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Diane Newman: Welcome everyone to the UroToday Pelvic Health Center of Excellence. Today, I have a urologist expert, Dr. Ariana Smith, who's the director of pelvic medicine reconstructive surgery, associate professor of urology and surgery at the University of Pennsylvania, and in Pennsylvania Hospital. Welcome, Ariana.

Dr. Ariana Smith: Thanks, Diane. It's great to be here with you.

Diane Newman: Can you tell us a little bit about your practice, profile your patients and some of your treatment options?

Dr. Ariana Smith: Sure. I am board certified in both urology and female pelvic medicine reconstructive surgery, so my practice is primarily geared toward women with pelvic floor disorders. However, I do also see some men with those types of complaints. I see women who are seeking surgical options, as well as medical treatments or behavioral treatments for their complaints and I'm often in a situation where I'm counseling patients on the risks and benefits of pelvic floor surgery. I spend a lot of my time discussing surgical options, behavioral options, and the decision making process for undergoing surgery. I offer patients a pretty wide array of options, including mesh, pelvic floor reconstructions, as well as native tissue and completely mesh-free alternatives for both urinary incontinence and pelvic organ prolapse. 

Diane Newman: Ariana, do you see both men and women or just primarily women? 

Dr. Ariana Smith: Primarily women, but I do see men with neurologic disease, men with urinary incontinence, or other complaints of the pelvic floor that are unrelated to urologic cancer. 

Diane Newman: You mentioned that you do surgery using mesh, and I know you're aware of all the controversies around it and some recent publications in the New York Times and the piece on 60 Minutes about actually the misuse of mesh. Can you tell us a little bit about when you use mesh, do you always use mesh, what your views are on the use of that material for surgery?

Dr. Ariana Smith: Absolutely. As you know, this is a very heated topic and one that's brought up much controversy in the media and among the lay public as well as among experts in the field, and it's something that's discussed commonly at professional meetings. The real issue with mesh, if I could just try to simplify it down for maybe some of the audience who doesn't use mesh every day, is that mesh was brought into the arena of female pelvic floor disorders to improve the durability of the surgeries we offer, and mesh has a role in pelvic floor surgery, but it needs to be used with caution and it needs to be used when patients are appropriately counseled on the risks and the benefits. I don't think of mesh as a bad product in all situations the way the media has sometimes portrayed it, but I do think it needs to be used responsibly and it is our job as surgeons to make sure that the material is used responsibly.

Diane Newman: You know Ariana, since I practice with you at Penn, I know you do a lot of what we call redos. You're taking out already existing mesh in women who are having problems. Can you tell us a little bit about that part of your practice?

Dr. Ariana Smith: Sure, sure. As much as I believe that mesh has a role, there are times when things go poorly for patients and they have bad outcomes. We see that whether they're having a mesh surgery or even in the setting of a non-mesh surgery. Oftentimes I do see patients who need either a revision of their original surgery or something removed to improve a symptom, and I'm often faced with a discussion about removing a segment of mesh or removing an entire mesh, and it really does depend on the patient's clinical situation, the complaints that they have, and their physical exam findings. 

There are many times where patients will come in and they attribute the symptoms they're having to the mesh that's in their body because of something they heard on television or saw in the media, and many times when I evaluate the patient, I find that the symptom they're having has absolutely nothing to do with the mesh and it's something that could be treated in another way. I do spend a lot of time trying to understand the complaints that the patient has, where their mesh is located, what was done with that mesh, and I really spend a lot of time on the exam phase to really figure out if the mesh could be the cause of their symptoms.

I do take them for surgery in situations, and I think this is what you were getting at. I do take patients in many situations and I have to take their mesh out and then do some other kind of repair to either kind of address their underlying symptom, whether it be incontinence or prolapse, or repair something that the mesh may have caused. I have several options at my disposal, using their own tissue, harvesting tissues from other parts of their body, or in some situations when patients opt for it, we may use mesh again.

Diane Newman: You're of course in Philadelphia. Where do you see women come in from? Other areas? Because you are an expert in pelvic floor reconstructive surgery and I know you see many, many women. What is your population, from what areas?

