BackTable OBGYN: Recent Episodes
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The BackTable OBGYN Podcast is a resource for practicing OBGYN's to learn tips, techniques, and practical advice from their peers in the field. Listen here or on the streaming platform of your choice.
This week on BackTable Urology, Dr. Suzette Sutherland (University of Washington) and Dr. Olivia Chang (UC Irvine) discuss reasons for uterine preservation and hysteropexy techniques for prolapse repair.
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First, Suzette and Olivia discuss the value of keeping the uterus in place for women undergoing prolapse repairs, as well as the indications for apical suspension surgery. They also note the historical context of hysterectomy and why it has been the go-to treatment for so long. Next, the doctors discuss the advantages of hysteropexy over hysterectomy for prolapse repair, such as a shorter operative time, less bleeding, and a quicker recovery. The doctors then go into more detail about the best approaches for prolapse repair, like weighing the options of permanent sutures versus delayed absorbable sutures. They also analyze recurrence rates after prolapse surgery, specifically in the anterior compartment.
Then, they explore the data on how the choice to keep the uterus in place can stem from a woman's personal and cultural views. Olivia shares about the Value of Uterus questionnaire, a six-question survey instrument that can quantify how a woman values her uterus. It can streamline clinic visits and help to predict whether a woman would choose a uterine-preserving procedure. The doctors note that there is research demonstrating a correlation between valuing the uterus and sexual activity.
Finally, Suzette and Olivia contraindications for leaving the uterus in place. They emphasize the importance of assessing for abnormal uterine bleeding and cervical pathology before recommending uterine preservation. They suggest that listeners review the current guidelines around preoperative workup and consider transvaginal ultrasound or endometrial biopsy first. Lastly, they emphasize the importance of symptom and risk stratification and shared decision making when it comes to uterine preservation.
RESOURCES
Chang OH, Walters MD, Yao M, Lapin B. Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus. Am J Obstet Gynecol. 2022 Jun 25:S0002-9378(22)00483-5. doi: 10.1016/j.ajog.2022.06.029. Epub ahead of print. PMID: 35764134. https://pubmed.ncbi.nlm.nih.gov/35764134/
In this episode, Dr. Mark Hoffman invites Dr. Ted Lee, an OBGYN specializing in MIGS and professor of OBGYN at University of Pittsburgh Medical Center, about the ambulatory workup of endometriosis patients.
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SHOW NOTES
The episode begins with the physicians discussing the difficulties of diagnosing endometriosis, including: the stigma of pelvic pain/not believing women’s pain, recognition that pelvic pain is not normal, the discomfort of physicians asking the appropriate questions for pelvic pain, and the hesitancy towards surgery by physicians and patients all play a role. Many patients have been having pain for years that may have been covered up by OCP use or misdiagnosed as IBS or interstitial cystitis.
Ted emphasizes the importance of a thorough history in diagnosing endometriosis. Essential information includes age of onset of symptoms, gravidity and parity, prior C-section (abdominal wall endometriosis) and the “3 D’s” of dyspareunia, dyschezia, and most importantly dysmenorrhea. A quality physical exam can also elucidate endometriosis. Ted starts by palpating the anterior vaginal wall, then the levator ani muscles and cervix, and finally the rectovaginal exam. Palpation of the uterosacral ligament and posterior cul-de-sac in endometriosis patients causes a visceral reaction, and advanced disease may also have nodules felt. The majority of patients don’t require additional imaging since ultrasound is insensitive for stage 1 and 2 endometriosis. Indications for MRI include endometrioma, nodularities felt on exam, and abdominal wall endometriosis. When it comes to surgery, both doctors emphasize the importance of having other surgeons on your team, including colorectal surgery, general surgery, and urology. Ted dives into some surgical tips and techniques from his years of experience.
