Hysterectomy in the next decade

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Dr. Hugo Verhoeven:  “My name is Hugo Verhoeven, I’m a member of the Editorial Board of OBGYN.net, and I’m reporting from the 9th Annual meeting of the International Society for Gynecologic Endoscopy at the Gold Coast in Queensland, Australia. I have the pleasure of talking this morning with Peter Maher who is an Associate Professor at the University of Melbourne and organizer of this important meeting of the International Society for Gynecologic Endoscopy. The topic that I would like to discuss with you today, Peter, is the future of hysterectomy. As we learned during this meeting, endometrial ablation is the treatment of choice for patients with irregular or heavy bleeding if hormonal treatment doesn’t bring the wanted results, and also that fibroids or an enlargement of the uterus or adenomyosis is not a reason anymore for performing hysterectomy. So let’s go back to ablation and the laparoscopic treatment of fibroids. What is the state of the art?”

ProfessorPeter Maher:  “The situation back in 1989-1990 was that doctors really didn’t think that endometrial ablation was a very difficult procedure and it tended to be performed without appropriate training. There were complications, there was a fairly high failure rate and subsequent hysterectomy rate, and so it really fell into disrepute in Australia. So really ten years on, there’s only a small hard core of people who are doing the procedure. What we see now is an increasing number of gadgets, I suppose to use the term, expensive disposable gadgets that are trying to repeat the principle of endometrial resection without the dangers and without the so called failure rates. Now in my experience, and I have tried most of the new products available, the failure rate is still going to be with some of those products unacceptable in view of the cost. Patients have a want, I suppose, of amenorrhea on most occasions. If in fact you counsel the patient properly, you can turn their way of thinking around so that we can bring their periods back to being normal and that is perfectly okay. But the concept of –" I’m sick of those very, very heavy periods and now I want amenorrhea "- you can really still only offer that with hysterectomy. The rate of hysterectomy in Australia has dropped down minimally over the last ten years but that’s probably more due to the use of drugs, certainly there’s been a fairly constant as I say use of endometrial resection without what one would expect a result in impact on the hysterectomy rate. If you look at the number of hysterectomies for example performed in the private sector over about the last ten years there has been a decrease of about 20 percent but interestingly the endometrial ablation rate has dropped also from about 4000 to half that. It’s dropped because of medical treatment but also I would believe, and I don’t know the exact figures, I feel there’s been an increase in the incidence of myomectomy over the last ten years. Traditionally, myomectomy in this country was very, very rarely performed unless there was a fertility problem. Patients with myomas who suffered heavy periods and who were sort of post-childbearing years were all treated by hysterectomy. The number one indication in this country for hysterectomy is menorrhagia and fibroids.”

Dr. Hugo Verhoeven:  “So if you say that’s your impression that the number of myomectomies is going up, what does that mean - also with 20%, 40%, or 60%? It’s very amazing to me that a good technique with a low failure rate with a good compliance like endometrial ablation is not frequently performed in a highly medically educated country like Australia, it is a little bit confusing for me.”

ProfessorPeter Maher:  “One of the main reasons, I think, that it is not universally performed, is that, as I said, in the early days there was a bad experience because of the high failure rate. The operation got bad publicity, doctors lost interest in learning how to do it properly and, therefore, patients weren’t aware that there was another alternative to hysterectomy. Doctors, of course, are reluctant to recommend a procedure that they themselves are not proficient at and may be a source of lost revenue. They’re not going to be telling patients about a procedure that they can’t do and tell the patient this is the best thing for you. Over the years, most of the patients that I have operated on have in fact been referred from friends. For example," I had this operation and it’s wonderful; I was in hospital for six or eight hours, and I was back at work within two days". So it’s a word of mouth referral system as opposed to a general practitioner to consultant.”

Dr. Hugo Verhoeven:  “There’s a lot of educational work not only from the side of the patient but also for the doctors to do. So from the many different techniques there are available, what is your method of choice at this moment?”

ProfessorPeter Maher:  “I’ve had experience recently with the microwave endometrial ablation, and I think that that procedure is simple. It appears to have a very, very low complication rate, and the results appear to stand up or equal to even better than endometrial resection in good hands. I’ve had experience with the hot water balloon in its early days, and I thought that the concept of that was very good but the results I don’t believe stood up, certainly in my hands. One of the things that worries me about all of these new technical apparatuses is that there’s almost a promotion from the companies to go beyond the skill of hysteroscopy, for example, and just use these techniques. I think personally that everybody who performs endometrial ablation should be competent to perform it in the traditional way before actually going on and performing it in these newer ways. I think that there is probably going to be a lot of pathology missed because they are often promoted as not requiring hysteroscopy, for example, and I think there’s going to be pathology missed not so much even malignant pathology but maybe fibroids and things that could be easily treated by a far less expensive and effective method.”

