ISGE February, 2001 Volume 7 Issue 1

Editor: James E. Carter, MD
Regional Editors: Togas Tulandi, MD 
Istvn Rakoczi, MD and Prashant Mangeshikar MD

Inside this Issue:

• Gynecologic Endoscopy – Partnerships without Borders
• Editor’s Corner
• Laparoscopic Surgery in the Year 2001
• The Lap-Loop Utilization for Laparoscopic Subtotal and Total Hysterectomy
• The Use of Endoscopy in Fetal Medicine
• Painless Laparoscopy?
• Should Young Women with Uterine Fibroids be Treated with Uterine Artery Embolization
• Interview with Dr. Camran Nezhat
• Letters to the Editor

President's Letter
John J. Sciarra, MD, PhD

“Gynecologic Endoscopy – Partnerships without Borders”

Dear Colleagues:

We are entering a time in the development of the discipline of gynecologic endoscopy where there is an opportunity to build bridges, both ideologically and functionally. The science and practice of endoscopy have progressed to the point where core groups of advanced endoscopic surgeons have organized themselves in every corner of the world, not only to exchange knowledge, but also to set goals and plan for the future of the field.

Having entered the age of lightning-fast communication, we find in each area of medicine a shift towards virtual communities – communities developed out of shared goals and ideals, even shared resources and administration. This is especially true in the high technology fields of medicine, such as gynecologic endoscopy. In the past decade, since the founding of the International Society for Gynecologic Endoscopy, we have experienced an unprecedented and explosive growth of new membership groups in both surgical laparoscopy and gynecologic endoscopy. With the help of resources like the World Wide Web, these communities are comprised of members in every area of the world. Communication is no longer local, regional or national, but has become global. With such a large number of organizations, local societies, regional societies and sub-specialty societies in gynecologic endoscopy operating worldwide, there is now more than ever the opportunity for both functional consolidation and working partnerships to be developed within our discipline. It is my belief that our common ideal should be a shared goal.

Towards this end, the ISGE must adapt to allow a collegial exchange of resources with partner organizations whenever and wherever possible. We have a diverse membership with over seventy countries represented. Clearly, our Society is in an excellent position to foster and further the goal of creating a unified international climate in the specialty of gynecologic endoscopy and to share information and resources with its partner organizations worldwide. 

I hope you will consider our 10th Annual Congress as an opportunity to work with other physicians across geographical borders to develop these sorts of functional communities. I also invite you to enlist the senior members of our organization to facilitate these efforts and create lasting partnerships. We have our annual business meeting on Friday, March 30th from 11:00am – 12:15pm and I certainly encourage all members of the Society to attend this meeting and become active participants within our own organization. The theme of this year’s event, Gynecologic Endoscopy, Today and Tomorrow, urges us to look forward – to plan globally and continue to develop our shared goals through partnerships without borders.

The Editor's Corner
James E. Carter, MD, PhD, FACOG
Editor, ISGE Newsletter
Ultimatev@aol.com

As we approach our next 10 years of planning for events with the ISGE, I am very excited that we are able to have our annual meeting here in Chicago, as well as our upcoming regional meeting in Brazil. Having just recently returned from a vacation in Brazil, I can strongly encourage all of members of the ISGE to make the trip, which is very worthwhile. I had the opportunity to spend time in both the rain forest areas and the beaches of Brazil and my wife and I both enjoyed ourselves immensely.

As we approach our next years of planning with ISGE there are two issues that I would like to have us begin to address. These areas overlap and interact in ways in which we are only now beginning to understand and appreciate. These are the areas of pelvic pain from hernias and pelvic floor support problems. For the future I would like to see ISGE involved in research and in the publication of studies in these areas.

Pelvic Pain from Hernias
First with regard to hernias, it is my belief that hernias as a source of pain are not diagnosed frequently enough, especially in women. If we are to apply the strictest definition of hernia where a protrusion of tissue must occur through a fascial split, then I believe many women will suffer needlessly because in my experience early breaks in the fascia prior to any protrusion are the source of pain. These women seek help because they are experiencing pain and this pain is frequently diagnosed as having an organ as its source. All too often that organ is the uterus or an ovary and a woman with a small split in the fascia ends up with a hysterectomy or an oophorectomy. After she has recovered from her organ removal, she finds that the pain that started her problems is still with her and she looks for help once again. In my experience, we as gynecologists have not developed the skills required to make a physical diagnosis of early hernia formation and general surgeons have too easily dismissed the complaints of women, who may well have a hernia that is difficult to detect, as needing surgery on her uterus and ovaries for her complaint of pain. 

I would ask that you look for certain things in the history of your patients that would lead you to an exploration for a hernia as a source of a problem with pain. This list is from my own experience and requires validation by others much more knowledgeable than myself. However, I offer it to you with the hope that some of your patients might benefit, as many of mine have, from having a previously undiagnosed hernia repaired. Look for complaints of low abdominal pressure; pain from recurrent muscle spasms of the back and pelvis; pain made worse with bending, lifting or other physical activity; sensitivity or tenderness in the low abdomen and pelvis that comes and goes, frequently with increase in activity; pain along a distribution of a nerve that passes close to or in the area of the hernia. Examine your patients for fascial defects in the abdominal wall and pelvis. Err on the side of referring too many rather than too few of your patients for evaluation of a possible hernia as the cause of her pain. Better that your general surgeon colleague send you a note stating that a hernia is unlikely than you leave a patient with a treatable hernia uncared for.  Use the simple pulsion test, and refer not based on your feeling that there’s a bulge but on the patient’s complaint of pain when they cough with your finger appropriately placed over the suspected fascial split/ hernia defect. Gynecologists, general surgeons and urologists all have a need for an atlas of the appearance of laparoscopic hernia defects. The importance of this can only be estimated, but it is instructive to review the work of William Saye, whose work was documented by John Miklos in a landmark study on sciatic hernias. They found that in up to 2% of women undergoing laparoscopic intervention for undiagnosed pelvic pain a sciatic hernia was identified and upon repair a substantial number of these patients had significant reduction in their level of pain. To paraphrase Bill Saye: “The eye doesn’t see what the mind doesn’t know.” Although the laparoscope is a tool that improves our vision, it has placed upon us a great responsibility to know what it is we see.

