EDITORIAL

Just because we can, doesn't mean we should

I'm very excited about this year's technology issue. It's an especially thought-provoking issue for gynecologic surgeons who are constantly being barraged by new technologies that come with the promise of improving patient care.

The technologies we discuss are at various stages in development. Dr. Jay Cooper, for instance, details the novel technologies used for hysteroscopic tubal occlusion, with particular emphasis on the new Essure device that was approved by the FDA in the fall of 2002. On the opposite end of the development spectrum is the external transabdominal use of high-intensity focused ultrasound for the treatment of uterine fibroids. As Dr. Elizabeth Stewart explains in her article, the procedure requires no abdominal incision but has yet to undergo Phase III clinical trials. A third article—a point/counterpoint discussion between Drs. John Petrozza and Barbara Levy—delves into the controversy surrounding uterine suspension for the treatment of pelvic pain and dyspareunia.

Gynecologic surgeons face difficult questions when it comes time to decide whether or not to adopt such new and exciting technologies: Should we replace a time-tested procedure like laparoscopic tubal ligation with a hysteroscopic tubal occlusion device? Are we more adept at laparoscopic surgery than hysteroscopic surgery? Is the $990 price tag for a disposable tubal occlusion device going to offset the expense of laparoscopic surgery? Will the progesterone-secreting IUD replace both of these technologies? As for the ultrasound treatment of uterine fibroids, how extensive must the follow-up data be before we can recommend this to patients? We are just now collecting valuable data on uterine artery embolization and that procedure was introduced 8 years ago.

Not only should a surgeon carefully evaluate techniques such as the uterine suspension UPLIFT procedure described by Dr. Petrozza, but we must carefully examine the best evidence available to determine whether any surgery is indicated for the symptomatic retrodisplaced uterus. The need for such critical thinking was dramatically driven home by a recent paper in the New England Journal of Medicine, which reported on the use of arthroscopy for arthritic knee injuries. It concluded that patients did just as well with sham surgery as with therapeutic surgery. While the ethics of sham surgery can be debated, these data should make surgeons reevaluate not only the technology they're using but the value of the procedure as well. Interestingly, we've yet to see evidence that the numbers of arthroscopic knee surgeries have declined since these data were published.

Keith Isaacson, MD, Issue Editor, is Director, Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Newton, Mass., and Associate Professor of Obstetrics and Gynecology, Harvard Medical School, Boston, Mass.

Keith Isaacson. Editorial: Just because we can, doesn't mean we should.

Contemporary Ob/Gyn

2003;48:6.