OBGYN.net Conference CoverageFrom the 31st Annual Meeting of the American Association of Gynecological Laparoscopists (AAGL)
Hugo Verhoeven, MD: Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Dusseldorf, Germany. I’m on the editorial board of the OBGYN.net and we are reporting from the AAGL meeting in Miami, Florida, sitting here together with Doctor Mark Glasser at the Olympus booth. Dr Glasser, thank you very much for giving me the pleasure to talk to you.
Mark Glasser, MD: Thank you.
Hugo Verhoeven, MD: You are head of the Department of Obstetrics and Gynecology at Kaiser Permanente Hospital or Medical Centre, better, in San Rafael in California.
Mark Glasser, MD: Yes, I am.
Hugo Verhoeven, MD: Thanks again for being with me.
Mark Glasser, MD: Thank you.
Hugo Verhoeven, MD: The topic we want to talk about is the use of the resectoscope in hysteroscopic surgery.
Mark Glasser, MD: Yes.
Hugo Verhoeven, MD: So first of all, hysteroscopic surgery. What does that mean exactly? What are the indications for doing surgery in the uterine cavity?
Mark Glasser, MD: Well, surgery in the uterine cavity is a phenomenal advance in women’s health. This allows us to manage some of the most common problems which afflict women and probably the most common reason hysterectomies are done in this country. Abnormal bleeding is the symptom that affects probably 40% of women that come into our office have complaints about abnormal bleeding and some are managed easily with hormone manipulation, but others have intrauterine pathology and, in the old algorithm, these people were tried on hormones, had two or three D&Cs blindly and then when those failed, which very often they did, unless fortuitously they removed a polyp which was the cause of the bleeding, and these patients went on and had hysterectomies. We started doing alternatives to hysterectomy in about 1990 in our medical centre. We felt that operating within the uterus was a minimally invasive way to manage these problems. We have a population of women who often are self-employed and are professional women and are really motivated to get back to work very quickly and were looking for alternative procedures and would be very upset at the thought of having a hysterectomy and having to be debilitated for several weeks.
Hugo Verhoeven, MD: But we are talking now about the certain population of patients coming to see you because of irregular bleeding, not controlled or managed with medicaments where the alternative would be hysterectomy and you say, no, no, no, we are going to do something in the endometrial cavity, we are going to remove the endometrium, we’re doing an ablation of the endometrium.
Mark Glasser, MD: Absolutely.
Hugo Verhoeven, MD: For that reason, you are using this instrument that we have here, a resectoscope?
Mark Glasser, MD: Yes.
Hugo Verhoeven, MD: It is my understanding that it is one of the many possibilities of removing the endometrium. There are many other techniques. Why are you a fan? Why do you prefer this Olympus resectoscope? What is special about that?
Mark Glasser, MD: Well, resectoscopic surgery is really the gold standard for ablation and I know there are several new ablation technologies, global ablation technologies, which we have been very supportive of and we’re using for women who have normal cavities by and large or who want to terminate child-bearing. There is a subset of women, however, who have intrauterine pathology who do not want to terminate childbearing and endometrial ablation essentially will terminate childbearing, although it’s not a method of birth control. So the most common presenting problem are fibroids, submucous myomas which are very vascular and they need to be resected in those people who want to maintain the ability to have children.
We’ve been using Olympus resectoscopes now for about twelve years and the older model of the resectoscope was quite reliable; however, they’ve improved this due to suggestions by physicians at meetings like this and we find this new one to be very, very nice because of some of the improvements that have been made. Now, most significant, I think, is the diameter has gone down from about 10mm to 8.5mm and this is a, the 27 French instrument which we were very used to using, we’d have to dilate the cervix to 10mm or 11mm and occasionally we will have a patient who is maliporous, who hasn’t had a child and has a very narrow cervix and that cervix may be scarred from previous surgery, cryosurgery or a LEEP procedure for abnormal PAP smear, the cervix may be very difficult to dilate and oftentimes we can’t get it dilated to more than 8mm or 8.5mm and we found with this narrower instrument we are still able to get a good amount of resection because the instruments are the same size and we don’t have to forcefully dilate the cervix up to 10mm or 11mm. So that is a very significant advantage to this new instrument as opposed to the ones that we used previously.
Now, I’d like to tell you that we’ve have had tremendous success, we have done over 1,000 ablations and fibroid resections using the resectoscope in our practice since 1990 and our hysterectomy rate is only 4.5% following endometrial ablation fibroid resection, so we’ve got a tremendous amount of success using these instruments and hopefully our success will be as great with the global ablation technologies. But there are instances where a resectoscope must be used and I mentioned the patient wanting to maintain childbearing.
Hugo Verhoeven, MD: So the advantage of this technique is that even if you have an irregular cavum, if the cavity of the uterus is irregular, with the techniques like thermal ablation, with balloons, that you could still have technical problems. That’s not the case with the resectoscope?
