Surgical Treatment For PCOS and New Possibilities for Anesthesia during Laparoscopic Procedures

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Dr. Hugo Verhoeven:  “My name is Hugo Verhoeven, I am a member of the Editorial Board of OBGYN.net, and I’m reporting from the 9th Annual Congress of the International Society for Gynecologic Endoscopy at the Gold Coast in Australia. It is my special honor to talk with Johan van der Wat from Johannesburg, South Africa, who is worldwide one of the leaders in the field of Endoscopy. His team produced the first test tube pregnancy in South Africa many, many years ago. I intend to discuss with Johan van der Wat two topics today, the first topic is the surgical treatment of polycystic ovary syndrome and the second topic will be : new possibilities in the field of anesthesia for laparoscopy. Johan, good afternoon and thank you for giving me the pleasure to interview you.”

Dr. Johan van der Wat:  “Thank you Hugo, we’ve been friends for a very long time and I think we’ve grown together in this specialty.”

Dr. Hugo Verhoeven:  “Our first topic is PCOS - you know that this is an interview not only for doctors but especially for patients. So let us shortly summarize what the meaning of “Polycystic Ovarian Syndrome” is. What is that?”

Dr. Johan van der Wat:  “Polycystic ovarian disease or Stein-Leventhal disease, there are many other names attached to this syndrome. This is a condition whereby a woman secretes male hormones in a higher concentration than the average female population and this male hormone might have an effect on them. Some will grow beards, some will get more obese, some will develop acne but most of them will not see their periods, they will be infertile. They will not have periods at all and a combination of all these symptoms and signs will make your doctor realize that you have this disease and then you will have to go for biochemical tests. A very important one is your testosterone level, that’s your male hormone level. If that is elevated, you have certain management approaches. One should probably attempt at first a hormonal approach, that’s to treat you with hormones, and it will be basically to stimulate ovulation. Now often that’s very expensive and where I come from, South Africa, that is an option for say the more affluent people or people who have access to medical care or insurance but often we cannot stay on that route very long and we have to revert to surgical correction of this disease.”

Dr. Hugo Verhoeven:  “Talking now about the surgical approach of polycystic ovaries, what possibilities do you have and what is your preferred option?”

Dr. Johan van der Wat:  “The surgical option has been around since the thirties when some surgeons realized that by cutting out a piece of the ovary, women will ovulate but those women will not necessarily fall pregnant because of adhesion formation. Then with the development of endoscopy, and that is looking through your belly button with a scope, certain techniques were designed whereby the area that produces the offending hormone, that is the male hormone, which lies inside the surface of the ovary and more towards the middle, if one can approach this area and burn that area out, one would then correct the production of this hormone and revert the patient’s hormonal status to normal. Now we’ve designed a technique whereby we approach the ovary from its top point and drill a hole into the center of the ovary and burn out the offending area. There have been different techniques described where this area which produces the hormone is approached from different holes drilled from different angles from the surface of the ovary so your ovary will eventually look like a golf ball punctured with little holes. We don’t like this technique very much because it also forms adhesions, and adhesions means that you will not be able to ovulate because your ovaries are covered in a silky like material which prevents the eggs from coming out and you’ll also destroy a lot of eggs by punching holes all around the ovary. Now the single puncture technique we’ve been doing since 1988 is a very good technique. It gives the same hormonal response that you’ll get with surgery or the multi-puncture technique and you don’t damage the surface of the ovary.”

Dr. Hugo Verhoeven:  “You’re doing this since 1988, that’s twelve years, you must have a large follow-up. Many of your patients started ovulating spontaneously after the procedure, what was your pregnancy rate without giving additional ovulation induction?”

Dr. Johan van der Wat:  “Hugo, yes, that’s a very interesting question. Now if you look at the literature and we compare wedge resection, multi-puncture and single-puncture, you will find that the hormonal response is the same. What actually happens is that testosterone gets out of your body very quickly and within twenty-four hours the levels go very low, and most women will have their first egg produced within the first month. There are variable responses, a lot of women will fall pregnant within a year and I would say it’s approaching about 30%-50%. If there are no additional infertility factors, the pure cases where the testosterone level was the only factor, the chances are very high. But 50 % of the patients will not get pregnant, despite the fact that their hormone levels are low. These women will need further therapy and we would push for further therapy quite early because we know that a percentage of women will revert back to higher testosterone levels, the ovary would recover from the surgical correction and will then start producing more hormones. I have a series of women that got the surgery, fell pregnant, got high levels again, got re-operated, and had a second child. So the women have to be monitored, a large percentage of them will fall pregnant either by themselves or by further therapy and then some ladies will have to have a repeat operation. The benefit of this repeat operation is that it’s not a major operation, it’s an easy procedure. You come in, you have your procedure, and you can walk out the same day and probably within a month you’ll have your periods back and you may be pregnant. There are better technologies developed now, one specifically is the Versapoint. It’s a needle, which we’re going to introduce into our surgical treatment, which will burn the center of the ovary very precise. We’ve done one case, I think it’s the first one in the world; we did it about a week ago. Within the next year or two we’ll have this development perfected and will be able to report about the results.”

Dr. Hugo Verhoeven:  “So that is the future. Many centers in the United Stated are starting with medical treatment for PCOS, in Europe we already do this since many years. We’re treating the PCOS patients with a medicament called metformin, which is an antidiabetic medicament. Do you have any experience with that medication, and what’s your opinion on that?”

