Kim (00:01.678)
Hello, Dr. Lazar. Thank you very much for joining me on this episode. We're gonna talk all about the more cosmetic side of pelvic floor vaginal rejuvenation. And I'm looking forward to sharing your expertise. So if you can start out by just introducing yourself, what you do, how you became a urogynecologist, and then we will jump into some questions.
Darren Lazare (00:24.046)
Hi, it's good to see you.
Kim (00:25.61)
Nice to see you too.
Darren Lazare (00:28.717)
So how did I become a Eurogyne? Well, that's a good question, because you don't wake up one morning going, this is what I'm gonna do for the rest of my life. And I certainly love what I do. So I really like the challenge of obstetrics and gynecology. I think that was the key. You have wonderful kind of patients. You have complicated problems. You're looking after moms and babies.
Kim (00:36.875)
Hehehe
Darren Lazare (00:56.453)
and you get to do really cool surgeries. And I think that's probably where it began, the, just the challenge of all that. And then you sort of have one experience after another that take you on this journey. And I've had some amazing mentors over the years and they said, oh, you've kind of seemed like you're enjoying this part of OB-GYN and, have you thought about doing more of this?
Well, yeah, that sounds great. Let's do that. And just, you know, through that, you know, one path leads to another. And I, you know, for a while thought, oh, maybe oncology was my thing or infertility. But I really enjoy the surgical aspect, really enjoy working with patients, really, really like quality of life type.
outlets in terms of medicine and how can we improve this person's quality of life through interventions, whether it's non-surgical or surgical. And Eurogyne is a great platform for that.
Kim (02:07.31)
Awesome, cool. And we're gonna talk about both the surgical and the non-surgical that you offer in your clinic. So I wanna start out with just by a couple of definitions. So oftentimes with pelvic reconstructive surgery, you'll see Plasti and you'll see Pexi. So what are those two kind of, I guess, that they're like the end part of the word. What do they mean? Where do they come from?
Darren Lazare (02:34.833)
Perfect. So I think you have to kind of look to maybe the Latin and Greek background because pexy would be to lift and so to bring up whereas plasti I think would be to make normal. And so people might argue with those definitions but so you know you think about a sacral culpo
Darren Lazare (03:03.985)
three words there brought together. And so in a situation like that, what you're doing is you're lifting up really the vagina, the top of the vagina, and attaching the copo, the vagina to the sacro, which is the sacrum. And so you are pexing that and you are attaching it and lifting it up. Whereas you would do a vaginoplasty and what you're doing is restoration or returning to normal of the tissues of the vagina.
maybe from aging, from childbirth, trauma, different things.
Kim (03:39.774)
Okay, so I want to start with vaginoplasty because I know that is something that's offered cosmetically, I guess you can say, for through many surgical offices. But I guess when I when I look at if I'm reading what is happening on a website or a description of it, is the process the same as a colporophy?
anterior or posterior colporophyte. Would it be, because when you're doing a prolapse surgery, like a bladder or rectocele repair, there's an incision into the vagina, pushes back the bulge, sew that back up. And if I understand correctly, vaginal plasty, you're going in through the vagina and making that incision, maybe there's no bulge to push back, but is it sort of the same?
Darren Lazare (04:24.545)
That's a great question and the answer is I think it's very similar. I think the difference is the indication is the why What the what you know your Or the how is really this the colporephy or the anterior repair or posterior repair or vaginoplasty different words maybe for the very similar things but the why is different and so when you look at somebody who may have pelvic organ prolapse
you know, let's go back. What is pelvic organ prolapse? So it's, I liken it to a hernia because people get that. They're like, Oh yeah, I had a hernia or, you know, my husband had a hernia of his belly button or his inguinal hernia and, and that was fixed. And so a hernia is a weakness in the supportive layer or supportive tissue. When it comes to prolapse, that could be the supportive layer in the front wall of the vagina, between the vagina and the bladder.
could be in the back wall of the vagina between the vagina and the rectum. And so that's a prolapse. That's a hernia in the supportive layer and the rectum bulges into the vagina just the same way that bowel can protrude into the belly button. When, and so you're, you're doing a functional repair when you're doing a prolapse repair because you are restoring a damaged or attenuated layer.
so that it is back to normal, so that the patient functions normally. You can empty your bladder properly, you can empty your rectum properly. You don't have the discomfort of a bulge in the vagina. And then when you're talking about a cosmetic surgery, the surgery itself is similar, except that there really isn't a bulge there. What we're doing is we're restoring the vagina.
back to the way it was, let's say before aging, before childbirth. So the principles are the same, but there wouldn't be prolapse for a cosmetic procedure, necessarily.
