State of the Union: Urogynecology and Reconstructive Pelvic Surgery (URPS)
We spoke with Wai Lee, MD, Director of Urogynecology & Pelvic Reconstructive Surgery (URPS) for the Department of Urology at Columbia University Irving Medical Center/NewYork-Presbyterian, about the state of care in the field, including breakthroughs in treatment and ways to overcome social stigma that keep patients from seeking care.
Current State of Care
Can you tell us about the field of URPS?
It's a subfield in urology where we focus on women's health and bladder function, including storage issues, which we might see in neurogenic bladder resulting from nerve damage, emptying issues, such as urinary retention, which is the inability to completely empty the bladder, or issues like incontinence, meaning the involuntary leakage of urine.
We also treat other issues that plague women, such as pelvic organ prolapse, where the pelvic floor weakens and organs shift and bulge into the vagina, and fistulas, which are openings that form between the vagina and the bladder. And, last but not least, we deal with conditions that can occur in men, including urinary storage and emptying issues.
How do these conditions affect the quality of life for your patients?
These conditions are very limiting. For example, one that is very common is overactive bladder, which causes a frequent and urgent need to urinate, and can affect 30% of all patients, rising to about 50% as they get older. This can lead to incontinence, affecting all aspects of life.
I have patients telling me they no longer go to the movies, they won’t drive anywhere that involves more than an hour or so on the road. And if they do, they have every rest stop mapped out. They sometimes seek comfort at home and stop going out with their friends. It's very costly; they're spending a lot of money on diapers, liners, and pads.
There are two domains to this: stress urinary incontinence and urge incontinence. I tend to see stress urinary incontinence, which is caused by increased abdominal pressure during activity, more in the younger patients, and can definitely affect their activities like exercising, going dancing, things that they used to enjoy. Overactive bladder and urge incontinence can affect patients across all ages. It can affect their sleep, because they're waking up more at night. They're limiting their day-to-day activities.
What are some of the challenges facing the field today?
For voiding conditions, I think that the biggest obstacle is getting the message out. Most of my patients have not dealt with this issue for many years. And it's not until they speak to a family member or relative, or happen to mention it to another doctor, that they decide to seek care.
The great news is we have so many developments, so much new technology, and so many advances in treating many of the conditions I mentioned. And also most of the interventions are very minimally invasive. Even with some of my most advanced surgeries, my patients go home the same day. So it's very exciting, and we have a lot of really happy patients.
I think there's a little bit of stigma to overcome; it can be hard to talk about it with your friends. And there’s an information gap for our patients, who don’t know what can be done. It’s a constantly improving field, with advances happening all the time, and it's really exciting. So I’d like to see the stigma reduced and have more people be aware of their options.
Do you have any ideas on how to get that message across?
I think there's the traditional approach, which is educating first-line doctors: OBGYNs, primary care doctors, and community healthcare providers. There's also online literature and websites that educate patients about these conditions.
And then I think there's marketing, which has been relatively successful. I know Boston Scientific Axonics did a lot of marketing for overactive bladder, with major spots on TV shows and other platforms.
On the institutional side, we should explore ways to educate the public about the many treatment options available to them.
I think one surefire way to reach patients is to use social media to provide a space for them to interact and learn. You can read it on the Reddit forums; there are so many patients learning from each other. It’s an opportunity for us to get the word out. Knowing more about their options will make it easier to seek help.
What's the greatest unmet need right now?
I would say overactive bladder. I think, with pelvic organ prolapse, when patients realize something's wrong, they usually seek care and are then referred to the right people. With neurogenic bladder, these patients are seeing their neurologists and primary care doctors regularly.
But with overactive bladder and urgency incontinence, these patients have often been dealing with this for years. The problem is that when they see their doctors, most doctors will just give them medicine and send them on their way. And the problem with medicine is that about 50% to 70% of patients don't respond to it. So there are many patients not getting effective treatment, and just living with their symptoms.
Treatments and Technologies
For patients who are apprehensive about surgery, are there any completely non-invasive treatments?
We have many options that are noninvasive or not overly invasive, and we explore them when appropriate.
Pelvic floor physical therapy can be effective; success rates aren't the highest, but for some patients, it’s the right choice. The main issue is that it requires time. Many patients don't have much free time; they're working and can't regularly take a day off without losing money, so it's not the best option for them.
We offer a number of noninvasive office procedures. For prolapse or overactive bladder, we might place a pessary, a removable, medical-grade silicone device inserted into the vagina to provide support.
We also offer office electroacupuncture to the ankle, which is completely noninvasive. It’s also known as percutaneous tibial nerve stimulation (PTNS); it’s a form of neuromodulation that reduces the intensity and frequency of urges.
For overactive bladder and recurrent urinary tract infections, we're using vaginal estrogen, which is not only extremely safe but also easy to maintain. It's essentially three nights a week, so the application is very minimal.
We also have office procedures that are just a bit more invasive, such as bladder botox using a camera called a cystoscope. It takes about 2 to 5 minutes in the office; the patient remains awake and typically goes home right away. So while that's a little invasive, it's extremely fast, very convenient, and patients are extremely happy with the results, which last 6 to 9 months.
Are there any technologies that are either on the market now or coming down the road soon that you're particularly excited about?
I'm very happy to announce that we will soon be offering two implantable devices for overactive bladder and urinary urgency incontinence. These implants go in the ankle. They deliver PTNS therapy to the nerve that relaxes the bladder, which can reduce leakage.
