Collaborative Surgery: The Superior Approach for Pelvic Floor Disorders

Medical specialties are defined by their expertise and prescribed scopes of practice. Clear boundaries protect patients and practitioners. There is only so much one individual can master, particularly as our medical knowledge grows exponentially.

The challenge is that bodies don’t abide by those boundaries. The hip bone connects to the thigh bone, whether convenient for medical care or not.

When patients present to the University of Rochester Urogynecology and Reproductive Pelvic Surgery (URPS) practice for a visit, it’s usually because they have a concern related to their pelvic floor that impacts their bladder or vaginal support. Urinary incontinence and pelvic organ prolapse are the most common presenting complaints.

But sometimes patients’ concerns also include bowel-related pelvic floor dysfunction, such as defecatory dysfunction, rectal prolapse, and fecal incontinence. Evaluation and management of these conditions usually falls to gastroenterologists and colorectal surgeons.

While the muscles, nerves, and organs of the pelvis are interconnected, the specialists who study and care for the pelvis often are not.

Dr. Joseph Panza has been working to change that.

A Different Approach

Dr. Panza joined the University of Rochester URPS faculty in 2020. Since then, he has forged partnerships with colleagues in the Colorectal Surgery division to offer a unified approach to pelvic floor dysfunction.

"A lot of women who have vaginal prolapse also have rectal prolapse or another outlet obstruction like intussusception," he says.

Patients seek care for their most urgent problems first. As Dr. Panza notes: "I probably get more referrals from [colorectal surgery] than I send to them because if a patient has a mild or moderate uterine or vaginal prolapse and severe problems with their bowels, they’ll end up there first."

In the traditional model, each specialty treats the patient for their presenting problem. This often leads to multiple surgeries, prolonged interaction with the medical system, and unnecessary suffering.

Seeking a better alternative, Dr. Panza worked with colleagues in colorectal surgery, primarily Dr. Jenny Speranza, to establish protocols that identify patients who would benefit from an inter-specialty approach to care.

This requires proactivity. Instead of relying on the patient to recognize and report related symptoms, the surgical teams do standard screening of new patients for all types of pelvic floor dysfunction.

This standard screening ensures that patients get the right care by the right specialists. It also leads to more frequent consideration of combined surgical approaches.

The Benefits of Collaborative Surgery

In addition to more accurate diagnoses and interdisciplinary care, the partnership between colorectal surgery and URPS has paved the way for combination surgical procedures that better address the patients’ needs.

"There’s a growing body of data­—especially for rectal prolapse—that the traditional repairs don’t work as well as collaborative surgery," says Dr. Panza. This is due, in part, to the evolution of surgical techniques.

"We’ve [URPS] started to shift more to mesh-augmented prolapse repairs because the data show it has much better efficacy than a native tissue repair. The same thing is true for [colorectal], they used to do a surgery for rectal prolapse that didn’t have great results. An abdominal approach which uses mesh or biologic graft is more effective," he says.

When a patient has more than one form of pelvic floor dysfunction, one abdominal surgery that will address both problems is preferable to multiple stand-alone procedures.

While patients spend more time in the OR and under anesthesia during a multi-step surgery, the benefits are substantial. Studies show that patients have better outcomes, higher satisfaction, fewer anesthesia events, and reduced medical costs with a combined approach compared to the traditional approach. Plus, most patients can still go home on the same or next day. Dr. Erin Duecy, URPS division director says:

The evidence is clear, patients do better when we work together to address their problems holistically. It takes extra coordination on our part, but addressing both bowel and GYN-related pelvic floor disorders in one surgical case offers the best chance for symptom resolution and functional improvement.

Catching On

Dr. Diego Hernandez-Aranda graduated from the Urogynecology Fellowship at URMC and joined the faculty in 2022. Having trained in the collaborative approach during his fellowship, he has incorporated combined surgeries into his practice, as well.

It’s not just seeing me do these cases. The collaboration with colorectal surgery allows fellows to work with their team, too. So, you’re getting more experience handling the bowel, doing more complex dissection, working up the broader range of problems, and interpreting specialty imagery as part of our fellowship.

In addition to Dr. Hernandez-Aranda, more members of the colorectal surgery team have begun to participate in these cases, including Dr. Gabriela C. Poles and Dr. Zhaomin Xu.

While he has dramatically increased the number of combined surgeries, Dr. Panza is quick to note that he is building on the work done by his former colleague, Dr. Jenifer Byrnes, and his Division Director, Dr. Erin Duecy.