Peter Maher, MD

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Coverage of the 37th Annual Global Congress on Minimally Invasive Gynecology

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In the U.S. there are over 600,000 hysterectomies performed each year, about 1,643 a day. In fact, by the age of 60, 1 in 3 women will have had a hysterectomy. You may be feeling anxious, but remember that there are 599,999 other women this year who will feel like you. In addition, you can take comfort in knowing that recent medical advances have made this common procedure much less invasive. Follow these links to OBGYN.net resources tthat help you get the most minimally invasive treatment option possible:

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Coverage of 36th AAGL Congress November 2007, Washington, DC

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:  “This is  Dr. Demco reporting from the AAGL meeting here in Orlando, Florida.  I’d  now like to interview Professor Peter Maher from Melbourne, Australia,  and the topic we’d like to talk about is the future of hysterectomy in  the practice of gynecology in the year 2000.  Peter, can you give us a  little scope of where we’re standing with hysterectomy on your side of  the water?”

:  “Yes,  good-day, Larry.  Certainly in Australia the incidence of hysterectomy  has dropped quite considerably over the last twenty-five years.  In the  early seventies about 40% of all women who reached the menopausal age  had had a hysterectomy and that accounted for, I think, about close to  40,000 hysterectomies.  Now there are about 23,000 hysterectomies done  in Australia and obviously the same is occurring around the world and  maybe that’s influenced by other means of treatment, in particular, some  of the more popular ablation systems for heavy periods.  I also think  women’s attitudes have changed quite considerably and there are new  medical treatments available.  We started doing laparoscopic  hysterectomy in 1990 and we thought that that together with ablation,  which we’d started the year before, might in fact influence where  hysterectomy was going within our own centers.  I work at the Mercy  Hospital for Women but unfortunately laparoscopic hysterectomy hasn’t  really increased much in our society, I think about 12% of  hysterectomies are done       laparoscopically.  In fact, before its introduction, we had about  the same ratio as the rest of the world - about 75% of them were done  abdominally and 25% vaginally and most of those of course were  associated with vaginal       prolapse.  The balance has changed very, very little and I think  the number of vaginal hysterectomies has gone up about 6% and at the end  of the day they rise up to about 12% are done       laparoscopically.  We believe when we introduced it into Australia  that there would be a total swing, and I think that is everybody’s  feeling that that’s where it was going to go but it hasn’t altered  enormously.  We run many, many courses in Australia to improve the  awareness and the surgical skills of people wishing to perform the  operation but as everywhere, the majority of the time, gynecologists or  obstetricians just won’t take the time out to learn the procedures.  We  believe that all of the things that are said about laparoscopic  hysterectomy in terms of patient benefits are true but because our  colleagues, as I say, don’t take the time to learn these new skills, the  patients aren’t able to enjoy the benefits.”

:  “One  of the concerns when I learned laparoscopic hysterectomy was that the  technology at the time made you dependent on your laparoscopic skill,  and there has been various technologies to improve the approach through  laparoscopy doing a hysterectomy       laparoscopically.  If someone said to go and look at redoing them  or the idea of approaching yourself to do a laparoscopic hysterectomy  now, what new technologies do you think would help to make it easier  than if you would have approached it back in 1990-1992?”

:        “Interestingly, I think that I, for example, have probably  come the full circle.  We did the first hysterectomy using bipolar  forceps and then we went through stapling devices, and then we went  through the ultrasonic shears.  Now, I believe that the bipolar forceps  because of changes in design and more efficiency probably still offer  the best way.  We also went through a suturing phase but I think that  all of the benefits or the perceived benefits in terms of pain relief,  for example, a lot of those were a result of lack of distortion of the  anatomy that you get with suturing, and I don’t believe that there’s  probably a great benefit in suturing.  As I said, I think the new  bipolar forceps where you can get good coaptation of the tissues make  the operation quite easy, quite inexpensive, and the other important  issue of course is the early ureteric injuries that were occurring and  most of our colleagues didn’t really realize it.  I don’t think that  true anatomy of the ureter down near the ureteric tunnel and early  stapling devices were picking them up, of course, because there were  only a couple of millimeters.  I think even the industry realized that  because then they brought in hinged stapling devices but in Australia  they’re very expensive, and I’m sure it’s the same internationally.   We’re watching our health dollars very closely so you’re more popular if  you use less disposables.”

