Good Morning!
Winter is on it's way to Central Oregon, as the temp this morning was 16 degrees. Now all we need is some snow in the mountains to start the ski season.
This past week has been an exciting one in our office. We've been refining some of our educational information and will soon be modifying our website so it can better inform potential patients regarding incontinence and pelvic prolapse. There is so much information on this topic, it's hard to know what to include and what would just be contributions to your "cesspool of useless information", so to speak. The trick is how to organize it, and to explain things in ways everyone can understand. Don't worry, it's coming and will soon be better than it is now.
I'm starting to build up my surgical numbers, and last week we repaired a large cystocele (bladder fallen down), and did a laparoscopic sacrocolpopexy. This is a procedure where the top of the vagina is resupported via a piece of mesh sutured to the sacrum (the base of the spine). This procedure has been done for years through a big incision, but over the past few years a few centers have started to perform them through the laparoscope, which allows for a much faster recovery. To my knowledge, we are the only center in Oregon doing these laparoscopic procedures.
I want to let you all know that we will be at the Central Oregon Womens Expo at the fairgrounds in Redmond Nov 11 and 12th. For those of you who live in this area, I'd love to meet you and discuss any issues you may want to talk about regarding womens health, or anything else on your mind. It will be exciting to meet a lot of people (hopefully) and try to address their health concerns.
Take care, and have a great week.
Dr. Mos

Hi there again.
Thanks to those of you who are reading this, and who have written comments. If there's anything you would like me to address, please let me know.
Today Deena, our nurse, brought her 3 legged dog to the office after her bath. It reminded me of Tommy, my cat, and his adventures before we left Hawaii. I was worried that an outside cat who doesn't have front claws and lost his top fang teeth wouldn't fare well here in Bend with the cougars, foxes, wolves, and whatever else is out there lurking. I took him to Mililani (the middle of Oahu) to give him to a family I'd gotten to know there who really wanted a cat. Three days after I left him there, the family called and said Tommy was missing for the last day and a half. A friend of mine and I went up there and spent 3 hours looking for Tommy and calling him, and just as we were ready to give up, I heard him, but I couldn't tell where his howling meow was coming from. Finally, I looked down and realized he was in the storm drain! After rescuing from his wild travails, I couldn't leave him there, so he came to Bend with me. The only thing that wasn't right about taking him back was that the family that wanted him had a little 5 yr old toehead who loved Tommy. So, we went to the pound and found a little 3 month old kitty that looked just like Tommy, and took him up to Kaeden, the little boy. Now, all is well in the feline world, and Tommy's happy being a mostly indoor cat (he doesn't like the cold weather).
I'm currently working on a series of educational talks geared both for women in the community and for physicians. I think there's a great need for better understanding of incontinence and prolapse in both groups, specifically regarding modern treatment options that don't require big huge surgeries. Most primary care docs don't bother asking their patients if they're incontinent because they don't want to deal with it if they are. The other reason is that with only 10 minutes to spend with each patient, they feel it's more important to deal with their high blood pressure and diabetes than with their incontinence, which is understandable to some extent. This is why I'm trying to educate the patients themselves so they can self refer to doctors who like treating these types of problems, and then tell their friends thereby spreading the word that they don't have to suffer in silence. We're going to the Central Oregon Womens Expo at the Redmond Fairgrounds the second weekend in November. Kate and Deena and I will be there to talk with women about incontinence, prolapse, and endometriosis, to try to spread the word that there are some great new procedures that work great with minimal surgery.
Which reminds me, I have to work on my handouts....
See you next week,
Cindy

Here we are again - it's hard to believe it's been a whole week since I last wrote. Two wonderful things happened in the past week - someone actually posted a comment so I know at least 1 person is reading this (thanks!), and more importantly, I did my first case here in Bend. Dr Redwine talked me through my first laparoscopic lymph node dissection. For those of you, probably most, who don't know what this is, it's a procedure only recently adopted by most oncologists for staging cancers of the uterus. You may be thinking, 'well what the heck does this have to do with endometriosis? I don't have cancer.....', and there is an answer to that question. The laparoscopic lymph node dissection is actually the perfect case to learn the deep retroperitoneal pelvic anatomy. This is the part of the pelvis where 99% of general gynecologist never go. It is also where we go quite frequently in the pursuit of invasive endometriosis, and in those cases the anatomy isn't always normal or easy to navigate through, so this was actually a great learning case. More importantly, Dr. Redwine was pleased and impressed with the way we operated together. Plus, I'm showing him a few new tricks that were invented in the 21st century....