Finally, the physicians end by discussing the future of endometriosis diagnosis. A Japanese study has recently found fusobacterium in the uterine microbiome in endometriosis patients more often than those without. Also, a French study has taken saliva samples and found signature microRNAs for endometriosis. It will be interesting to see how studies like these change the future of endometriosis diagnosis and if it will bring new challenges, such as overtreatment and overdiagnosis.
RESOURCES
Muraoka, A., Suzuki, M., Hamaguchi, T., Watanabe, S., Iijima, K., Murofushi, Y., Shinjo, K., Osuka, S., Hariyama, Y., Ito, M., Ohno, K., Kiyono, T., Kyo, S., Iwase, A., Kikkawa, F., Kajiyama, H., & Kondo, Y. (2023). Fusobacterium infection facilitates the development of endometriosis through the phenotypic transition of endometrial fibroblasts. Science translational medicine, 15(700), eadd1531. https://doi.org/10.1126/scitranslmed.add1531
Bendifallah, S., Suisse, S., Puchar, A., Delbos, L., Poilblanc, M., Descamps, P., Golfier, F., Jornea, L., Bouteiller, D., Touboul, C., Dabi, Y., & Daraï, E. (2022). Salivary MicroRNA Signature for Diagnosis of Endometriosis. Journal of clinical medicine, 11(3), 612. https://doi.org/10.3390/jcm11030612
In this episode of BackTable Urology, Dr. Aditya Bagrodia speaks with PGY4 urologist Dr. Chloe Peters (University of Washington) and OB/GYN Dr. Beverly Gray (Duke University) about their work in women's health and advocacy, and how the Dobbs ruling has impacted their respective medical fields.
SHOW NOTES
First, the doctors explore the implications of state abortion laws on the OB/GYN and urology workforces and how they may directly impact where people choose to live and work. Dr. Peters and Dr. Gray explain the complexities of state abortion policies, as well as the differences between restrictive and nonrestrictive states. The Dobbs ruling in June 2022 gave individual states the power to regulate any aspect of abortion not protected by federal law, thus overturning Roe v. Wade. Both doctors emphasize that this ruling affects all urologists and OB/GYNs in private and academic settings, because they provide unsafe environments for patients who need them.
Recent studies and surveys show how restrictive abortion laws are impacting the urology rank lists and applications. One in five applicants to the urology match took programs off their list because they are located in states with illegal abortion laws, and almost 60% said they would worry about their health and safety if they matched in a state with restrictive laws. In summary, all three doctors agreed that restrictive laws can have a direct impact on residency and urology recruitment efforts.
Finally, they observe that the increasing diversity in the field of urology has encouraged younger, female members to advocate for better access to healthcare. They remain optimistic that the current generation can use their voices to create change and provide better access to care for all.
RESOURCES
American Urologic Association (AUA) Position Statement on the Supreme Court’s Decision to Overturn Roe v. Wade https://www.auanet.org/about-us/aua-statement-on-overturning-roe-v-wade
American College of Obstetricians and Gynecologist (ACOG) Abortion Policy https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/abortion-policy
Ryan Residency Training Program https://ryanprogram.org/
In this episode, Drs. Mark Hoffman and Amy Park invite Drs. Rebecca Stone and Kara Long Roche to speak about opportunistic salpingectomy to prevent ovarian cancer, specifically serous carcinoma.
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The episode begins discussing ovarian cancer as a whole and how it affects 1 in 78 women in their lifetime with high mortality rates, no screening tests, and hardly any symptoms before it becomes metastatic. Most ovarian cancers (80-90%) are epithelial, and of those, most are high grade serous carcinomas, which are very lethal.
Drs. Stone and Long Roche go on to explain how ovarian cancer is actually disseminated tubal cancer, and that there is data showing dysplasia in the fallopian tube before it turns into ovarian cancer. In fact, the fimbriated ends of the fallopian tube are very high in p53 mutations, and there is data showing a decreased risk of ovarian cancer with tubal ligation. As a result, salpingectomy can be used as primary prevention for ovarian cancer. They have been doing opportunistic salpingectomies on women already in the OR for hysterectomies, Cesarean sections, ovarian cystectomies, etc. They would like to expand it to women receiving abdominal or urologic surgeries, including hernia repairs or cholecystectomies, which would require education, training, and communication across multidisciplinary teams.
