Barriers to Performing Combined Surgical Procedures

Traditional approaches to treating PF problems involved either one surgeon performing all of the indicated repairs at one setting, or scheduling sequential surgeries at different times by different surgeons. In most communities, a clinician will evaluate and treat the symptoms within his area of expertise. It is still rare that a team of clinicians is available for multidisciplinary evaluation. Identified barriers to multidisciplinary care include:

1. Expertise availability. Lack of availability of subspe-cialists capable of addressing specific PF problems is a significant barrier in many communities or hospital systems. This may be particularly true regarding urogyne-cologists, who are currently present in relatively small numbers.

2. Training issues. Most postgraduate training programs do not foster the concept of a team approach to evaluation or therapy. As such, combining surgical procedures performed by different specialty surgeons at one setting is not the standard in most universities or communities.

3. Turf issues. Certain PF problems are within the surgical armamentarium and can be surgically treated by more than one subspecialist. Examples include anal sphincter repairs, rectocoele and cystocele repairs, and stress incontinence procedures. These procedures can be performed by various specialty surgeons, each using different approaches. With the goal of optimizing patient outcomes, we believe that the approach associated with the highest reported success rates should be the one the patient undergoes. As such, clinicians should be aware of these outcome differences when planning surgical therapy. Based on these principles, at Cleveland Clinic Florida, the col-orectal team performs all anal sphincteroplasties and the urogynecology team performs all rectocoele repairs. We do not believe that one surgeon can satisfactorily address all PF problems. Turf issues should be put aside in the patient's best interest.

4. Procedure scheduling challenges. A requirement for a multidisciplinary surgical intervention is the availability of different specialty surgeons. This can lead to inefficient use of time. Thus, preoperative planning is crucial. Ideally, two patients are operated on simultaneously, such that each team performs their designated procedure on a patient in one room, while the other operates in the other room. The teams then switch, after completing their respective operations. We have found this to work rather efficiently, as long as the procedures are planned and scheduled appropriately.1

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