One is called eCoin; It's about the size of a nickel. The other one is called Altaviva, which has a longer-lasting battery.
These devices are placed in a quick surgery, typically around 30 minutes. It's an extremely safe procedure, and these devices are much more effective than medication. And they can last a very long time. We should hopefully have these available to patients by the end of the year.
There is also a new device called Glean: it’s a wireless, catheter-free device that can be inserted into the bladder. It’s shaped like a coil.
When patients have bladder issues, whether it be storage issues or emptying issues, there is a study called urodynamics. It's sort of the best study we have to understand bladder storage and bladder emptying, and it can look into safety and predict how patients might possibly respond to therapy or even guide us on which type of therapy to use.
The problem is, it's about a 45-minute test. It involves placing catheters into the bladder and rectum stickers. It's very time-consuming.
With the Glean device, it probably takes no more than five minutes to place it. And then the patient would leave it in their bladder, and it would record information over the next three hours. And then we would have the patient come back in, and we can easily remove it.
This is pretty much the cutting edge; it was released in the last four to five months and is FDA-approved. So I'm hoping by the end of summer we might be able to get one of these performed. It’s very exciting.
What about on the surgical side?
There are many conditions we operate on, and for each condition, there are multiple options. Which is great for the patient. During the visit, I tell a patient, "Think of me like a waiter; I'm offering you menu options." There's no right or wrong.
And we explore all options, surgical or otherwise. For example, with stress urinary incontinence, if it's non-invasive, it's physical therapy. If it's in the middle, there's an injection called Bulkamid that has been around for only about maybe five, six years; it helps prevent leakage. And then for surgery, we're doing a traditional urethral sling; those patients do extremely well. They're very happy.
For overactive bladder, we’ve found the InterStim, a sacral neuromodulation (SNM) device, to be the most effective. It’s implantable as an outpatient procedure and has a 10- to 15-year battery life. It's a little bit more invasive, but up to about 80 to 90% of overactive bladder patients with incontinence are responding to this therapy. So we're getting very good results.
I have been performing robotic surgery, and those patients are doing extremely well; they're going home the same day. For pelvic organ prolapse, we're offering two types of vaginal surgery, and their prolapses are being addressed with very high satisfaction rates.
I'm also now offering robotic surgery for advanced neurogenic bladder, although it is a little bit less common. We augment and expand the bladder using tissue from the intestines. This is usually reserved for patients with either significant spinal cord injury or neurogenic conditions like spina bifida, where their bladders just don't store very well. Even the catheters are no longer really helping them. So we have to go a little bit beyond that.
Do you think robotic surgery will be important for URPS and urology in general?
I think it's already very important. But it’s still new. When I offer it to a patient, I make it very clear that it's a tool. It's not a robot doing the surgery: it's more like a screwdriver. The robot's “hands” are smaller than mine, so that means a smaller incision, a faster recovery, and I would say 9 out of 10 patients go home the same day, which would not even be a conversation after open surgery.
Columbia is getting the new single-port robot, so we should have even happier patients. Instead of four to five small incisions, you now have only one slightly larger incision at a single site. I've done single-port robotic surgeries in my old job, and these patients do extremely well. The incision's very small, and so it’s a welcome new technology.
Academic and Research Advances
How about new areas of research?
We are wrapping up a study on whether antibiotics are needed before Botox. Not too exciting or sexy, but it is relevant to antibiotic stewardship and minimizing the need for antibiotics for patients. I’m currently researching recurrent urinary tract infections and am planning a study on a very good cranberry product.
Another area that is sort of pushing the needle is combining current treatments. Many patients will either get treatment for their stress incontinence, which is an injection of Bulkamid, or get treatment for their urgent incontinence and overactive bladder, which is often an injection of Botox.
But there's a subset of patients with both types of incontinence, and usually they only treat one or the other. I've been exploring using the Bulkamid and the Botox together in the same procedure, and so far, these patients are doing very well. So that is an area that we will hopefully explore deeper once we have a good study design.
There's also a very common surgery being done for an enlarged prostate, transurethral resection of the prostate (TURP), where you're essentially opening that prostate up. About 16% of men have persistent storage symptoms afterward. So while they can empty their bladder, they're going to the bathroom all the time, sometimes every hour. And they can still experience leakage related to that.
For about half of those patients, they do better three to six months after surgery, but for the other half, symptoms can persist, at which point we offer treatment.
So rather than wait three to six months, we've been offering some of that treatment at the same time. For some patients, we'll perform TURP surgery for an enlarged prostate and bladder botox at the same time. That's not very well established or studied. How do we distinguish whether the Botox is helping, or if it's just the TURP surgery alone? So that's something that I'm working on with some of my colleagues to study moving forward.
From the perspective of someone who is training the next generation, do you have any thoughts about the future of your field?
Urology, especially on the URPS specialty side, is actually severely underrepresented. I believe recent research shows that about 20-30% of academic institutions lack a urologist specializing in URPS. But there's a shortage of residents willing to complete an extra 2 years of training to specialize in this field.
As a result, there aren't many of us; only about 5% of urologists, according to the census, are trained in URPS. So that’s not a lot of people. We need to do more to reach different residents at different levels of training, whether through courses or other educational approaches, or by getting the message out at the national level and at conferences. And we should be getting involved at the medical student level. I think that would be beneficial to our field and ultimately to patients.
At the end of the day, the rewards are great when you pursue this field. It’s very satisfying.