The physicians continue to discuss the impact of opportunistic salpingectomies, mentioning 2000 lives could be saved every year in addition to 0.5 billion health care dollars saved as a result. They compare it to the HPV vaccine with a number needed to treat around 1 in 300 to 1 in 500 and a risk reduction of 65% or greater.
Technically speaking, the physicians mentioned the difficulties of ensuring adequate fimbriae removal of the ovary without causing more harm; overall, data shows that if done correctly, this procedure does not result in early menopause or impaired ovarian function. They also stated there is no specific procedure code for opportunistic salpingectomy along with conflicting state laws on reimbursability for the procedure, which could affect data collection and implementation.
Finally, the episode ends with talk about the future of opportunistic salpingectomies. Data shows there is a decreased incidence of high grade serous ovarian carcinoma, but more data is needed on mortality effects. The physicians strive to educate providers and patients about the procedure while ensuring no woman becomes sterilized before she is ready. Their target population is women in their 40s who will be in the OR already, as they don’t see opportunistic salpingectomies becoming indicated for the general population soon.
RESOURCES
Break Through Cancer Organization: https://breakthroughcancer.org/
ACOG Guidelines: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian-cancer-prevention
On this episode, Dr. Mathew Leonardi of McMaster University Medical Centre joins Drs. Park and Hoffman at the mic to discuss his experience with advanced ultrasound for endometriosis.---SHOW NOTESDr. Leonardi is a minimally invasive gynecologic surgeon and sonologist (ultrasound specialist) in Hamilton, Canada. He received his PhD at the University of Sydney, studying the role of ultrasound for diagnosis of endometriosis and its influence on surgical management of the disease. He then completed a 2-year fellowship in advanced gynecological surgery and ultrasound in Sydney, Australia. He now conducts a comprehensive clinic for the diagnosis and management of endometriosis.The episode begins with Dr. Leonardi describing his initial fascination with ultrasound as an OB/GYN resident and discussing his various training internationally for advanced gynecological surgery and ultrasound. He highlights specific steps he took, colleagues he collaborated with, as well as barriers he encountered and overcame along the way.The group then talks about the current role of ultrasound within gynecologic care and its potential in the field. Dr. Leonardi explains how he built a gynecologic ultrasound unit, detailing the workflow of his clinic. During this time, he also compares the use of ultrasound versus alternative imaging (e.g., MRI), ultimately favoring the dynamic, efficacious, and cost-effective benefits of ultrasound.Lastly, the group discusses the topic of bowel endometriosis. Dr. Leonardi describes the limitations of ultrasound in this setting, such as diagnosis of disease that spreads beyond the pelvic brim. The group then transitions to describe the involvement of colorectal surgeons in these cases and brings to light the need for additional training and exposure for minimally invasive gynecologic surgeons.---RESOURCESLeonardi M, Espada M, Condous G. Closing the communication loop between gynecological surgeons, diagnostic imaging experts and pathologists in endometriosis: building bridges between specialties. Ultrasound Obstet Gynecol. 2021 Apr;57(4):523-525. doi: 10.1002/uog.23595. PMID: 33491846.
In this episode, Dr. Kelly Wright of Cedars-Sinai Medical Center in Los Angeles joins Drs. Park and Hoffman to discuss sustainability in surgery.
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SHOW NOTES
Dr. Wright is the Director of the Division of Minimally Invasive Gynecologic Surgery at Cedars-Sinai Medical Center. She has served on various hospital committees regarding patient safety and cost-optimization. She actively researches operating room cost-effectiveness and waste minimization, most recently publishing a manuscript titled, “Sustainability in Healthcare: A Call to Action for Surgeons and Healthcare Leaders.”
