Angela Chaudhari (Host): Welcome to Parts and Labor, a roundtable discussion with our Urogynecology experts here at Northwestern Medicine. My name is Dr. Angela Chaudhari, and I'm a minimally invasive gynecologic surgeon and serves as our Chief of Gynecology and Gynecologic Surgery here at Northwestern Medicine. I will be your host today discussing Urogynecology and Reconstructive Pelvic Surgery, a comprehensive medical and surgical program that we have across the Northwestern system.

I have an amazing group of panelists here with me today. I'm going to start over here with Dr. Bretschneider. Dr. Emi Bretschneider is our Division Chief of Urogynecology and Reconstructive Pelvic Surgery, as well as the Director of the Northwestern Women's Integrated Pelvic health Clinic. She's an Assistant Professor of Urogynecology and OB-GYN. And in her role as division chief, she is our de facto leader of all things Urogynecology here at Northwestern Medicine.

Next up, I have Dr. Julia Geynisman-Tan, an Assistant Professor of Urogynecology and Reconstructive Pelvic Surgery. She serves as the Program Director and Director of Fellow Research for our Urogynecology Fellowship Training Program. She has very unique clinical interests in congenital abnormalities and has created programming to serve people who are victims of sexual trafficking and exploitation here in the Chicagoland area.

Next, we have the one and only Dr. Teni Brown. She is an Assistant Professor of Urogynecology, OB-GYN, and in the Department of Medical Education. She serves as the Director of Diversity and Inclusion at the McGaw Medical Center of Northwestern University for all of our trainees across the Northwestern Medicine system. Dr. Brown is also the recent recipient of the prestigious Robert Wood Johnson Harold Amos Award.

And finally, rounding out our panel is the formidable Dr. Doug Luchristt, an Assistant Professor of Urogynecology and Reconstructive Pelvic surgery and Obstetrics and Gynecology. He is our very own homegrown, a graduate of our Northwestern Medicine OB-GYN Residency Program, and now has returned as an attending over the last few years after his fellowship.

So, with all that, let's get started, okay? So obviously, all of you know what Urogynecology is. I'm happy to say I too know what Urogynecology is, but I'm not sure actually all of our listeners do. So, I would love to really start off talking about what this specialty is all about. Dr. Bretschneider, take it away.

Dr. Carol Emi Bretschneider: So, Urogynecology is a subspecialty of OB-GYN, and we see women with pelvic floor disorders, and that ranges from conditions such as bladder and bowel control issues, as well as pelvic organ prolapse. We also see women who have, you know, lower urinary tract symptoms, such as overactive bladder and recurrent UTIs. Being, you know, fellowship-trained reconstructive pelvic surgeons, we offer a wide range of different surgeries for all these pelvic floor disorders. And we also see women who've had complications from various pelvic surgeries and suffer from things like rectovaginal fistulas, vesicovaginal fistulas. We also see women who have obstetric complications such as perineal lacerations. We also see patients who've had complications from mesh-augmented surgeries and manage those patients often surgically.

So, yeah, we see a lot of different types of patients. And Teni is going to probably talk a little bit more about that. But yeah, that's kind of the nuts and bolts of what Urogynecology involves.

Host: Yeah. So, Teni, tell me, what is really the type of patient-- like what's your everyday patient that you see in the office? What are the patients coming to you and where are they coming from?

Teni Brown: Yeah, like Emi said, you know, really, I would say the bread and butter of Urogynecology and maybe the top two diagnoses that we see are urinary incontinence and pelvic organ prolapse. And because we are in four regions, we get patients from all over the Illinois borders, like Wisconsin, Indiana. And, you know, I'm sure our listeners probably already know, but in case they don't, about one in four women have a pelvic floor disorder.

And so, at some point in a woman's lifespan, during their reproductive years and then as they age, somebody's going to get a pelvic floor disorder. So, we have a lot of patients who have stress urinary incontinence, which is leaking with coughing, laughing, sneezing; urgency urinary incontinence or overactive bladder, where you feel like you need to use the bathroom, you leak on the way there. And then, of course, pelvic organ prolapse, where, you know, the gynecologic organs are falling out of the vagina.

