A Surgeon for the Pelvic Floor: Dream or Reality?

Abstract As surgeons, we have evolved from barber surgeons to superspecialists. In the future, the pelvic floor surgeon will be even more specialized and most likely cross-trained so there is true understanding of all aspects of pelvic floor disease. Probably more importantly, there will be a team for the pelvic floor, and pelvic floor problems will be addressed by a true multidisciplinary team with the surgeon as a major stockholder in this process. All aspects of care will evolve to comprehensively consider the entire pelvis along with the entire GI tract and nervous input. This chapter reflects my crystal ball for the future care of our pelvic floor patients. As surgeons, we all started as barber surgeons. Our tools were used to cut hair and then perform surgical procedures. As medical and surgical knowledge was advanced, we broke away from our barber heritage and concentrated on our surgical skills. Initially, surgeons were all generalists operating on the entire body. But the body is complex, and vast quantities of knowledge were deciphered for each specific region or organ system. With time, the combination of knowledge and technical demands were overwhelming for a true general surgeon, and therefore our predecessors began to focus their skills toward specific organ systems or regions. Thus, specialists were born. However, humans are curious and always striving to learn more and improve. Our knowledge and tools have exponentially advanced over the past 50 years, and superspecialists were needed as the problems continued to become more complex. The pelvis is one of those extremely complex regions of the body. It is unique being a box made from the boney pelvis with a floor made of muscle. Piercing that muscular floor are the urinary and bowel systems in men and women (additionally the vagina in women). We have learned that all of these pelvic systems are interrelated. Changes or compromise in one area can lead to a problem in another area. For optimal pelvic health, all regions must work individually and together as a unit. When looking at the treatment of pelvic disorders, we are at a crossroads that is steering us toward further specialization by the current health care specialists that treat this area of the body. The multiple surgical specialists that have a stake in its treatment include general surgeons, colorectal surgeons, gynecologists, urologists, and some other branches. Each of these disciplines many times work in isolation when assessing and treating their compartment of the pelvis. Ironically, this contradicts the pelvis being a unit with each compartment – anterior, middle, and posterior – interrelated. Additionally at many current symposiums and educational meetings, it is promoted as being essential for all healthcare providers treating pelvic disorders to work together and treat the pelvis as one entity. However in practice, this does not seem to be a uniform reality. Therefore, the future of pelvic healthcare requires this area be treated by a multidisciplinary team (just like occurs with rectal cancer) in order to provide optimal care. This will require surgeons treating disorders currently designated as “pelvic floor problems” to think broadly and in concert with all providers that participate in treatment and care for this region of the body. “Pelvic floor surgeons” may become true multidisciplinary surgeons. They could draw from the experience of each compartmentally trained surgeon (colorectal and general from the posterior compartment; obstetrical/gynecologists and urogynecologists from the middle compartment; and urologists and urogynecologists from the anterior compartment). This type of surgeon would be broadly trained and able to treat and operate on all aspects of the pelvis. Another option which may be more likely is that they will lead a genuine integrated multidisciplinary team with a common goal to provide expert care for the entire pelvis. While nobody knows how we will care for these patients in the future, I have taken this opportunity to think of my “wish list” and look into my crystal ball. The following are my thoughts about idealistic future care for our pelvic floor patients.