Evo Terra (Host): Urogynecology is a specialized field that deals with female pelvic medicine and reconstructive surgery. Today, with the help of Dr. Julius Szigeti, a urogynecologist and minimally invasive gynecologic surgeon at TriState Health, we'll find out more about the services offered at TriState Urogynecology.

 This is TriState Health Talk from TriState Health. I'm Evo Terra. Dr. Szigeti, thanks for joining me. I'd like to give a better overview of your field to the listener. What is Urogynecology and what do you do?

Julius Szigeti II, MD: Thanks, Evo. I'm excited to be here. Urogynecology is a relatively new subspecialty that involves kind of the treatment of female urinary incontinence, which is leaking urine for women when they don't want to, or being unable to control the flow of urine. Also, problems with emptying the bladder properly and other pelvic floor problems, which there's a number such as prolapse, which is basically weakening of the vaginal supports, usually from childbirth damage and other trauma that allows the bladder or the uterus or the bowel or the rectum to bulge and push down through the vaginal wall, creating a bulge.

Now, to become a urogynecologist, either an OB-GYN or a urologist, can then go on to a fellowship of three years to do Urogynecology. So, that's four years of medical school, four years of residency, three years of fellowship. So, it's a little bit of training.

Host: Got it. So, did you start out as a urologist or a gynecologist?

Julius Szigeti II, MD: I was a general OB-GYN. And then, after a while, stopped doing the Obstetrics and focused on the surgical side of the specialty. But I got into urogynecology before there were fellowships. I started back in the days where there was nobody else to send my patients to with these problems, so I decided I had to figure out how to take care of it myself, and went on from there.

Host: Yeah. I can definitely understand the need for that specialized field. I mean, I have a urologist, obviously. I'm 56 years old, of course I do. And some of those symptoms aren't quite familiar to me. But definitely, the female anatomy certainly presents its own unique set of challenges. Is there something specific that you can remember? Like you kept seeing something in your patients, and that's what made you want to take this turn?

Julius Szigeti II, MD: So basically, it was the combination of having patients with leaking, as a general gynecologist, you're not very well trained to address. And then, people with severe prolapse. Way back in the day, we had a limited number of techniques, and all of them had relatively high failure rates, so I decided I was going to dedicate myself to try to get the best possible results I could.

Host: Yeah, yeah. Well, let's talk about that prolapse for just a moment, and possibly even incontinence if you need to talk about them together. You described what it is. How is it repaired, I guess is the right word I'm lookin for?

Julius Szigeti II, MD: There's a wide variety of ways over the years that has been done to repair them surgically. It's basically a surgical repair. And originally, it was vaginal surgery. There's also ways to do it abdominally, there's ways to address it laparoscopically. And then, more currently, we use the robotic laparoscopic systems to take care of it.

Host: You mentioned the da Vinci robot, which I have seen do a variety of things. But obviously, there's implications in your field as well. Can you tell me about the benefits of using the da Vinci robot?

Julius Szigeti II, MD: The da Vinci allows us to do surgery better, less invasively, with less pain and more rapid recovery. It's basically operating through four little holes in the abdomen, each about the diameter of a dime. And it allows the surgeon to use a console where you control the instruments that are going through those little holes, in a very precise way, and it gives you true 3D vision. So, it's almost like doing microscopic surgery with fancy instruments with more precision than what the human hand can do.

Host: Just looking at what AI has done for us today, I don't want that operating on me, Julius. I'm glad there is a skilled--

Julius Szigeti II, MD: No, it's going to be a while.

Host: Yes, a very long time. I'm happy that there are skilled physicians on the other hand. Surgeons who know what they're doing, running the show is certainly helpful. So, this procedure that you're talking about, these small laparoscopic incisions, they go in. Are you repairing the muscles? I don't want you to describe everything for me, but in general, what's happening?

Julius Szigeti II, MD: So basically, the problem with prolapse is the vaginal walls have various parts where the support is deficient. The vagina is kind of like a hollow tube sitting between two hammocks. And the hammocks are broken. And so, the best way for us to fix that is we take a permanent, lightweight, surgical mesh, and we wrap it all the way around the vagina, so it supports all areas. And that mesh is sutured to the muscular layer of the vaginal wall. And then, there's a strip of that mesh that comes up that we anchor to the strong ligaments on the lower spine that gives a very solid connection and helps hold everything back up.

Host: Is it a similar procedure for incontinence?

Julius Szigeti II, MD: So incontinence, usually the main procedure for incontinence, the version called stress incontinence, which is where women leak with laugh, cough, sneeze, moving, lifting. And it's usually because there's loss of support of the urethra, the tube coming out of the bladder. To fix the loss of support there, the best procedure we have is actually done from the vaginal side through a small incision. And we put a little thin strip of mesh, a little hammock of mesh, underneath the urethra to support it so that it can't go down when people laugh, cough, or sneeze. And that's also a minimally invasive and a minimally painful procedure.

Host: Right, right. Good. I want to get to some of the services that we're offering at the hospital. But before I do that, there's one other condition I want to speak about briefly that I'm aware of, and that's endometriosis. Talk to me a little bit about that and how can we treat that?