Host: Yeah. I mean, I think all of those different areas, first of all, I think this is like a horribly underdiagnosed condition. So, you know, patients are not necessarily telling their primary care doctors. I often tell, you know, when I hear about this from my patients, because unfortunately I have to send patients on to you too, in my gynecologic surgical practice, oftentimes I have patients that say, you know, I waited until I couldn't wait anymore, because I just assumed it was a normal part of aging, right? And that like I should leak because I'm older and I had babies and like that's a normal thing. And I see women who are my age who say that. And I think, "Oh my gosh, you have 30 more years to live, plus 40 years, 50 years," right? And really, this is not something that you should have to live with. So when I think about sort of who the right people, as our like referring doctors, what are the questions they can be really asking their patients to elicit this information? And when is the right time to refer? Dr. Geynisman-Tan, can you take this one?

Dr. Julia Geynisman-Tan: Yeah, sure. Well, so I think in terms of what all of us can be asking our patients, the most common thing that we ask our primary care doctors and our gynecologists to ask is, "Do you have bothersome symptoms of urine control or of urine leaking out?" You know, and it doesn't really matter what the conditions are, we can suss that out when they come to us. But just, "Does it happen to you? Does it bother you?" I think in terms of prolapse, I mean, the most common question we ask patients is, "Is there a bulge in the vagina or something that feels heavy or like pressure that's coming out of the vaginal opening?" All of those would be good patients to send over.

I think in terms of when they should come, there really isn't a right time. You know, we see some patients who are in the very early stages of some of these conditions, and they just want information and they want reassurance, and we see patients who we wish we would have seen 10 years ago, you know, because we could have really changed the course of their life in that time. So, it really doesn't matter. I think you could send it at any point in that trajectory, and we have something to offer them.

Host: You know what I really love about this? Usually, when you think about referring to a specialist here at Northwestern, there's a lot of hoops to jump through. Obviously, getting a call into the phone room or getting a request online for an appointment is often a thing that can be a barrier for people. But often, for our primary care providers out in the Chicagoland area, another big barrier is like, "What tests do I order that this doctor isn't going to be mad that I sent them?" And I think the really beautiful thing that you highlighted was like, "Send them. We will figure all that out." Those are tests that we do in our office. They don't need to go in for a bunch of imaging before they come in. Like, you guys are able to really take care of that as really, truly like a one-stop shop.

And so, I think my real message for our referring providers out there is like, "Oh my gosh, just send the patient." And they might not need anything. This might be fine for them to just observe. They might need a little physical therapy, right? So, thinking about sort of what all the different things that you guys do outside of just surgery, right? And I think that's sometimes the biggest barrier for referring providers is they honestly feel like, "Oh my gosh, we don't know how to refer. We don't know what we need to do or get a patient ready because there's so many of these patients." Well, that's okay. They can send them on and we can sort that out on our end in the department. So, I love that. Thank you so much.

I'd love to hear too, you know, you both mentioned sometimes, you know, where patients have waited longer, patients get more complicated, or we do a lot of second opinions or complications from things. And Doug, you being our newest provider in the group, I'd love to hear some of the patients in some of those situations that you are starting to see more regularly and how we really go about approaching those here at Northwestern.

Dr. Douglas Luchristt: Yeah, thank you. I think that our bread and butter, as was mentioned already, is leakage of urine and prolapse. Those are the most common conditions that we see. And we see individuals who this is a new diagnosis for them. But given that we are at Northwestern, we're covering a broad area with a lot of different referring providers and individuals coming, sometimes, you know, across multiple state lines to see us. Those rarer conditions are things that we actually end up seeing relatively commonly.

So, Emi mentioned, we'll see individuals with fistulas, which are inappropriate connections between different organs that should not be connected, so between the bladder and the vagina, between the bowel and the vagina. Those, if you look at the numbers, are relatively rare things, but things that we treat regularly. And additionally, mesh complications, so individuals who maybe they don't have a new prolapse diagnosis, but have undergone a potentially multiple different surgeries and are now experiencing, unfortunately, some of those rarer complications, are things that we see pretty regularly at Northwestern, and specifically within Urogynecology. I'd say we take a very comprehensive approach.