The other fun thing I did in the past week was go to Seattle to watch a laparoscopic sacrocolpopexy. This is a procedure done laparoscopically in only a handful of locations around the country, but regardless of the approach (open or laparoscopic) it is the best way to resupport the top of the vagina after it falls down. I've been doing sacrocolpopexies open for many years, and now we will be doing them through the scope, which allows the patient to recover a lot faster than if she has a big incision, as the incision is the part that hurts the most and limits activity the most. A mesh is sutured to the upper vagina, then sutured to the sacrum (the bone at the base of the spine). This procedure gives stronger support and a longer vagina than do most vaginal approaches to apical descent. It also allows better sexual function after the repair, so for most women in their 50s and 60s, it is the ideal surgery for repairing that stubborn nasty prolapse. Sometimes I wake in my sleep and hear vaginas around the world calling "help I've fallen and I can't giddy up....."
But seriously, I'm really excited about how my 2 passions, endometriosis surgery and pelvic prolapse surgery are dovetailing. The joy of helping women return to their normal lives comes from both types of surgery, and the surgical challenges, understanding the anatomy, and doing everything with the most minimally invasive techniques are nothing new to me. Nonetheless, being here and getting to operate with Dr. Redwine is exciting and fulfilling and challenging all at once, and I love it.
Well, I'm off to the hospital for more fun and excitement.
See ya next week, and a hui ho.....

Well, today was a very exciting day, as I got my new toy - a brand new Urodynamics machine. We had 2 pts for the nurses to learn on, and for me to get used to the new machine. It was nice to find out that although this machine is 7 years newer than my old machine, it works very similarly, but better. We can now accurately test for all different types of incontinence, and even detect occult incontinence in women with more severe prolapse, which is a condition where they would leak if it were not for the severe kinking of the urethra which happens when the bladder is falling out. We can also check the strength of the urethra itself, which can indicate just exactly which type of sling should be done, or if a sling is even necessary. Sometimes, especially in the context of a failed prior procedure, a low urethral strength can indicate that a very simple procedure of injecting a bulking agent around the urethra can help resolve the incontinence with essentially no surgery or recovery! Sometimes, though, we find out that the prior procedure has failed, and we gain information from the urodynamics that helps guide the choice of the correct procedure for the patient. Basically, when it comes to incontinence and prolapse, one size does not fit all, so we need all the information we can get to design the right procedure for each individual. The urodynamics also test the emptying phase of the bladder, to ensure that after surgery the patient will still be able to empty her bladder. Believe me, being able to empty your bladder may be something most people never think about, but when you have to go and can't pee, it's MISERABLE!!!!!!
So, off I go to conquer the world of incontinence and put the Depends people out of business....