Besides sciatic hernias and the common, but also under diagnosed, groin hernias in women what about the obturator canal? It is well known in cadaver studies up to 70% of women have obturator hernias. What we don’t know is how many women experience symptoms from this hernia and we don’t know this because we don’t look for this as a source of pain. Having co-authored the textbook “Pelvic Pain: Diagnosis and Management” and having contributed the chapter on hernias, I am humbled by the complexity of the problem and grateful for each hard won success. There is nothing so rewarding to each of us as physicians as these words from our patients: “The pain is gone”; “I can do what I want now and it doesn’t hurt”; “That horrible ache just isn’t there anymore.”

Albert Schweitzer once wrote: “We must all die. But that I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” 

Pelvic Floor Support
The process of the breakdown of pelvic support is one that is initiated by trauma or aging, resulting in nerve injury, weakness and decline in the muscle structures leading to tears and breaks in the fascia. These same tears and breaks in the fascia which we call hernias in the abdominal wall have carried many names in gynecology when applied to the pelvis in women, such as cystoceles, rectoceles, enteroceles and urethroceles. Now we understand that these are true hernias. These are breaks in fascia and ligaments that require the same attention and the same techniques as general surgeons have applied to hernias for the last 50 years. This is a paradigm shift for us as gynecologists to realize the fact that much of what we must do for our aging population is hernia surgery. The enterocele is, in fact, a break in the pubocervical from the rectovaginal fascia and this fascia must be repaired. Vaginal vault and uterine prolapse are the result of breaks in the uterosacral ligaments and these ligaments must be repaired for this support to be re-established. Rectoceles are, in fact, protrusions through breaks in the rectovaginal fascia or the Denonvilliers’ fascia. We are now beginning to understand as gynecologists that we must repair these breaks in the fascia as if they were true hernias. We need help from our surgical colleagues and our urological colleagues to improve our techniques. Our rate of failure is unacceptably high. The recurrence rate of rectoceles after rectocele repair prior to the application of site specific fascial repair was up to 50%. Now with site specific repair the failure rate at 5 years has been reduced to 20 to 30%. This is still unacceptably high. Any hernia surgeon would find it unacceptable to have a recurrence of groin hernia after repair of 20 to 30%. We as gynecologists have difficult problems to address in this area. How do we create tension-free repairs for the hernias that we call enteroceles, cystoceles, rectoceles and vault prolapse? How do we create ligamentous support for the vaginal vault that can then prevent future recurrence of prolapse. And just as we now understand, through the anatomical dissections of A. Cullen Richardson, the nature of these fascial breaks, we also understand from the pathophysiological studies of John Delancey the importance of pelvic floor muscle rehabilitation in sustaining these repairs. However, all of the pelvic floor rehabilitation that can be offered will not repair the tears in fascia and the breaks in ligaments. General surgeons, when faced with recurrence rate such as we gynecologists are now confronting developed the tension-free techniques that have reduced groin hernia recurrence to its currently acceptably low levels. We need to look at our techniques and look at our results and interact to find better solutions and more permanent answers to these pelvic floor support problems. 

Mark your calendars now for an exciting venture to Brazil. Surround your Congress visitation at our Regional Meeting to be held in So Paulo with exciting ventures into the Brazilian countryside. During my last visit to Brazil, I found the treasures of Iguaz Falls and a short visit to Rio with stopovers at the township of Ipanema very worthwhile. Perhaps, this trip a venture into the northern portions of Brazil with stopovers at the remarkable beaches and the beautiful interior would be in order.

Original Contributions and Scientific Summaries:Laparoscopic Surgery in the Year 2001
By Kurt Semm

Surgery in all its branches changed considerably in the last decade of the twentieth century. Minimal access surgery has made its mark and is here to stay clearly nullifying the old adage “big incision, big surgeon.” 

This new surgery also heralds the final step in the development of surgery –robotic surgery. The human brain will no longer be the initiator of physical movement at surgery. Robotic arms propelled by signals given to a computer by the surgeon will move forceps, needles, and scissors. Any extraneous movements will be eliminated. The robotic arm will move in an axis forwards and backward and also allows rotational movements. This simplification of the movements required to do surgery began with laparoscopic surgery. Without laparoscopic surgery we would not be on the path to robotic surgery. Currently, it sounds unrealistic and impossible, but in looking into the future we must see that the reality of one master teacher helping at cases all over the world while sitting at one center will undoubtedly help all mankind. As I began with laparoscopic surgery there was much criticism that this technique was unrealistic and impossible for routine use. Today, laparoscopic surgery has become a mainstay of surgery. Everything in science is possible; it only requires time and patience.

The major factor in improving surgical procedures in the next decade will be to further minimize the port of access. Hospitalization will be reduced even further and surgical ambulatory clinics will become routine even in the university setting. It is important that the administration and insurance companies keep pace with our rapid surgical developments. The scar is smaller and patients return to the work force earlier, but it should not be forgotten that it is increased surgical skill that has brought about these benefits. The industry does its best to develop instruments to make our task easier but laparoscopic surgeries are without doubt much more difficult that the open procedure.

The LAP-LOOP Utilization for Laparoscopic Subtotal and Total Hysterectomy
*Jacques Dequesne MD, **Norman Schmidt MD, LEC. Lausanne Switzerland. 
* Prof J. Dequesne is founder of the Lausanne Endoscopic Center (LEC), Lausanne, Switzerland. **Dr. Schmidt is a fellow at the Lausanne Endoscopic Center. 
Address of author: Jacques Dequesne MD Croix-Rouges 16, 1007 Lausanne, Switzerland.