Kim (06:30.878)
And in a vaginoplasty, where would, is there one incision or multiple incisions and are like they're inside the vagina, is that correct?
Darren Lazare (06:39.609)
Yeah, that's the nice thing about this surgery. It's as minimally invasive as you can be. It's not abdominal, it's not laparoscopic surgery. There are instances where we do that, but for the most part when we're talking about doing a prolapse procedure for the anterior wall, the front wall of the vagina, or the back wall, or a vaginal plasty, it's all done through the vagina. And what we're doing is very small incisions, as you mentioned.
it can be multiple incisions. So usually, you want to address what's going on in the front wall of the vagina through a small incision and then the back wall of the vagina. And those are in the midline. Incision is usually anywhere from, let's say, three to four or five centimeters. And we repair that at the end of the case. And oftentimes, you don't see any stitches or anything anywhere because it's all...
hidden inside.
Kim (07:40.79)
And what would be the recovery time be? Is it similar? I know there can be different recovery times depending on the length or how involved the surgery is. The most typical we think of is a six week. So what would the recovery guidelines be for a vaginoplasty?
Darren Lazare (07:56.825)
Right, and so any type of vaginal surgery for the most part. I usually say, look, by the next day after surgery, you're up and walking, you're eating and drinking, oftentimes peeing normally, you can shower, you can do stairs, if it's minor surgery, you can drive a car usually within 24 hours. In terms of, we'd say no heavy lifting, no vigorous exercise, hot tubs or swimming and...
no penetrative sexual intercourse. And that's for the most part six weeks. But this is an interesting number, six weeks. Like where did that come from? And is there evidence to support the six week thing? And so what I tell patients is, need to listen to your body. Nobody knows better than you. You'll find that depending on what was done, that if you're doing more activity, if you're up and walking more,
then, and things are going well, we'll keep going. If you're having pain or swelling or issues, reach out to us or maybe it's time to dial that back a little bit. The stitches are still dissolving and so the stitches can take some time to dissolve. And so certainly, it can be uncomfortable to have stitches in the vagina and so we need those to resolve. But healing and recovery are very different things.
Typically I'll say, look, we're at your six week visit, I want you to slowly start to do all the normal things that you like to do. Whatever that happens to be, whether it's working, traveling, whether it's exercise, intimacy, you need to slowly get back to doing what's normal for you, whatever your goals are. But you haven't really healed yet. We know that there's a lot of scar formation.
still remaining at six weeks, that does need to heal. And so, you know, you don't really get to see the full benefit until three months from surgery, six months, and your body to some degree is healing all the way out to about 12 months from surgery.
Kim (10:07.466)
Yeah, totally agree. And I know you have a pelvic floor physiotherapist in your office. Is it part of whether the person is coming in for the government covered surgeries or the cosmetic surgeries, does pelvic floor physio play a role regardless?
Darren Lazare (10:28.293)
Yes, absolutely. I'm a huge proponent of pelvic floor physio. You know, this is a team effort. I think that the patient is the captain of the team, not the physician. They're the ones that really, you know, direct therapy based on their goals, right? My job is to get you where you want to be, you know, and to help you with that. So maybe, you know, I'm the quarterback.
but they're the captain. And so they choose, they get to decide, you know, what their journey is going to look like. I'm here to provide good, safe, evidence-based options. And so this is a team effort. And so pelvic floor physio plays a role. We have a great network of pelvic floor physios. In BC, pelvic floor physiotherapy is not a covered benefit by the government. That's a problem.
Kim (11:02.646)
Yeah, I love that.
Darren Lazare (11:23.161)
because a lot of patients can't access pelvic floor physiotherapy for economic reasons. It's a burden, it's very expensive, and it needs to be covered. This is a no-brainer. It prevents people from needing surgery. There's a huge cost savings to the system, and it's a win for patients. So if we can treat them just with pelvic floor physio alone, it often, you know, it helps. Surgery is not always the answer.
Sometimes it is, but not all the time. The other thing is we have wonderful nurses, nurse continence advisors, who again play a critical role in non-surgical management, whether it's counseling, whether it's pessary fittings, and so this is a team effort.
Kim (12:13.951)
Yeah, yeah, I love that. Alabia plasti is what I'm moving on to now. So plasti meaning returning to normal. So we're now talking about the labia and this could be menorah or majorah, is that correct?
