Hysterectomy in the Future

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Dr. Larry Demco:  “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?”

Dr. Peter Maher:  “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.”

Dr. Larry Demco:  “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?”

Dr. Peter Maher:  “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.”

Dr. Larry Demco:  "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?”

Dr. Peter Maher:  “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.”

Dr. Larry Demco:  “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?”

Dr. Peter Maher:  “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.”

Dr. Larry Demco:  "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?”

Dr. Peter Maher:  “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.”

Dr. Larry Demco:  “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.”

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

Dr. Larry Demco:  “You bet.”