Drs. Park and Hoffman begin the episode by asking Dr. Wright to bring to light the overall carbon footprint of healthcare in both the US and the world, as well as what should be included in biohazardous waste containers in the operating room (OR). During this conversation, Dr. Wright demystifies the common assumption that single-use products are related to better patient outcomes postoperatively. The group then breaks down the utilization of reusable, re-processable instruments in the OR, ultimately agreeing upon a reduced carbon footprint when using these products in comparison to those that are single-use.
Dr. Wright further explains what surgeons can do in order to mitigate these issues. She discusses various approaches at the individual, institutional, and federal levels. She highlights options that include making conscious efforts to reduce waste, demanding the industry to develop reusable products, and advocate for tighter regulation to reduce carbon emissions in hospital facilities. Throughout the episode, Dr. Wright charges listeners to collaborate with members of their institutions / hospitals who are directly involved in OR waste (e.g. human factors groups, quality and safety officers, heads of linen services) to find ways to mitigate waste and engage in sustainable practices.
RESOURCES
Schwartz KM, Wright KN, Richards EG, King LP, Park AJ. Sustainability in Healthcare: A Call to Action for Surgeons and Healthcare Leaders. J Minim Invasive Gynecol. 2022 Sep;29(9):1040-1042. doi: 10.1016/j.jmig.2022.06.024. Epub 2022 Jul 1. PMID: 35788396.
Malhotra GK, Tran T, Stewart C, Battey H, Tegtmeier B, McNeese K, Flood A, Melstrom L, Fong Y. Pandemic Operating Room Supply Shortage and Surgical Site Infection: Considerations as We Emerge from the Coronavirus Disease 2019 Pandemic. J Am Coll Surg. 2022 Apr 1;234(4):571-578. doi: 10.1097/XCS.0000000000000087. PMID: 35290277.
https://practicegreenhealth.org
https://noharm.org
On this episode of BackTable OBGYN, we introduce our co-host Dr. Amy Park, the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic. She and Dr. Mark Hoffman raise awareness about the importance of surgeon ergonomics in preventing work-related musculoskeletal (MSK) injuries and optimizing career longevity.
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Dr. Park, a co-founder of the Society of Surgical Ergonomics, begins the episode by sharing her personal experience with a work-related shoulder injury and how it inspired her to prioritize surgeon ergonomics in her daily practice. She and Dr. Hoffman then encourage listeners to acknowledge the role of optimizing factors such as table height, body posture, and more in order to maximize the longevity of a surgeon’s career and thus patient care.
The co-hosts then cover pitfalls commonly identified in normal, open surgery (e.g. excessive neck flexion, truncal deviation, arm abduction) and laparoscopic surgery (e.g. body posture, monitor height). They transition to highlight possible resolutions to these pitfalls, including anti-fatigue mats, appropriate footwear, and proper posturing; ultimately addressing a need for further research in this aspect of medicine. Lastly, they cover the role of robotic surgery and the potential to either mitigate or worsen the risk for work-related MSK injuries.
The episode wraps up with a call to bring awareness to the value of surgeon ergonomics and to proactively impart this knowledge onto trainees, as the overall goal for surgeons is likely to continue operating and impacting patient care.
RESOURCES
Epstein S, Sparer EH, Tran BN, et al. Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis. JAMA Surg. 2018;153(2):e174947. doi:10.1001/jamasurg.2017.4947
Society of Surgical Ergonomics: https://www.societyofsurgicalergonomics.org
The FIRST Trial: http://www.thefirsttrial.org
The SECOND Trial: http://www.thesecondtrial.org
For this episode of BackTable OBGYN, Drs. Park and Hoffman invite Dr. Louise King, MD, JD of Brigham and Women’s Hospital to talk about the legal perspective of Roe v. Wade.
