Surgical Innovations in Genitourinary Conditions with Drs. Julia Grabowski & Julia Geynisman-Tan

Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern Medicine have established the Collaborative Advanced Reconstructive Evaluation (CARE) Clinic, which provides multidisciplinary care for children, adolescents and women with congenital anomalies and acquired diseases of the genitourinary tract. In this episode, two of the clinic’s leaders, Dr. Julia Geynisman-Tan and Dr. Julia Grabowski, talk about the transformative surgical innovations they’ve developed and life-changing procedures and supportive care they offer to help girls and women achieve functional vaginal anatomy, relief from pain, the ability to menstruate and more.

“We now have a rhythm (to doing innovative vaginoplasty) and we can do it pretty quickly and efficiently. And so patients have been reaching out to us from other places being referred from other institutions, knowing that we have this really pretty amazing technique that can change their life.”

Julia E. Grabowski, MD, FACS
Attending Physician, Pediatric Surgery
Associate Professor of Surgery, Northwestern University Feinberg School of Medicine

“What's unique about this clinic is our most interesting cases are cases of patients who, for example, had spina bifida and had really intricate genitourinary reconstructions as children who then end up in adulthood having prolapse and need a urogynecologist as well as a pediatric urologist who understands what happened to them 25 years ago and where everything is reconnected.”

Julia Geynisman-Tan, MD
Attending Physician, Northwestern Medicine
Assistant Professor of Obstetrics and Gynecology (Urogynecology and Reconstructive Pelvic Surgery), Northwestern University Feinberg School of Medicine

Show Notes

• The clinic was formed after experts at both Lurie Children's and Northwestern Medicine recognized that many patients with complex genitourinary conditions were not being treated effectively as they grew from childhood to adolescence and into adulthood. This led to a collaborative effort of pediatric and adult specialists to provide comprehensive care.
• The close proximity between Lurie Children’s and Northwestern Medicine allows for seamless collaboration and flexible care for both pediatric and adult patients. The clinic serves patients as young as 10 or 11, entering puberty, and even adults in their 30s and beyond.
• Some of the most common conditions treated, including vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome), vaginal septum, and complications from early surgical interventions for other congenital anomalies.
• During the first visit, the team reviews the patient’s history and provides education to both patients and families to address confusion about diagnoses and treatment options. The team is trained to take special care when discussing fertility and sexual function with patients, particularly regarding cultural and family concerns. One unique aspect of the CARE Clinic is it is an all-female team. The doctors say patients appreciate the understanding and empathy that comes from a team composed entirely of women, especially for those with complex gynecologic issues.
• Recently, Dr. Grabowski and her team have developed an innovative vaginoplasty procedure using a fish skin graft, which creates a new vagina for patients with vaginal agenesis or structural abnormalities. This less invasive procedure offers faster recovery and fewer complications than traditional methods.
• Dr. Geynisman-Tan says the CARE Clinic focuses on goal-oriented care rather than just anatomical restoration, ensuring that patients’ personal goals, whether related to school activities or future health plans, are taken into account in treatment decisions.

Transcript

[00:00:00] Erin Spain, MS: This is Precision, Perspectives on Children's Surgery from Ann & Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. Today, we are talking about transformative surgical innovations designed to address the unique needs of female pediatric patients with congenital anomalies or acquired diseases of the genital urinary tract. Through a collaborative effort between Lurie Children's and Northwestern Medicine, experts in this field have come together to offer life changing procedures and supportive care that can lead to functional vaginal anatomy, relief from pain, the ability to menstruate, and improve sexual function for these young patients. Joining us to discuss these advancements are Dr. Julia Geynisman-Tan and Dr. Julia Grabowski. Dr. Grabowski is an attending physician in pediatric surgery here at Lurie Children's and founder of the CARE Clinic. Dr. Geynisman-Tan is an attending physician specializing in urogynecology and reconstructive pelvic surgery at Northwestern Medicine. Together with their partners, Dr. Alborno and Dr. Yerkes, they help lead the Collaborative Advanced Reconstructive Evaluation or CARE Clinic. Welcome to the show, both of you.

[00:01:26] Dr. Julia Grabowski: Thank you.

[00:01:27] Dr. Julia Geynisman-Tan: Thank you.

[00:01:28] Erin Spain, MS: Dr. Grabowski, let's start with you. Tell me about your area of specialty.

