By Chris Motola
OB-GYN specializes in advanced pelvic organ prolapse and pelvic reconstructive surgery: “I handle some of the cases that aren’t handled by other OB-GYNs in the community”
Q: Tell us a little about your OB/GYN practice. Are you more of a generalist or do you subspecialize?
A: I am a generalist. I do have a niche, though; I specialize in advanced pelvic organ prolapse and pelvic reconstructive surgery. I do some advanced surgical procedures, including robotics. So there’s a little bit of a tendency for me to be more surgical-related. I handle some of the cases that aren’t handled by other OB-GYNs in the community.
Q: What kinds of conditions require these interventions?
A: For pelvic organ prolapse, uterine prolapse, dropped bladder, dropped uterus, urinary incontinence, things of that nature. For the robotic surgery, it’s more complex GYN surgeries. Large fibroids, bleeding problems, endometriosis. For the prolapses, it’s pelvic reconstructive surgery where you’re pretty much reconstructing the pelvic floor or managing the symptoms of pelvic organ prolapse. But I also do basic obstetrics and office GYN.
Q: How intense are these surgeries? How hard is it to repair a pelvic floor?
A: They can be fairly complex. There are different degrees of pelvic relaxation. It involves all the different compartments of the pelvic floor. You basically divide the pelvic floor into three compartments: anterior—the bladder, posterior—the rectal and then central area is the uterus and top of the vaginal canal. Most women who have pelvic relaxation have defects of all these parts. So in one case they may need a bladder elevation, repair of the rectal wall, anchoring of the vaginal wall, incorporating a hysterectomy at the same time. So it’s a fairly involved surgery even if it’s not a very lengthy one. Post-op recovery to resume full function without any restrictions is usually six to eight weeks. It’s usually an outpatient surgery, or one overnight stay. It’s typically done vaginally, so you don’t need to deal with a lot of abdominal incisions except in the case of robotic repair, which uses a minimally invasive incision.
Q: What generally causes pelvic floor relaxation?
A: The biggest culprit is pregnancy. Just carrying the weight of the pregnancy stretches the uterus, compromises the integrity of the pelvic floor, the ligaments, the connective tissue, the muscles. With vaginal deliveries, as opposed to C-section, as the baby passes through the birth canal, there can be some damage to the pelvic nerves, which can compromise the integrity of the ligaments. The length of the labor and the size of the baby are also factors. Then there are a whole other host of conditions that affect it. Smoking can affect it. Having a high BMI puts weight on the pelvic floor. Doing activities that are constantly straining the pelvic floor: lifting, pulling. Underlying medical conditions like diabetes, hypertension, connective tissue disorders, autoimmune diseases, they can also predispose you. There is some genetic predisposition as well; you can see it show up more often in some families. Aging is a factor as women enter their later menopause years.
Q: Is there a preventive medicine side of practice for dealing with these issues?
A: To a certain degree. Exercise, working out, keeping your weight down. Kegel exercises done on a regular basis can help prevent development of the problem or help to keep it from progressing. Some women will choose an elective primary cesarean section during pregnancy; in some countries like Brazil, the rate is more than 80%.
Q: What’s your practice mix between office GYN and surgery?
A: It’s fairly busy on all fronts. I generally do about 150 to 200 deliveries a year. It used to be more than that when I used to be the director at Catholic Health Mercy OB-GYN clinic. I was doing upwards of 300, 350 deliveries a year. So the obstetric deliveries are down. I’m in the office pretty much every day of the week. I see about 50 patients a day. My surgical days are very busy. As a surgeon you get something called block OR time and my block OR time is fairly full. On average I’m doing about 400 surgical cases a year. I’d say obstetrics, surgery, and patient visits each take about a third of my time.
Q: You’ve been recognized fairly recently for both efficiency of treatment and patient satisfaction. How do you square those two factors?
A: I don’t know. I practice alone. I’m solo. I have sort of a unique practice. I get a lot of referrals. I don’t share my patients’ care with other providers, so there might be more of a bond between me and my patients. It’s not that I’m a better physician necessarily, they’re just seeing different providers from visit to visit, there’s a lot more continuity and more of a chance to build trust and understanding. If you’ve been in practice for a while, your work is your best advertisement. Happy patients will refer their friends and family. So I have pockets of patients who are groups of friends are family members that I care for. That in itself can make the experience better. As far as efficiency goes, you try to do good work and you get better at it and sometimes you get recognized for it. I got those awards through Catholic Health System. They survey the patients about their hospital experience. I think a big part of it is that patients didn’t feel like their care was disjointed, for lack of a better term. When you’re in a comprised position, anything that improves comfort level has an impact. With efficiency in my field they look at surgical outcomes, complication rates, length of stay, need for transfusion for parameters and then you get an efficiency index. What I’m doing to get that is kind of a difficult question to answer.
Name: August A. Bruno
Position: OB-GYN with General Physician, PC
Education: Medical degree, State University of New York at Buffalo School of Medicine (cum laude), 1991; State University of New York at Buffalo, Obstetrics & Gynecology
Awards: Received Catholic Health System’s Physician Award for Efficiency, June and December 2019 and Physician Award for Patient Experience, December 2019.
Affiliations: Kaleida Health; Catholic Health System
Organizations: American College of OB-GYN, American Board of Obstetrics and Gynecology, Erie County Medical Society; American Medical Association
Family: Married, three sons
Hobbies: Restoring furniture, exercising, listening to podcasts, helping with wife’s garden