Darren Lazare (12:28.641)
Oh yes, and I'm going to be a little bit careful about how I use the term normal. It's extraordinarily rare to see an abnormal labia. Patients come in, they have a vision of what they want, but their labia, their vulva is normal. There is nothing wrong. I refuse to believe that there is a norm.
that there are parameters. So labia come in all different shapes and sizes. They are perfectly imperfect all the time. Now yes, trauma could be an exception. Female genital mutilation is obviously an exception. But when it comes to labia, menorah, majorah, it's perfectly imperfect. There are differences in symmetry, size, shape, texture,
proportionality, pigmentation, and it's all normal. My job is to give women a safe option if they want to go from one version of normal to another.
Kim (13:39.818)
Yeah, I love that. And so a family member of mine had a friend in her early 20s who had a labiaplasty. And it was because she had constant irritation from exercise, from certain clothing items. So is this a reason why somebody would potentially pursue a labiaplasty? And then if they, for whatever reason, they're choosing it, how is the procedure done?
Darren Lazare (14:09.533)
Right, and so, you know, different motivation for having the procedure, whether it's cosmetic, functional, you know, typically there's never any guarantee that discomfort is going to change with surgery, and certainly surgery has risks, including creating discomfort or pain. In terms of, you know, a person's decision, they deserve to have the option.
autonomy to make a decision over how they want their body to look. Whether a patient decides whether it's a breast lift, you know, after aging and having children, whether it's a labiaplasty. Certainly there's options and, you know, you know, whether it's... we don't tend to make any judgment in terms of what your motivation is. We just want to provide good, safe options. I'm not sure if I addressed your question.
Kim (15:01.31)
Yeah. Yeah, so the second part of the question was, what was, how is a, how is a labiaplasty performed? I guess it would be dependent on the goals of the person. So for, if this person had a, you know, a part of the labia that was, it was constantly being irritated, then it would be looking at how we can reduce that.
Darren Lazare (15:10.407)
Oh yeah, okay.
Darren Lazare (15:24.493)
It's so that's a tough one because like I said, there's never a guarantee that it's going to make a difference. And so I usually try to be very realistic about expectations and that, you know, I don't think necessarily you're going to see a significant change in discomfort and maybe other options. If we're talking about a cosmetic change, then yes.
there's, you know, that's an easily achievable goal through surgery. Yeah.
Kim (15:58.582)
Sorry, and then how, so is it, it's, is part of the labia removed or how, and then, so then there's also labia fat grafting. So we're the, I'm assuming one is sort of removal and one is adding, like plumping up almost.
Darren Lazare (16:14.457)
Yeah, so with respect to the labia majora, you can remove tissue if there's a lot of redundancy or deflation, or you can graft where you remove fat from one part of the body and then position it within the labia majora. And so oftentimes that's just done from removing a wee bit of fat from the area just underneath your belly button. And then...
putting that into the labia majora. So that would be a fat grafting procedure. It's commonly done there. It's commonly done with breast augmentation, although it's outside of my wheelhouse. The labia minora reduction is basically done through a variety of different techniques to remove part of the labia minora. Certainly we don't want to remove too much. You want to...
really to create a very natural normal, very natural, gotta be careful about the word normal, so a very natural look that the patient is going for. You know, we advise people to be very conservative when we're talking about removing any tissue.
Kim (17:17.174)
I'm sorry.
Kim (17:28.302)
Right. And I would think the from a population who might be pursuing the grafting side, because as we approach and move beyond menopause, we have atrophy that happens, it can affect our vulva tissues. Is that, do you see that is kind of coinciding with the population that will generally pursue that?
Darren Lazare (17:52.597)
Right, and so you have to, and that's a conversation we have with every patient, is the natural changes that occur throughout a woman's lifespan, whether it's before, you know, you have kids, certainly with pregnancy there can be changes afterwards. Weight change, weight loss, weight gain, affects proportionality, particularly the labia majora, and then also menopause, a shrinking of the labia minora. And so what people don't realize is that
I liken it, the analogy is you need to buy an outfit that's going to look good for decades, right? And so you have to buy that, you're buying that perfect outfit that has to look good whether you're in your 20s, 30s, 40s, 50s or an up, right? And so we need to think about that and the changes that occur over the course of your lifetime so that it always looks the way you want it to look, right? To get that goal, yeah, not just today.
Kim (18:51.15)
Mm-hmm. So, yeah, I love that. Moving on to the clitoris, so there's clitoral hood reduction and clitoral pexie. So again, the pexie meaning a lift or I guess, fixation. So what are those two procedures who would pursue them and how are they performed?
Darren Lazare (18:52.037)
This isn't fast fashion.