:  "That’s  right.  One of the things that we’ve noticed too is that a common  statement that is often said by healthcare providers is that some of  these alternate therapies such as the ablation techniques only delay the  hysterectomy.  What’s your thought on that?”

:        “I think that certainly that was the experience in  Australia but the main reason for that was that people started doing  endometrial ablation before they really knew how to do hysteroscopy.  I  think in our hands, endometrial ablation has a hysterectomy conversion  rate of 15% and that was in a personal series of 500 patients over six  years, and 15% of the patients ended up having hysterectomies.  I think,  importantly, as long as the indication for endometrial ablation or the  alternative indication is hysterectomy, what you can say to patients is  that they’re not only having a 15% failure rate, but they’ve got a 85%  success rate because of the population you’re dealing with.  I do  believe some of the newer devices are probably delaying devices as  opposed to curative.”

:  “A  person in today’s day and age and with the technology today has a  choice, we know that there is the vaginal approach, the laparoscopic  approach, and the abdominal approach to a hysterectomy.  As we see it  today, what’s your views on, say, the ideal situation with technology  today and where do you see the exact proportion of hysterectomies in  each category?”

:        “I think there’s several issues, time is an important  factor and I believe that sometimes too much time is wasted trying to do  an operation       laparoscopically, for example, when it could be done vaginally.  I  think there are very, very few indications for abdominal hysterectomy  and size would probably be the single common factor.  What size that is,  I’m not sure but maybe over 750 grams would probably be reasonable to  do an abdominal hysterectomy.  I would recommend for the majority of  people to attempt a vaginal hysterectomy associated with       laparoscopy, now I know that’s what some people might call an  ‘LAVH’ but I mean literally to have a look with the laparoscope through  the vaginal hysterectomy, have another look, and if there’s any oozing  clean it up - I believe that that’s probably the ideal situation.”

:  "It  adds a certain degree of safety plus assures the patient that  everything was tried for the contraindications and problems that have  always been in vaginal surgery.  One other idea of when you’re looking  at these uteruses of larger size, what are your views of leaving the  cervix behind or the so-called ‘subtotal’ hysterectomy?”

:  “I  don’t think there’s any great benefit in leaving the cervix in terms of  sexual satisfaction which has probably been the single most common  reason that women are told that it’s better to leave the cervix.  I  don’t think there’s any real evidence to support that.  I do believe  that these women do very, very well post-operatively if the pelvic floor  is left intact.  The operations, normally speaking, are increased in  length because of the morcellation factor in particular, and there is  always the difficulty of actually cutting the uterus off.  I don’t think  that anybody has a good device yet to cut the uterus off.  Probably one  of the ultrasonic devices offers the best method, certainly in my own  hands, but certainly in terms of recovery and satisfaction in the group  that really desire that operation.  It’s not an operation that I would  offer to somebody, but I’d perform it if I were asked to perform it.  I  don’t believe that leaving the cervix is bad in terms of the risk of  developing cervical cancer, which of course has often been one of the  reasons put forth for its removal.  But you could say to a woman in that  age group – well, you should have a mastectomy at the same time because  you have more of a chance of having breast cancer than you are of  having cervical cancer so there’s no real indication.  In the bleeding  group, of course, if you remove the endometrial cavity you’ve solved the  problems so I think there’s a bit to be said for subtotal in terms of  the actual outcomes but, as I say, it’s a lengthy operation.  I suppose  the best thing to do is really do the operation that you’re most  comfortable with and that the patient is most comfortable with.”

:  “That  sounds like a sound piece of advice to leave it here, and I’d like to  thank you very much for giving us a little world tour of hysterectomy.   Thank you again, Peter.”

:        “It was great to catch up with you, Larry.”

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsOrlando, Florida, November 2000

Peter Maher, MD

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Hysterectomy in the Future