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007: Transvaginal Mesh, Making Uncomfortable Topics Comfortable And Much More – A Conversation With Dr. Cary Fishburne

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SUMMARY

Double board certified urogynecologist Dr. Cary Fishburne shares his insights on a range of topics for anyone living with incontinence or pelvic floor dysfunction, including the state of transvaginal mesh implants, antibiotic resistance, how to make the conversation around personal topics easier, and how it’s never too late to seek help – including the story of a 104 year old who was able to find relief for her symptoms after being told for 20 years that there was nothing that could be done for her.

For more information about the National Association for Continence, visit us online at www.NAFC.org.

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TRANSCRIPT

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America’s leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers, all available at NAFC.org. This podcast is supported by our sponsor partner, Medtronic, maker of InterStim systems for bladder and bowel control. To learn more about InterStim therapy, visit controlleaks.com.

Welcome to another episode of life without leaks. I’m your host, Bruce Kassover and joining us today is the executive director for the National Association for Continence, Steve Gregg. Welcome Steve.

Steve Gregg: Thank you Bruce. Glad to be here.

Bruce Kassover: Excellent. And our guest today is Dr. Cary Fishburne, a double board certified urogynecologist with more than 20 years experience specializing in female pelvic medicine and reconstructive surgery. Welcome, Dr. Fishburne.

Dr. Cary Fishburne: Thank you so much for having me. I’m excited to be here.

Bruce Kassover: Excellent. Now I see here, I have, I happen to have a list of some of the areas where you do work and it’s a remarkable list. There are things like urinary incontinence and fecal incontinence, but also conditions like pelvic organ prolapse and urinary retention and fistulas and, I mean, it goes down to things like painful intercourse and chronic constipation. Can you tell us a little bit about the range of conditions you happen to treat?

Dr. Cary Fishburne: Absolutely. You covered a good range of these, but really the whole spectrum involves female pelvic dysfunction. So dysfunction of urination, of bowels, of pelvic pain. We do manage all aspects of urinary incontinence. We manage all aspects of bowel incontinence dysfunction, voiding and dysfunction of moving the bowels.

So difficulty voiding and moving bowels, female pelvic organ prolapse, chronic pelvic discomfort; there are many conditions that can create a chronic daily pain that can truly be disabling for a lot of these patients. So we are very involved with a lot of those conditions and evaluating and treating those conditions.

And then also complicated surgical needs and medical management beyond the the more general OBGYN and urologic conditions. Things like recurrent bladder infections and blood in the urine conditions, those sorts of things.

Bruce Kassover: So when a patient comes to you, do they usually know what their problem is or do they know they have symptoms, but they’re not really sure what’s going on in their, in search of a solution.

Dr. Cary Fishburne: I think it’s a mix of both. I think some people just know that things aren’t working well and are looking for answers about what could be going on. And, you know, sometimes there are underlying neurologic conditions like multiple sclerosis or Parkinson’s that can dramatically affect function. So sometimes people come in and just know that things are not working well and want answers.

And sometimes people walk in and are quite clear about what’s going on and very defined about what’s going on and are looking for not just answers, but also options of management. I do frequently because it is a, it’s a world of private symptoms where patients often suffer in silence, I not infrequently have patients come in who’ve been suffering for a really long time and just not wanting to talk about it because they assume that maybe there’s not good treatment options, or maybe everybody has to suffer with this and they shouldn’t complain about it. Or a lot of other women are taking care of other members of their families and putting their needs first and kind of suffering along with their own dysfunction while focusing their attention on others.

So there are a lot of, a lot of layers of dynamics that play into these conditions, because they’re very personal, but also very important issues that people are dealing with.

Bruce Kassover: I think that’s something that we hear a lot is that that particularly among women is that they tend to put their own needs second or third. And by the time that they actually decide that something has to be done, it’s already very far along for a lot of them. When people do come in to you, do you find that they have a lot of misconceptions about incontinence-related issues in general and what treatment options are available or do you get some people who are pretty well educated?

Dr. Cary Fishburne: I think it spans across the board. I think one of my true goals of my career is to break the misconception that I have heard and just countless times when women say, “Oh, I’m not complaining about this, because it’s just something a woman has to put up with as she gets older.” And I can’t tell you the number of times, I hear that and people therefore suffer in silence or may talk about that with their close friends and continue for everybody to suffer in silence.

But the, the awareness, so one of my missions is really to try to spread the awareness of how common this condition is, that we have wonderful treatment options that are very effective, and that we have a variety of treatment options to really meet the individual needs and goals of each unique patient.

And that these options don’t have to be very invasive. We have very, we can have office-based approaches and various medications and simple procedures that we really need to increase the awareness on so that patients and indeed physicians in the community understand all that is available to help these people to live their more full and complete lives.