Dr. Ariana Smith: Yeah, at the University of Penn, we certainly draw from the whole mid Atlantic. There are certainly patients who will travel, depending on what exactly they're looking for. For this particular issue with mesh redos and removal of mesh, we do see patients coming quite a distance up and down the East Coast looking for somebody that has some experience with mesh removal. There are more and more providers coming out in female pelvic medicine and reconstructive surgery as the fellowships have grown, so there's more providers entering the workforce at various institutions across the U.S., but there was a time when it was challenging for patients to really find a surgeon who had experience. 

Yeah, at the University of Penn, we certainly draw from a much larger area than just the city of Philadelphia. We extend into the suburbs and north and south of Philadelphia and east and west as well. 

Diane Newman: Saying I was a woman in maybe my 40s or 50s and I was looking for surgery for either my incontinence or for prolapse. What should I ask the physician to make sure that I'm going to get someone who's competent and really is someone I'm going to trust to be able to do this surgery the correct way and use either mesh or native tissue, whichever they feel is the best for my situation? 

Dr. Ariana Smith: That's a great question, Diane, and I wish that a lot of the patients would come in the door sort of hoping to have discussions about this. Sometimes patients walk in the door and think they already know what they should have based on either what they've read or their prior experiences. It's certainly my preference when patients walk in the door with an open mind and want to just hear what their options are. 

What I like to start with is actually confirming that they need surgery. As you know, many, many patients do not need surgery and there are often behavioral interventions we can do or pessaries or other strategies that allow patients to have relief of their symptoms without the use of surgery. I think it's important for all patients to understand that before they ever make a decision about undergoing surgery. There is certainly controversy about what we do in pelvic floor disorders and we need to make sure that patients are well, very much understanding the risks and benefits of what we have to offer. 

After I've at least confirmed to the best of my abilities that the patient is a good surgical candidate and they in fact would like to proceed with surgery, I discuss mesh and non-mesh alternatives. I think it's important for patients to have that dialog with a provider and I think it's best when the provider can offer both a mesh and a non-mesh alternative. It gives them equipoise in the discussion and it gives them the opportunity to report what the differences are in their patient population when patients have used mesh and when they haven't used mesh. 

I think a really important discussion point to have with a surgeon if you're thinking about having surgery is about those specific risks and how they may apply to you as an individual patient. We know that complications occur, but they tend to occur in patients who are at risk. If a patient could best understand what about them as an individual puts them at potential risk for say a mesh complication, that may help them understand and make better decisions about their treatment options. 

Then the other really important thing is to talk about your expectations of surgery. If you are walking in the door and you really want to have one surgery for the rest of your life and you're willing to accept some risk knowing that you hopefully have the most durable operation possible, you're going to get counseled in a different direction than if you say, "My primary concern is avoiding any potential complication moving forward." Those are right now two very different things when we discuss pelvic floor surgery.

Diane Newman: You mentioned the fact with prolapse, you're right there, the initial treatment may be a pessary. Many women, you and I both see women who do very well with pessaries, which are vaginal support devices that women can use to really support that prolapse. Prolapses we see in women and aging women, who is too old to have these surgeries? Do you consider age as one of the risk factors when considering operating in a pelvis?

Dr. Ariana Smith: That's also a really great question and I'm faced with that almost every day in the clinic. As the literature on aging has evolved, specifically in the surgical realm, we're learning more and more about frailty and measures of frailty and how important those measures are when counseling patients on surgery. I'm using less ... I'm not really using an age cut off, I'm trying to look really at the whole patient and understand what their physical status is, what their social support network is before I really say whether or not surgery may be an option for patients. 

I think historically we were reluctant to operate on patients in their 80s and 90s out of fear of medical consequence to anesthesia or should a complication develop, the difficulty in overcoming that complication. However, I am seeing very healthy 80- and 90-year-old women walking into my clinic on a regular basis who are fit and who desire a lasting treatment, because they plan to live another 20 years or more. I'm really not using any age cut-offs. I certainly have had patients well into their 90s who have elected to undergo minor pelvic floor surgery and I think that those options should be left available to those who are healthy in aging, and I think as reconstructive surgeons, we really need to hone in on their frailty indices and really try to make sure we're selecting patients who are not too frail to undergo surgery as opposed to too old.

Diane Newman: Thank you so much, Dr. Smith, for talking with us about these interventions for ... surgical interventions for stress urinary incontinence and pelvic organ prolapse. Have a good day. 

Dr. Ariana Smith: Thank you, Diane.