"We're moving from an era where it was all based on judgment, and experience, to an era where treatments will be based on firm evidence of the structural failures present in each patient," says John O. L. DeLancey, MD.
Like any other field of surgery, pelvic floor surgery has seen improvements in technology over the past few decades and continues to evolve so that it can be performed more effectively, efficiently, and safely.
In a recent interview, John O. L. DeLancey, MD, discusses this evolution in terms of what he expects and hopes for the future of pelvic floor surgery, integrating key points from his State-of-the-Art lecture at the 2021 International Continence Society Meeting.1 DeLancey is the Norman F. Miller Professor of gynecology, Professor of Urology and the director of female pelvic medicine and reconstructive surgery and the Pelvic Floor Research Group at the University of Michigan Medical School, Ann Arbor.
I've been doing surgery for several decades, and I've spent my whole career trying to understand what goes wrong with people who have prolapse so that I could be a better surgeon and try and get better results for my patients. When any of us who are experienced and done a lot of prolapse surgery looks at our long-term results, they're not as good as we would hope. The NIH's Clinical Trials Network, the PFDN, using the gold standard operation currently available, had a 25% failure rate at 7 years. So, these are the best surgeons with the best operation. A 25% failure rate is not what we would hope for if we were patients. The main motivator for me in terms of trying to figure out what's wrong is that there really is this huge need to be able to come up with higher success. Randomized trials have done a lot so far with comparing existing operations, but we're only testing existing operations against one another. In many fields, once they could determine mechanisms of disease, new treatments were developed, and treatment plans based on the cause of each individual patient’s problem could be developed.
It is unbelievable what we can see with advanced imaging. We can see every fiber of every muscle, we can see every band of connective tissue, we can see the entire structural apparatus at rest, and we can see what happens in 3 dimensions with straining down when they've pushed their prolapse all the way out. In addition, this visualization, using new computer modeling software, we can actually make of the status of each aspect of the support system.So we can stop guessing about what we think is wrong and to be able to come up with a diagnostic battery that would tell us where failures have occurred. Let me just give you a brief example. So, when I get my electrolytes drawn, they come up on a little display with a normal range for all the things and there's a little “x” where my value is. And if my potassium was high, any clinician looking at that, in an instant, would be able to see that the potassium was high. That's what I believe we'll be at 10 years with pelvic floor imaging.We will have a way to be able to actually assess not “what fell” which is our current way of looking at things, but what structure broke or failed to let it fall. Right now, we say that there's a cystocele 3 cm outside, but is that because the muscles are broken? Is that because the cardinal ligaments have failed? Is that because there's some problem with the midline or lateral vaginal fascia? Do all patients who have those same measurements have the same problem? This is the type of approach that echocardiography introduced to diagnosis of cardiac disease.With echocardiography, each person gets a specific series of measurements and a diagnosis. So, with imaging, I think that's what it is.
The exciting thing about computer modeling is that we can simulate any combination of things that we want experimentally. We can take an individual woman's MRI, we can put it into what's called a finite element model, which is just a computer model that has all the ligaments, muscles and fascia. We can load it with a certain amount of pressure, and we can see what happens. Then we can say, "Well, what if we did an operation that elevated the apex to 7 cm above the hymen? What would the result be like? What would it be if rather than having this problem, the woman had a different one?" So, computer modeling is giving us the ability to test out those ideas and see what's going on because it's not ethical in human beings to go in and cut a ligament to see what happens.
We're moving from an era where it was all based on judgment, and experience, to an era where treatments will be based on firm evidence of the structural failures present in each patient. We will know the cutoff values for what's normal and we'll be able to identify in each individual what components of the system are abnormal and what different corrective strategies can and cannot do in that situation. It's important to recognize this is a revolution in thinking that's going on, to see that we're moving from an era approaching these problems based on “what fell” to “why it fell”. That's what I think the take-home is, this transition from it being empirical before to actually having evidence to be able to know what's broken and how to fix it.
1. DeLancey JOL. How Imaging and Computer Modeling Help Improve your Pelvic Floor Surgery. Lecture presented at: 2021 International Continence Society Meeting; October 14-17, 2021; virtual.