By Helen K. Kelley
Atlanta Medicine recently spoke with some Atlanta-area gynecologists to learn about new effective surgical techniques, comparisons of surgeries in terms of costs and advantages, and how conversations about family planning and contraception choices are reducing the number of unintended pregnancies among their patients.
New tissue removal techniques for hysterectomy
Algernon O. Steele, a board-certified gynecologist with Southeast Permanente Medical Group, says that new techniques for removing tissue have allowed a return to minimally invasive surgery for hysterectomies.
“One of the problems we had in the progression of minimally invasive gynecological surgery was the ability to remove larger uteruses and fibroid tumors from the body,” he says. “This tissue removal was greatly facilitated by the use of a power tissue morcellator, which allowed us to cut the tissue into smaller pieces that could then be removed through a small laparoscopic incision. However, in the last three years, the FDA discouraged its use for uterine procedures, issuing a warning that morcellators may spread occult cancer in the course of surgery. As a result, some hospitals chose to completely ban the device.”
With the morcellator out of commission for gynecological use, what would have been laparoscopic hysterectomies in some cases became total abdominal hysterectomies. The abdominal surgeries included longer recovery times, larger blood loss and higher morbidity rates.
Steele says that new tissue removal techniques have allowed gynecologists to return to performing minimally invasive hysterectomies.
“We can now use tissue containment bags that can be used through a small incision to manually remove a larger uterus or fibroid in a contained way,” he says. “We put the specimen in the bag, use a scalpel to cut it into smaller pieces and remove them through the incision.”
Newer devices are being developed that will allow power morcellation to take place within a bag. Steele adds that the banning of the tissue morcellator is still a controversial topic.
“For women under age 50, the known risk of spreading cancer by using a morcellator is very low,” he says. “However, the data is still being collected. And if it happens to even one person, there are people who would say that is one too many.”
Comparative study of vaginal, abdominal and robotic laparoscopic hysterectomy
During a presentation at the 65th annual meeting of the American College of Gynecology in May, Magdi Hanafi, M.D., a board-certified gynecologist with Gyn & Fertility Specialists, spoke about a comparative study he conducted among vaginal, abdominal and robotic laparoscopic hysterectomies. The study, which included 122 patients with symptomatic leiomyomata at Saint Joseph’s Hospital of Atlanta (now Emory Saint Joseph’s Hospital) took place from February 2007 to June 2009. Participants underwent either robotic-assisted laparoscopic myomectomy or abdominal myomectomy.
The study compared short-term surgical outcomes of robotic and abdominal myomectomy and analyzed the factors affecting the short-term outcomes. The variables investigated included the type of surgery, age, body mass index, gravity, parity, number of leiomyomata, diameter of largest tumor size, total operative time, estimated blood loss and length of hospital stay.
“The study found there were no significant differences between the two groups regarding age, gravity and parity. However, BMI, numbers of leiomyomata and tumor sizes were significantly higher in abdominal myomectomy compared with robotic-assisted laparoscopic myomectomy,” Hanafi says. “While the total operative time was significantly longer in robotic-assisted laparoscopic myomectomy compared with abdominal myomectomy, estimated blood loss and length of hospital stay were significantly lower. We concluded that blood loss, post-operative pain, length of hospital stay and cost were significantly higher for abdominal hysterectomy versus all other methods.”
Hanafi adds that robotic surgery has many advantages for both patient and surgeon.
“First, robotic surgery has reduced the number of open surgeries. We have improved visibility and are able to do more precise work as surgeons,” he says. “This results in an improved quality of post-operative care and better outcomes for patients.”
Long-acting contraceptive methods, family planning
Long-acting reversible contraceptives (LARC) – methods of birth control that provide effective contraception for an extended period without requiring user action – include intrauterine devices (IUDs) and subdermal contraceptive implants. According to Fonda Mitchell, M.D., a gynecologist with Southeast Permanente Medical Group and clinical assistant professor at the department of obstetrics and gynecology for the GRU/UGA partnership at Medical College of Georgia, LARC have made a significant impact toward decreasing the number of teenage and unintended pregnancies.
“Intrauterine devices and subdermal implants have minimal side effects, can be placed in the physician’s office and can provide good contraception for three to five years,” she says. “These methods have proved very successful for our younger patients who want a reliable form of contraception that they don’t have to think about daily or for those who may not necessarily be compliant with taking medication.”
Mitchell adds that opening up a dialogue with patients provides an opportunity to educate them and help them make an informed decision about contraception and even their future.
“In our practice, most of our conversations with reproductive-age women now center around the question, ‘Are your plans to conceive this year or not to conceive this year?’” she says. “We talk about options for contraception and their ability to actively participate in family-planning goals. And we tell them [that] if their desire is to complete high school and/or college, we can offer them a contraceptive that will allow them to focus on their future. When a young woman has that conversation with her clinician, she has the opportunity to learn about all of the alternatives available to her to help ensure she achieves her goals.”
Fellowships in family planning are now available in obstetrics and gynecology programs at many medical schools around the country. Mitchell says that the additional two years of study allows residents to hone their knowledge of family-planning alternatives.
“As the millennials are completing residency training, they’re telling us that they are enhancing their fund of knowledge in the family planning arena,” she says. “They are learning more about how to counsel patients, as well as how to identify good candidates for various forms of contraception. And they are running clinics in areas that have a high-risk population for unintended pregnancy.”
Conflicting advice regarding pelvic exams
Two physician associations have released differing opinions when it comes to annual pelvic exams for women.
The American College of Obstetricians and Gynecologists (ACOG) recommends an annual pelvic examination for women age 21 and older as “a fundamental part of medical care,” and that it is “valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems and establishing the clinician–patient relationship.” The exam is recommended regardless of whether the woman shows any symptoms of disease or not.
Meanwhile, the American College of Physicians (ACP) recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women. The ACP cites harms, including overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain and discomfort as the reasons for its recommendation.
A recent study published in the American Journal of Obstetrics & Gynecology found that when women were informed that one prominent medical association recommended against the yearly exam, it substantially reduced their desire to have one.