So for an individual that's coming into my office with some sort of complication, whether it be related to childbirth or related to a prior surgery, we're going to speak with her and see, you know, "What is your history? What are these symptoms that you're now experiencing related to this complication? And is this something that we can help you with or do we need to bring in other colleagues as well?" And I think one of the great things about our program and the resources that are available at Northwestern, you mentioned we'll figure it out. So if you aren't sure whether you need to be seen by Urology or seen by Colorectal Surgery, individuals who focus potentially on the kidneys and the ureters, or individuals who might treat complex issues related to the bowel, We'll work with you to figure that out and we'll get you set up with those individuals. And if you need surgery with multiple providers, then we'll help coordinate that as well. And that's something that I feel very fortunate to have those resources available so I can ensure that patients are getting coordinated and optimal care.

Dr. Julia Geynisman-Tan: I think, if I can piggyback off of that, I think one other thing that we see really commonly, and that we haven't mentioned yet is recurrent prolapse. You know, I think that what's really nice about our team overall is that all of us are trained in all of the modalities of prolapse surgery. And sometimes, you know, we see people who have had particular surgery, maybe once, maybe twice, you know, sometimes even more, and they clearly need a different approach. And the fact that we have a team that can kind of look at things and has the skill set to do things in different ways, we can figure out the best way to treat that recurrence.

Host: And can you share some of those different modalities that maybe patients have experienced or not and the other things you guys can offer?

Dr. Julia Geynisman-Tan: Sure. I mean, I think that all of us kind of do everything, but, you know, some of us actually have even more experience or history in doing certain approaches. So, all of us do all options of native tissue repair, and we talk about, you know, uterosacral ligament suspensions, sacrospinous ligament suspensions, with and without uterine preservation, which I know Dr. Bretschneider is really passionate about. We offer all kinds of laparoscopic and robotic and even single-port robotic, you know, mesh-augmented surgeries for prolapse and, of course, do obliterative surgeries. And sometimes, you know, we kind of have to figure out something even more unique or rare amongst those things and kind of combine different approaches, do things both vaginally and abdominally, or do it together with other teams or other kinds of surgeons to really make sure we get the optimal outcome.

Dr. Carol Emi Bretschneider: And to piggyback off of what Jules is saying, I think one of the strengths of our team is that we do have such a diverse, you know, training experience and skill set, and that we come together to discuss these really complicated cases. I think that's what makes our team uniquely strong. We have case conference where we discuss these complicated patients, we discuss their needs, and as Doug mentioned, identify patients who may benefit from referrals to other departments. And I think that that makes our team really, really special.

Teni Brown: And not to keep bragging about our team, you know, I think, you know, there's no shortage of folks who can treat these conditions. We're lucky in Chicago. But you'll find in some places, some people may do something and someone else doesn't do this in a group, right? And I think this group is unique in the sense that every single person can, like Jules said, offer all of those options. And we love that because we can take care of each other's patients, right? I think it increases access for patients. You can have the confidence. You know, it's difficult sometimes to get in with the provider and you don't have to wait for one person. Any of us can take care of you. You know, I'm out of town. I know my partners can take care of my patients to the level that I feel, you know, is beyond the standard of care. And I think it's really a unique thing. And I think sometimes patients and even providers may not know to look for that, because you want a place where anyone can take care of the patient appropriately.

Host: Yeah, I mean, I can certainly vouch for that. As a frequent referral or somebody who does joint surgery with this group of providers, I really find my patients will ask me, "Who should I go see?" And I actually tell them, "Well, what's closest to your home?" And I can tell you which provider works at that location. And when we do the surgery downtown together, it might be any of their partners, because we have different people who come in on different days of the week when I'm operating. And it is to me too, honestly, a relief that I'm able to offer that and we're able to be so flexible in terms of giving patients what they need, when they need it, and where they need it all over the city.

So, I 100% agree and I don't think we're talking about it too much, because it is such an important aspect. Patient access is such a problem across not just our city, but across the country as we know and specifically for your gynecology procedures, these sort of hidden problems that a lot of our patients don't like to talk about there is really so much availability. And I say, you know, obviously, this is very much geared towards referring providers, but I know we have some patients listening, too. You're allowed to refer yourself. You can actually call and make an appointment with this amazing team, and we'll talk a little bit about that at the end.

But, you know, one thing that I find really interesting in some of the work you do is, as a minimally invasive surgeon, I'm always looking for all the least invasive options for my patients to pursue when it comes to surgery. And often when I do surgeries with you, it's because we've decided on a hysterectomy and the patients need some additional procedures in addition to that, but I'd love to hear more about the work you guys do in uterine-sparing surgery, because we know how important this is for patients. How does that work that we leave the uterus in and do urogynecologic procedures?