Abstract
This paper describes a new technique for cervical section during laparoscopic supracervical hysterectomy (LASH) through the use of an electrosurgical loop. This monopolar device consists of a specially designed Tungsten wire adapted at both ends to be held in the introducer. It is positioned around the cervix at the level of the isthmus following dissection and occlusion of the uterine arteries. The cervix is rapidly and cleanly cut with minimal bleeding, making LASH a safer procedure and reducing operating time. New applications for pedunculate myomas and total laparoscopic hysterectomy are describe.

However, this technique is reserved for experienced surgeons aware of the proper management of electrical energy in laparoscopy.

Introduction
Supracervical or subtotal hysterectomy is a procedure that has regained interest and is currently being evaluated in patients presenting benign uterine disease with a healthy cervix. The technique for laparoscopic supracervical hysterectomy (LASH) has only been introduced in the early 1990 1-3. Some of the potential advantages of this procedure include shorter operating time, fewer complications and earlier return to normal activity including sexual function4.

A difficult and time consuming part of the laparoscopic procedure is the sectioning of the uterine cervix. Conditions are often far from optimal due to the angle of approach of the cutting electrode or scissors and due to the proximity of neighboring structures that are sometimes difficult to keep at a distance. 

The LAP-LOOP Utilization for Laparoscopic Subtotal and Total Hysterectomy
*Jacques Dequesne MD, **Norman Schmidt MD, LEC. Lausanne Switzerland. 
* Prof J. Dequesne is founder of the Lausanne Endoscopic Center (LEC), Lausanne, Switzerland. **Dr. Schmidt is a fellow at the Lausanne Endoscopic Center. 
Address of author: Jacques Dequesne MD Croix-Rouges 16, 1007 Lausanne, Switzerland.
continued

The authors have refined the technique by introducing an electrosurgical loop to cut the cervix during LASH. This electrode loop consists of a 10 cm long Tungsten wire (disposable) which has been screw on one side and finish by a ball to facilitate the handling (Fig1).In order to provide additional security, the device is also electrically isolated except at the extremities of the introducer and the middle portion used for cutting. After proper placement of the loop around the cervix at the right level of the isthmus (over the ligation of uterine vessels), monopolar current is applied resulting in facilitated separation of the cervix from the corpus uteri with less danger to neighboring structures.

Surgical technique
Preparation for LSH includes placement of a uterine manipulator and catheterization of the bladder. Surgical approach is through the usual laparoscopic portals: a primary portal for the optic and two or three secondary portals (5 and 12mm) for ancillary instruments. Treatment of the round ligaments and adnexae follow standard hysterectomy technique. The broad ligament and vesico-uterine fold are dissected to the superior cervix.

The various ways of managing the uterine arteries have been described and are used as the basis of a classification system for supracervical hysterectomy5,6. Prior to applying the electrosurgical loop, the authors dissect and section the uterine vessels after occluded them with bipolar coagulation or placement of sutures. Treatment of the uterine arteries in this fashion corresponds to a type III procedure according to the Munro-Parker classification system.

Once the uterine arteries are cut, it is important to remove any manipulating device that has been placed in the uterus. The wire electrode loop is then introduced into the abdominal cavity and placed around the cervix (Fig. 1). The extremities are firmly held with the introducer to form a lasso around the cervix at the level of the isthmus. The uterus is retracted laterally by pulling on the stump of the round ligament in order to allow clear vision of adjacent structures: bladder, rectum, intestine etc. (Fig. 2). Sectioning of the cervix is accomplished by applying high frequency monopolar current to the electrosurgical loop while it is displaced horizontally (Fig 3). Often it is necessary to pause during section to remove smoke and maintain good vision during amputation. After the cervix has been cut, any residual bleeding may be treated with bipolar coagulation if necessary.

For total laparoscopic hysterectomy, the technique is the same till uterine artery ligation, after that the cervical dissection is going on with the help of the Clermont canulator or easier with the Australian tube (McCartney), a vaginal window is then perform on the opposite side to anchor the loop; struggle the vagina and permit precise cut around the cervix when the monopolar current is activated. For pedunculated fibroids this device is also very efficacious, up to now it has been use only for pedicule less than 2cm. 

At the end of the procedure the uterine corpus is removed from the abdominal cavity by either morcellation or extraction through a culdotomy incision.

Discussion
The authors have now successfully employed the Lap- loop technique in 127 patients for LASH, 15 cases of TLH and 12 cases of fibroids. No complications have been observed in any of these cases. The main advantages of the loop are safety , reduced operating time and precision of the cut.

Safety has always been an important consideration when choosing a supracervical procedure over total hysterectomy. By avoiding the risk of cervical dissection with possible ureteral lesions, the complication rate may be reduced with a supracervical technique. However, when cutting the cervix with any monopolar instrument there is an associated risk of damaging adjacent structures. This risk seems to be reduced considerably with the use of the electrosurgical loop because it is very precise and because a large portion of the loop is electrically isolated. Use of this monopolar device remains however an advanced laparoscopic technique and should be limited to only experienced laparoscopic surgeons.

Another advantage of laparoscopic supracervical hysterectomy is reduced operating time7-9. A further decrease in operating time has been achieved with the loop technique for cervical amputation. Prior to the development of the electrosurgical loop, the time required to section the cervix was inconveniently long (around 16 minutes). With the introduction of this new device the time has been greatly reduced to about four minutes with actual cutting time being less than one minute. Section is also rapid in cases where the uterus is large or irregular.

