Clinical Visit - Female Reconstructive Surgery in the USA

by Nikesh Thiruchelvam, Consultant Urological Surgeon, Addenbrookes Hospital, Cambridge Univerity Hospital NHS Trust

Nikesh Thiruchelvam spent four weeks in the USA at some of their most advanced urology departments, and took an eye-opening trip to the American Urological Association (AUA) meeting in Chicago.

I have recently returned from an exhaustive trip to the United States to further my experience and knowledge of expert practice in female and reconstructive urology. This was a 4- week trip, with the first week at the annual American Urological Association (AUA) meeting in Chicago, Illinois, followed by 1 week at the University of Texas Southwestern in Dallas with Professor Phillipe Zimmern, and then finally 2 weeks with Professor George Webster at Duke University, Durham, North Carolina. Impressive and Informative AUA Meeting.

I left feeling in awe of some of the studies that were possible, at least in the American system.

The timing of my trip made it an ideal time to attend the AUA meeting in Chicago. This was my first attendance at this meeting and I was incredibly impressed by the quality of the meeting. The plenary sessions were informative and delivered by world experts. The free and paid teaching courses were equally clear and worth while. Topics were exhaustively covered but slightly biased to American ways of doing things. There were also excellent networking opportunities (18,000 delegates).

I left feeling in awe of some of the studies that were possible, at least in the American system. World experts would not only describe a new technique (typically a slight modification on a previous one) but also the results for their first 60 or 70 patients. Nonetheless, I left with ideas for my practice and for new studies that I hope I will be able to pursue back in the UK. I will certainly return to this meeting.

Amazing Facilities in Dallas, Texas

The second week of my visit was with Professor Phillipe Zimmern. He is a world expert and author on female urology. He is also an incredibly patient man who takes great effort and time with his patients and is clearly very well liked by them. My time with him was spent in clinic and in theatre.

During these periods, he ensured that I was looked after at all times and took time to teach me. As he has slightly different views from the ‘consensus’ on patient management (especially on the use of mesh in pelvic surgery), it was useful to debate certain concepts with him. Professor Zimmern greatly enjoys teaching and, despite 12-hour days with him, he would often give me further reading material for the evenings. I couldn’t complain at 7 am starts when all the juniors start at 6 am for every day of their intensive training years.

Professor Zimmern greatly enjoys teaching and, despite 12-hour days with him, he would often give me further reading material for the evenings.

When I mentioned that I missed his BAUS plenary talk last year because I was away on my fellowship, he took me to the urology lecture theatre and gave me a repeat personal plenary talk! Together with discussion on incontinence and pelvic organ prolapse, I was also able to pick up tricks on the difficult management of interstitial cystitis.

With stalwarts in the field within the department, I was able to hear a teaching session by Gary Lemack on urodynamics and a lecture by Claus Roehrborn on his verdict of the REDUCE study (announced the previous week at AUA) and to observe in clinic the successful outcome of robotic sacrocolpopexy and single-incision (18 mm scar) laparoscopic sacrocolpopexy (Jeffrey Cadeddu).

I was also very lucky to spend a third of my week with Allen Morey who gave a plenary talk at the AUA with Professor Mundy on the use of buccal mucosal grafts in urethral surgery. Again I was able to witness complex urethral surgery in theatre and complex decision making in the outpatient department. Again, my teacher was open to discussion and debate.

The amazing facilities available in Dallas were almost depressing...

The amazing facilities available in Dallas were almost depressing: the urology corridor had offices for the entire faculty, together with offices for the residents and juniors (who total 18) and research fellows, urological research laboratories and a urology lecture theatre. Not to mention the numerous theatres, two robots and single-incision laparoscopic equipment and outpatient facilities.

With widespread philanthropy, the department receives many grants; Professor Zimmern has a research fellow funded for life thanks to the generosity of one of his successfully treated patients. The department also has a full-time administrator whose sole employment is to coordinate research grant applications and ethics approval applications. The facilities were eye-opening and something to strive for within the confines of the UK NHS system.


A rather strange machine that both units had - a secure scrubs dispenser. You are issued with a card with scrub credits on it. You swipe your card to get a pair of scrubs and then reswipe to deposit it back at the end of the day.

Physician assistants provide a valuable service in Durham, NC

My final 2 weeks were spent with Professor George Webster who is a senior leading expert in reconstructive urology. He too took great time in explaining the principles of his work and was open to discussion and debate on patient care. He also had a tertiary practice which allowed me to see complex cases and failed surgery cases and he took me through the thought process involved in determining management plans and predicting successful outcome.

The amazing facilities available in Dallas were almost depressing...

I was fortunate to be able to witness Cindy Amundsen (Professor Webster’s wife) who is a leading expert and author on urogynaecology. This was a very useful opportunity to see different ways of dealing with similar complex incontinence and pelvic organ prolapse cases. It was also useful to discuss training and management issues with Professor Webster’s senior fellow and, as in Dallas, to observe the successful use of physician assistants who take on a large amount of patient administration and perioperative care that we in the UK devolve to junior medical staff. With the confines of the European Working Time Directive, such physician assistants may become useful aids to UK consultant practice in the future.

Once again, facilities were beyond belief, with a huge hospital complex and the closely associated research and educational facilities of Duke University. Patients fly in from far and wide to see leading experts and often have complex surgery to be discharged (to a local hotel) the same day.

I am extremely grateful for the financial support The Foundation has given me to undertake this clinical visit. In addition to learning expert practice in patient care and building a research portfolio (‘aim to get every patient into a multicentre trial’), I have learnt, in especially complex reconstructive cases, that there is often no one right way of doing things. For successful patient management (more so in a tertiary practice) it is clear that doing the one right operation once is the best way forward.

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