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Dr. King, who works in the Division of Minimally Invasive Gynecologic Surgery, is also an Assistant Professor and Obstetrics, Gynecology and Reproductive Biology and the Director of Reproductive Bioethics at Harvard Medical School. Initially a lawyer of constitutional law, Dr. King utilizes the combination of her legal training with her medical knowledge to educate patients and colleagues on the essential and compassionate delivery of abortion healthcare.
The episode begins with Dr. King providing the legal history of reproductive care in the United States. She walks listeners through a timeline that includes the Comstock laws, as well as U.S. Supreme Court decisions, including Griswold v. Connecticut, Roe v. Wade, and Dobbs v. Jackson Women’s Health Organization. When discussing the history, Dr. King emphasizes the role of healthcare professionals in combating the current legal state. Specifically, she urges listeners to go beyond simply stating that discussions about abortion should remain between physicians and patients. Instead, she shares how providers should continue the conversation by vocalizing what abortion is, why it is essential, what makes it a complex topic, and why each person should defend the right for themselves and others.
Dr. King then describes how to develop a space that promotes others to engage in conversation about abortion. Her approach to this dialogue includes allowing people to identify what gives them pause and determining ways to validate someone’s discomfort about the topic. Dr. King provides examples of how she frames her discussion with medical students at Harvard Medical School, which involves utilization of the pillars of ethics as a scaffolding for conversation. She then goes on to define reproductive justice for listeners.
Lastly, Dr. King charges the audience to practice their first amendment right and educate about abortion care. She also discusses the developing course for OBGYN residency programs and acknowledges the varying levels of training based on geographical location. The episode concludes with Dr. King sharing avenues of support for physicians who regularly practice abortion care.
On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR).
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SHOW NOTES
To set the stage, Drs. Rampersad and Shanks explain the definition of PPH based on the American College of Obstetricians and Gynecologists (ACOG) guidelines. They further describe the differences between early / acute versus late blood loss, in addition to the most common etiologies using the “Four T’s” pneumonic: tone, trauma, tissue, thrombin. Drs. Rampersad and Shanks then describe their approach to the workup and management of PPH. The group discusses topics such as uterine massage, oxytocin, hemabate / methergine, tamponade (e.g. Bakri balloon, the JADA System), embolization, and hysterectomy.
The physicians then describe the role of cross-specialty collaboration between OBGYN and IR, specifically in the management of PPH. When highlighting the role of IR, Dr. Beck describes how he counsels patients for uterine artery embolization (UAE), and he provides an anecdote regarding a repeat UAE. He also shares his perspective with utilization of gel foam versus coils. The group then transitions to describe diagnosis and management of placenta accreta spectrum (PAS), its association with PPH, and the role of radiology in this disease process.
Lastly, Drs. Rampersad and Shanks allude to what the future may hold for PPH, including more personalized medicine and potential technologies to prevent PAS. The group ends the episode by providing IR colleagues with insight to what may strengthen the collaboration between OBGYN and IR in order to provide optimal care for patients with PPH.
RESOURCES
Silver RM, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32. doi: 10.1097/01.AOG.0000219750.79480.84. PMID: 16738145.
Bienstock RM, Eke AC and Hueppchen NA; Postpartum Hemorrhage. New England Journal of Medicine 2021 Vol. 384 Issue 17 Pages 1635-1645. Accession Number: 33913640 DOI: 10.1056/NEJMra1513247. https://www.nejm.org/doi/full/10.1056/NEJMra1513247
ACOG Postpartum Hemorrhage: https://www.acog.org/en/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
In this cross-specialty episode of BackTable OBGYN, Dr. Amy Park chats with Dr. Jose Silva, a board certified urologist and co-host of BackTable Urology, about the workup, counseling, and management of urinary incontinence and pelvic organ prolapse.
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SHOW NOTES
The co-hosts begin by briefly discussing the workup for pelvic organ prolapse (POP). Dr. Park identifies common symptoms of prolapse and special exams (e.g. Pelvic Organ Prolapse Quantification System or POP-Q and urodynamics) that may be utilized for initial evaluation. She then explains the clinical indications for treatment of isolated POP, in addition to POP with concomitant urinary incontinence.