Darren Lazare (19:12.413)
So typically, again, it's a matter of proportionality. So oftentimes we'll have patients who've had labia minora reduction and all of a sudden the clitoris is now out of proportion to the rest of the vulva, you know, per the patient's goals. And so sometimes we are bringing the, usually it's the focus on the clitoral herd and not the clitoris itself. And so what you're doing is removing excess skin.
or bringing the clitoris in towards the body. Occasionally removing some of the clitoral skin to unhood a small portion of the clitoris itself or just the glands clitoris because really you don't get to see most of the clitoris. And then occasionally lift, which is a procedure that we perform very rarely.
Kim (20:07.582)
And why would somebody pursue those? Is it the appearance or is it from a functional perspective? Is it maybe they don't have as much capacity for arousal or what are the improvements they would be looking to address or looking for?
Darren Lazare (20:25.405)
I would say this is mostly cosmetic. In terms of arousal, I think you're getting into a very complicated equation. We know that arousal may have to do with clitoral sensation. It may have to do with vaginal penetration. And it mostly has to do with what's going on up here, both in the moment, in your life, in your relationship.
Kim (20:43.327)
Mm-hmm.
Darren Lazare (20:52.377)
what's happening with the kids and work and finances and everything else and being present in the moment. It's a very complicated equation. Typically, we're talking about more cosmetic goals than anything else. And we always sort of say, look, there's a cost and a benefit to everything. And what is the cost of doing this or any other type of surgery?
Kim (20:54.625)
Mm-hmm.
Kim (21:00.576)
Mm-hmm.
Darren Lazare (21:21.409)
And when I think of cost, really what I should be using is the term value, because we don't want to cause a complication that will have a really negative impact on your quality of life, whether it's the way it looks cosmetically, whether there is discomfort or pain afterwards. And so very cognizant of value.
Kim (21:37.942)
Right.
Darren Lazare (21:49.873)
There has to be a real tangible upside for the patient in terms of what their goals are before considering any type of intervention, particularly surgery.
Kim (22:01.502)
Yeah. Are there any other surgical procedures that are done cosmetically that I haven't asked about before we move on to the non-surgical?
Darren Lazare (22:13.021)
I think you've kind of covered a good portion of it. If anything comes to mind, I'll bring it up, but yeah, I think that's good.
Kim (22:20.766)
Alright, okay, so moving on to non-surgical options. If I look at what is currently offered and there may be others, but the three predominant ones are Morpheus-8, V-Tone, and PRP. So I wanna start with Morpheus-8. So many, even med spas now have vaginal rejuvenation therapies that could include laser
heat, like different types of light sources, there's different technologies available to help address certain challenges within the pelvic floor, within the walls of the vagina. So what is the technology of Morpheus 8 and what is it looking to address?
Darren Lazare (23:11.069)
Okay, perfect. I'm going to address the last part of the question first. Because I think you need to look at what the patient's goals are. You know, what is the goal here? Is it to rejuvenate on a cellular level the skin? Is it to create more healthy tissue within the vagina? Yeah, I have patients, I had a patient just this morning who had Morpheus for an indication
I don't think is necessarily going to get them where they want to go. And so we have to be careful about putting technology ahead. I like to think that I offer the full spectrum of options so that in fact we could say, okay, what are your goals? Okay, well this is what is going to get you there. And here's the value or the risks and benefit of each one and the success rates of each one.
what I think might be a good thing or a good combination of things to get there. I'll answer the question about Morpheus. One of the reasons we brought on all these new technologies is because of what was happening within the Euroguide space with respect to mesh complications, which is of course one of my favorite topics is mesh. Such a controversial area. It's a wonderful conversation I really enjoy having with patients.
They'll often have Googled stuff or have known somebody who had a mesh complication. I feel that I love tackling mesh complications with patients because I think there's a huge quality of life improvement that can be had oftentimes, whether it's even non-surgical physio stuff, surgical stuff, a combination of the both. And so patients might have incontinence. They might have prolapse. And they want an option.
that's good that doesn't involve mesh. And so that led to, okay, what else is out there that doesn't involve mesh? What else can we be doing that's augmenting surgeries that we're doing or maybe doesn't require surgeries? And so that led to looking through the literature, what different options there were. You know, at that time there was laser and then there was radio frequency. And then a little later on, there was radio frequency with microneedle.
Darren Lazare (25:37.753)
And so all of a sudden you have an option that does have some evidence behind it. There are some randomized trials there. They're not perfect. We need to acknowledge that. But there is evidence there, and there's really good evidence that it's safe, that there really isn't going to be harm, which is critical. Nothing comes through the door in terms of technology that is unproven, and that has to, you know, has to be safe. So...
