spontaneously.
Speaker 1 (00:50:49):
So I think the key is, there’s two strategies. One is to prevent injury to the bladder, in which case, unrelated to how long the operation is and so on, you put in the second is to prevent the bladder from over distending because of a long operation.
Speaker 2 (00:51:06):
I mean the main point is, is that catheters aren’t just put in because as surgeons and as doctors, we understand that catheters always introduce a risk of infection. So if we can avoid it a hundred percent, we will.
Speaker 1 (00:51:25):
Yeah, we’re almost done. Can you believe it? Okay. I’m going to leave the most controversial, but also the most informative questions. Last. You deal with prolapses and transvaginal replace Mesh and bladder SLS and so on. You also remove Mesh. So this is kind of answer. It sucks. Yeah. Describe your thoughts about it because I’ve shared my thoughts for sure. It kind of pisses me off that because for hernias, a lot of, the reason for the Mesh complications is the surgeon, not the Mesh. And then the other part is the Mesh itself too. And I hope that that resolves. But what are your thoughts on what you see? And
Speaker 2 (00:52:17):
Really it is not a fun process for anybody. A lot of times, it is really stuck. It can be really difficult to remove. It’s in certain instances it’s scary because it’s adhesive to the bladder and you’re worried that you’re either going to thin the bladder muscle and risk bladder dysfunction, or you have to take part of the bladder because you just can’t separate it. And then you’re going to make the bladder smaller, which that can make bladder dysfunction. So that’s
Speaker 1 (00:52:51):
From which procedures are they? Is the Mesh stuck to bladder?
Speaker 2 (00:52:55):
Usually a transvaginal anterior repair.
Speaker 1 (00:53:00):
Speaker 2 (00:53:01):
Speaker 1 (00:53:01):
Speaker 2 (00:53:04):
I if haven’t had to do a redo, redo of a [inaudible] plexy yet, just because most people don’t do them unless they actually know what they’re doing. But the anterior, the vaginal approach to the anterior repair, that Mesh can be really, really socked in there. But some of the older Mesh actually comes out fairly easy because it’s encapsulated. So it really just depends. It also depends if they got in the right plane. If they’re not in the right plane, then it tends to be more stuck.
Speaker 1 (00:53:52):
And some of these are trans obtuator, so Right. Yeah. So you can’t get
Speaker 2 (00:53:58):
All of it unless you are really going to do a thigh dissection. And then I’m going to bring in somebody
Speaker 1 (00:54:05):
Speaker 2 (00:54:06):
To help me with that because that anatomy I’m not super comfortable with in terms of dissecting through the muscles. So I might get an orthopedist who deals more with the hip and those muscles than something, than somebody else.
Speaker 1 (00:54:22):
And how much of what you see in retrospect, because it’s almost forensic when we do these, you kind of analyze why they had it, how it was placed, what was placed, the technique that was used, how much of what you see do you think is kind of surgical technique and how much of it is just a poorly designed product?
Speaker 2 (00:54:48):
I think it’s about 70 / 30 in terms of surgical technique versus poorly designed product. The, and honestly I’ll say 70/ 30/ 10 with 10% being patient factors like horrible vaginal atrophy that hasn’t been addressed. So the tissue is so thin and fragile, it’s almost impossible to avoid having Mesh put through come through the vaginal wall. So that’s
Speaker 1 (00:55:17):
Also that part of the decision. And
Speaker 2 (00:55:18):
That’s also poor patient selection.
Speaker 1 (00:55:20):
Yeah, yeah. By the surgeon. Yeah. I would say the same for her injury. So I’m going to send you that 60 minutes episode. Oh,
Speaker 2 (00:55:30):
Speaker 1 (00:55:31):
Yeah, yeah. By Scott Kelly 2015. I recently kind of revisited that. I mean, they proved it to be true for Boston Scientific, where they went from taking the brand name Marx Mesh out of Austin, Texas, and instead went to China and got this kind of generic resin of polypropylene. And in that one episode, they showed that of the nine ingredients that compose chemically composed the Marx Mesh, which is the original Mesh capital M for Marx. Yeah.
Speaker 2 (00:56:09):
Speaker 1 (00:56:11):
It only had two of the nine, the other, yeah. So it was very dissimilar and
Speaker 2 (00:56:19):
Similar-ish is not good enough when it’s an implant. Right.