Conclusion
An electrosurgical loop has been designed and successfully employed to decrease the time required and facilitate section of the uterine cervix during LASH for benign uterine conditions, it is more recently use successfully for total laparoscopic hysterectomy and pedunculate myomas. It facilitates and increases also the safety of these procedures. It must however be emphasized that safe use of the electrosurgical loop requires an experienced staff and surgeon aware of the proper management of electrical energy in laparoscopy.

References1 - Semm K: Hysterectomy via laparotomy or pelviscopy. A new CASH method without colpotomy. Geburtshilfe Frauenheilkd 51:996-1003, 1991
2 - Pelosi MA, Pelosi MA 3d. Laparoscopic supracervical hysterectomy using a single-umbilical puncture (mini-laparoscopy). J Reprod Med 37:777-84, 1992
3 - Donnez J, Nisolle M: LASH, laparoscopic supracervical (subtotal) hysterectomy. J Gynecol Surgery 9:92-94, 1993
4 - Dequesne J: Avantages de la subtotale par laparoscopie. Presented at the Champry Laparoscopic Winter Course, Champry Switzerland, January 18-22, 1995
5 - Munro MG, Parker WH: A classification system for laparoscopic hysterectomy. Obstet Gynecol 82:624-9, 1993 
6 - Munro MG: Supracervical hysterectomy: a time for reappraisal. Obstet Gynecol 89:133-9, 1997
7 - Lyons TL. Laparoscopic supracervical hysterectomy: A comparison of morbidity and mortality results with laparoscopically assisted vaginal hysterectomy. J Reprod Med 38:763-7, 1993
8 - Lalonde CJ, Daniell JF: Early outcomes of laparoscopic-assisted vaginal hysterectomy versus laparoscopic supracervical hysterectomy. J Am Assoc Gynecol Laparosc 3:251-6, 1996
9 - Richards SR, Simpkins S. Laparoscopic supracervical hysterectomy versus laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 2:431-5, 1995

Figures (click thumbnails for larger images)

Figure 1: Placement of the electrosurgical loop electrode around the uterine cervix at the level of the isthmus. A new electrosurgical loop technique for laparoscopic supracervical hysterectomy - Dequesne, Schmidt

Figure 2: The uterus is held by the round ligament stump, clear of adjacent structures. Lateral traction on the loop while applying monopolar current cuts the cervix. A new electrosurgical loop technique for laparoscopic supracervical hysterectomy - Dequesne, Schmidt

Figure 3: View of the cervical stump while displacing the uterine corpus A new electrosurgical loop technique for laparoscopic supracervical hysterectomy - Dequesne, Schmidt.

The Use of Endoscopy in Fetal Medicine
Jan A Deprest, MD, PhD
Telephone : 32 16 34 42 15
Facsimile: 32 16 34 42 05
e-mail: Jan.Deprest@uz.kuleuven.ac.be 

Today, fetoscopy has gained clinical acceptance in fetal medicine, due to technical innovations in millimetric endoscopes combined with increasing insight into the pathophysiology of some conditions that can be diagnosed prior to birth. Two types of fetoscopy are to be considered: obstetrical endoscopy and endoscopic fetal surgery. 

Obstetrical procedures include surgical interventions on the placenta, umbilical cord and fetal membranes. The most common procedure today is laser coagulation of chorionic plate vessels for severe mid-gestational feto-fetal transfusion syndrome (FFTS), and to a lesser extent cord occlusion in monochorionic pregnancy with one non-viable fetus. In the former, the placenta is inspected by fetoscopy and selected vessels involved in the transfusion process are coagulated by means of Nd:YAG or diode laser energy. This procedure is causative as it addresses, at least in theory, the pathophysiology of FFTS. Experience is large (over 500 cases registered in Europe) with survival rates of 65 – 70 % and an increasing number of pregnancies with two survivors. Prospective follow-up of live born fetuses showed a reduced risk for neurologic morbidity as detected by neonatal brain scans (5 % in contrast to >20 % in case of amniodrainage). There are however no solid data to support the view that laser coagulation would be superior to amniodrainage, and therefore a multicentre, open randomized trial has been initiated by the EUROFOETUS research consortium (over 40 patients enrolled, protocol at http://www.eurofoetus.org). Patients and data can be entered via the Internet and a well-defined neurologic follow-up has been proposed. Fetoscopy has also been used to guide cord occlusion as a technique for selective feticide in case of monochorionic twins in a variety of conditions. We recently described ultrasound-guided bipolar coagulation of the umbilical cord, which offers an alternative for fetoscopic laser coagulation at a more advanced gestational age. Survival is over 75 % today, with a risk for ruptured membranes (PPROM) of < 20 %. Fetoscopy has also been suggested to section amniotic bands. Via http://www.eurofoetus.org,  any fetoscopic procedure can be registered. This world wide registry, funded by the European Commission, has as primary target the assessment of maternal and fetal safety.

The second type of fetoscopic intervention addresses some rare fetal conditions requiring in utero fetal surgery. These interventions have a different historical and experimental background but share technical aspects as well as potential side effects with obstetrical endoscopic procedures. We suggest that future developments of fetal endoscopic operations will involve a mixture of concepts from both fetoscopy types to reduce maternal invasiveness and complications, eventually improving acceptance by parents and doctors. Most experience has been gathered with congenital diaphragmatic hernia. Fetuses with herniated liver and severe pulmonary hypoplasia have been shown to have an extremely poor prognosis, and are therefore the best candidates for in utero intervention. Today’s approach involves tracheal obstruction as a trigger for lung growth. Different techniques have been described, including fetoscopic tracheal clipping an endo-luminal tracheoscopic balloon plugging, first described by our team. Even as the debate on the best timing and duration of TO is ongoing, clinical cases have been done, with encouraging outcomes. This type of experimental surgery can only be done in experienced centers within appropriate protocols or trials. At present, in the USA, the NIH funds a RCT comparing in utero TO and standard postnatal therapy.