Dr. Johan van der Wat:  “I personally haven’t used that drug yet, I think it has a great future. As new drugs come out, the cost and the benefits will always have to be weighed against the surgical approach or other drugs. I think within the next few years we’ll have the answer, and I personally think that a drug therapy for PCO would probably be the best therapy ultimately.”

Dr. Hugo Verhoeven:  “At the beginning of our talk you said you come from South Africa, there are a lot of people who cannot afford hormonal treatment and laparoscopy is also an expensive procedure. That means you will do everything to reduce the cost of the laparoscopy and especially in the field of anesthesia. If you’re putting a needle into the ovary of a patient, that must hurt. So let’s talk a little bit about the alternatives to general anesthesia, how are you working in South Africa?”

Dr. Johan van der Wat:  “In South Africa we have very special circumstances. Let me just illustrate a classical case scenario : a patient is coming to our center from far away, somewhere in the North of South Africa, she only has one chance. They bring all their life savings to try to have a baby, so you cannot take them through consecutive cycles of ovulation induction with any agent because they cannot stay for that period of time. In addition, they cannot afford the drugs so we would go for the one shot treatment for polycystic ovarian disease which is the needle puncture and coagulation of the ovarian medulla. Now as far as anesthetic is concerned, we’re doing a lot of work to see how we can minimize the cost but you must remember that your aim is that the patient is comfortable and the doctor must be comfortable. That means, the patient must be fully relaxed and cooperative, and the doctor shouldn’t struggle against an uncooperative patient or one that has pain and anxiety, it just complicates the whole procedure. For this specific disease, I think that with ovarian cautery you still need general anesthesia because the ovary is a sensitive organ. I haven’t done any cases under local anesthesia. It’s a very precise technique, the patient has to lie completely still otherwise you’re working with instruments that can actually destroy or burn other organs and make holes in where you don’t want this, so we want a completely relaxed, quiet patient. So I would not recommend this operation to be done under local but there are lots of operations that can be done under local or regional. I think the most important determining fact is the skill of your anesthesiologist. You need a long working relationship with this person, you have to trust him, you have to know his capabilities, and the team effort here should be completely optimized. My anesthesiologist has been working for me for twenty years, we discuss every patient, and we have now identified certain surgical procedures, that can be performed without general anesthesia. We will give general anesthesia only if we have a special indication for it. Otherwise, we do a regional anesthesia, called epidural block. We can also do a spinal block. The third procedure, which we use a lot now for all our endometrial ablations, and that means we destroy the inside of the uterus in woman that bleed too much, is a combination of an epidural and a spinal. That means we give local anesthetic in the back, and we give an opioid - that’s an opium like drug - in the spinal fluid. The benefit of this is that your bladder doesn’t get paralyzed and your legs don’t get paralyzed. We will take your pain away, then we will do the procedure, you will go to the recovery room, and two hours later you will walk out of the hospital. You will not be groggy, you will not be nauseous, and you would actually have had the luxury of watching your own operation being performed on television.”

Dr. Hugo Verhoeven:  “Is that kind of anesthesia really cheaper as a general anesthetic?”

Dr. Johan van der Wat:  “Yes, in our hands it’s cheaper. We use less drugs and gasses, and we don’t have to charge for any of the machines and equipment. There’s no induction agent, which is the drug that makes you sleep initially before the rest of the gas agents are applied. So all of that is cut out, we probably reduce our cost in some instances up to two-thirds.”

Dr. Hugo Verhoeven:  “So for all diagnostic procedures you do not need general anesthesia or conscious sedation, and for minimal operative procedures like, for instance, adhesiolysis you don’t need it either. It’s only for more invasive surgery that you would go to general anesthesia.”

Dr. Johan van der Wat: “Yes, that is correct.”

Dr. Hugo Verhoeven: “Johan, what is your vision for the future? ” 

Dr.Johan van der Wat: “My vision for the future on PCOS is that new drugs come out. You will have to wait and see what the efficacy is. New ovarian cautery techniques will be developed. They will allow a very quick procedure within an hour. As far as anesthetics are concerned, we are developing new techniques and I would like to add another very important factor which I didn’t mention earlier and that is the ambulatory epidural. This technique has been described only in 1994 after the development of the so called “laryngeal mask”. When you get paralyzed and have to breathe under anesthesia, it is necessary to put a pipe down your throat into your lungs, and that can cause injury, nausea, vomiting, and pain for many days after the procedure. Now they’ve developed a balloon-like tube, which they just put into your throat and they blow the balloon up and you can breathe through that. Now that technique is gaining rapid grown and in the future, I would say in the next five years, about 80% of laparoscopic procedures where deeper anesthesia is required will be done by the laryngeal mask. It’s also a cheaper instrument and it is maintaining the airway and it’s optimal so I think we will see all these new techniques coming through. There will also many new drugs coming out especially inhalational agents. As far as regional anesthesia is concerned, I think the combination of opium-like drugs or opioids and non-steroid anti-inflammatory drugs will make endoscopy a very safe and painless technique. I am really looking forward to the future because in the past we were basically using archaic drugs but there’s a rapid development, so that there will be no reason anymore for being afraid of endoscopic surgery.”

Dr. Hugo Verhoeven: “Thank you very much, Johan.”