So we stumbled onto Morpheus-8, which is a technology that involves energy. That's what ultrasound laser radio frequency is. And it's combining that synergistically with microneedling and the benefits of that to basically stimulate elastin collagen production. And so there is evidence that it does help with vaginal laxity. It helps with incontinence, overactive bladder. And so that is.
One of the reasons why Morpheus 8 became part of our practice. Is it perfect for everyone? No. Does it help? Yes. And so one of the things we need to think about, particularly within your organ is we're really good at moving things here and there. Surgery is very macro. You're pexing things and plasteing things and doing stuff, right? But what are you doing at a cellular level?
because we have a 30, sometimes even up to 50% failure rate with some of these surgeries. And that's just not, that's not me alone. That's in the literature, that's everybody. I quote what's in the literature. They haven't invented the perfect surgery yet, the perfect surgeon. And so we strive to provide good, safe, evidence-based options. And so I like the idea of surgery to restore tissues, to restore
the architecture of the pelvis, right? But then what about working on a cellular level at the same time? And now all of a sudden, we're doing macro stuff and micro stuff together. And so this is where I think there's opportunity within our little field of medicine to benefit patients. And so Morpheus8 is a way of helping on the cellular level to make those tissues a little bit better.
Darren Lazare (27:59.217)
Sometimes that's all you need and sometimes you need more, which is maybe surgery or physio or a pessary or a little bit of estrogen in the vagina. But then you gotta harness all of these tools that will hopefully give you the best possible outcome.
Kim (28:15.998)
Yeah, I love that. I have a few other questions added on to that. So coming back to Morpheus8, I love what you said about, you know, there's the architecture and then there's the tissue and potentially there's an opportunity for both. So is there times where you would have done a surgical procedure and while potentially the person is under the anesthetic from the surgical procedure, would...
Morpheus 8 be performed at that time or is it something that would happen at a later date?
Darren Lazare (28:46.557)
Both. You can do it before, you can do it during, you can do it after. Morpheus 8 in particular is, and I have no disclosures, we own a machine but I'm not paid by the company, you have three sessions, usually a month apart. I like doing one during the OR if I can because the patient is often anesthetized whether it's local or whether they're asleep and so they're pain free.
Kim (28:58.692)
Hehehe
Kim (29:14.91)
Yeah, so that's one thing I've heard about. I think there's Morpheus happens on the face as well. And a lot of people talk about micro needling on the face being very painful. So if I think about it in the vagina, I think that would be extra painful. So what happens, like how do you manage that pain for somebody who's not under anesthetic, who's not in a surgical situation? Is it numbing cream or local anesthetic injected or how does that work?
Darren Lazare (29:39.829)
Yeah, so the important thing is at the end of the day that the patient has the best possible experience and has the best possible outcome. Both. So both are important. How do you get there? It depends on the patient. So we have numbing cream that we use topically, whether it's the vulva or the vagina. And so usually we give people a good 45 minutes of freezing before attempting any procedure with the Morpheus.
There's ways of using the Morpheus machine. So I tend to go lowest energy level, lowest depth of penetration of the needles at the beginning. And even before that, for instance, we'll do a V tone just to give it extra time to work the anesthetic. And then again, starting with low energy and low depth of penetration of needles in order to drive the freezing into the tissues and then stepping up from there. So those are...
Those are sort of little nuancey things that we do. We do have access to laughing gas and so on for patients as well. So that's another option. We can provide local anesthetic if necessary. It's not usually needed for morphase eight, but if we're doing acutite, which is more invasive, but also radio frequency, then we're injecting local into the tissues.
Kim (31:09.042)
Okay, so I didn't see Accutite, but you talked about VTone. So I'm gonna go to VTone first. So what is VTone? And you mentioned that potentially the person may do both of them in the same appointment with you. So what is VTone and how is that working?
Darren Lazare (31:23.557)
Yeah, VTONE is just deep radio frequency energy. Again, we heat the tissues to 42 degrees. And that's for deeper penetration. It goes all the way down to the levators, the pelvic floor muscles, in a very safe way. 42 degrees is not enough to cause a burn in any sense. That's one of the benefits of Morpheus over laser. There's no burns. The machine.
has a shutoff and if it gets above that it no longer delivers energy so it's extremely safe. And so we do deep radio frequency and then we do the superficial radio frequency which is, you know, one to three or four millimeters depth of penetration with the Morpheus. And so we combine the two and so we'll use V tone or Forma V, you know, in the States it's called Forma V. And then we'll use the Morpheus 8.
or Morpheus 8V, just different microneedling tips that we have with our machine. Accutite is just again using the radio frequency, it's the same machine, and what that is, it's able to actually deliver the energy deep into the tissues, and so you could actually perform nonsurgical labiaplasty with Morpheus, with Accutite. That's for very subtle changes.