[00:01:33] Dr. Julia Grabowski: My sort of niche area is colorectal and anorectal malformations in infants and children. And within that realm, I overlap a lot with urology and in that pelvis is also gynecologic organs and reproductive organs and as I really got more and more involved in this area, I realized that we were doing some things that maybe weren't perfect, and we could improve upon. And I think that is actually something that the world of colorectal surgery and pediatrics is realizing. And so there's a lot of discussion on how we can make reproductive and gynecologic outcomes better for these patients with colorectal and anorectal anomalies. And so as I grew in my colorectal field, I realized that I was also pretty passionate about the gynecologic aspect .

[00:02:18] Erin Spain, MS: Dr.  Geynisman-Tan. How about you?

[00:02:20] Dr. Julia Geynisman-Tan: You know, I am a urogynecologist. So 99 percent of my time I spend taking care of adult women with pelvic floor disorders, you know, prolapse, incontinence, things like that. But in doing that, one of the unique things about our field is a very good understanding of the anatomy and relationships of various structures in the pelvis and how to reconstruct. I mean, that is integral to the name of our specialty. We are pelvic reconstructive surgeons and how to reconstruct that anatomy. And so, I think as Dr. Grabowski and her team were sort of realizing that we were seeing a transition of these patients from infancy into adolescence and adulthood. It made sense to bring in an adult surgical team to understand and really kind of add to the discussion of how best to manage these things.

[00:03:03] Erin Spain, MS: So let's talk about these patients that you see at the CARE Clinic. Dr. Grabowski, you have a really unique collection of patients with lots of different needs. Urologic, reproductive, obstetric, and gynecologic needs, yet they're able to find expert care in your clinic. So tell me about the genesis of this clinic and why it's important to have a place like this for girls and young women with these GU anomalies.

[00:03:27] Dr. Julia Grabowski: Well, we started this clinic many years ago when we started to realize that there were patients who were getting a little bit lost in the shuffle . When they are born and are infants, there are some surgical things that we do for congenital anomalies and we're pretty well versed in doing that as pediatric surgeons. There are certain needs that grow with the children and into adolescence and young adulthood that we were not really treating the best way that we could because some of the treatments and procedures that we have for pediatrics are a little bit different in adults. And some of the expertise that we have in pediatric surgery and pediatric urology are different than what we see with our adult collaborators, And so, in talking to folks next door at Northwestern, we realized that we could really bridge this gap by working together. What's unique about the clinic is that instead of just sending emails or talking to each other on the phone about these complex patients, we decided that the best way to take care of them would be to see them all together in one room where we could talk about the needs that they have as pediatric surgical patients, the needs that they have as complex urologic patients, and needs that they have in terms of their gynecologic outcomes. And then together we could tap into all of our expertise and all together treat the patients in the most appropriate and beneficial way.

[00:04:36] Erin Spain, MS: For people who don't know, Northwestern Medicine and Lurie Children's are literally across the street from one another. Dr. Geynisman-Tan, can you tell me about that, the proximity and how that helps you with this collaboration?

[00:04:49] Dr. Julia Geynisman-Tan: what's really nice about this clinic is that we have been able to figure out a way to take care of patients regardless of their age or which specialists are needed to take care of them because we can take do their surgeries or do their medical care between the two campuses. So for some of the younger patients that we see who are most appropriate to get their care at a pediatric hospital, we have that resource available and for those who are actually older and, you know, might be into their 20s and even 30s who are seeking care from us and are more appropriate to be cared for in an adult hospital, we have this collaborative relationship between both.

[00:05:21] Erin Spain, MS: So to be clear, the patients seen at this clinic are between very young children all the way up to someone in their 30s or beyond?

[00:05:28] Dr. Julia Geynisman-Tan: They are usually coming to us as adolescents, you know, sometimes as young as actually 10 or 11, kind of entering into their initial phases of puberty. But sometimes we see patients who first find out that they have a congenital anomaly in adulthood. It might be that you know, they weren't sexually active until later in their adulthood and didn't realize that they had a hymenal abnormality or a septum. Sometimes patients have actually had prior surgeries in other places when they were younger and have complications of those surgeries and need revisions.

