The Future in Hysteroscopy

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Dr. Smith: "Here at OBGYN.net today, we're honored to have with us, Dr. Steve Cohen, from the Columbia University. We're honored that he's going to be with us and is going to talk to us a little bit about hysteroscopy and some of the newer things that we're seeing at the ASRM meeting this year. Dr. Cohen, thank you very much for joining us."

Dr. Cohen: "It's a pleasure."

Dr. Smith: "What's new in hysteroscopy here this year?"

Dr. Cohen: "What's new in hysteroscopy - what's happening with hysteroscopy is a number of things. First of all, people are discovering it. It's been around, as you know, for 150 years but we're rediscovering hysteroscopy as we enter the new millennium. So I think the first thing that I found out that's new is that companies are really going to - as we cross into the year 2000 - push hysteroscopy as a viable technique, as a easy technique, as a cost effective technique, and most importantly - as a safe technique that allows one to really diagnose what is significant about pathology, so patients and doctors immediately know what the problem is. For so long, so many years, gynecologist have been doing blind sampling of the endometrium and repeating that over and over again, and never when you get a negative answer you never really know what the possibilities are; we miss polyps and we miss small lesions. We are now going to enter an era where we'll do hysteroscopy, and we won't be doing it in the operating room in the diagnostic area. We're going to be doing it in our own offices where we can control the patient, the comfort of the patient, the anxiety of the patient, and we can control our timing - we can get these procedures done very quickly. So that the big thing about hysteroscopy is not necessarily the technology, although we'll touch on that in a minute, but it's letting the world know hysteroscopy is available, it's there, and it's a powerful tool to diagnose. The second thing that's happening in hysteroscopy is that the instrumentation is getting much better. For those of us that remember hysteroscopy from a decade ago…"

Dr. Smith: "Unfortunately I'm one of those."

Dr. Cohen: "Right, we had to take this large instrument, dilate the cervix, put it into the uterus - and we saw Campbell Soup, tomato soup, or we saw nothing. It was like the Emperor's new clothes. One would say to the other, "Do you see that?" And the other one would say, "Of course I see that." And you take it that neither one of you did, and in your mind you'd be saying, "I don't know what I saw in there." That's changed and unfortunately the word hasn't quite gotten out to everybody that it's better now, with instrumentation becoming remarkably reduced in size so you don't need to dilate the cervix like we used to. Lighting is dramatically better, in the old days it was a very dark lighting, and you had to shut all the room lights off. You could barely make out what you saw unless you were right up against the lesion. Now you can put the scope in there, it's brilliantly lit. You have continuous flow systems, almost all systems now are continuous flow so that you put the scope in - and if you have in a New York minute, if you have a little bit of patience, not everybody has that - but if you have a little bit of patience, the image will clear in front of your eyes. You don't have to do anything, and you can immediately see the entire uterus from the cervix. You can make your diagnosis in a minute to two, and you can be done. So technology has dramatically improved in the diagnostic realm, the word has come out. Lastly, I think in the operative areas, the technology has gotten significantly better as well. The new resectoscopes, for example, are much smaller, the loops are much better, and we're talking about ablation techniques using modified loops that give us higher power densities. And of course, we're all talking about ablation with techniques that will be available shortly, hysteroscopic techniques, which I think will surpass the blind techniques that are out there."

Dr. Smith: "It is exciting, and I see so many of our peers much more receptive to doing hysteroscopy than in the past. It used to be just kind of an accessory procedure that was occasionally done, and the instrumentation - finally it works when it's suppose to."

Dr. Cohen: "Yes."

Dr. Smith: "And occasionally at my hospitals, they'll bring out one of the older instruments and we'll fiddle with it for a while until we realize they haven't got the new set out."

Dr. Cohen: "That's right, that's exactly right. And that's one of the words that we should get across at this meeting and also in this program, if you haven't tried it for awhile - come on back, because if you get the new stuff you'll be amazed at how much better it is. If you're still thinking hysteroscopy was like it was five years ago, or ten years ago, you really should give it another try. It's totally different."

Dr. Smith: "It's a whole different procedure."

Dr. Cohen: "Absolutely."

Dr. Smith: "Also, the thing that you touched on about the clearing, if you cannot see sometimes all you have to do is wait.

Dr. Cohen: "That's right."

Dr. Smith: "And it clears."

Dr. Cohen: "A little bit of patience, and I think that gynecologists should learn these techniques now because, for example, at this meeting we saw a patient on hydrothermal ablation. Now one of the ways that we're going to be doing endometrial ablation for controlling menstrual flow is we're going to be placing a hysteroscope into the uterus. We're going to just be heating the distension fluid, which means you need to know hysteroscopic techniques for some of these procedures that will be coming down to us very shortly. They're very safe, they're invaluable, they're going to eliminate a significant number of hysterectomies and more invasive procedures that carry more complications. So as gynecologists, if you're going to take care of women as we enter the next millennium, we need to know these new techniques. It's not just as you alluded to anymore, it's not just a gimmick or interesting, it's interesting but not - what am I going to do with that. I think we are actually now going to be able to do something with that and something significant, not just to look but we're going to be able to take a patient who would have had a hysterectomy, and we are not going to have to do that anymore."

Dr. Smith: "It's very exciting."

Dr. Cohen: "Yes, it's very exciting."

Dr. Smith: "Do you think the heated distention media will be an office procedure?"

Dr. Cohen: "Absolutely, I think the heated distention media will be an office procedure, certainly in offices that can do a little bit of conscious sedation and minimal conscious sedation. It will definitely be an office procedure, and I think that makes everybody happy. That makes the gynecologist happy because their time can be used efficiently. That makes the patient happy because the anxiety level of going to your office is certainly lower than having to go to the operating room of the hospital. And it certainly makes payers happy because the cost is much reduced, just doing the procedure in the office, not even talking about what the procedure would have been if you'd did the hysterectomy, for example, in the O.R. So it's a new situation for everybody involved."

Dr. Smith: "That's right, it's a different mindset for the patient."

Dr. Cohen: "Yes."

Dr. Smith: "They think they're going to do better in a office procedure."

Dr. Cohen: "Absolutely. You're coming to my office for a procedure or we're going to take you to the operating room. We're going to meet everybody you've never met before, and I mean it's just totally different, absolutely."

Dr. Smith: "Thank you very much, Dr. Cohen, for being here with us. He's one of the national and internationally well-known experts on hysteroscopy. We appreciate your thoughts on the new things that are in here on the move."

Dr. Cohen: "Very exciting, it's great to be here. Thanks for inviting me."

Dr. Smith: "Thanks very much."

Dr. Cohen: "A pleasure."