And so you're not going to have the same impact you would as with labiaplasty, for instance. But it is a non-surgical way of performing a labiaplasty. It's used not by me, but I tend to stay in my lane. But certainly you can use that on arms, on chins, on faces as well. But I like to stay in my lane and focus on my area of expertise.
Kim (33:18.71)
Got it. And how does the V tone differ from the VIV?
Darren Lazare (33:23.481)
Right, so the VIV was the initial, we actually have a VIV machine, that was the first one we bought. We still have it, and that's radio frequency. But it doesn't have the micro-needling. And so, when it came time to updating our equipment, we did a little scan, had a look at what was out there on the market, and we found that the Morpheus would be a better option for our patients. And so, we do have both, but we tend to use them.
Kim (33:54.186)
And it's so it's just to clarify with VTone and Viviv, does VTone have microneedling as part of it as well? Or so how would VTone differ from Viviv?
Darren Lazare (34:05.809)
They're very similar. Yeah, in fact, I would be, I'm not exactly sure of the difference because I think they would both be very similar technologies. There are probably some nuance differences there.
Kim (34:17.591)
Right.
Darren Lazare (34:22.813)
Yeah. I think the V tone is a bit quicker in terms of time. Yeah.
Kim (34:23.212)
Yeah, okay.
Kim (34:26.71)
Got it, okay. Okay, and then I wanna move on to PRP, which, so PRP, I've heard it called PRGF, platelet-rich plasma or platelet-rich growth factors. So this is, if anybody's seen the vampire facial, that's similar to kind of where it started, but it's been used in regenerative medicine. The O-Shot is a version of the application of PRP within the vagina, around the vulva. Like,
I see tremendous opportunity here and you mentioned earlier how you may involve Morpheus as part of a surgical procedure and I know that there are physicians who are incorporating PRP as part of their surgical procedures to potentially encourage healing or better outcomes maybe. So what from a PRP perspective what protocols are you using in your office?
Like is it just the O-Shot or are there other ways that you could potentially be using it for vaginal rejuvenation?
Darren Lazare (35:29.465)
That's a great question. And so again, this is another, it's not that new, but it's certainly the application is fairly new. The evidence, I think, is still evolving. It's in early, you know, early phases. What we know is it's safe. It's your own blood spun down. We remove that
Darren Lazare (35:58.877)
I think in orthopedics for a long time. And so there is some evidence emerging that it does help with tissue healing. So our application, yes. So we use it at the time of surgery. Sometimes we'll just use it at the time of amorphous or on its own. And so we draw the blood, spin it in our centrifuge and then inject that platelet-rich plasma back into the body. And we'll do that into, for instance, at the time of the labiaplasty to help healing.
And then it can be injected into the periclitoral tissues, into the, just under the bladder in the vagina. And so lots of different applications there. There's emerging evidence that it can be used for lichen sclerosis. So again, you need to be careful in terms of really sticking with the evidence, but also making sure that you're safe. And so this has been around for quite some time. There is good safety data.
Kim (36:53.378)
to have it again.
Darren Lazare (37:00.162)
and we have a lot of very happy patients.
Kim (37:02.306)
Mm-hmm. And how do you manage, like again, thinking of a needle inside the vagina that doesn't sound super comfortable? So is it something that they can also have numbing cream? Is there a way to manage pain or is there pain when you're injecting in the vagina?
Darren Lazare (37:18.609)
Right, and so that's critical. Again, good experience, great outcomes, happy patients. So we use numbing cream, and I use a little bit of local freezing.
Kim (37:33.198)
Got it, cool. What have I not asked? That's I think the list that I had here of what I wanted to ask about, but is there any, like I asked from a surgical, any other non-surgical that I didn't ask about that you offer?
Darren Lazare (37:49.537)
Um.
Kim (37:50.798)
That's a lot. Ha ha ha.
Darren Lazare (37:52.185)
No, I think that's a lot. I think that the important thing to know is that, oftentimes we're just there to reassure patients. And in fact, that they are normal, that there are normal changes that happen throughout patient's life, that you don't need surgery necessarily. This is, you have to love your body. And so oftentimes patients just come for conversation and...
Kim (38:15.828)
Mm-hmm.