Steve Gregg: Dr. Fishburne, we have a lot of folks that come to us, trying to seek help for a loved one. And we know those conversations, particularly in multigeneration households can be really difficult. Do you get caregivers coming to your office that are either translating for an older adult, a parent, or a grandparent, or even a loved one.

Do you get a lot of caregivers? And if so, how do you then help educate them regarding the patient’s situation?

Dr. Cary Fishburne: Absolutely. We, we absolutely get caregivers coming in with the patients to express concerns for these issues and how much it, it can impact the care of these folks towards the other people in their world who are helping to take care of them.

To me, it’s all about, that’s part of the balance of understanding the unique goals and priorities of each patient. And what I love is that we do have a lot of treatment strategies that really meets people where they are in life. And so a lot of our caregivers are, come in, they’re maybe frustrated and concerned, but, but also maybe not wanting to consider something very invasive and very dramatic as care.

And many of them are very pleased with the minimally invasive options we can offer both with medical management and sometimes very minimally invasive surgical management to dramatically improve the lives, both for the patient and for the caregivers and make these issues much more tolerable, much better managed.

You know, I’ve had a patient who was 104 years old, came into me and said, “For 20 years, I’ve been being told I’m too old to do anything for. Is there anything you can do for my condition?” And to be able to give her a treatment strategy that was appropriate for her at 104 in a way that dramatically improved her quality of life was a joyous thing for her and her caregivers to realize.

So we do have treatment options across all stages of life. Many of them are surprisingly minimally invasive or noninvasive. And so having that discussion with the caregivers is really part, part of understanding the unique needs of that individual patient and tailor-fitting an approach.

Steve Gregg: That’s fantastic. I don’t know that I know of many physicians that actually say they have treated patients that are in excess of a hundred years old. So congratulations for that.

Dr. Cary Fishburne: Well, you know, what was wonderful about that is, you know, this a hundred, four year old who articulately expressed, here’s how my life is miserable, and for 20 years I’ve been talking about it and being told I’m too old to do anything for, can’t you just give me a good night’s sleep?

And with that frank discussion, I’d do anything for her. And we did, we did something absolutely appropriate for her and the rest of her life she had improved quality of life, and that was a wonderful, wonderful experience for both of us.

Steve Gregg: So that’s fantastic. Just fantastic.

Bruce Kassover: So over the past couple of decades, have you found that when people come to see you, that they tend to be more open and more comfortable having these sorts of conversations, is there a general increased openness towards conversations of this nature you think? Or is it still something that there’s a lot of stigma associated.

Dr. Cary Fishburne: That’s a, that’s a very interesting question. I think there’s probably a two part answer to that. On the one hand, I think as a culture, I think we’re really encouraging more openness and honest conversation about things that even are very private things.

So think, I think people are talking more about these things. I think there’s more awareness that there are better options out there even though patients may not know the specific options available. They just know that there, there there’s been progress. So I think there’s more openness to talking about these private issues with that as much stigma, but I will also say that, you know, there was a very well publicized debate and drama associated with some of the pelvic floor mesh kits that were more widely used in years past. And when, when the FDA pulled those off the market a couple years ago, it did, it did create a considerable amount of controversy. And the residual out there is that there is a certain, maybe, distrust about some of the options that are available.

The concerns for the risks and benefits with some of the approaches that we used in the past, learned a lot about and no longer use, but, but that has with some patients that suppresses the, the conversation, because there is a little bit of distrust created by that controversy.

Bruce Kassover: I know that there’s a pretty broad range of potential treatments that are available to them. When you start to talk about some of the more invasive treatments, do you, do you get a sense of resistance from, from certain patients then?

Dr. Cary Fishburne: I do. I think there’s a range. I think some patients really do come in and they, they develop that trust with me and other physicians and just say, well, doctor, you know, the common question I hear is, “What would recommend if I was your family member?” And my response is always, well, that’s exactly how I treat my patients, because that’s, that’s how it’s supposed to be. I’m supposed to treat them as I would family members. And so some, some people really have that trust and we can navigate through the pros and cons and what we can learn, it’s an easy discussion, and some other patients really do have concerns of that impression created and really need to be talked through in, in great detail about the pros and the cons of the various options. My patients frequently are surprised to know that the options available to them don’t have to be as invasive as they’re concerned about, that oftentimes are very, very minimal, non-invasive, may involve a simple 10-minute office procedure that they, you know, were not previously aware of that can dramatically change their lives.

Having that conversation and giving people the various options out there oftentimes is a, is a real surprise to them because they have in mind something much more invasive that they were, you know, initially concerned about.

Bruce Kassover: So when a patient comes to see what do you do to get them, to share their symptoms and to really open up so that you can give them a proper diagnosis and put them on the right treatment path.