[00:05:58] Erin Spain, MS: So you just mentioned a couple different conditions there, and I'd like to dig into those a little bit more and find out more about them. Tell me about some of the most common congenital anomalies and conditions that you treat at the clinic, and how these conditions might impact a patient's health and quality of life.

[00:06:13] Dr. Julia Geynisman-Tan: One of the most common things that we take care of, there is congenital absence of the vagina and sometimes with or without a uterus. This is a condition called Mayer-Rokitansky-Küster-Hauser which is a very long name for it, but the other name is vaginal agenesis. And these are kids who are born without a vagina. They still have a normal urinary tract, they might have a normal bowel tract, and those things function normally up until their adolescent years when suddenly they realize they're not getting a menstrual cycle. And find out that they actually don't have a vagina and may actually be obstructing blood or may not be producing any menstrual blood if they don't have a uterus as well. And so we take care of that probably most commonly. Other things are, you know, vaginal septum, so basically walls or tissue forming in places it shouldn't be within the vaginal canal that can create problems either with menstrual flow or with intercourse. Sometimes, you know, like Dr. Grabowski was sort of alluding to, we are taking care of patients who in infancy had very clear congenital anomalies of either their reproductive tract, their urinary tract, or their bowel tract, and they had surgeries in infancy to create function in those organs, but that may have impacted the length, width or function of their vaginal canal as a result. And so, they need revisions, you know, later on in their adolescence or adulthood.

[00:07:29] Erin Spain, MS: Some folks know about the clinic. They were diagnosed as maybe a baby and they come and see you when they're a little bit older. How do other patients find their way to you?

[00:07:38] Dr. Julia Geynisman-Tan: Many times people find our clinic through their other doctors, whether that's their pediatric or adult urologists or gynecologists, but I think there's only so many of these patients that are already being treated within the Northwestern system. And many of our referrals actually come from patients who find us online or find us through their pediatricians or gynecologists at outside facilities. I would say certainly for something like vaginal agenesis, a lot of times, you know, a 13 year old's mom will say, Hey, you haven't gotten your period yet. Let me take you to my gynecologist. And that person realizes there's something you know, a miss does the imaging and then sends it to us.

[00:08:14] Erin Spain, MS: For patients and families that find their way to the clinic, what might that first visit look like? Can you describe it to me?

[00:08:20] Dr. Julia Grabowski: Well, it's a lot of people together because we want to hear the story all together so that we can discuss it. So we usually review the patient's charts ahead of time, go through whatever previous studies that they've had, any imaging studies, surgical reports that we can find or that have been done. And if there's nothing, that's fine too. You come to our clinic, you meet our coordinator and that you meet our nurse. And we just get a story of what's going on. We want to hear how they found us, what their concerns are, what's been done. And then really hear exactly what are their goals and treatment. And then we go through any studies that have been done with the patient and with each other, and we make a plan from there.

[00:08:57] Dr. Julia Geynisman-Tan: I think that what's unique about this clinic is that a lot of times we do a fair amount of patient education and family education during these visits. Very often patients come to us with a lot of confusion because they've received a lot of diagnoses, labels, et cetera, and they don't exactly know what they have and what they don't and what that means for their sexual function, their fertility goals, you know, all of this. And oftentimes they come to us before they're actually ready to have any kind of surgery to correct the issue at hand. And I think one of the common fears that we hear from kids, but mostly their parents, is about their fertility goals, right? And what that means, what their particular anomaly means for their ability to have children in the future. And I think one really nice aspect of this clinic is that we have a very close relationship with the reproductive endocrinology and fertility specialists here at Northwestern. And actually a nice collaboration with the Lurie Children's cryopreservation specialists. And so, as applicable per case, you know, we have had people cryopreserve ovarian tissue, or we talk to them about, you know, egg retrieval and things like that, and what it would mean for them to build a family in the future. I think that the other very common fear we hear is about what reconstruction means for their sexual function, their virginity status, all kinds of things along that line. I think a unique aspect of this clinic is that because we've now heard these concerns over and over, I think we actually have a really good way of addressing some of family, cultural, sort of religious concerns around what this means for you know, sexual function and virginity.

[00:10:33] Dr. Julia Grabowski: And I think another thing that's actually quite unique is that there are multidisciplinary clinics for many different things at Lurie Children's and at other places. But what's unique about this is that we're all in there together getting the story, talking as a team, and so there's not a game of telephone that's happening. It's all right there, like one stop shopping, and we can all have this really nice, thorough multidisciplinary conversation all together in one place.