Painless Laparoscopy?
Larry Demco, MD Calgary Canada
Email: larrydemco@home.com  

Laparoscopy has brought many changes in our approach to surgery, with a gradual movement from the traditional laparotomy approach to surgery with in the abdomen to a minimally invasive approach. Although this has affected the doctors, the main benefactor of this technology has been the patient. Post-op recovery times were reduced from 6 weeks to 1 to 2 weeks with the laparoscopic approach. Although a quantum leap in the post-op recovery period was recognized, surgery still involved a painful recovery. A laparotomy scar was replaced with the shoulder pain of laparoscopy. The shoulder tip pain was thought to be due to the reaction of the carbon dioxide gas reacting with the water to form carbonic acid. This in turn irritated the nerves in the diaphragm resulting in the shoulder pain. Recent work has determined that this premise was not correct. The actual cause of the shoulder pain is the result of the cellular death caused by the combination of a temperature change from the gas at 21 C and the drying effect of the gas at .0002%. Just as the cold dry wind of a Canadian winter causes exposed skin to freeze in less than a minute, the same cold dry gas of laparoscopy kills the peritoneal cells resulting in the shoulder pain. Just as the Canadians flock to the warm moist air of Florida to escape the pain of frost bite of a Canadian winter, heating and humidifying the gas during laparoscopy can prevent the cellular dearth of the peritoneum and result in less shoulder pain. With out shoulder pain, the patient's recovery is markedly affected. There is little need for pain medication and a shorter post-op recovery time. 

We are now seeing another quantum leap in the patient's perception of surgery. From surgery with shoulder and trocar site pain, to trocar site pain, prevented by local injection of anesthetics, and shoulder pain prevented by heating and humidifying the gas. The result is laparoscopy far less painful to the point of painless.

These advancements have also resulted in a resurgence of performing laparoscopy with the patient awake. Tubal ligation and diagnostic laparoscopy, utilizing the technique of pain mapping, has resulted in new information about the causes and referral patterns of pain associated with endometriosis and other conditions. This has also allowed the physician to confirm, with the patient, the exact cause of the pain, and that the therapy planned will treat the cause of the pain. The patient is no longer a person to be operated on, but rather a person to be operated with, as a equal partner in the operating team.

Should young women with uterine fibroid be treated with uterine artery embolization?
Submitted by: Togas Tulandi MD
Professor of Obstetrics and Gynecology and Milton Leong Chair in Reproductive Medicine, McGill University. Email: Togas@rvhob2.lan.mcgill.ca 

Leiomyoma is the most common benign tumor occurring in the uterus and female pelvis. It is estimated that 25% of women over the age of 35 have leiomyoma. Accordingly, not all women with myoma should be treated. As women continue to delay their childbearing until the third and fourth decades of life, leiomyoma will be encountered more frequently.

The conventional treatment of women with symptomatic leiomyoma who wish to preserve their reproductive potential is myomectomy. One of the newest treatments of uterine myoma is uterine artery embolization (UAE). The main purpose of UAE is to reduce the size of the myoma and to treat excessive uterine bleeding. According to a survey among the members of the Society of Cardiovascular and Interventional Radiology (SCVIR), 4165 UAE have been performed in the United States as of September 1999. Obviously, the procedure is gaining popularity and more centers will be performing UAE.

In this review, we will evaluate whether uterine artery embolization should replace myomectomy in young women with uterine fibroid.

Myomectomy
Symptomatic leiomyoma includes the spectrum of pelvic pain, pressure and bleeding as well as unexplained infertility or recurrent pregnancy losses. In women with submucous myoma, it has been shown that hysteroscopic myomectomy improves the reproductive outcome. In women with large uterine myoma particularly when the uterine cavity is distorted, myomectomy by laparoscopy or laparotomy has been associated with increased live birth rate. 

Myomectomy, however can lead to adhesion formation. Intra-abdominal adhesions can cause abdominal pain and bowel obstruction and adnexal adhesions can lead to infertility. Adhesion formation after laparoscopic myomectomy is less than after myomectomy by laparotomy. The incidence of adhesions is approximately 48% after laparoscopic myomectomy and 70% after myomectomy by laparotomy. Whether UAE is associated with adhesion formation is unknown. It is possible that necrosis of a subserous myoma can also lead to adhesion formation. 

Uterine artery embolization
UAE is an alternative treatment to hysterectomy in women with symptomatic myoma who have completed their family. In a review of 119 cases of UAE, McLucas and Adler reported that about 70% of the patients had an immediate cessation of menorrhagia and improvement of pain and pressure symptoms after the procedure. At 6 months follow-up, the total uterine volume decreased by 56% and the average diameter of the largest myoma decreased by 36%. It is clear that uterine artery embolization is an alternative treatment for women who do not wish to undergo a hysterectomy. 

Post-embolization symptoms
During and following UAE, patients may experience abdominal pain. The abdominal pain following UAE could be severe necessitating hospitalization. In general, an overnight admission for pain control is sufficient. 

Low degree fever following UAE is not unusual. Women with high fever following UAE deserve a thorough investigation. One of the severe complications of UAE is septic uterus. Several authors have reported this. One death related to septicemia was reported by Vashist et al. Another death related to UAE was due to pulmonary emboli. The risk of death appears to be minimal. In the survey of SCVIR members, no death was reported. 

Premature menopause
Although, pregnancies following this procedure have been reported, several women have become menopausal. This is due to embolization of the utero-ovarian collateral circulation compromising the blood supply to the ovaries. Although, perimenopausal women with their declining ovarian function tend to be more affected than younger women, it has also been reported in women less than 40 years. The estimated risk is about 1%. 

The occurrence of menopause in premenopausal women results in a decrease in estrogen concentration leading to the shrinkage of the myoma. Although, this is beneficial, these women will need hormonal replacement therapy. It is important to carefully weigh the benefits and the risks of UAE in these women. Those who do not want to take the risk of possible early menopause can be offered a hysterectomy. On the other hand, myomectomy is a better alternative than UAE in women of the reproductive age who have not completed their family. 

