Experts gathered at a recent conference to discuss the latest minimally invasive techniques and to promote their uptake into gynecologic practice
Conference: 36th Annual Global Congress of Minimally Invasive Gynecology
Location: Washington, DC, USA
Date: November 13–17, 2007
Experts at the 36th Annual Global Congress of Minimally Invasive Gynecology have highlighted some of the exciting new developments set to transform gynecologic practice and stressed the need for women to become empowered to ask for these procedures.
“Historically the American Association of Gynecologic Laparoscopists (AAGL) has been devoted to introducing and testing new surgical techniques and educating surgeons how to perform endoscopic and laparoscopic procedures,” said Charles E Miller, MD, President Elect of the AAGL. “Today we are broadening our mission to include education and empowerment of our patients.”
Despite the advantages of minimally invasive techniques, their adoption in gynecology lags far behind that of other specialties. For example, while laparoscopic surgery for gall bladder removal reached an 80% rate of adoption in the 10 years after its introduction, laparoscopic hysterectomy is still only used for less than 15% of hysterectomies in the USA.
At the congress, Keith Isaacson, from Harvard Medical School, highlighted new in-office procedures; hysteroscopy, endometrial ablation and tubal occlusion; that can now be performed safely, effectively and without anesthesia in the gynecologist’s office. This approach has the advantage not only of health cost savings, but also reduced trauma and anxiety for patients. “When you reduce the stress level with any procedure, you have a better outcome,” said Dr Isaacson.
Javier F Magrina, MD, of the Mayo Clinic at Scottsdale (AZ, USA) described the advances in robotics for minimally invasive gynecologic procedures and emphasized the increased precision and control these techniques provide. “For the first time, the surgeon can sit comfortably at a console, become immersed in the patient via a 3D image, and control the most minute and complex operations using robotic arms,” he explained. “In the future, the patient will be next to you in the room or thousands of miles away. All this is possible because of robotic-assisted laparoscopy.” The advantages to the patient may include less bleeding and tissue trauma, less damage to adjacent organs and faster recovery with less pain.
Marie Fidela-Paraiso, MD, from the Cleveland Clinic (OH, USA) described the way miniaturization is transforming treatments for pelvic organ prolapse and stress urinary incontinence (SUI).
“Just as tension-free vaginal tape revolutionized the treatment of SUI in the mid-1990s, the new mini-sling is a major treatment advance today, requiring only one tiny incision in place of three. With a 90% success rate, this procedure is comparable to earlier ‘gold standard’ methods,” she said. “The reduction in time and trauma means that the mini-sling procedure may soon move into the physician’s office. Like the prolapse repair kits, these miniaturized devices are helping more doctors transition to the use of newer procedures, improving patient care and the quality of life for more women,” added Fidela-Paraiso.
However, despite the availability of these new techniques, the majority of women are not benefiting. For example, many of the 600,000 hysterectomies performed annually in the USA might be avoidable if minimally invasive techniques were used earlier to treat fibroids, abnormal uterine bleeding and other common conditions. Furthermore, many hysterectomies may remove more than is necessary and healthy. “Half of all hysterectomies remove the ovaries, even when there is no cancer involved. We now know that after menopause, the ovaries continue to secrete hormones that help keep bones strong and hearts healthy,” said William Parker, MD, of UCLA School of Medicine (CA, USA).
The limited uptake of minimally invasive procedures so far may be due to lack of patient education, lack of physician training, reimbursement issues and women being reluctant to question their doctors.
“Women’s treatment choices should always include minimally invasive options,” stressed Parker. “Women should not be afraid to ask for what they want or hesitate to pursue a second opinion.”
Source: American Association of Gynecologic Laparoscopists. www.aagl.org
Supracervical hysterectomy not superior to total hysterectomy
Report finds supracervical hysterectomy may not have benefits in terms of postsurgical outcomes
Supracervical hysterectomy, which removes the uterus while leaving the cervix intact, is not superior to total hysterectomy in women without cancer, according to a new Committee Opinion released by the American College of Obstetricians and Gynecologists (ACOG).
According to the report, current research does not show a clear benefit of supracervical hysterectomy in terms of postsurgical outcomes and should not be recommended as a superior technique. Furthermore, studies to date have shown that supracervical hysterectomy may increase the risk of future problems with the retained cervix that may lead to further surgery being required.
Techniques such as laparoscopic vaginal and supracervical hysterectomy are sometimes offered as an alternative to total abdominal hysterectomy. However, the Committee Opinion claims that research has not shown an advantage of the supracervical technique in terms of postoperative outcomes such as urinary incontinence, quality and frequency of sex, sexual desire, and body image.