Dr. Cary Fishburne: Absolutely great question. The theme right, right away is to be respectful and caring and to then normalize the conversation. I have to normalize the conversation to let them know it’s okay to talk about things they are usually not talking about. And I find the best way that I can do that is to just be very honest and straightforward and ask honest and straightforward questions and set that tone of normalizing that conversation.

Age range may range from teenagers all the way to over a hundred, and people of different generations may have a different comfort level talking about these sorts of things. So the best thing I can do to normalize that conversation, I also recognize that I am a male in a woman’s world. And so, I, it’s so important for me to set the tone of respect and dignity to, and help them understand that I am there to help them in a way that hopefully can make them feel comfortable sharing what is going on in a very private way.

I think when we do that and we, when we establish that normalized conversation, patients will begin to open up and have a relief, really, that when they’re opening up, they realize they’re not the only ones, that I’ve heard this story before, that other people live with the same issues, and there’s kind of a relief and the patients feel better knowing that they’re, they’re not only not the only one, but, but now we start to explore what those options are.

So I really listen to their story and listen to how things impact them. I start to understand what their own individual goals are. And then I, I match that story with the, what we can understand by a physical exam to really understand what’s going on anatomically and I, I frequently tell patients that I am a, I’m their carpenter and their plumber, so I am looking to see where things are breaking down and not working. And then once we understand their story and understand their exam, it typically becomes pretty clear what our various options can be. So the big theme with that is, again, normalizing that conversation.

Bruce Kassover: And once you do normalize the conversation, you get patients past those initial stages where it’s uncomfortable, do you think that they have realistic expectations or, or some of them defeatist and they don’t expect anything can be done or some of them may be too hopeful? What do you get a sense from patients regarding their expectations of what you can do as a physician?

Dr. Cary Fishburne: That’s a great question. You know, I care about my patients. I want perfect outcomes every which way, every time, and sometimes we need to accept that “better and improved” is, is really an achievable outcome versus “absolutely perfect all the time.” And so walking that expectation walk with my patients is very important. I need to understand what their goals and expectations are.

That’s what they’re there for. They’re not there for my goals and expectations. They’re there for their own goals and expectations. And so the art of it is sometimes as I understand them, helping them to realize what attainable expectations and goals are and working towards those.

But also sometimes accepting that improvement is what our goal needs to be rather than perfect or, you know, helping to, to really navigate those expectations. Both ways – I have patients who come in and I’m their last hope, but they really don’t have much faith that there’ll be much attained by our meeting each other.

And so the joy in that of course, is to give them some optimism that we can improve upon things. And then sometimes, too, on the flip side, we have to let patients know that this may be a journey: we may deal with one issue now, and once we address that, we may have to build upon that by dealing with other issues, almost like layers of an onion, we kind of address the biggest concern first and keep working at things.

Bruce Kassover: I can imagine, it must really be, be rewarding when you do see the sort of meaningful improvement that that patients could have only hoped for.

Dr. Cary Fishburne: I had a patient about two months ago, who said it so well, I just, it really resonated with me. And she said, “Dr. Fishburne, I had no idea how much freedom I had lost in my life until you gave it back to me.”

And, you know, I was flattered, had nothing to do with me. I was just able to put together plans that other folks much smarter than myself had innovated, but it really, it really resonates how impactful that management plan was in her life. And that comment is one that I have not forgotten.

Bruce Kassover: That’s great. So is there anything in particular that patients who are, well, I guess all patients are hoping to maximize their outcomes, but is there anything particular that patients should do even before they come to see you that can help them get the most out of their visit with you?

Dr. Cary Fishburne: There’s an old saying that if, if you listen to a patient long enough, she will tell you what’s wrong with her, and think it’s a wonderful saying, because it really highlights how much we need to listen and truly listen to our patients. And the more a patient can explain her own personal experience and be thoughtful about things that may make her condition, her condition and her symptoms worse and may make them better, put that in context of her own life and what, what her goals are in life, what she’s looking to achieve, really coming in and telling me this story helps me a lot. And then also, too, if patients have had other treatments in the, which may have worked and may not have worked, having that kind of context is also very helpful for me to know.

Bruce Kassover: In terms of the standard of care today, do you feel like you can generally offer most of your patients solutions that will really make a difference for them, or are there some conditions that are just still very challenging to find meaningful solutions for?

Dr. Cary Fishburne: I truly think that, one of the things I love about my subspecialty is, as I’ve grown into this space, I’ve learned a big and deep and wide toolbox of different options with ways to approach different conditions, so the more options we have, the better able we are to meet the needs of our individual patients in a meaningful, meaningful way.

And I will say that I really take great joy in the subspecialty because we can meet the needs of most of our patients in a very substantial way. And it’s a joyous specialty. We participate in the joy of our patients because as they feel better, it’s a very happy specialty, so I do, we are in a specialty that has a great deal of positive satisfaction.