Darren Lazare (38:21.521)
And we need to, and you need to undo the damage that some horrific person may have done at some point in their life, telling them that they have a problem. You know, it's heart wrenching. And so a lot of times it's just reassurance and education. Right? This is what, you know, the wall of vulva looks like. This is normal. We need to celebrate it. Certain cultures, bigger is better. Certain cultures, smaller is better.
you know, it's all a variation of normal. I think that's the real take home message is really to provide that education to patients. I'm not in the business of taking away options from women. We're in the business of providing good, safe options. And so, you know, whether it's pelvic floor dysfunction,
whether it has to do with cosmetic stuff. That's what we're here to provide, right? And so, you know, there's so many great, going back to where we started with Why You're a Guy, there's just so many great options that we have. And the hardest part for me is that patients
Kim (39:40.099)
Mm-hmm.
Darren Lazare (39:47.281)
don't know that there's an option out there that providers don't know to refer because they don't understand that we have so many great technologies available to patients that are minimally invasive, that don't involve mesh, that are natural tissue for prolapse, for incontinence, and that we have this amazing network of urogynecologists throughout the province of BC.
who are able to provide the full scope of all of these options, particularly when it comes to Euroguine, non-surgical and surgical options. And so that piece is really important. From an advocacy point of view, we need more Euroguines, we're desperate in BC for people who can provide these options to patients in a timely fashion. Right now, wait times are absurd.
consults, wait times are ridiculous for surgery, this needs to be addressed. You know, and we are certainly working on it. And, and I'm optimistic. I, I'm a, you know, I have rose colored glasses, but I am optimistic that we are going to continue to make improvements. We're working together as a group as well to make those improvements happen. Um, but there's so many wonderful things out there. Uh, Botox for overactive bladder.
You know, one of my favorite things. What a difference that makes over some of the traditional forms of therapy. You know, we're working at getting that covered. Whereas before it was expensive, now within a lot of our centers, it's covered for patients. And so, you know, there's certainly a lot of layers to the onion, whether we're talking about incontinence, prolapse, pain, mesh complications, or cosmetic.
Kim (41:29.474)
That would be amazing.
Darren Lazare (41:41.497)
procedures. Again. Yeah.
Kim (41:43.386)
Yeah. One thing that I forgot to ask that you just brought up before we go, if I may, you talked about your passion for mesh and I guess a question, is there mesh ever used in any of the cosmetic labiaplasty, vaginoplasty? And then also just if you can clarify, mesh is still used in many surgeries but it is different from the mesh that created the complications. So can you just
different for those that may be, mesh is something that really would make their surgical outcome better, but they're afraid of using it. So can you just talk a little bit about the mesh before we run away?
Darren Lazare (42:23.525)
Yeah, when you say passion for mesh, I think passion for the conversation, passion for dealing with people who've had complications from mesh. But within, so within cosmetic gynecology at this point, at this moment, I don't see any indication for the use of mesh, probably contraindicated. And for everything I could...
Kim (42:28.636)
Yes, okay.
Kim (42:32.395)
Yes.
Kim (42:43.89)
even with incontinence surgeries like the slings.
Darren Lazare (42:46.945)
Oh, that's not cosmetic. Yeah, so for cosmetic. But, you know, so there's a time and a place for mesh. And when you go back to what was happening in the late 90s and the early 2000s, you know, if I can just take a second, you have to remember, you know, what was the problem? The problem was that surgeons were treating patients and they were seeing
Kim (42:48.838)
Oh, cosmetic, sorry. Okay, yes. So for cosmetic only, got it.
Darren Lazare (43:16.289)
failure rates in the realm of 30% and disappointed patients. It's really hard to have a patient who comes back who's undergone surgery and the risks of surgery and pausing their lives for weeks and weeks and the discomfort of surgery and then to have a failure, whether it's early or late, it's hard to see a disappointed patient and to navigate them then through that. And so...
They said, well, there's this great thing out there, this mesh that's used thousands of times every day for hernias, right? Let's try that. And unfortunately, what we saw was a failure rate go from 30% to zero almost, but a complication rate that went from very low to 25%, 30%. And the complications weren't small. They were life-alteringly bad.