Pregnancies following UAE
Pregnancies following UAE have been reported. The largest number of pregnancies from one center was reported by Ravina et al. They noted 12 pregnancies in women aged 22 to 41 years. Of these, 5 resulted in a miscarriage and 3 in preterm deliveries. This high rate of miscarriage is concerning. Although, it has not been reported, the decrease in uterine blood flow after UAE can also lead to intrauterine growth restriction. Regrowth of the myoma during pregnancy has also been reported. 

Conclusions
UAE is an alternative to hysterectomy in women who have completed their family. Due to the risks of premature menopause, it is not recommended for women of reproductive age. Furthermore, to date, report of pregnancy following UAE is anecdotal and the description of live birth is still limited. 

Recommended readings
1. Bradley EA, Reidy JF, Forman RJ, Jarosz J, Braude PR. Transcatheter uterine artery embolization to treat larger uterine fibroids. Br J Obstet Gynecol 1998;105:235-40. 
2. Hurst BS, Stackhouse DJ, Matthews M, Marshburn PB. Uterine artery embolization for symptomatic uterine myomas. Fertil Steril 2000;74:855-69. 
3. Hutchins FL Jr. Worthington-Kirsch R. Berkowitz RP. Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. J Am Assoc Gynecol Laparos 1999; 6:279-84.
4. McLucas B, Adler L. Uterine artery embolization as therapy for myomata. Infertil Reprod Med Clinics of North America. 2000, 11: 77-94.
5. Ravina JH, Cigaru-Vigneron N, Aymard A, Le Dref O, Merland JJ. Pregnancy after embolization of uterine myoma: report of 12 cases. Fertil Steril 2000;73:1241-3. 
6. Ravina JH, Herbreteau D, Cigaru-Vigneron N, Bouret JM, Houdart E, Aymard A, et al. Arterial embolization to treat uterine myomata. Lancet 1995;346:671-2. 
7. Spies JB, Scialli AR, Jha RC, Imaoka I, Ascher SM, Fraga VM, et al. Initial results from uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol 1999;10:1149-57.
8. Vashisht A, Studd J, Carey A, Burn P. Fatal septicemia after fibroid embolization. Lancet 1999;354:307-8.

Interview with Dr. Camran Nezhat
By James E. Carter, MD, PhD, FACOG
click here to launch the audio version of this interview
Dr. Carter:
I am here with the endoscopic surgeon, Camran Nezhat. Camran and his brothers, Ceana Nezhat and Farr Nezhat, are pioneers in laparoscopic surgery. Camran, especially, in publishing one of the first authoritative textbooks in laparoscopic surgery. Camran what we would like to find out is something everyone asks you, which is, how did you get started in this? What happened, what motivated you, what were the events and how did you really begin to foster all of this teaching and education in laparoscopic surgery?

Dr. Nezhat:
Good morning Jim. Thank you very much for giving me this opportunity. When I finished my residency I did a postgraduate training course in Augusta, Georgia with Drs. Robert Greenblatt and Donald Gambrell. They were very busy practitioners in reproductive endocrinology and infertility. During that fellowship with Dr. Robert Greenblatt and Dr. Donald Gambrell, in Augusta, Georgia, my interest increased in operative laparoscopy and infertility surgery. At that time I started using very heavy video cameras attached to our laparoscope and I was trying to operate on the monitor standing up doing laparoscopic procedures. The video cameras were very bulky, very heavy and sometimes you had to actually hold them or hang them from the ceiling to be able to work on the monitor with very dim light. I felt that if one can operate on the monitor and doesn't have to look through the operative laparoscope, the whole operating room team could assist him and could be part of the team. The operative laparoscopy from a one-man band becomes a true orchestra with the participation of the whole team. This initially was associated with some disbelief by naysayers, but we continued our interest in operative laparoscopy by this method.

Dr. Nezhat:
Gradually the video equipment has got better and we continued to do our work in the early '80's with our infertility patients by laparoscope. As you know a large number of the infertility patients have endometriosis, and at those times a large group of them were undergoing laparotomy. We felt a significant number of the laparotomies these could be avoided. We knew different physicians had done some very good basic work. From the time of Halsted and until recently Gomel, Tony Luciano and Michael Diamond and Alan DeCherney, and others have shown that when you do laparotomy the incidence of adhesions are much higher than if you do laparoscopic surgery. We felt that by laparoscopic surgery you can decrease the amount of adhesion formation if the surgery is done properly and then you could contribute to the infertility patients better and of course, smaller incisions, faster recovery for infertility patients means they can get back to their lives and their activities earlier, getting pregnant faster. 

As endometriosis is a multiple organ involved disease, it can involve the bowel, bladder, ureters, sometimes diaphragm, appendix, we ended up working with several different disciplines making operative laparoscopy, a possibility in different branches of medicine. Progress happens when there is collaboration between different disciplines. We have been doing operative laparoscopy for more than 20 years, since the early '80's. During our work we were very privileged to have worked with several different specialties. For example, after our early work in operative laparoscopy that it was associated with disbelief, more and more gynecologic surgeons in this country started adopting the techniques that we had been advocating. They started operating on the monitor and coming up with the same results or opinions that we had come up with. For example, when we proved that even severe endometriosis could be treated by laparoscope with good results then other groups, like Dr. Dan Martin from Memphis, Tennessee, Dr. John Rock per Emmey, Dr. David Olive from Yale University, Dr. Tony Luciano, and others proved the same points. This went on and we collaborated, for example, with colorectal surgeons Dr. L. Pennington, Guy Oranjio and Ambrose in Atlanta and then later at Stanford University with Dr. Mark Vierra and James Stone for colorectal surgery by this technique. The endometriosis involves the GU tract, so we worked with urologists like Frieha, Payne and Gill at Stanford and Rollenberg and Green in Atlanta. We did new work on the GU by operative laparoscopy, including bladder and ureters, working in the upper abdomen with gastrointestinal surgeons. We worked in the chest with thoracic surgeons and vascular surgeons. These are the types of work that we were doing and predicting as the future of operative laparoscopy. 