“There has been renewed interest in supracervical hysterectomy as a way to reduce operative complications and reduce the effects of hysterectomy on urinary and sexual function. Unfortunately, these possible benefits are not supported by recent evidence,” said Denise J Jamieson, MD, chair of ACOG’s Committee on Gynecologic Practice.
“Since laparoscopic hysterectomy techniques have not been carefully evaluated in randomized trials, it is unclear how preserving the cervix with laparoscopic techniques might compare in terms of risks and benefits,” Jamieson added.
Source: ACOG Committee Opinion No. 388: supracervical hysterectomy. Obstet. Gynecol 110(5), 1215–1217 (2007).
Meta-analysis finds adverse effects of antenatal indomethacin
Drug should be used with caution for tocolytic indications
Researchers at the University of Rochester (NY, USA) have performed a meta-analysis to determine whether indomethacin used as a tocolytic agent is associated with adverse neonatal outcomes.
The study analyzed the results of 15 retrospective cohort studies and six case-control studies published between 1966 and 2005. Antenatal indomethacin was associated with an increased risk of periventricular leukomalacia, an ischemic brain injury that can occur when decreased blood flow affects the white matter bordering the lateral ventricles of the developing brain. Recent exposure to indomethacin was also associated with necrotizing enterocolitis, a condition in which the intestinal tissue is damaged that can require surgery and may lead to death.
“As pediatricians and neonatologists, it’s important for us to know whether the benefit of these drugs outweighs the potential for complications for these medically fragile children,” said lead author Sanjiv Amin, MD, Assistant Professor of Pediatrics at the University of Rochester Medical Center. “In the case of the tocolytic agent indomethacin, we know it impacts blood flow but there have been no large randomized studies to evaluate the effects on the baby.”
Coauthor Christopher Glantz, MD, MPH, Professor of Obstetrics and Gynecology at the University of Rochester Medical Center, said he hoped that the findings would prompt obstetricians to exercise caution when prescribing the drug and only use it for women experiencing very preterm labor.
“It’s important for us to realize that these drugs are not benign,” he said. “None of the drugs we have to stop labor work all that well, and we’re stuck between a rock – a premature baby who could benefit from more time in the womb – and a hard place – a baby who may develop problems because of drugs such as indomethacin that may provide extra time in the womb. We need to use the drug only on those who need it most.”
Source: Amin SB, Sinkin RA, Glantz JC. Metaanalysis of the effect of antenatal indomethacin on neonatal outcomes. Am. J. Obstet. Gynecol. 197(5), 486 e1–e10 (2007).
Down syndrome markers obscured by smoking
Smoking could change levels of markers and lead to misleading screening results
New research has shown a link between smoking and first-trimester markers of Down syndrome that may lead to misleading results of Down syndrome screening.
Researchers from Saudia Arabia recruited 2337 fit and healthy women, pregnant for the first time with a singleton pregnancy, from primary care centers and antenatal clinics and asked them about their smoking habits. The women were classified as nonsmokers (n = 1736), cigarette smokers (n = 420) or sheesha smokers (n = 181). Women were classified as smokers if they smoked one or more cigarettes or sheeshas a day, and this was confirmed by measuring maternal serum cotinine levels. This is the first study to investigate the effect of sheesha smoking on pregnant women.
At a gestational age of 11 weeks 0 days to 13 weeks 6 days, all women were tested for fetal nuchal translucency thickness (fetal NT), maternal serum free-β human chorionic gonadotropin (free β-HCG) and pregnancy-associated plasma protein- A (PAPP-A), all tests for Down syndrome.
The women who smoked were found to have significantly higher serum cotinine levels. This was particularly true in those who smoked sheesha pipes, owing to the higher tobacco content in a sheesha.
Smokers had significantly higher levels of fetal NT than nonsmokers, and significantly lower levels of free β-HCG and PAPP-A.
These changes could be caused by the damaging effects of smoking on the placenta, although it should be borne in mind that genetic and nutritional factors could also affect the results.
The researchers concluded that these changes in the fetal NT, free β-HCG and PAPP-A could lead to misleading results of first-trimester Down syndrome screening in pregnant women who smoke. As a result, screening could be less effective in this group. Correction for this effect in women who smoke could improve the accuracy of screening to the level in nonsmokers.
Professor Philip Steer, Editor in Chief of the British Journal of Obstetrics and Gynaecology said, “The effects of smoking during pregnancy are well documented. Babies of mothers who smoke during pregnancy are small for gestational age and tend also to deliver earlier. This research indicates that smoking may also cause overestimation of the risk of Down syndrome, thus exposing the mother to a higher risk of an unnecessary amniocentesis.”