Mark Glasser, MD: That’s not the case with the resectoscope. Now, thermal ablation, hydrothermal ablation, can be done in patients with fibroids and we’ve done several. But occasionally the fibroid obstructs the entire cavity and you can’t get the saline to circulate around it and therefore you must remove the fibroid. So for this reason, we still use the resectoscope, we think it’s a very important part of our practice and we have decreased the hysterectomy rate at our facility to approximately 200 per 100,000 women, whereas in the state of California, the hysterectomy rate is 560 per 100,000 women. This is for benign disease, and certainly these instruments have helped us accomplish this goal.
Hugo Verhoeven, MD: So what do you do exactly? Describe the technique that you use.
Mark Glasser, MD: Well, what we do is, first we dilate the cervix, we generally inject a dilute putrescent solution, four units per 60ccs of saline that contracts the blood vessels, makes it easier to dilate the cervix, we dilate with this instrument to an 8mm Hagar dilator, we put the resectoscope into the external ossa of the cervix, turn on the fluid, the fluid pressure will dilate the cervix the remaining half millimeter and we are able to see the inside of the uterine cavity. The optics on this instrument are excellent, it is a 12 degree deflection of the lens so we’re able to see by deflecting the scope in either direction up to the cornula, the tubal ostia, the openings of the tubes, we are able to usually get around the fibroid because of the increased length of this new instrument.
Hugo Verhoeven, MD: Okay.
Mark Glasser, MD: So that’s another advantage, another improvement to this instrument. Now there are various electrodes. The most commonly used is the wire loop, as you can see, I know this is sometimes not visible well on the videotape, but basically what we do is put the instrument in behind the fibroid, extend the wire loop and, as we come back, the wire loop will cut a section of the fibroid with electrosurgical current. The light source is connected here and the electrosurgery is connected here and it goes to a standard electrosurgical generator and we use pure cutting current at about 80 to 100 watts and we just resect the fibroid in small segments, remove the segments, oftentimes we’ll cut the fibroid in half and resect part of the base and then we’re able to remove larger segments with an ovum forceps.
Hugo Verhoeven, MD: Is it technically a difficult procedure?
Mark Glasser, MD: At this point in my experience, it’s not technically difficult, but there is a learning curve and once you get used to the procedure, once you get used to the hand-eye and the visualization and three-dimension, it really is quite a simple procedure, but I wouldn’t say someone who’s never done it could go out and begin doing resectoscopic surgery.
Hugo Verhoeven, MD: Do you use some general anaesthesia?
Mark Glasser, MD: We often do it under spinal anaesthesia or epidural anaesthesia but there are some people who do it under paracervical block with conscious sedation.
Hugo Verhoeven, MD: How long is the duration of the procedure?
Mark Glasser, MD: The procedure generally takes between 15 minutes and a half hour to do, but with larger fibroids or multiple fibroids, we sometimes can take up to an hour to do the procedure.
Hugo Verhoeven, MD: Something that always our listeners are interested, what can go wrong?
Mark Glasser, MD: Well, several things could go wrong. Certainly whenever you put instruments into the uterus and whenever you use electrosurgical current, there is a risk of perforation of the uterus and with subsequent injury to the bowel. All of this is extraordinarily rare. The beauty of doing this under direct vision, of course, is you can recognize injuries when they occur. The other risk is a condition called dilutional hyponatremia. We use a non-electrolyte solution in order for electrosurgical current to work and if this gets absorbed into the vasculature, a condition can occur where the patient’s sodium goes down, dilutional hyponatremia, the brain can swell, there can be very serious consequences and even death. This has been largely eliminated with the use of fluid monitoring systems, electronic fluid monitoring systems, and stopping the procedure when the fluid input exceeds the output by more than 1000 to 1500cc.
Hugo Verhoeven, MD: So those complications are quite seldom?
Mark Glasser, MD: They’re very, very seldom and certainly while the physician must be aware that these complications can occur, it certainly should not be a barrier to doing resectoscopic surgery.
Hugo Verhoeven, MD: Could we conclude that there are practically no more indications for hysterectomy?
Mark Glasser, MD: I wouldn’t say that. I think fibroids that are quite large, where bulk symptoms are a problem, as well as abnormal bleeding, then a hysterectomy is certainly indicated.
Hugo Verhoeven, MD: Remove them laparoscopically.
Mark Glasser, MD: You could remove them laparoscopically, but oftentimes a myomectomy is a more difficult operation than a hysterectomy and we must remember that most women who are symptomatic, either by bulk from fibroids or bleeding who have a hysterectomy are happy with the hysterectomy. But certainly if they can undergo a procedure that was done in a same-day centre, where they came in, had their surgery, were able to go home two or three hours following the surgery and back to work or back to family the next day, that is a tremendous advantage to having a hysterectomy, being in the hospital for three or four days and having a six to eight week recovery period.
Hugo Verhoeven, MD: Okay. Is this a perfect instrument or do you think some details could be improved?
Mark Glasser, MD: This is a close to perfect instrument, but nothing is perfect and I’m sure as we get more and more experience using it, this is very new on the market, we will find some little things to tweak and improve even further.
Hugo Verhoeven, MD: Well, I wish you all the best with your new instrument. Thank you for giving me the pleasure, again.
Mark Glasser, MD: Thank you so much, it was my pleasure
Hugo Verhoeven, MD: Good to meet you. Bye bye.
Mark Glasser, MD: Bye bye.