As this was going on, the equipment was getting better, the interest was getting more and more, the video laparoscopes were becoming much better and it was in the late '80's, with the help of video laparoscopes, cholecystectomy was done and performance of the cholecystectomy made it like a brushfire for the interest of the other disciplines of surgery, we continued our work also teaching and sharing these techniques since September of 1982, we have been doing these postgraduate courses every year, between 4-10. Courses that still are going on for sharing our experiences with our colleagues. Also, it was around the early '90's that several different universities, wanted us to come and start teaching our technology and techniques in the university settings and that is why we decided, and we felt that we had a responsibility to share our experiences and our thoughts with our other colleagues and we accepted the invitation of Stanford University Medical Center. We continued our collaboration with several different disciplines at Stanford. For example with Dr. John Adler in the neurosurgery department. Also, in the chest working with Dr. Christopher Zarens and Dr. Tom Fogerty and Dr. Walter Cannon adrenalectomy and splenectomy with Dr. Mark Vierra, Dr. Christopher Zarens and Dr. Ron Weingold and urology with Dr. Friehat and Dr. Christopher Payne and in colorectal surgery with Dr. Jim Stone, Dr. John Neideruber and Dr. Mark Vierra. Organ transplant Dr. Carlos Esquivel and Dr. Sam So and others. In gynecology and gynecology oncology with Dr. Nelson Tang, with this collaboration we were, hopefully, able to share our experience with our colleagues, and hopefully, make life a little bit better for our patients. 

Dr. Carter:
Camran, early on in my career, I remember learning so much from you, and still do. I remember sitting in the audience one time in Germany in a conference with 1500 other people while you were giving us your vision of the future, which involved the extension of laparoscopy to all of these other fields and for this we are so incredibly grateful that you have been able to share this, to give this information and also have given so much of your time to teaching all of us. I remember early on reading, and then learning from you, techniques of video laparoscopy. The application of video, the application of the laser through the laparoscope in the performance of incredibly, beautiful, elegant surgeries and your teaching at all of our conferences. We are so grateful to you for everything that you have done for all of us. I just cannot give you enough respect or honor for everything that you have contributed and for that we thank you very much. 

Dr. Nezhat:
We all learn from each other. We learn from each other and we build up on it, hopefully, to help our patients. You are kind to say and to remember that and again I have to say that progress only happens when there is collaboration within our different disciplines between our colleagues. Whenever there is a need to do elegant microsurgical work anywhere in the body, even if there is no cavity, when you are able to create a cavity by expanding that area and you need to do delicate work, endoscopy surgery is a good way to do it. You can even do it in some areas of the organ transplant, like the donor kidney. The limiting factor, we have learned, is experience and skill of the surgeon and the availability of the proper instrumentation. At the present time, probably the only area that you should not attempt doing endoscopic surgery is when you are dealing with extremely bulky tumors that need extensive debulking and very large masses. Otherwise, whenever you need any kind of delicate procedures done, video laparoscopy and operative laparoscopy are the way to go. 

Dr. Carter:
Camran, thank you very much for taking this time. I will say good-bye now, but only for a brief time, because I look forward to seeing you again soon in the future. Thank you again. 

Dr. Nezhat:
I thank you very much also, Jim.

Letters to the Editor


The Endometriosis Association
The Endometriosis Association was the first organization in the world created for those with endometriosis, and has just celebrated its 20th anniversary with a one-day conference in Milwaukee, where it was founded in 1980 by Mary Lou Ballweg and Carolyn Keith. 

As an independent self-help organization of women with endometriosis, doctors, researchers, and others interested in the disease, the Association is a recognized authority in its field. It offers mutual support and assistance to those affected by endometriosis, educates the public and medical community about the disease, and promotes and conducts research.

The Endometriosis Association is now a worldwide, organization with a network of chapters, support groups, and women with endometriosis in 66 countries. Its popular yellow brochure is available in 28 languages. The Association has also published two books: Overcoming Endometriosis and The Endometriosis Sourcebook. A wide range of literature, fact sheets, videotapes and audiotapes can also be obtained through the Association.

Since its creation, the Endometriosis Association has achieved many goals, including the undertaking of massive educational projects involving mailings to every gynecologist, hospital and college health services in several countries. The Association has recently embarked on extensive educational campaigns to raise awareness of the disease in a number of countries with mailings to schools, colleges, hospitals, health authorities, nurses, physicians, etc.

Operating as a non-profit organization, the Association aims to establish funds to enable more research into the causes of endometriosis. In 1994, as part of its research program, the Association established a special research unit at Dartmouth Medical School, and has funded and assisted a number of researchers in various parts of the world. It maintains a large data registry and continues work on the relationship between dioxin and endometriosis -- a relationship first discovered through the Association.

In 1998 the Association teamed up with prestigious Vanderbilt University School of Medicine to create a dedicated research facility to address the mechanisms responsible for causing endometriosis. As part of this joint venture, the Association has undertaken to raise $5 million for research, and to enhance its support and educational programs. More recently, it has established an Open Research Fund, and in September 2000 made six grants available to support new investigators in the field of endometriosis to develop promising new ideas. Grants will be awarded again in the first half of 2000. For more information on how to apply for funding, please contact the Association’s international headquarters. The deadline for applications is 1 March 2001.

Other research projects supported by the Association includes a study of dioxin-exposed young women in Seveso, Italy; publicity and help obtaining patients and families for a genetic study at Oxford University, England; investigation on a non-invasive diagnostic technique by a US researcher; and small grants and tissue samples for a number of researchers studying dioxin and related toxins and endometriosis.