Dr. Carol Emi Bretschneider: Yeah. So traditionally, you know, surgery for uterovaginal prolapse involved a hysterectomy. But more recently, there's been a lot more attention towards uterine-sparing surgeries. And there's actually been a lot more literature on this topic. And I think patients themselves are expressing that desire to keep their uteri for one reason or another, whether that's body image or the desire for the most minimally invasive approach. I forgot the question.

Host: So, how does it, how does it work? How do you do that?

Dr. Carol Emi Bretschneider: So, there are many different approaches. You know, like you mentioned, patients who seek uterine-sparing options are often looking for the most minimally invasive approaches, and so we decide that often involves, you know, a vaginal approach without mesh. So, that would involve the sacrospinous hysteropexy, which is a surgery that we all perform pretty regularly for those patients who are looking for uterine-sparing surgeries.

There are other options too though, you know, that aren't just vaginal native tissue repairs. Like Jules had mentioned, we do abdominal repairs, minimally invasive as well, robotic or laparoscopic-assisted uterine-sparing procedures that may involve mesh, may not. But the mesh-augmented uterine-sparing surgery that we do most frequently would be a sacrohysteropexy. And so, that's reserved for patients who may have more severe prolapse or may have actually undergone one of those native tissue uterine-sparing procedures in the past and have failed for one reason or another.

So ,there are many different options that we can consider, and I think it's a really exciting option to offer our patients, especially since, you know, we really pride ourselves in a patient-centered approach, and I think offering uterine-sparing approaches really can meet the patient where they are.

Host: And I'm going to break down that big Latin word, sacro being sacrum, right? Hystero meaning uterus, pexy meaning tagged up. And that's really literally pulling that uterus up such that it is no longer hanging down and causing prolapse, and therefore attaching it either with native tissue or mesh to the sacrum.

I mean, just the coolest procedures, really, that you guys do to really get the patients what they need, what everybody personally needs, as well as really getting these symptoms that are so honestly terrible for these patients. So, what I hear is bread and butter, prolapse and urinary incontinence. That's what you guys do. You cover all of it. You'll take care of all the imaging. You'll get the patients where they need to go, with the right doctor, at the right location. I love it so much.

But even with all that, I know you guys do way more than that, okay? You know, we just described all that bread and butter stuff as well as all the second opinions and the more complicated stuff that Dr. Luchristt mentioned. But I note too that there are patients out there who look and come to tertiary care centers because they were actually born with congenital anomalies. And oftentimes, they go and they find these out at very young ages in the pediatric population. And oftentimes, I feel like those patients will come to see gynecologists and not know who to go to as they continue to have time. And I'm really excited for Dr. Geynisman-Tan to talk a little bit about the CARE Clinic that we have here, the Collaborative Advanced Reconstructive Evaluation Clinic that our urogynecology team is a part of. So, can you share a little bit more about that?

Dr. Julia Geynisman-Tan: Of course, yeah. So this clinic is really interesting. It's actually a multidisciplinary collaboration between our team, Lurie Children's, which we work together with one of their pediatric general surgeons, as well as one of their pediatric urologists, and then a pediatric and adolescent gynecologist who is here over at the NM side. And the way that this clinic runs is we all come together collaboratively to look at the imaging, to do the physical exams, to talk with these patients together, and to come up with the best and really patient-centered care plan for them.

Most of the time we see, you know, teenagers or young adults who are born with differences in how their vagina formed. And that could be a transverse septum, something that's kind of occluding horizontally across the vaginal canal. It might be a complete agenesis of the vaginal canal and sometimes with or without the uterus. And some kind of rarer, more unique anomalies where there's almost like a diagonal septum through the vagina, and sometimes, you know, absence of a kidney or other kind of ureteral or bladder anomalies.

And so, we see a whole bunch of different conditions, but, you know, we have to figure out what is best for that individual's surgical plan for their sexual function, for their future reproductive function. And so, it's a really kind of unique clinic where we all kind of put our heads together and make sure that we're thinking about what that girl needs now and what she needs 15 years from now.