Source: Ardawi MS, Nasrat HA, Rouzi AA, Qari MH, Al-Qahtani MH, Abuzenadah AM. The effect of cigarette or sheesha smoking on first-trimester markers of Down syndrome. Br. J. Obstet. Gynaecol. 114(11), 1397–1401 (2007).
Project to monitor early impact of HPV vaccine
A new project under the Connecticut Emerging Infections program will look at diagnoses since the introduction of the human papillomavirus vaccine
Virus: Human papillomavirus
Tradename: Gardasil®
Manufacturer: Merck & Co., Inc. (NJ, USA)
Yale School of Public Health, in association with the Connecticut Department of Public Health, is to monitor the early impact of the human papillomavirus (HPV) vaccine. HPV infection is the most common sexually transmitted infection in the USA. Infection with the virus can lead to the formation of precancerous cervical intraepithelial neoplasia (CIN) 2/3 lesions and, ultimately, cervical cancer.
The vaccine Gardasil™ received US FDA approval in June 2006 and is currently licensed for 9–26 year-old females to prevent HPV-related cervical cancer; cervical, vaginal and vulvar cancer precursors; and anogenital warts. The vaccine is also approved for use in Canada, Mexico, Brazil, Australia, New Zealand, Malaysia, Serbia, Croatia, Israel and the EU. Gardasil targets the HPV strains 16 and 18, which are thought to cause 70% of cervical cancers, as well as HPV 6 and 11, which cause 90% of genital warts.
In order to monitor the early impact of the vaccine, the Yale office of the Connecticut Emerging Infections Program will analyze information on new CIN2/3 diagnoses in women in New Haven County (CT, USA), using data obtained from pathology laboratories and healthcare providers.
The aim will be to determine whether there has been an increase in new CIN 2/3 diagnoses since the introduction of the vaccine.
“We expect to see the greatest impact among young women, but over time we also expect to see effects for women over 26 who were vaccinated at a younger age,” said Linda Niccolai, Assistant Professor and director of the project under the Emerging Infections Program. “Also, there will presumably be less transmission to male partners, who can reinfect their partners.”
Niccolai noted that a positive result may lead to the vaccine being made available more widely. “Perhaps structural and financial policy changes also will be made to increase accessibility for those who want the vaccine,” she said.
James Meek, Associate Director of the Emerging Infections Program, explained that another goal will be to watch for changes in the HPV strain responsible for the precancerous lesions.
“As vaccine use increases, we expect to see a decrease in the occurrence of lesions caused by HPV strains 16 or 18,” he said. “It will be important to know if other less common cancer-causing strains of HPV, such as HPV33 or HPV45, become more common.”
The project is supported by the US CDC (GA, USA), which currently reports 9710 new cervical cancer cases each year in the USA, leading to approximately 3700 deaths.
Source: Yale University. www.yale.edu
Survey reports ob–gyns’ practice patterns regarding HIV screening
Many ob–gyns found to be unclear on HIV screening recommendations
Almost all obstetrician–gynecologists (ob–gyns) in the USA recommend HIV testing to their pregnant patients, although some are unclear on their state’s requirements for recommending such testing, according to a study published in the November issue of Obstetrics and Gynecology.
Dr Jay Schulkin and colleagues from the Practice Activities Division of the American College of Obstetricians and Gynecologists (ACOG) in Washington (DC, USA) conducted a survey of ACOG Fellows and Junior Fellows in practice. The survey questionnaires included information on ob–gyn characteristics, testing practices and knowledge about HIV screening.
A total of 582 questionnaires were returned. Approximately 97% of ob–gyns reported that they recommend HIV testing to all their pregnant patients; 52% reported using an opt-in approach to testing, while 48% reported using an opt-out strategy.
The majority of ob-gyns reported providing counseling prior to HIV testing (73.9%), while 84.6% reported that they provide post-test counseling.
Almost a third of ob–gyns reported that they are unaware of whether their state recommends HIV testing during pregnancy. This led the researchers to suggest the importance of having increased awareness of, and timely access to, state laws and regulations regarding HIV testing, in order to strengthen perinatal HIV testing practice patterns.
“The results of this study suggest that obstetrician–gynecologists may benefit from additional information that could improve their knowledge and practice regarding HIV screening,” the authors write. “Although most respondents report being at least moderately knowledgeable about HIV during pregnancy and report recommending HIV testing to all pregnant patients, they may need to be more aggressive in following up with patients who decline HIV testing.”
Source: Gray AD, Carlson R, Morgan MA, Hawks D, Schulkin J. Obstetrician gynecologists’ knowledge and practice regarding human immunodeficiency virus screening. Obstet. Gynecol. 110(5), 1019–1926 (2007).