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 Minimally Invasive Surgery |
NEW SURGICAL TECHNIQUES
Significant advances are occurring in the field of reconstructive pelvic surgery. Most of these advances are geared towards improving functional outcome while at the same time minimizing operative risk and increasing the speed of recovery.
It is important for you to understand that one of our prime objectives in surgical patient care is the above. Our surgical procedures have been designed to this stuff in mind, from our specific choice of suture and implant material to the type of anesthesia that we recommend.
One of the most significant trends in modern surgery is the advancement in minimally invasive surgery. Minimally invasive surgery focuses on performing surgery through smaller incisions, with the hopes of reducing postoperative discomfort, lowering the risk of infection, speeding recovery and minimizing the formation of scar tissue. Many minimally invasive techniques are relatively new, and as such, long term clinical data regarding complications and success are less available than some traditional procedures.
Our surgeons carefully scrutinize currently available techniques and focus on the ones that we feel offer the best balance of safety and efficacy, while also meeting the needs and expectations of our patients. We are both fortunate and honored to work closely with several of the leading medical device companies in the world to work with state-of-the-art tools and techniques. At the same time, we are skilled in traditional vaginal and abdominal techniques and will offer them to patients when we think the choice is appropriate for the individual.
We consider vaginal approach to reconstructive surgery to be a form of minimally invasive surgery. Dr. Toglia has had extensive training and experience in vaginal surgery, and is nationally regarded to be one of the leading specialists in the Philadelphia Region. At Urogynecology Associates we have made the commitment to embrace these emerging technologies when we feel that they offer the right balance of efficacy and safety. We remain actively involved in closely following the results of scientific studies involving these techniques by attending national and international scientific meetings, and reading published studies.
The two most common surgical procedures performed by Dr. Toglia involve innovative, minimally invasive mid urethral slings for the treatment of stress urinary incontinence and total vaginal mesh repair of pelvic organ prolapse. These approaches, while becoming extremely popular in both the US and Europe, do differ significantly from traditional surgical approaches and are not performed by the majority of gynecologic surgeons in this country.
Minimally Invasive Mid Urethral Slings for SUI (TVT, TVT-O)
The TVT tension-free support system is an innovative, surgical device and technique for the treatment of female stress urinary incontinence. Clinical studies over the past 10 years have demonstrated that 85% of women experience resolution of their incontinence, with an additional 11% reporting significant improvement. Overall, patient satisfaction has been extremely high. Currently, Bonnie Blair, the five time Olympic gold medal speed skater, is the national spokesperson for the TVT technique (link)
How does Surgery correct stress urinary incontinence?
Female stress urinary incontinence is believed to be the result of a poorly functioning urethra, not an intrinsic problem of the bladder. In a young, healthy woman, the urethra is supported from within and the outside by fibromuscular connective tissue which maintain a seal along the length of the urethra to prevent involuntary urine loss. Normal voiding involves a process by which the muscular walls of the urethra relaxes and the bladder contracts to allow drainage of urine. As a women ages, the connective tissues of the urethra and pelvic floor oftentimes weaken, and as a result, the urethra cannot maintain its tight seal to periods of exercise or exertion, and urine escapes.
The TVT tension support system combines a traditional operation known as a pubovaginal sling with polypropylene mesh material that has been specifically designed for the application of treating female SUI. The sling material is inserted through a small incision in the vagina and positioned underneath the mid portion of the urethra to create a supportive sling. This unique tape material is capable of providing support to the urethra during physical activity, without interfering with normal voiding function. The unique properties of this mesh allows for the tension-free placement of this material within the pelvic floor, reducing the incidence of post operative voiding difficulties, or urinary retention.
What are the Key Benefits to the TVT System?
- Short operative time - The TVT procedure is typically completed within 30 minutes, under local anesthesia and heavy intravenous sedation.
- Outpatient procedure - The TVT system is performed through several small (1/4 inch) incisions which allows patients to be discharged home from the hospital 3 to 4 hours after surgery
- Short Recovery with Minimal Pain - Most patients can drive a car the next day and return to work in 2 - 3 days.
- No traditional anchoring - the tape is held in place initially by surface tension (e.g. like Velcro) as it is sandwiched between several layers of tissue. Over time, in-growth of connective tissue through the mesh locks the tape into place
- Low risk of postoperative voiding dysfunction. The tape is "adjusted" by the surgeon intraoperatively utilizing a cough test which improves the likelihood of the mesh being tight enough to prevent leakage, but not overly tight, making it difficult to void. In addition, the positioning of the tape at the level of the mid-urethra provided unique support, reducing the need for postoperative catheterization. In our experience, approximately 90% of patients are discharged from the hospital without a catheter. The remaining patients typically have an indwelling catheter overnight only. In our experience, less than 2% of patients experience long term voiding dysfunction which could require surgical revision of the tape.
What are the risks of this type of surgery?
All surgical procedures present risks.  As the patient, you must decide whether the anticipated benefits of a particular operation override the inherent but fortunately uncommon risks.
TVT type sling procedures are associated with a small but recognizable risk of bleeding, injury to surrounding structures such as the bladder, urethra, vagina, bowel, blood vessels and nerves. A small percentage of patients continue to have significant leakage of urine following their surgery, or difficulty emptying their bladders. Some may experience erosion or exposure of the mesh material which may need to be removed. A very small percentage of patients may experience long-term pain or discomfort within the surgical field, or even muscle weakness from nerve injury
PROLIFT PELVIC FLOOR REPAIR SYSTEM
Pelvic organ prolapse (aka "dropped bladder"and "dropped uterus") affects at least one in three women over the age of 45. Prolapse of the pelvic organs into the vaginal canal can cause uncomfortable pelvic pressure and interfere with bladder, bowel and sexual function in women. It has been estimated that 1 in 10 women undergo surgery at some point to correct this problem. Traditional surgical repair techniques have been associated with a 15 to 30% failure rate, necessitating re-operation in a significant number of women. Fortunately, advances in our understanding and treatment of pelvic floor disorders with the field of Urogynecology have significantly reduced the need for re-operation. In addition, innovations in surgical techniques have allowed for a minimally invasive approach, reducing both postoperative pain and recovery, and may increase successful results.
The PROLIFT Pelvic Floor System is a revolutionary new minimally invasive surgical technique that offers promising long-term results for women suffering from pelvic organ prolapse. Prolift offers a unique approach for the placement of a specially designed supportive soft mesh placed within the pelvis through several small incisions inside the vagina and pelvis. The surgery can be completed in less than half the time of traditional surgery, and many patients are discharged to home the next day. It is hoped that using a synthetic soft mesh material rather than a patient's own weakened connective tissue will provide long-lasting results.
Dr. Toglia was the first Urogynecologist to be trained in the Mainline
suburbs of Philadelphia in this new technique, and has performed more than 100 procedures within the first year of its introduction. The vast majority of our patients have been satisfied with their results and delighted with the shorter hospital stay and quicker recovery compared to more traditional approaches.
PROLIFT is a reasonable approach for the treatment of pelvic organ prolapse for women seeking a vaginal approach to reconstructive surgery, especially if they desire preservation of the uterus. Because this is a relatively new surgical approach, with limited long term follow up, some women may still prefer a more traditional repair technique, which may be performed via a vaginal, abdominal or laparoscopic approach.
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