[00:10:57] Erin Spain, MS: I can imagine that this sometimes is a difficult conversation to have, especially the topic, the subject matter, some of the ages of the patients that you're dealing with. Talk to me about that and the sensitivity that you really do use when working with these families and patients.

[00:11:13] Dr. Julia Geynisman-Tan: You know, I think that's another really nice aspect of this collaborative team. I am not a pediatrician, but Dr. Grabowski is very adept at talking with, you know, with young kids and with their families who have a lot of fear and a lot of anxiety about what's happening with their children. And Dr. Alborno, who is a pediatric and adolescent gynecologist, really specializes in some of these tough conversations with adolescents around their reproductive goals, their contraceptive goals, their sexual function, right? Which is, it's a tough conversation to have with an adolescent, especially when their mother is in the room. And so I think having all of us together there makes it a really nice and positive experience. I think also the nature of the specialties within our team is unique. There are some sort of, you know, multidisciplinary groups like this that might exist between a pediatrician and a gynecologist, but I think having some urologic presence and then also having sort of subspecialty surgical gynecology presence really makes a difference in a clinic like this where everybody has different expertise and if they don't have the expertise, sort of has the relationships to create the right expertise within our realms.

[00:12:16] Erin Spain, MS: Something else that's unique about this clinic is that it is an all female team. Everybody on your team is a woman. Why does that make a difference in the care that you're able to provide your patients?

[00:12:27] Dr. Julia Geynisman-Tan: Yeah. I think that's a unique sort of happenstance of this clinic, but something that our patients really appreciate. I mean, we certainly love all of our male colleagues and if they were the experts, you know, working alongside us, we would be happy to work with them. But I think that again, because these are oftentimes adolescents or frankly, I mean, when they're adult patients, they've been through a fair amount of medical trauma. A lot of times they have had multiple surgeries, sometimes by individuals who have some outdated techniques and they are coming to us hoping for a different level of understanding and appreciation of their issue. And so I think that they really love seeing that the team understands, you know, what it's like to live with the organs that they have and how to make them function.

[00:13:07] Erin Spain, MS: Something else that's really special about this clinic is some of the innovative surgeries that you're able to provide. And some of these are really life changing such as vaginoplasty using a graph made from fish skin, Dr. Grabowski, and your team developed this new technique. So tell me about this procedure. You've had excellent results with it. Who are good candidates for it? And what have the outcomes been for the patients who've received it?

[00:13:32] Dr. Julia Grabowski: Yeah, we are very proud of this technique that we've developed. So vaginoplasty is when you make what we call a neovagina, so a new vagina for someone who doesn't have one or whose vagina has had issues with stricture, narrowing, some sort of scarring after previous operations or radiation, for instance. Historically, the ways to make a new vagina have been a little bit let's say not perfect. There have been descriptions and people still do make vaginas out of a piece of intestine, which as you can imagine has some side effects and is a relatively intense operation with some morbidity . Also there's operations that we can do where we take a little piece of the lining of the cheek and use that similarly to the way that we use this graft, and people were not really loving that technique either because there is some morbidity to having that piece of cheek taken and people didn't like the way that felt. So we thought that there had to be a different way. And there are so many uses for these graph materials that actually act sort of like a scaffold. We put it around a mold. So to make that sort of tube and put it into the vaginal canal that we create and then that attracts new cells to make vaginal mucosa in that area. It has been really a labor of love for us to develop the technique, and patients have done really well. The operation to make a vagina historically had been several days in the hospital on bed rest. Sometimes there were wound vacs in the area for five, seven days, and there was a lot of morbidity associated with it. And now the way that we have developed this new technique, people are in the hospital, oftentimes it's an ambulatory procedure. They come in one day, they go home the same day, that mold is in place for five to seven days. We take it out and then they start dilation therapy. So this has been very life changing for patients with MRKH or vaginal atresia and patients who have had strictures in that area where they need us to make a new, better vagina without the morbidity of the other types of procedures that have been previously used.

[00:15:24] Erin Spain, MS: And you've published about this technique. Is it now being used in other places as well?

[00:15:28] Dr. Julia Grabowski: Yes. Not as ubiquitously as we do it here because we now have a rhythm to it and we can do it pretty quickly and efficiently. And so patients have been reaching out to us from other places being referred from other institutions, knowing that we have this really pretty amazing technique that can change their life.