Host: I really love that you, as an adult urogynecologist, is a part of that clinic and is a part of that conversation. I've had some experiences working with pediatric surgeons in other locations than here and sometimes I think decisions are made a bit more unilaterally about what patients and parents want at any given time for their child and maybe the whole discussion about all those other things in terms of sexual function and childbearing and all those things don't come into the discussion because it's not something that our pediatric colleagues are used to counseling patients about, frankly, it's just too young an age.

So, I love the fact that you're a part of it and then able to really bring both the clinical knowledge, as well, later on as they get older, some of that surgical knowledge into the picture. It's just so, so important. And, you know, this partnership with Children's, we are together and separate on many things, but this is one of those areas that it's so wonderful that we can be together and really be able to take care of patients across their lifespan, who have these very, very difficult conditions that definitely impact their personal as well as their reproductive lifespan. So amazing.

You guys do such amazing work taking care of patients. I'm always so impressed and thank you for all the care you've taken of just my patients. But I'd love to hear a little bit on the academic side too, what you guys are doing from a research perspective. So, what are the big areas of research you guys are all focused on? I'll open it up.

Teni Brown: Yeah. I think another fabulous thing about our team is that everyone is actually actively engaged in research. We feel like it's a part of our mission, because it really does help patients, right? Figuring out what the best treatments are. Opportunities to impact policy and women's health, which is really, really important. We have to set that conversation. And so, we do a broad range of research. We do surgical outcomes research. So, we are primarily surgeons. And while we have a lot of data on our surgeries, there's still so much opportunity to say what surgery is best for which patient. So, we have some clinical trials and that's where we're actively, you know, involving our patients who are undergoing surgery that various members of the team are leading.

Some other work that we do is some sort of microbiome research like Dr. Daniels Montan's research and what that means is we know that the vaginal environment bladder has bacteria and this those bacteria serve different function and could probably have some role in the kind of the way patients present and what their symptoms may be like. I mean, that's really an exciting area of research that we're actively involved in. And, you know, my particular interest is in community-based participatory research and implementation science. So, you know, we know that sometimes there's a lag between what we find in research and how we put it into practice.

And I think that's just a real synergistic part of our programs as we are discovering these great things, thinking about how do we translate that to care delivery and really change the way that certain patients are receiving their care. I'm particularly interested in marginalized populations, right? Folks who aren't always showing up in our research. And it's really easy to forget about those groups. And so, that's one thing that each of us has in a lens that we bring to all of our research. You know, Chicago is really diverse and there are lots of different folks in Chicago and making sure that those individuals participate in research, not just to participate in research, but to really benefit from it and really make sure that our science is stronger.

Host: What would you say if there's any patients listening who say, "Hey, I have some problems and maybe I want to be a part of research, but I'm just not sure I trust the research," what would you tell those patients?

Teni Brown: I'd say, "Get it." The medical field hasn't been very trustworthy, right? We have to earn our patients trust. But I would say research is so exciting. Like actually people don't realize that they do research all the time, right? You think about a problem and you think about the different ways you can solve it and you test it. That's really all it is. Sometimes just calling it research makes it seem like some big, weird saying and like, you know, we're not experimenting on people. It's really putting an organized process to say really what works best and figure out what it is that works. So if anyone is on the fence about it, I think you have a right to ask questions. That's one thing. There's no emergency in research. You can take your time. You can probe. You can share those concerns. There's no such thing as a silly question. Trust me, somebody else has had it. Because I think a lot of times it's just some misconception about what it is and what you may be getting out of it.

I think the biggest thing is a lot of our patients, because about how distressing these conditions are, especially when they get help, they want to help other women, right? Like, it's that same drive that we all had to go into this field. And you do that with research, right? You know, you can touch one patient with clinical care. With research, you can just impact a whole lot of people. And so, I tell them, if there's any part of you that wants to help other women who have the conditions that you have, research is an excellent way to do that because your experience contributes to making our treatments better.

Dr. Julia Geynisman-Tan: Absolutely. Absolutely. I love that so much. I think also, you know, so much of the research that we do in this field is about symptoms and not about, you know, poking or prodding or doing something physical to somebody, right? I mean, the conditions we treat are quality of life conditions. And the most important outcome that we study is how this has impacted your quality of life as a patient.