Julius Szigeti II, MD: Endometriosis is a very common disorder of young reproductive age women. It's often associated with very painful periods, pelvic pain in general, pain with intercourse, pain with bowel movements. And it's basically a condition where the tissue that lines the inside of the uterus that bleeds every month when women have a period, that tissue is growing other places it shouldn't, either in the muscle layers of the uterus, on the outside surface of the uterus, inside the surface lining of the pelvis sometimes involving bowels, sometimes bladder, sometimes ovaries or tubes. It can actually affect anything inside the abdomen, so it can be in a number of places. But it's most commonly down behind and around the area of the uterus. And so, when women have their period every month, that tissue bleeds and causes a lot of inflammation and pain and discomfort and scarring. And so, secondarily, the scarring can become a problem after many years of things going on.

Host: How do we treat that?

Julius Szigeti II, MD: So, endometriosis can be treated initially with hormonal treatments, the simplest of which are birth control pills. A lot of women will experience a lot of relief from that. So, we're mainly treating symptoms initially. But if those symptoms persist or women can't get good relief of their pain, and pain becomes the main issue, then endometriosis at that point is best treated surgically.

The best way to do that is with the robotic laparoscopy system because of the precision it affords us in operating. And the best bet is to be very aggressive about removing all visible endometriosis that can be seen. Now, that's best in women while they're still trying to have children. Once women have completed childbearing, then they're still having problems with endometriosis, the best treatment there is, again, robotic excision of the endometriosis, but also a hysterectomy, removing the cervix, uterus, and tubes. In women who are younger than their 50s, we tend to leave the ovaries behind for normal hormonal function. In women who are past their 50s, then we usually remove the ovaries as well, because they provide minimal benefit at that point. And you also have the benefit of reducing future cancer risk.

Host: Yeah, yeah. Exactly. It all makes sense. Well, we talked about a lot of treatments. I think we should now just talk about the services that the clinic at TriState offers for women in this urogynecologic area. Can you help us with that?

Julius Szigeti II, MD: Sure. So first, I'll talk about the things specific to Urogynecology. So as part of the evaluation of women's incontinence and their pelvic floor problems, the mainstay of that is a procedure called urodynamics, which we in detail evaluate the bladder function. And then, there's cystoscopy, where we look inside the bladder through a small skinny flexible tube that has a camera on it to make sure there's nothing abnormal going on inside the bladder.

Once we're done with all their evaluation, we, you know, sit down and have a discussion of kind of what we found and what are all the options. Some of the non surgical things may be pelvic floor physical therapy, possibly medications for certain types of urgent continence or overactive bladder, or surgery for the stress incontinence or other pelvic floor problems. There can be non-surgical management of prolapse, which is using something called pessaries. They're kind of like a big diaphragm, a big silicone rubber device that fits inside the vagina to help hold things up so things don't bulge down. We can manage that sometimes for our older patients or younger patients can manage it themselves. And for some people, it works very well for years, especially in older patients who aren't excited about the prospects of having any surgery.

And then, outside of the realm of the Urogynecology, we have a nurse practitioner working in our clinic as well, Dezirae Berry. And between her and I, we work together and take care of other GYN problems as well, including just routine pap smears, evaluating and treating abnormal pap smears; other problems, irregular periods, heavy periods, painful periods, pelvic pain, contraception counseling, problems with that whole process of the menopausal transition, and basically all other things gynecology. We also do a number of office procedures, such as colposcopy, which is kind of a microscopic evaluation of the cervix in people who have abnormal Pap smears; office hysteroscopy, which is Looking inside the uterus through a skinny tube with a camera to diagnose certain problems associated with bleeding, or sometimes to remove IUDs where the string has gotten up in there and they can't be removed the usual way. We also do IUD insertion and removal, and basically any gynecologic procedure that needs being done in the office.

Host: Is there anything I did not ask that you wanted us to have a quick conversation about?

Julius Szigeti II, MD: I would say the only other thing is that women commonly have heard things like surgery for their prolapse will fail. Well, you know, that was true in the old days, but that's not really true these days. We have less than 5% long-term failure rate with the mesh suspension of the vagina, which is called sacrocolpopexy. And lots of times people think that leaking is just a part of aging. It's not a normal part. It's common, but it's not normal. So, we have things to do to evaluate and treat it and make it better.

Having said that, we still have limitations to what we can do. There are types of problems with very overactive bladders that require more extensive advanced procedures that we don't offer in our clinic, then those would be referred out. And then, there's just problem with some of those very overactive bladders that never can be fixed, only improved and the symptoms managed. So, it's good for people to have the right expectations. There's a lot that we can do these days that's better than it used to be. But, we're still not quite to the point where we can fix everything for everybody.

Host: Understood. Well, Doctor, thank you very much for helping us understand the services that are offered there at TriState Urogynecology. You have an enjoyable rest of your day.

Julius Szigeti II, MD: Thank you. It was a pleasure.

Host: Once again that was Dr Julius Szigeti, a urogynecologist and minimally invasive gynecologic surgeon at TriState Health. For more information please visit tsh.org/urogynecology. That's U-R-O-G-Y-N-E-C-O-L-O-G-Y You'll learn more and can even fill out a new patient form today If you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Evo Terra, and this has been TriState Health Talk from TriState Health. Thanks for listening.