Drs. Park and Silva then transitioned to cover the management of urinary incontinence. The two co-hosts reveal the benefits of pelvic floor physical therapy and other conservative management options, such as core-centric exercises and weight loss. In length, they elaborate on the benefits and takeaways of using sling procedures versus urethral bulking agents (e.g. Bulkamid). When discussing these topics, the co-hosts bring to light the possible differences in approach between Urogynecologists and Urologists. In regard to urethral bulking agents for treatment of urinary incontinence, Drs. Park and Silva highlight the potential role for stem cell injections. In addition, Dr. Park provides a tip to maximize patient comfort during in-office periurethral injections for urethral bulking. When focusing on sling procedures, Dr. Park highlights her preferred approach and encourages listeners to become proficient in the approach of their choosing.
Lastly, they describe their approaches to treatment of stress urinary incontinence. In their discussion, Drs. Park and Silva consider factors such as patient age, desire for future fertility, and pregnancy. When wrapping up the episode, Dr. Park emphasizes the importance of patient counseling when it comes to management of these conditions, as well as practicing shared decision making to determine the best next steps for her patients.
RESOURCES
Nager CW, et al. Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations. Contemp Clin Trials. 2009 Nov;30(6):531-9. doi: 10.1016/j.cct.2009.07.001. Epub 2009 Jul 25. PMID: 19635587; PMCID: PMC3057197.
Erin A. Brennand, Shunaha Kim-Fine. A randomized clinical trial of how to best position retropubic slings for stress urinary incontinence: Development of a study protocol for the mid-urethral sling tensioning (MUST) trial, Contemporary Clinical Trials Communications, Volume 3, 2016, Pages 60-64, ISSN 2451-8654, https://doi.org/10.1016/j.conctc.2016.04.004.
M. Abdel-Fattah, D. Cooper, T. Davidson, M. Kilonzo, M. Hossain, D. Boyers, et al. Single-Incision Mini-Slings for Stress Urinary Incontinence in Women New England Journal of Medicine 2022 Vol. 386 Issue 13 Pages 1230-1243. DOI: 10.1056/NEJMoa2111815 https://doi.org/10.1056/NEJMoa2111815.
Persu C, Chapple CR, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POP-Q) - a new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar;4(1):75-81. Epub 2011 Feb 25. PMID: 21505577; PMCID: PMC3056425.
BackTable began five years ago as a podcast for the field of Interventional Radiology. Since then, the podcast has developed additional series for various areas of medicine, such as ENT/Otolaryngology, Urology, Med Tech Innovation, and now Obstetrics and Gynecology (OBGYN). On this inaugural episode, Dr. Aaron Fritts introduces one of the BackTable OBGYN hosts, Dr. Mark Hoffman, a minimally invasive gynecologic surgeon at the University of Kentucky.
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SHOW NOTES
Dr. Hoffman shares the story of his training in minimally invasive surgery and chronic pelvic pain, and discusses the challenges he faced when starting his practice at the University of Kentucky where he treats complex, benign gynecologic concerns. Notably, he started a uterine fibroid embolization program alongside the Division of Vascular and Interventional Radiology. He also discusses caring for an underserved population in rural Kentucky may look like, in addition to factors that influenced his decision to practice in an academic versus community-based setting. Lastly, Dr. Hoffman highlights the role of podcasting and collaboration in medicine, which inspired his involvement in BackTable OBGYN.
Drs. Hoffman and Fritts wrap up the episode by previewing the upcoming episodes for BackTable OBGYN, such as cross-specialty treatment of postpartum hemorrhage and the legal perspective of Roe versus Wade. The hosts encourage listeners to prepare for authentic, open conversations that address women’s health in both realms of obstetrics and gynecology.
RESOURCES
BackTable OBGYN Twitter and Instagram: @_backtableobgyn
BackTable website: www.backtable.com