Well, I'm officially a Bend-ite as my household goods arrived last week. And, my hospital priveleges are official as of tomorrow am, so now I can actually start operating instead of just watching. Of course, when you watch someone whose surgical technique is so different than most (translation - better), you can learn a lot just by watching. Dr. Redwine is actually a very good teacher, and explains his rationale for why he does what he does along with explaining what he's doing. I actually have done quite a few of the surgical techniques in Hawaii that I learned from him last fall when I was visiting Bend. It's difficult and requires skill and perseverence, but it's so rewarding to have patients come back and say their pain is gone after you've removed their endometriosis. I met with some physical therapists today who specialize in womens health and pelvic PT, which is also very important for some women in relieving all of their pain. Sometimes pain starts from a stimulus like endometriosis, or surgical incisions, then muscle spasm sets in, then nerve irritation from the spasm, then more pain, and on and on. When you remove the initial stimulus, ie the endometriosis, in most people the pain goes away, but in those women who have started the cycle with muscle spasm, they continue to have some pain, usually a little different than before their surgery, but still bothersome. That's where the PT comes in. These therapists are experts at finding out exactly which muscles are in spasm, even the deep internal muscles of the pelvis, and then getting them to relax, which usually results in long lasting pain relief of the rest of the pain. I realized firsthand how important this was a few years ago after having my appendix out. I went back to work 3 days after my surgery (typical doctor) and started having terrible muscle spasms of my right side. I tried to fix it on my own, but I was unsuccessful. After a few visits to my trusty PT friend, I was dramatically improved. I strongly believe in a team approach to caring for patients. Whether it's regarding pain management or for incontinence, working with other professionals with a slightly different skill set and a different approach, yet the same ultimate goals, I think gives patients a better outcome, and that's what it's all about.
Well, although the movers came and went last week, I still have a house full of boxes begging to be unpacked, so I better go answer their calls. A Hui Ho...

Aloha,
My name is Cindy Mosbrucker and I'm going to be Dr. Redwine's "clone", as he calls me. I just moved to Bend from Hawaii where I was in private practice for 8 years as an OB/GYN. I've been doing quite a bit of surgery in Hawaii, both for endometriosis as well as for pelvic prolapse and incontinence, but now I'll be able to "learn from the master" and operate with Dr. Redwine on a daily basis. I guess I've been destined to be a surgeon since I was little. When I was in the 3rd grade, Carly Simon's song "You're so vain" was a big hit. My teacher asked us if we knew what it meant, and I raised my hand and said "it's kinda like an artery..." Then when I was in high school, I worked on a ranch and always helped the vet take care of the animals that were injured. We had a sheep with a big abscess ( like a huge zit) on it's back, a horse that ripped the skin off his leg, and various animals who had to get "fixed". I loved being in on the action. I went to Medical school in Chicago at Northwestern, and because it was quite expensive applied for and received a Navy scholarship. My last year of med school I went to Pakistan for 3 months to work at a little mission hospital. What an experience that was - patients would come in extremely sick, and we knew that we had to operate on them even though we didn't know exactly what we'd find, but if we didn't do anything, they would surely die. I'll tell you more stories about this later. I did my residency at Bethesda Naval Hospital, which is where President Reagan was operated on a few times, and had some great experiences there, as well as opportunities for doing a lot of surgery. It helped that I had done quite a few cases in Pakistan, because it gave me more experience than any of the other interns, so I was given more surgeries and more responsibility at an earlier time than most. After residency, I went to Guam for 3 years. It was a nice break from residency where I was working 80 -100 hour weeks. We worked hard and played hard - diving, fishing, golfing, etc. I started doing urogynecology there, where I worked closely with a urologist friend of mine doing complex cases. Then, I moved to Pensacola, Florida, to complete my obligation to the Navy. After a year there, I moved to Hawaii where I was in private practice in Windward Oahu. There I continued my quest to master pelvic reconstruction procedures and curing, or at least improving incontinence in women. As time went on, I refined my procedures to optimize the longevity of the repairs, so that the likelihood of recurrence of the prolapse was less likely. I became the referral gynecologic surgeon for my hospital and although I was still doing some OB, the main focus of my practice was surgical. The biggest reward I get is my patients being so happy after realizing that their small surgery relieved the suffering they'd been enduring from leaking urine, or being uncomfortable from their prolapse. I was happy because I was good at what I did, and could make a difference in the lives of my patients, but I still felt that there was more that I could accomplish. I thought about doing a fellowship in Urogyn, but as I researched this, I realized that I already knew 90% of what I would learn. As I continued my quest to optimize my potential I considered moving from Hawaii, somewhat for family reasons, and partially because I felt that it was time to come closer to home. Then I met Dr. Redwine, and my life changed forever. More later.......