[00:15:46] Erin Spain, MS: How many of these procedures have you been able to do and, how many do you do per year, for example, as well?

[00:15:51] Dr. Julia Geynisman-Tan: So I would say for all of the different conditions for which we might do a vaginoplasty like this, we have done around 15 to 18, something like that over the last few years. So on the average of five to seven a year.

[00:16:05] Erin Spain, MS: You discussed that there is some therapy that has to take place after this procedure, vaginal dilation therapy. Can you talk to me a bit more about that? What is this type of care for the patients who've undergone this sort of reconstruction or surgery and why is it an important step? 

[00:16:20] Dr. Julia Geynisman-Tan: Dilation therapy is critical to the success of this procedure the way that works is right after the mold comes out, you know, five to seven days later, girls are starting to use medical grade dilators, which we provide them to start to keep that space open. You know, the best example that I give all of the patients is it's like having an earring in, right? If you puncture your ear and you put it in an earring. It will keep that space open. If you take out the earring, the space will close. And so until the neovagina has fully healed and scarred itself, you have to keep that dilator kind of coming in and out at least once a day in order to keep the space open.

[00:16:56] Erin Spain, MS: Dr. Grabowski, can you talk to me about some of the other common conditions that you're treating in the clinic and what options are available that might not be available elsewhere?

[00:17:04] Dr. Julia Grabowski: So, one of the things that Dr. Geynisman-Tan had mentioned is that we do see some patients who are not quite ready for their definitive procedure. Patients with vaginal atresia or transverse septa who aren't ready for the operation to achieve a vaginal outflow tract which does require dilation. However, they sometimes do have menstrual blood that accumulates. Many times we're able to decrease the amount of menstrual blood or completely stop it by using hormone suppression, but sometimes that's not successful. And previously pediatric surgeons and gynecologists had used percutaneous drainage of this what we call hematometrical posts. So blood within the vagina or the uterus that is quite painful and can also sort of drain through the fallopian tubes. the wrong way. And so we want to avoid that. And so there has to be a way for us to drain this blood, and as I said previously we had used percutaneous drainage, which means we put a needle through the skin into the vagina or into the uterus and drain that blood, and that was successful, except that there is a high risk of infection with that. It also requires a drain to be left in place, sometimes for a week. Sometimes for months, and that's pretty unpleasant for anyone, but specifically an adolescent girl who's, you know, in seventh grade. So, there had been some data about laparoscopic assisted vaginal aspiration, LAVA, and the safety of being able to drain the vagina laparoscopically, and we have modified that technique and started doing it for our patients who need drainage of their hematometrical posts or hematocole posts, and it has been quite successful. It's not used at most institutions. Most data that you look at is still talking about percutaneous drainage, which as I said is shown to be safe, but has a lot of morbidity and there is a much, much higher risk of infection. It can be an outpatient operation. Three small incisions just almost similar to what we would use for an appendectomy where we drain the vagina, the back of the vagina laparoscopically, suck out all of that blood that is causing pain and discomfort, and then the patient is able to go home that same day without a drain left in place. We've used it for patients who have many different types of anomalies, not just for a septum, which had been initially was thought to be a good use for it, but also for vaginal atresia or for other issues where they have an outflow obstruction.

[00:19:21] Erin Spain, MS: Something I hear both of you saying is that you're really interested in innovative ways to care for these patients and make their lives easier. Can you talk to me about that a little bit, this approach that you're taking to really care for them as a person, not just treat the condition or problem that they're experiencing?

[00:19:38] Dr. Julia Geynisman-Tan: I think that one of the unique aspects of this clinic is that we are very goal oriented, right? That we're not so much anatomy oriented as much as goal oriented. I think so much of what we treat here has to do with what stage of life the patient is in, the goals they have for the, you know, next years or months of their life. I mean, so often we have these conversations where people are like, well, I'm in pain but I have a track meet that I have to be at in two months, you know, like what can you do to reduce my pain until I can achieve this other goal, right? And I think, what we try to do is meet our patients where they are rather than focusing on just restoring anatomy for the sake of restoring anatomy, which I think is what, you know, many surgeons have been trained to do.