And so, you know, there's so much of the research that we do that involves filling out questionnaires or telling us about how your life has changed in an interview, right? It doesn't have to be, you know, getting shots and needles and medicines and things that, you know, some patients perceived as being riskier. And so, I think that there's different ways that you can be involved in research and still, you know, help other women going through this condition.

Host: Yeah.

Dr. Julia Geynisman-Tan: And in a place where every patient is comfortable.

Host: Right.

Dr. Julia Geynisman-Tan: Yeah.

Host: I love that. Okay. So to close us out, I know now everybody's going to be calling the phones or phone lines and all that, where can our patients see you and who can they see? Kind of share with us a little bit about that and we can put some numbers and things in as well.

Dr. Carol Emi Bretschneider: So, we have several clinics in the Chicagoland area. Doug spearheads the practice up at Lake Forest. We actually just had a new partner join us up there. It's really exciting. She started in September. Her name is Dr. Vi duong. So, women who live in the North region who prefer to get their care up in the north, please seek Dr. Luchristt or Dr. Duong up there. Out west, Dr. Geynisman-Tan and I see patients out there as well as downtown, and Dr. Luchristt, sorry, he also sees patients downtown. So, out at CDH, that's in Winfield, so patients who prefer to get their care out west can see us there. And Dr. Brown, Dr. Teni sees patients down at Palos Mokena in the south region, as she sees patients downtown as well. So, we have a very wide range, wide-- yeah, catchment, thank you. They have a wide catchment area, so patients can see us at wherever location is most convenient for them.

Host: And I know some patients will ask this question, you guys are all kind of based downtown. Must they come downtown for their surgery, or are there opportunities for them to have their surgeries out, for example, up at Lake Forest?

Dr. Douglas Luchristt: Yeah, that's a common question we definitely get. And I think the important thing is we've talked about how we offer the full spectrum of urogynecologic care. And importantly, we can provide that at all of those locations. We have full access to all of the different robotic technologies if your surgery would necessitate that. Or for really any of these complex or more straightforward conditions, we can provide care within those hospitals, whether it be at Lake Forest, Central DuPage, or Palos, down in the South region. So, you are not required to come downtown unless you want to, and we're always happy to see you here too.

Dr. Carol Emi Bretschneider: And unless there's a need for multiple providers, yeah, but we don't.

Host: Yeah, or a tertiary care center, but most of the time patients can have their procedures out and about.

Teni Brown: And, you know, patients, because our programs are standardized across all of our sites, we all have patients who will actually flip-flop sometimes just depending on what's more convenient. So, let's say a patient wants Botox and there's just a more convenient Wednesday at a different location. Again, this is why it's so important that, you know, the confidence that anybody can take care of our patients. Sometimes patients will go to a different region or maybe they have a particular relationship with one of our advanced practice providers at a different location and they'll see them for some more sort of follow up lower level care at a different location maybe because they have a family member that they go see once a week. And it's convenient to get their care at Lake Forest when they're up north, so that is also an option that's available to the patient.

Host: I love that. I think my real message about this is, as Northwestern's expanded, obviously, there's more and more providers that have come into our system. What I really wanted to point out was, our urogynecology division, these are our academic doctors. They are working downtown with our trainees. They are working out in the suburbs. They are all part of our academic mission and really the like high-level providers that you expect to get when you come to Northwestern Medicine. And so, we're really, really amazed by how much you guys sort of move throughout the Chicagoland area to really get the services that patients need where they live, which I think is so, so important. So, thank you guys for all that and the driving on the highways to get to all those places, of course.

As we close out here, any final comments for all you guys, either for our referring providers or for our patients listening today?

Dr. Douglas Luchristt: I think that one thing that I did want to, you know, kind of point out and highlight, we talked about our care clinic, you know, working sometimes with these adolescent populations, we talked about the uterine-sparing options that are available. There's no age at which it's appropriate to consider treatment of your pelvic floor disorder and below which it's not. And so, just kind of hammering home the point that if you think that they have distress or issues related to any of these pelvic floor conditions, please send them to see us. And, you know, we'll help work with them to figure out what's the best fit for them.

Host: Amazing. All right. Well, thank you guys so much. It's been such a pleasure. Thank you for joining Parts and Labor today. And I look forward to sending many patients to all of you.

Dr. Carol Emi Bretschneider: Thank you so much, Angela. It was a great time. Thanks so much.

Host: Thank you.