Dr. Hugo Verhoeven:  “How expensive is an endometrial ablation, let’s say, with the new microwave technique?”

ProfessorPeter Maher:  “I am actually just involved with the company now trying to set up a price structure, etc. in Australia, and I believe that the disposal element of this device will be in the vicinity of $600-$1200 Australian dollars, for the thermal balloon, for example, it’s about $600 single use. The important thing about that is that you can get the same results without that added expense if you are able to do TCRE or rollerball ablation, and I think that what will happen is that patients who do have, for example, submucosal fibroids might be appropriately treated by a device such as the hot water balloon. The microwave device may in fact be able to deal with these better than most other devices but it’s going to be in that group of patients that you’re still going to have a hard core that can’t be treated by the doctors because they can’t do the hysteroscopic surgery and various patients will still then of course not be advised as they’re not know that there is another alternative to hysterectomy and that will still be the hardcore of hysterectomy.” 

Dr. Hugo Verhoeven:  “So it’s not the optimal solution at this moment.”

ProfessorPeter Maher:  “I don’t think it’s the optimal solution, I think it’s one of many satisfactory solutions. Certainly in Australia, and I would assume worldwide, there’s a decreasing interest by patients in having a hysterectomy. Most women want to retain to their uterus into and after menopause, and that’s one of the reasons why we’re doing more myomectomies, for example, combining myomectomy with endometrial ablation for patients with menorrhagia and large fibroids is an alternative treatment that I’m offering patients.”

Dr. Hugo Verhoeven:  “Let’s go now to the problem of myomectomy, a resection of fibroids, and we are not talking about the infertile patient, we’re talking now about pre-menopausal patients with irregular bleeding, pain, or pressure. What are the indications for myomectomy, and what is your method of choice for resection?”

ProfessorPeter Maher:  “I think that the indications are blurred to say the least. Any operation can have an indication, myomas have a very, very low malignancy rate, for example, about 1 in 800 to 1 in 1,000 malignancy rate and when you compare this, for example, to breast cancer which has an incidence of about 5 in 100 there’s really no indication from that point of view to remove myomas. From a menorrhagia point of view, there’s no real evidence I believe that removing myomas, particularly intramural myomas or subserosal myomas, will have any impact on menorrhagia. Pressure symptoms, certainly there are a group of patients who get bowel and bladder pressure and sometimes heaviness in the pelvis can be an indication but I think with large myomas there is a definite indication which is discomfort, swelling, etc. but most other indications appear to be in the grey zone. I think with doctors increasing confidence in doing laparoscopic surgery, it’s become an operation that can be performed, and therefore, I think often is performed as opposed to having a really good indication. I think that rather than possibly rushing into laparoscopic surgery, we should be advising these patients that there are other alternatives, in particular, arterial embolization. GnRH analogues? I think in my hands, they really have a very, very small part to play in the treatment of myomas, and I don’t use them pre-operatively because I believe it makes the surgery more difficult. I don’t think it has a major impact on blood loss at the time of the surgery, and in Australia, GnRH analogues are only subsidized by the government pharmaceutical system for endometriosis, and therefore, it costs about 400 or 500 Australian dollars.” 

Dr. Hugo Verhoeven:  “To conclude, myomectomy is certainly the treatment of choice if myomas need to be resected for whatever reason. But removing the complete uterus, just for a myoma. That is anymore the state of the art.” 

ProfessorPeter Maher:  “That’s correct.”

Dr. Hugo Verhoeven:  “But for bleeding, ablation is not the solution. There is still place for hysterectomy.”

ProfessorPeter Maher: “I think that in a relatively normal size uterus it’s not unreasonable to offer a patient endometrial ablation in the course of treatment and explain to the patient that certainly in my hands endometrial ablation has a failure rate of about 15%. I tell the patients that I believe that it would be in their best interest to try an endometrial ablation knowing that they would have a 15% possible failure rate but today in hospital it can be done under local anesthetic and it has a virtually zero complication rate when performed by a competent surgeon..”

Dr. Hugo Verhoeven: “Any visions for the future?”

ProfessorPeter Maher: “I can see that with these ablation systems we’re going to continually be inundated with new technology .I think that drugs will probably improve. In this country, for example, cyclocapron which has been used for many years in Scandinavia in particular is just becoming popular and so there are many patients now who have been treated conservatively with a great deal of success. I think that probably medical therapy will be where most of the advances will come and all of this gimmickry that we’re being presented with now will not advance much further. 

Dr. Hugo Verhoeven: “Peter, thank you very much for this interview.”

ProfessorPeter Maher: “Thank you very much.”