C/- UGSA Secretariat
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Victoria 3002 Australia

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It was a pleasure and privilege to receive the UGSA - AMS Travelling Scholarship for 2011 from Prof Kate Moore on 18th June 2011, an annual award created by UGSA in partnership with American Medical Systems (AMS).  John F. Nealon, their US based Senior Vice President and General Manager Women's Health was present at the UGSA event and it was obvious that AMS valued its association with UGSA in Australia.

The award included a fully funded trip to the United States to attend the “International Academy of Pelvic Surgery (IAPS) - Annual Fellows Programme” at Cincinnati, OH on August 18-19th, subsequent visits to at least two major vaginal surgery centres within the U.S and a visit to the manufacturing facility & cadaver lab at the AMS HQ in Minneapolis, spanning nearly 2 weeks.
Sharee Mitchell, the national manager for AMS in Australia, accompanied me during the trip and we arrived in Cincinnati on the 17th Aug to attend the IAPS annual fellows programme directed by Professors Mark Walters and Micky Karram. It was an early start on the first day and at the stroke of 06:30, I walked into the breakfast area dressed in business attire, only to find everyone in their scrub cloths and everyone instantly got to know who I was without me saying even “hello”!
The morning sessions were around the use of mesh in prolapse repair and very soon, it was obvious that the FDA Safety Communication on serious complications associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse issued on July 13 and the subsequent unequivocal support of FDA’s position by the American College of Obstetricians and Gynaecologists (ACOG), appeared to weigh heavily on the proceedings.  

An increase in the number of serious adverse events associated with transvaginal mesh led FDA to identify mesh repair of POP as an area of "continuing serious concern". They concluded that serious complications associated with surgical mesh for transvaginal repair of POP are not as rare as previously thought. The discussion during the proceedings was rigorous. During the wrap up session, I felt a dilemma among the fellows about the use of mesh in secondary prolapse procedures due to the significant uncertainty relating to the safety and efficacy. On the plus side, the high success rates of sacrocolpopexy in treating recurrent prolapse in women was discussed at some length.  

Dr Chi Chiung Grace Chen from John Hopkins got everyone’s attention when she shared her experience in treating women with complex urinary fistulae and urethral diverticulae in Africa. Dr Chen’s visual presentation was humbling. Dr Chen followed that presentation with an equally impressive lecture that evening on “Developing World Medicine:  From Robotic Surgery to Surgery in a Hut”, further sharing her experience from the developing world.
The cadaver lab consisted of 10 stations for anatomy and surgery  with demonstrations of several mesh products. There were three stations where vaginal, paravaginal and sacrospinous dissections were demonstrated in prepared specimens. I noticed that the rules of play included a strict prohibition of product sales by participating industry.

Day 2 started with talks on robotic surgery and it is obvious that the use of robotic approaches has taken off in the United States far more than in Australia and I guess it has to with the economies of scale offered by a larger market place. Prof John Gebhart’s (Mayo Clinic, Minnesota) demonstration of the use of SIS mesh surgery in the restoration of short and constricted vaginas was particularly interesting given the volume of pelvic reconstructive surgeries performed these days. It is generally recognized that the surgical correction of iatrogenic vaginal shortening or constriction was not well described in the literature until recently and Dr Gebhart’s presentation focussed on various techniques and approaches to successful correction.

I arrived at the AMS headquarters at Minnetonka to a warm welcome by John Nealon, Mike Ryan and Geoff Ashenbrenner. After exchanging pleasantries, Mike Ryan presented a brief overview of AMS and discussed the goals for the day. The manufacturing tour lasted an hour and a different perspective slowly unfolded as I was trying to understand the design and quality control processes involved in delivering a product for clinical use. Subsequently, their current development efforts were discussed in some detail and the development team’s keenness to obtain a practitioner’s perspective and feedback was unmistakable. Though it was a short stay, the visit was memorable and their spirit of hospitality was unmistakable!

After arrival in Atlanta there was another warm welcome from Drs John Miklos and Rob Moore.  What unfolded over the next couple of days was a spectacle of very well organised and efficiently run system of four surgical theatres where in the surgeons seamlessly moved across to maximize the use of surgeon time. While the workload was quite high and the work almost mechanical, the theatre staff somehow seem to believe that busy theatres are the best places to practice their dance moves, often to peals of laughter from all around. Perhaps it is their way of getting through busy days and demanding surgical work. The day prior to departure to Florida for the final leg of my tour, I realised that I had brought my North Queensland’s tropical cyclone luck with me to the States. Hurricane Irene was declared as a category 4 storm approaching the Florida coast and AMS managers were quick to suggest that I spend extra days in Atlanta rather than risking a flight to Florida. Cyclone Yasi from Feb was still fresh on my mind and I was more than happy to oblige and stayed on at Northside.

Dr Moore was happy to accommodate my extra time, organised a visit to a robotic surgeon who was performing a radical robotic hysterectomy with lymph node dissection using Da Vinci. It was an interesting experience to watch him perform surgery with a coffee mug to his right and phone placed handily. I was also lucky to observe Dr Moore perform a laparoscopic, neovagina development for a patient with rare, Mayer-Rokintasky-Kustler-Hauser syndrome on my final day.
My stay at Atlanta was further made unforgettable with a visit to the local Hindu temple, a moving tour of the Dr Martin Luther King Jr national historic site and a fun trip to Coca Cola factory, the birth place of Coke. We had a choice of 60 different beverages from all parts of the world arranged geographically and the facility, to my relief, had numerous toilets in close quarters. This is one place where urge incontinence has a legitimate place!!

This report would be incomplete without my heartfelt thanks to Sharee Mitchell, who made a gruelling trip a breeze with her excellent planning and organisational skills. She was also a perfect and easy going companion throughout.  

During my long flight back, I could not help reflect my journey so far. At forty something, I am still a “trainee”, setting off on learning quests and often have the illusion that I am young! The fact is that I am not but I have come to realise that learning is a lifelong process for us all.