And fortunately, when I started, when I was doing my fellowship and my training and then early practice, I was taking out mesh every week. And first we have to really learn about the complications and how to treat them and then become expert at that. And that was my life for 10 or 15 years. I was dealing with a lot of that every week.
dealing with mesh complications in the office, in the OR. And fortunately now we're actually seeing very few. And I'll have months go by where I, we really don't have any patients come back with any mesh problems because, you know, most of that bad mesh is off the market. All of the kits that were used, these quick and dirty kits to place transvaginal mesh for prolapse are gone.
the there are no kits left. We for prolapse, we have kits for stress incontinence, but again, that's a very different disorder. It's a very different kit. It's a very different application. Are there still issues with respect to incontinence slings? Yeah. You know, short-term complications are probably three to 5% and maybe in 20 years, we're looking at 10 to 12%. Most of those can be dealt with.
Darren Lazare (45:38.513)
sometimes non-surgically or through small surgeries. And what we found is that there are fewer providers doing more surgeries, and I think that's helped with decreasing the complication rate, because people who are still doing these procedures, I think are having fewer and fewer complications and are doing a great job. A lot of the, you know, so the bad procedures are gone.
So there is a time and a place. But I think ultimately it's a consent discussion that needs to happen and process with the patient. They need to understand the nature of the problem and all of the risks and benefits and the different options that are available. And so, you know, it could be physio, it could be a pessary, they need to know that. It could be one of the various different continent slings. And we have other good options, periurethral bulking.
that I'm quite fond of, in fact, for patients, that's a great non-mesh option. And then, of course, using your own tissues to perform a sling, and so that's another option. So we provide all of those options to patients. I can leverage each and every one of those options for a patient. We offer them all. We have a physio in our office. We have a nurse. We gladly refer to others in the community because, you know,
Kim (46:59.438)
Mm-hmm.
Darren Lazare (47:05.457)
we have this network. And so that's really important. And then of course the new technologies. So when it comes to prolapse, we are still doing mesh, dominantly or laparoscopically, but not transvaginally. And so there is a time and a place for that. It requires a conversation with the patient and an education so that we...
Kim (47:09.986)
Mm-hmm.
Darren Lazare (47:33.593)
you know, that we go into this as a partnership and that we, you know, everybody is aware of exactly what's going on, the risks and benefits for doing this procedure and, you know, what they look for.
Kim (47:48.038)
Right, so the mesh is, is the application, where the mesh is used is different now, but is also the formulation, what the mesh is made of, is that different as well, or is that the same, it's just now not used transvaginally?
Darren Lazare (48:04.405)
The application, the transvaginal application, except for some research trials, there are no kits. There is no easy way of doing that. When I talk about mesh, it's very important to acknowledge that we're talking about polypropylene mesh. What is mesh? I probably should have clarified that for everybody.
Kim (48:13.378)
Got it.
Darren Lazare (48:32.101)
like suture material that's woven into a scarf that looks like a ribbon of material about a centimeter across and however long. And that's for incontinence slings. Mesh can be found in a sheet material that's used abdominally. So historically there were four different types of mesh out there when it came to pelvic floor surgeries typically. And all of those are gone except for type one mesh.
And why is that? What were the problems with mesh? And so mesh had to be monofilament, meaning it was just made of one sort of suture material as opposed to abraded material that was woven together. So it had to be this monofilament. It had to be non-absorbable. It had to be macroporous, meaning
The pore size, just like pores in your skin, so the pores in the mesh have to be large in order to allow your immune system, the macrophages, to get in and fight infection. And with some of the other types of mesh, the pores were too small and so you couldn't fight, your body couldn't fight infection if it was infected. So these are some of the qualities that make type 1 mesh type 1 mesh and make them safer. What we've also noticed...
since the early days of mesh is that it's more supple. And so it feels more natural. And that's very important in terms of achieving, ultimately, results. As I say to all my patients, everything has to look, feel, and work back to normal.
Kim (50:18.122)
Mm-hmm. Yeah, we'll have to do a whole episode just on mesh, I think. But yeah, thank you so much. And I wholeheartedly agree and love your approach that this is a team, a team we require kind of a village for our health care. And I also love that you are providing options at the end of the day. We need information and we need options. We need to be informed so we can make the best choice for our own bodies. And I love all the work that you're doing to support that. So thank you so much for sharing.
Darren Lazare (50:22.822)
Love it.
Kim (50:47.298)
your expertise and for all the work you do to help women. And men.
Darren Lazare (50:52.357)
Thank you. Yeah, funny. Well, so Kim, thank you. You know, we've known each other for quite some time now. I think we probably got started in our careers around the same time and appreciate your advocacy and all the work that you do, helping with education and knowledge translation and positivity for women's health. I think it's just massive and so truly appreciate what you do.
Kim (51:22.442)
Yeah, thank you so much. Yeah, I really, really appreciate it. Thank you so much for your time.
Darren Lazare (51:22.673)
Fabulous.