For further information contact: 
Endometriosis Association
International Headquarters
8585 North 76th Place
Milwaukee, WI 53223
tel: +1 414 355 2200
email: endo@endometriosisassn.org  
http://www.EndometriosisAssn.org 

Report on KU Medical School
Submitted by: Janak Koirala, MD MPH
ANMF General Secretary

It should also not be forgotten that these new surgical techniques are primarily based on the tried and true techniques developed throughout the past 200 years. 

Dhulikhel is mainly a resort town. If you look towards north from Dhulikhel Bazaar, you can see fabulous view of mountains standing behind the beautiful Panchkhal valley. On south and west, there is another beautiful valley in which lie Banepa and Panauti Bazaars. Kathmandu lies in the next valley beyond Banepa, which is about a 30 minutes drive. Kathmandu University lies between Banepa and Dhulikhel. Its modern buildings stand out amidst the old brick and mud houses of the surroundings. According to the mayor Mr Bel B. Shrestha of Dhulikhel, KU has become the major pride of Dhulikhel. Students from Kathmandu come to Dhulikhel for a better education. That is right, most of the students of KU take an hour ride on school shuttle from Kathmandu daily. The Dhulikhel Municipality has donated 500 Ropanies of land for construction of K.U. Medical School (KUMS) and its hospital in a very beautiful location. The mayor told us that he wants to make Dhukhel Bus Stand look like one in the USA.

Thanks to Dr Arjun Karki, during our visit to Nepal, we had a meeting with the Vice-Chancellor Dr. Suresh R.Sharma and the Planning Committee of KUMS. Dr Sharma spent 3 hours with us and also showed us around the campus. Prof. B. R. Prasai, ex-Dean of TU Medical School and director of Nepalgunj Medical College was also present in the meeting. Dr Sharma explained to us how KU came to be, starting from nothing but a group of dedicated people who wanted to make a difference. He also told us what he expects from ANMF in developing KUMS. There were four ANMF members in the meeting.

Kathmandu University is the first university not owned by the government of Nepal. It has done a tremendous development within less than a decade. Each building and facility of KU has been built by individual or institutional contributions. Dr Sharma likes to call it a nonprofit institution owned by the community. Only looking at the facility it has developed and the programs it has run successfully, attracting the best students and a gaining reputation as the leading university within such a short time, it cannot be argued that its next venture, the medical school, is indeed going to be an outstanding one. The VC and the committee are determined to start the medical school in August 2001. They have a school for nursing and physician assistant running. KUMS has already made arrangements with Univ of British Columbia for PBL curriculum development and Harvard faculties are planning to teach the first two years of basic sciences. For clinical rotations, they have made arrangements with Dhulikhel Hospital, Sheer Memorial Hospital, B&B Hospital, Tilganga Eye Hospital, National Dialysis Center and Katmandu Model Hospital. Dhulikhel Hospital is another marvelous story. This 100 bedded hospital was effort of one person- Dr Ram Shrestha, who went to Austria for medical education. During his medical school and residency, he raised enough money to build this hospital and has been running it with the support of Austrian people. The University of Austria is also willing to help KUMS. 

We were surprised to meet one of the staff in Dhulikhel Hospital, Dr Lani Ackerman, who is a family practitioner and associate professor from Univ of Texas. She has been working as a volunteer for over a year. She told us that she will stay for 2 more years to help KUMS. We were humbled to learn that she had four children with her in Nepal! (I just wondered if an American could do so much to help my country, as a Nepali what have I done for my country?)

The Vice Chancellor, Dr Sharma, expressed his desire to collaborate with ANMF in development of KUMS. He asked ANMF to help KUMS specifically to support its medical library. He also asked about possibility of training KUMS faculties and other staffs for short duration in United States. In addition, Dr Arjun Karki, coordinator of KUMS, asked if ANMF could find funds from external sources to support faculty travel from USA to Nepal. In response, I explained to the meeting that ANMF is working with its limited resources, but I would certainly communicate these proposals to the ANMF. 

Dr Sharma himself took us for the tour of the KU campus. He showed us great teaching facilities, laboratories, library and the computer lab with 150 computers. There is a tremendous construction going on in the campus. Each building or facility shows the name of the person or the institution that contributed for it. Thanks to Dr Karki, we also had opportunity to visit the KUMS construction site, dinner with its 16 prospective faculty members and tour of all affiliated hospitals. Though I did not get a chance to visit any other medical school, except TU and KU, I got an impression from physicians working in other medical schools that besides TU and Dharan Medical Colleges (both state owned), other medical colleges of Nepal are running in a poor state and the medical council has questioned about their quality. In the current setting of growth of private medical schools in Nepal, the concept of a different medical school by a non-profit academic institution, with stress on quality education and center of excellence seems to be plausible. This appears to be an arduous task but not impossible. 

In conclusion, I am impressed in the way Kathmandu University has developed in less than a decade and has established its position as a leading university of Nepal. They have done quite a bit of background work for opening its medical school and there is no doubt that it is going to be a leading one too! But being a non-governmental, non-profit and community supported school, they are seeking for external support. I think it is the right time and opportunity for all of us to show our support.

Figure 1: Placement of the electrosurgical loop electrode around the uterine cervix at the level of the isthmus. A new electrosurgical loop technique for laparoscopic supracervical hysterectomy - Dequesne, Schmidt 

Figure 2: The uterus is held by the round ligament stump, clear of adjacent structures. Lateral traction on the loop while applying monopolar current cuts the cervix. A new electrosurgical loop technique for laparoscopic supracervial hysterectomy - Dequesne, Schmidt

Figure 3: View of the cervical stump while displacing the uterine corpus A new electrosurgical loop technique for laparoscopic supracervical hysterectomy - Dequesne, Schmidt.