Cystocele- When the roof the vagina starts to bulge, this is called a cystocele. Commonly, women may feel that their "bladder dropped". What is felt or seen is actually the skin of the vagina. The bladder is inside the bulge. Symptoms of a cystocele include pelvic pressure, urinary frequency and urgency, waking up at night, the inability to keep a tampon in place, and discomfort during sexual relations. Traditional repair is done through the vagina to cut out excess skin and then pull the skin edges together in the middle. Most pelvic surgeons recognize that this approach will often make the cystocele worse by pulling the vagina off of the supporting ligaments on the sides. Dr, Garely uses a specialized technique that pulls the vagina up to its natural attachments. This is frequently done without any cutting in the vagina. As with rectoceles, most cystoceles are not "isolated" defects. Dr. Garely can usually fix all of the vaginal bulges at once, with minimal cutting.

Rectocele- A rectocele is a bulge that occurs on the floor of the vagina. The rectal wall pushes upward creating a pouch inside the vagina. Common symptoms include a feeling that bowel movements get "stuck". Constipation is a frequent complaint related to rectoceles. Sometimes women can get relief by pushing against the bulge with their fingers. This is called splinting. Most surgeons repair this with large incisions and pull the pelvic muscles together. Some surgeons will place materials and mesh in the area to strengthen the repair. Unfortunately, these methods often result in pelvic and sexual pain and dysfunction. The vagina is frequently overtightened resulting in an abnormally tight vagina. If the rectocele is not associated with other bulges in the vagina, Dr. Garely can fix this with tiny incisions, without distorting the normal anatomy. Improvement of bowel function is usually seen immediately. Often, the rectocele is part of a global prolapse of the vagina. In these cases, the rectocele can be fixed by "pulling up" the vagina without actually cutting any part of it. This eliminates the post-operative pain usually associated with rectocele repair. In some cases, based on preoperative testing, more complicated techniques are needed.

Vaginal Prolapse- When the vagina starts to drop or turn "inside out", this is commonly called a "dropped" bladder or vagina. The medical terms for this condition depends on which part of the vagina is actually dropping. A cystocele occurs when the supportive ligaments of the roof of the vagina weaken, displacing the bladder. When the uterus itself starts to fall, this is called uterine prolapse, or procidentia. When the bowels push the vagina down, this is an enterocele. Bulging of the rectum into the vagina is called a rectocele. These conditions can be repaired vaginally, abdominally, or laparoscopically depending on many variable which include the patients age, activity level, and severity of the condition. For major prolapse, Dr. Garely has pioneered the "mini-lap" minimally invasive sacralcolpopexy. Through a small skin incision lower than a "bikini cut", Dr. Garely is able to use laparoscopic instruments to complete a total pelvic reconstruction, including hysterectomy if needed. These patients are typically discharged home within 24 hours. Dr. Garely performs about 180 of these per year. Dr. Garely is an expert in the treatment and repair of all types of prolapse. Not all patients need surgery, and Dr. Garely is a strong advocate for non-surgical therapy including pelvic floor therapy, and pessaries.

Members of Dr. Garely's group have the largest series of da Vinci Robotic procedures for prolapse in New York City. This is also used to treat fibroids of the uterus.
Robotic myomectomies (removal of fibroids) are done with small incisions and rapid recovery times.

Stress Incontinence (SUI)- Women who leak urine when the cough, laugh, sneeze, or exercise can be treated with a minimally invasive procedure called a sling. Dr. Garely was the first surgeon in New York to use this technique, which he learned by studying in Sweden with the inventor. Since 1998, Dr. Garely has performed over 1100 of these operations. He has trained hundreds of physicians on this approach both at conferences and in his operating room.

Over Active Bladder (OAB)- Women who urinate frequently, have uncontrollable urges to void, wake up at night, and leak without control, will usually respond to pharmacologic therapy. Dr. Garely has written extensively on these well tolerated therapies, and can tailor specific drug regimens to each patient. When medications fail, Dr. Garely is a major provider of the Interstim Sacral Nerve Root Stimulator, which is a tiny pacemaker for the bladder which is placed in the lower back. Dr. Garely has implanted dozens of Interstim devices which control urinary urgency and frequency.
 
Vaginal Agenesis- Some women are born with the congenital absence of a functional vagina. While many centers will use traditional flap and bowel transposition operations, Dr. Garely is the only reconstructive surgeon in the New York area who uses the minimally invasive Vecchietti Procedure. This operation is done laparoscopically with minimal cutting, and rapid recovery time.