[00:20:21] Dr. Julia Grabowski: I think one of the other unique things about the clinic is that I come into it from a person who's a pediatric surgeon. I operate on babies. I obviously operate on older kids as well, but for many pediatric surgeons, they stop seeing their patients at 18 and aren't really seeing what happens to some of the surgical procedures or the techniques that we've done on them as babies when they are young adolescents or young adults. And Dr. Geynisman-Tan comes at it from a person who sees adult patients and sort of now we get to meet in the middle and really maximize our experience from both sides.

[00:20:54] Dr. Julia Geynisman-Tan: I think it's important to highlight that. What we do goes beyond the scope of general, like, pediatric and adolescent gyne, because we've spent a lot of time discussing conditions like vaginal agenesis and septums, and those are all very important and probably the most common things we treat, but they are, you know, well within the general scope of treatment of most adolescent gynecologists like fellowship trained pediatric and adolescent gynecologists. But I think what's unique about this clinic is our most interesting cases are cases of patients who, you know, for example, had spina bifida and had really intricate genitourinary reconstructions as children who then end up in adulthood having prolapse and need a urogynecologist as well as a pediatric urologist who understands what happened to them 25 years ago and where everything is reconnected.

[00:21:40] Erin Spain, MS: Could you share a patient success story with me, someone whose life you were able to really impact by one of these procedures? 

[00:21:47] Dr. Julia Grabowski: We had a patient probably about 16 months ago who was in her early 40s and had never really found the right doctors to help take care of hervaginal atresia. So she knew that she had an anatomic anomaly where she did not have a vagina. Someone had mentioned to her that she could make one with dilations when she was younger, but she wasn't really comfortable with that and never really got the training that was needed to be able to do that. And she felt like she was never going to be able to have intercourse. She had a partner, but just thought that it wasn't in her world to be ever able to ever have sexual intercourse and was pretty disappointed about that and she came to us just wondering what her options are. She had found us on the internet and we explained our procedure with vaginoplasties and what that would entail and that the process was essentially one week of watching Netflix and having a mold in place and she was remarkably thrilled afterwards. That week with the mold in place can be boring and not that pleasant. And she was just a real trooper and she was so appreciative and is now having a very happy life with her partner. She feels quote unquote, more normal she told us. She felt like she had never found anyone who would be able to fix her and now. She felt quote unquote fixed. So it was it was great. And as a pediatric surgeon, I don't treat that many young 40 year olds, but it was really awesome to be able to take care of someone with a congenital anomaly in adulthood who really didn't think it was possible.

[00:23:17] Dr. Julia Geynisman-Tan: This is a very unique case that will never, I think, happen in any of our lifetimes again. But the case that I always think of from this clinic is a young woman who was actually born as a conjoined twin or an omphalogous twin. Separated at birth and had duplicated organs. You know, had actually two uteri, had two portions of a bladder a very complicated urinary and menstrual system that actually intersected and who was trying to have intercourse and couldn't because of how these gender urinary things were intersecting, and actually during the process of our reconstruction, we realized that she actually had a bladder cancer that was growing in one of these portions of her bladder, and had to involve a urologic oncologist to do really a five team sort of multidisciplinary surgery. I think things like that are really only possible in a huge academic institution like this and with a multidisciplinary clinic like this.

[00:24:41] Erin Spain, MS: So for families or patients who have found this episode and they're interested in coming to the clinic, what message would you like to share with them as they're deciding to make that phone call and come and see you for a condition that they have?

[00:24:24] Dr. Julia Grabowski: I would say first and foremost, though it is in the division of surgery, coming to our clinic does not mean that we're signing you up for surgery. What you're signing up for to come to our clinic is a conversation about what's going on with you or your child. What options do we have? What their diagnosis may or may not mean. Do they actually need a procedure? Is everything totally normal? And that no question that you can ask will be too little or too big. That we are very serious about what we do, but also an informal group where we want to really get to know you, get to know what your goals are, and that coming to this clinic is the beginning of a very long relationship, as long as you need us.

[00:25:05] Erin Spain, MS: Thanks to both of you for your time today for explaining really unique procedures that are available at this clinic. And I hope that families and patients who are listening will reach out.

[00:25:15] Dr. Julia Grabowski: Thank you very much.

[00:25:16] Dr. Julia Geynisman-Tan: Thanks for having us.

[00:25:18] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit LurieChildrens.org.

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