Here is my Reader’s Digest short version of www.alinsodinstitute.com’s coverage of the basic problems women face when aging and gravity starts to win. Click on the section titles to lead you to more content.
Incontinence Slings
The “Slings” you hear about are for Stress Incontinence (leakage of urine that occur with laughing, coughing, sneezing, jumping, trampolines. Slings are made of polypropylene, an inert nylon, that is placed right under the mid urethra to act as a backboard when pressure from above (cough/sneeze/laugh/jump) compresses the urethral tube into the sling to prevent leakage. Slings are “Tension-Free” because the slings are free floating and not sutured into any structure. This is the current Gold Standard of incontinence surgery.
You may hear the term “TVT” or “TOT” which refers to the route the slings are placed. TVT, or tension-free vaginal tape is placed through incisions right above your pubic bone. TOT (transobturator tape) is placed through incisions on the crease of your inner thighs. Once healed you can barely see these incisions. Both procedures are outpatient surgeries of about 15 to 30minutes and can be done with pelvic floor repair and cosmetic procedures such as labiaplasty and vaginoplasty. The success rates vary from 80 to 95 percent. Occasional complications of mesh eroding through skin, urethra, or bladder do occur. Other complications are slings that are too tight preventing urination. I use a sling system I helped design back in 2002 which has proven to be safe, works well, and is enduring. They are shown in the example surgery below with my hands holding them.
The Luksenburg System for Mesh-Free Incontinence Treatment
Ariel Luksenburg, M.D., a gynecologist from Uruguay, introduced his system for the treatment of severe stress incontinence to the U.S. in 2021 at the International Society for Cosmetogynecology Pre-Congress workshop in Fort Lauderdale, FL. The course was repeated in 2022 and most recently in March of 2023. This time with FDA clearance to use his threads and patented delivery system. After hearing the system patent was granted, the PCL threads becoming CE and FDA compliant, and seeing the 3-year data presented, I became a believer. I was honored when Ariel Luksenburg and Jorge Gaviria invited me to become the first surgeon in the U.S. to be trained, perform, and to teach The Luksenburg System. They committed to also train my California colleague Judy Wei, MD. We trained on July 24 and 25, 2023, in Irvine, California, at Dr. Judy Wei’s beautiful office and now offer this in Dallas, Las Vegas and Irvine.
Here is a link to my Feminine Wellness Newsletter Video of the procedure: https://open.substack.com/pub/femininewellness/p/the-luksenburg-system-for-the-leaky?r=8vc2b&utm_campaign=post&utm_medium=web
Cystocele Repair or Fallen Bladder Repair
A bulge of skin that can be felt or seen coming out of the vagina looking like an egg or a golf ball is usually the bladder or rectum. Sometimes it is the urethra, cervix, uterus, or top of the vagina if there has been a hysterectomy. Urinary leakage often accompanies this bulge if it is the bladder falling down along with the tube that drains it called the urethra. Us gynecologists call this “Prolapse.” Pelvic pressure, feeling of fullness and heaviness are common symptoms. This is mostly caused by childbirth trauma and the aging process with loss of collagen support. The average age of my repair patients is 54. Sometimes there are minimal to no symptoms and you just see an unsightly mass. Cystocele repair (also called Anterior Repair or Anterior Colporrhaphy) is the surgical elimination of the bulge and restoring normal anatomy. This is done in the Surgery Center or hospital under general or spinal/epidural anesthesia. Traditional techniques of bunching or overlapping tissues with suture has a very high failure rate ranging from 25 to 60 percent. It is a challenging surgery. Modern repair treats this bulge as a hernia of the bladder going into the vagina aided by a graft to build a new firm wall. I have performed and taught this augmented surgery in the United States since 1997 with success rates of about 90% when using a dermal patch (cadaver skin). I currently use the product made by ARMS Medical called VNew Dermal Allograft. I designed the specialized shapes for its bladder repair and rectal repair products. The use of nylon patches works very well with failure rates less than 5% but the FDA has removed most of the nylon mesh products in the market. A company called Coloplast has an ultra-lightweight mesh that experienced Urogynecologist have used safely and successfully. I brought this into the United States from Scotland in 2004. It was first called POP Mesh, then MPathy Mesh, and now Restorelle. I may use this product for the most severe cases or use it for prior failed surgeries.
Rectocele Repair or Fallen Rectum Repair
When the bulge into the vagina comes from the rectum it is called a rectocele. As with other forms of pelvic organ prolapse (cystoceles, enteroceles, vaginal prolapse) childbirth, chronic cough, chronic constipation, and obesity are predisposing factors. Symptoms are similar to cystoceles such as pelvic pressure, an unsightly bulge in the vagina, and constipation. It is sometimes hard to tell if the bulge is from the bladder or rectum and the examining physician will need to use a “Half Speculum” to define what is hanging out. Furthermore, the need of reaching into the vagina to push stool out is not uncommon and a giveaway that the rectum is falling out and giving symptoms. Of course, both the rectum and bladder can fall out together at the same time. Surgical repair consists of using sutures to bunch up the bulging tissues together or bringing muscles together into a new flat floorboard. More modern repair consists of the use of mesh or donor tissues. Rectocele repairs have a 90-95% success rate when the muscles are approximated together.
Uterine Suspension
When a hard lump is felt or seen hanging out the vagina it’s usually a cervix and uterus and often with a bladder attached. A hysterectomy and suspension of the top of the vagina is the traditional cure. It works very well. If you don’t want a hysterectomy, then I can suspend the entire structure falling out with a suspension procedure I invented almost 20 years ago. This is a great option for those with a small cervix and a small uterus typical of menopausal women. I have taught this technique worldwide. I use either cadaver tissue or ultralightweight mesh as suspensory and supporting pseudo-ligaments like a pulley system. I do these in a surgery center or operating room under general anesthesia. It takes me 60-90 minutes. Again, a high-volume surgeon for this specific procedure is important to find if you want the best outcomes.
Vaginal Vault Prolapse (Fallen Vagina)
After a hysterectomy a vagina that loses its support may come down and out like an inside-out sock. If a woman still has her uterus then this is called a uterovaginal vault prolapse. If only the uterus falls out and the top of the vagina is still well suspended then it is called a uterine prolapse. Vaginal vault suspension can be done in many ways. You can use the patient’s own weakened tissues or augment the repair using a biologic product such as human cadaver skin dermis or polypropylene nylon. Some physicians prefer an abdominal approach to attach the top of the fallen vagina to the sacrum. Some highly skilled surgeons do this laparoscopically with a Sacralcolpopexy. That is when you suture the top of the vagina to a bony prominence of the sacrum deep inside the pelvis.
Robotic surgery has made this easier this past decade and today’s recently trained graduates use this route as their primary approach. The vaginal approach to suspending the top of the vagina used to be the most common but it is becoming less and less as their surgical numbers in training programs decline. The top of the vagina can be sutured to the uterosacral ligaments or to the sacrospinous ligaments through the vaginal approach. Either approach works well with different complications to consider. The vaginal surgery skills needed for this excellent technique is getting lost in today’s academic training programs. You have to find a high-volume surgeon that gets enough of these cases to remain competent. The success rates of all methods are approximately the same at 80 – 90%.Social Media:
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