Speaker 1 (00:56:24):
Oh my God. I was watching this episode back in when it was live, and at that time I was seeing and treating just tons of match complications and people really getting reactions to match rashes and hair loss and nobody white pain. And
Speaker 2 (00:56:39):
That never happened. I understand everything now,
Speaker 1 (00:56:43):
The hernia Mesh market is many times larger than the vaginal Mesh market. Yes. Yeah. So for a vaginal Mesh company, Boston Scientific, to go ahead and see the benefit of doing that, could you imagine
Speaker 2 (00:56:59):
Makes a lot of sense
Speaker 1 (00:57:00):
Companies, I mean it hasn’t been proven yet, but I’m willing to, yeah, I mentioned this is not the first time I mentioned you. I’ve said it on hernia talk multiple times. I’ve given talks on it. That really bothered me.
Speaker 2 (00:57:14):
Well, because it puts us in a really terrible position without even knowing that there’s such an issue with this product that we trust the company to make appropriately
Speaker 1 (00:57:28):
Correct. And we don’t have alternatives. We’re kind of at a loss.
Speaker 2 (00:57:33):
No. I mean, I sometimes will use flesh cadaver fascia, but Yeah. Doesn’t hold as well.
Speaker 1 (00:57:41):
Yeah. Yeah. It’s a problem. So I’m stressing out because like you said, our hands are tied a little bit. Okay. I will send that to you. Yeah. Two really good questions for you before we leave. Okay. Are there risks of inadvertent urination getting onto an open surgery, and then what happens if that happens?
Speaker 2 (00:58:06):
You mean if nobody catheterizes
Speaker 1 (00:58:09):
Like the scar, you accidentally peed on your scar,
Speaker 2 (00:58:13):
Speaker 1 (00:58:14):
It’s sterile, right? It’s
Speaker 2 (00:58:16):
Fine. Just rinse it off.
Speaker 1 (00:58:19):
Speaker 2 (00:58:20):
Rinse it off and dry. It’s fine.
Speaker 1 (00:58:24):
Speaker 2 (00:58:26):
The vaginal incisions that I make? I’m sure they get pee on them. It’s fine. Right?
Speaker 1 (00:58:31):
Yeah. Yeah. Always wondered that. Okay. Is it a normal procedure to put in a fully catheter after emergency surgery because a patient is urinating without the urge and doesn’t realize they’re doing it? Sounds like overflow.
Speaker 2 (00:58:45):
Yeah. I mean, yeah. And especially if there’s a reason to either make sure that they’re dry and you don’t want to just put a diaper on them. And there’s also a dignity component of it. It’s better to have a catheter in than to be wetting yourself, but also you Yeah, absolutely. Especially if there’s, God forbid that there is some sort of pelvic injury and nobody put a catheter in, they could definitely be in retention
Speaker 1 (00:59:18):
And that’s going to really,
Speaker 2 (00:59:19):
Speaker 1 (00:59:20):
And then last question, do you recommend Tamsulosin before surgery to prevent postoperative urinary retention?
Speaker 2 (00:59:28):
Only if you have a history of enlarged prostate and you’ve, it’s not enough where you need to be on tamsulosin or similar medication all the time, but that you’ve had some issues in a prior surgery, that would be the only time I would recommend it.
Speaker 1 (00:59:45):
Yeah, I agree. So I do a full history before about their urinary habits and if there’s any inkling, I send them to their urologist to get evaluated and then I would like them to start something. Sometimes they don’t get started on anything because the urologist is like, oh, it’s fine. So I do give them tamsulosin or some other rapa flow for surgery or right after surgery and that seems to help. Am I doing the right thing?
Speaker 2 (01:00:12):
Well, I mean if you’re really worried, I would start them at least three days before surgery because Okay, good to Tamsulosin can take like 48 hours to really start working appropriately.
Speaker 1 (01:00:23):
What about rapa flow?
Speaker 2 (01:00:25):
That’s supposed to be 24 hour onset within.
Speaker 1 (01:00:27):
Okay, good to know. So, alrighty. Well that was it. Thanks so much, Dr. Rusnack. This is Dr. Shirin Towfigh. I’m so glad to have amazing hour with my friend. Great urologist, very talented. Thank you for your time. This ends us for hernia talk Live q and a will be back again next week with another great guest. Thank you all for joining me. This will be posted on YouTube so you can watch and share. You can also see it again on my Facebook page at Dr. Towfigh. Thanks to everyone who follows me on Twitter and Instagram at Hernia doc. And that’s it for tonight. Thanks everyone. Enjoy your evening and thank
Speaker 2 (01:01:07):
Speaker 1 (01:01:08):
Enjoy your time with your family and your little cat.
Speaker 2 (01:01:11):
I know. Well she left
Speaker 1 (01:01:14):