Vesico-vaginal and Recto-vaginal Fistula- Some women will develop a opening between the bladder or rectum to the vagina. This can result from complications from previous surgery, pelvic radiation, or gastrointestinal illness. Dr. Garely is skilled in vaginal approach techniques that preserve vaginal function, without always submitting patients to a large abdominal incision.

Vaginal Rejuvenation
- After childbirth, the vagina will sometimes not regain its normal shape. Some women report decreased sexual sensation, or a "different" appearance.  Outpatient cosmetic procedures can be performed to restore the pelvic area to a more desirable look. Tightening the vagina can also be done at the same time. Utilizing the most advanced plastic surgical techniques Dr. Garely can help you achieve the appearance you desire.

Mesh Complications- Many patients have had vaginal prolapse operations done with mesh. These meshes have names such as Prolift, Apogee, Perigee, and Avaulta. In a few cases, the mesh can cause problems such as persistent bleeding, vaginal discharge, and pain. Sometimes urinary problems and difficulty moving your bowels can occur. Mesh problems are stressful for both the patient and the surgeon. Dr. Garely has extensive experience with removal, revision, and repair of these problems. He is frequently consulted by surgeons around the country for advice on how to manage these problems.

Hysterectomy- While a hysterectomy (removal of the uterus) is not absolutely necessary during a pelvic prolapse operation, many women choose to have this done at the same time. Dr. Garely believes that this is a decision that should be made by the patient based on her individual needs. Because of the high volume of surgery performed in his practice, Dr. Garely does about 120 hysterectomies per year. These are always done with minimally invasive techniques using either laparoscopy or the "mini-lap" incision.

If your doctor tells you that you need a hysterectomy and you don't have cancer, this should almost never be done with a traditional "open" incision. Dr Garely and his team can do an indicated hysterectomy through his revolutionary "mini-lap" incision (only a few inches long), laparoscopically, vaginally, or with the Da Vinci Robot. Dr. Garely routinely provides second opinions for patients who have been told they need a hysterectomy.

Optimal surgical outcome, complications, and recovery have been proven to be related to the experience of the surgeon (volume). Always ask your surgeon how many procedures he or she has done over the past year. You owe it to yourself to find the most experienced surgeon to do your surgery. Most patients are surprised to find out that the average gynecologist has very low surgical volume. Dr. Garely consistently is in the top 1% of surgical volume and this is reflected in his very low complication rates and rapid discharge rates from the hospital.

Pessaries- Dr. Garely believes strongly that non-surgical therapy should always be considered before embarking on surgery. While this is not always ideal for all patients, the option is always explored. Patients who opt for pessary therapy or pelvic floor therapy will be well attended in Dr. Garely's office. His office has expert Nurse Practitioners and Physician Assistants who are magicians with non-surgical techniques.

Bladder Infections- Women and girls of all ages can suffer from urinary tract infections. Usually these occur because of exposure to the normal bacteria of the vagina and skin. Sometimes these are related to specific events such as sexual activity. Rarely these are caused by previous pelvic and urinary tract procedures and surgery.

Most  urinary tract infections are easily treatable with antibiotics. Some patients experience frequent infections. This probably means that a specialist should help. Dr. Garely can usually diagnose and treat these infections with simple office based techniques. Using well tolerated and mild medications, chronic infections can be controlled and prevented.

Surprisingly, many patients that have been told that they have urinary tract infections do not have an infection at all. Urinary frequency and urgency, and waking up at night to urinate is usually not related to an infection at all. Dr. Garely can quickly determine the difference and help you with the appropriate therapy.

Labial Surgery- The outside of the vagina can vary in appearance. Some women are born with labia that are uneven. After childbirth, some labia can become misshapen or enlarged. Because of the labial size, some women experience discomfort during sexual relations. Some women desire to change the appearance of their labia. This is called a labiaplasty. A trained pelvic reconstructive surgeon is specially qualified to do this type of repair. Simply cutting off the extra skin does not lead to a cosmetic and natural appearance. Dr. Garely utilizes plastic surgical techniques which restore the labia to conform to the patients expectations. Women who have already undergone a previous labial surgery with unsatisfactory results can often be repaired. Dr. Garely is frequently consulted by both patients and physicians for revision surgery.

Hymen Repair- For religious and cultural reasons some women want or need the vagina to look "virginal". This is called a hymen restoration. Using plastic surgical techniques, the hymen can be restored to simulate a virginal state. This is usually considered a cosmetic surgery, and insurance does not cover the costs. In some cases, the hymen or introitus (opening of the vagina) has already been repaired elsewhere, and is too tight. This can make sexual relations difficult, painful, or impossible. Using a state of the art repair, Dr. Garely can widen and expand the opening, with a natural appearance. This can be applied to women who were born with a stenotic introitus (tight opening). Insurance will usually cover this operation.


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