I think some, some areas that, you know, I watch continuing to be frustrating in our area, we can make great progress with patients with recurrent bladder infections, for instance, but we have a real problem with emerging and evolving resistance to antibiotics with these bacteria. So we’re always trying to learn new ways to stay ahead of the recurrent bladder infections, which really can be a very significant issue for our effected patients, so that is one area that that is challenging now with the emerging antibiotic resistance.

Bruce Kassover: You mentioned earlier about people having concerns because of issues regarding vaginal mesh. And where does that stand today?

Dr. Cary Fishburne: Vaginal mesh really came into being because we just wanted to find solutions for patients that would last a lifetime, so that patients didn’t come back with recurrence of their symptoms.

But that growth of that area really exploded, and it exploded beyond our understanding about optimal mesh pore size and optimal implant techniques and really the way we should make those kits. And it exploded beyond, really, our training into the complicated implant techniques required to do these safely.

And so really because of that, concerns about side effects really accelerated. And of course the FDA got involved in wanting to make sure there was a good balance between risk and benefit from a safety perspective. And when they reviewed the more recent studies and did not find an appreciable benefit over a short term, they took those kits off the market.

Interestingly, as those same studies have matured out to three and five years, the benefits of the transvaginal mesh kits are actually starting to show superiority over the traditional repairs. So interestingly, the thing, very things, the FDA were looking at are now starting to favor, perhaps even reconsideration of transvaginal mesh kits.

The problem is, is that negative impression has been created. Whether or not industry will, will put the resources in again, to consider transvaginal mesh kits in the U.S. again is hard to predict. But as of right now, the FDA did take those kits off the market. So it is only very rarely that I will create a transvaginal mesh kit that I do tailor fit.

And we have to do that with great discussion with patients, being very transparent about it being off-label and have a very frank discussion about risks and benefits. But for some patients that’s truly maybe their only viable option to meet their goals. So right now it’s, it’s really off the market, it is hardly ever done; I will not say never because there are patients who don’t have any other options, and that’s behind us. Now that is to say, those issues are very distinct. transvaginal mesh kits are not the same as mesh slings, or mesh used for intra abdominal sacral colpopexy support procedures. Those procedures have been around for a very long time, and the FDA specifically recognizes that they offer great benefit to patients and are not part of the FDA concern that the transvaginal mesh kits were.

Bruce Kassover: That’s really interesting to hear. And I know that there are other technologies that maybe are not used as frequently as they might be, things like implants for neuromodulation and PTNS and or other modalities as well. What do you get the sense of in terms of patient awareness and education about all the different range of treatments that are available to them?

Dr. Cary Fishburne: I really think we’re at the infancy of patients’ awareness about those advanced therapy options. I have been in the Charleston, South Carolina, area for about four years and really participating a lot in trying to grow that awareness.

And it’s a, it’s an awareness that we need to grow both in the, with, within the community of patients, but also in the community of physicians. There really is a very limited awareness among many people, patients and physicians included, about what amazing benefits those neuromodulation options can offer.

And specifically in the area of overactive bladder and urinary retention and also accidental bowel leakage, fecal incontinence, is a really big deal. And so being able to manage these conditions in a much better way through the innovation of neuromodulation is exciting, but we have a lot to do to spread awareness about it.

I think an overarching theme is for any patients out there potentially who are listening to this today is to understand that pelvic dysfunctional issues are very important, very impactful. And we, we live in a world where we don’t have to ignore those or suffer through those in silence that there are excellent treatment options, and that coming in for a conversation does not mean that someone’s obligated to proceeding with a treatment option. It’s just about getting information and understanding one’s own condition so that they can understand what options are available. And that folks in our specialty, the specialty of urogynecology, both GYN, physicians and urologists, we are trained to be able to tailor fit a treatment plan strategy to meet the individual needs of our unique patients so that we can really try to address each patient’s unique individual goals and priorities. And so I think it’s, it’s an exciting time in this world because we really do have a lot of options that work well and can improve people’s quality of life. And so I always encourage that conversation.

Bruce Kassover: Dr. Fishburne, I want to thank you for taking the time to discuss all of these topics with us – it’s incredibly useful for patients and for caregivers to listen to your perspective and hear what you have to say and and certainly get the encouragement that you’re offering, that treatments are available as long as they’re willing to take action, so thank you for joining us. I really appreciate it.

Dr. Cary Fishburne: Thank you so much. I’ve enjoyed it tremendously, and this all just meets that goal of spreading the word of options out there to help people, so thank you very, very much.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. This podcast was supported by our sponsor partner, Medtronic, makers of InterStim systems for bladder and bowel control. To learn more about InterStim systems, visit controlleaks.com.

Our music is “Rainbows” by Kevin MacLeod and can be found online at incompetech.com.

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