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Michael C. East:  In an excellent talk of 16^th Annual Congress of the International Gynecological Endoscopy Society summarizing developments of hysterectomy up to the present day starting with the very first hysterectomy performed where the patient survived.

 

I have two questions for you and the first question relates to complication of vaginal hysterectomy, in particular, vault hematoma.  I would put the proposition to you that sometime in the future, probably in United States a gynecologist will be successfully prosecuted for performing a vaginal hysterectomy and not inspecting the pelvis laparoscopically afterwards.  Do you think this is a credible possibility?

 

Peter J. Maher:  Thanks, Michael.  I truly believe that that will be the situation and I think that that might be the turning point in terms of the role of laparoscopy in hysterectomy.  As I mentioned in my talk, it has been fairly disappointing since 1990 when we performed the first hysterectomy in Australia, laparoscopic hysterectomy, it has been fairly disappointing the procedure.  I firmly believed that when we did this that within five years, I thought, the incidence of laparoscopic hysterectomy would be as high as 50%.  Well, 17 years down the track, it is only 20%, and that’s probably 20% which would include vaginal hysterectomy with a touch of laparoscopy up to total laparoscopic hysterectomy.  The majority of people who perform LAVH really put the laparoscope in, may be tinker a little bit with the top of the broad ligament and then get into the vaginal hysterectomy.

 

Carl Wood and I in 1998 published a paper reviewing 50 patients that were actually studied prospectively and we performed vaginal hysterectomy on all of these patients, and then put the laparoscope in at the end of the procedure.  And to our surprise, 48% of the patients, 24 of the 50 patients, had bleeding.  In fact, 12 of the other patients had what we would consider significant bleeding, and of course, we were able to deal with that laparoscopically and the patients, of course, progressed very well.  With regard to the future after that particular study, I always put the laparoscope in at the commencement of the operation and then I look at the pelvis at the end of the operation if I am doing vaginal hysterectomy.  I think that there is no doubt that the incidence of pelvic hematoma is much higher than we believe.  Again, as I quoted, there have been ultrasound studies, in fact, they was one published in the early 80s or the late 80s in Australia on ultrasound examination of the pelvis at the end of vaginal hysterectomy and 90% of the patients had a collection.  It is difficult to say how many of those collections would become infected and would, in fact, result in an increased morbidity.

 

But, I think that having published that paper and combined with the ultrasound papers that have been published on this topic, I think that there is a very, very strong medicolegal argument to encourage people to do laparoscopy combined with vaginal hysterectomy because if in fact you do or the patient does suffer a pelvic abscess, that’s just as I said it was considerable morbidity and I do not think that, sadly, patients today do not tolerate any morbidity in reality, and I think that your comment about that happening in United States, would not surprise me if it happened in Australia.  Patients do not tolerate complications very well though and, in fact, I think as a practitioner of nearly 30 years experience, I am far more wary of patients if they have the slightest complication, and you are almost apologetic whereas we know in reality that surgery almost has built-in complications.  I mean you can’t afford to say that a surgery doesn’t have any complications, because no matter how hard you try and you look through the literature, you will always see, for example, ureter damages one in 200 cases.  It is fairly standard that if you do a hysterectomy, every one out of 200 have a chance of a lesion in the ureter.

 

So, I think that the time has come when you are really required to do everything in your power to improve the outcome of the surgery, and I think it is a good reason to contemplate viewing the pelvis at the end of the procedure to make sure.  And I think also the other positive thing about doing laparoscopy is that you can evaluate the pelvis before you start because it might not be appropriate for whatever reason endometriosis, pelvic infection, or whatever, or may be even ovarian pathology that hasn’t been detected.  Laparoscopy enables you to evaluate that situation and if you are a good vaginal surgeon, I think that it is probably better to go and do the vaginal hysterectomy, but then have a little look afterwards.  I think also as you and I were discussing earlier, it is really akin to doing cystoscopy at the end of hysterectomy.  I think that you would be negligent by today’s standards if you did not perform cystoscopy at the end of the hysterectomy.  And it is our standard routine even if we do abdominal hysterectomy, to do a cystoscopy at the end of the procedure.  In my own practice, that cystoscopy has saved the day on two occasions.  Now two doesn't sound like very many over a long period of time because we have been doing routine cystoscopies since 1993.  But, on two occasions, we have had an undetected kink in the ureter so that it was necessary at the time of cystoscopy to pass an uretral catheter and it was a matter of taking the sutures down and then resuturing it and we were able to pass the catheter.  So, what would have been a settlement probably near $500,000 for next 10 minutes would not only save myself a great deal of embarrassment but save the patient a great deal of inconvenience.  I hope I have answered your question here.

 

Michael C. East: Very well.  I would endorse that too.  Before I move onto the next question, I would just like to endorse what doctor said by underlining the fact that patients do tolerate complications if they are found at time and fixed immediately.  If they are missed and the outcome is a trip to ICU, then certainly they are intolerant.  Peter the next question I have got for you is fast forward really in time to 2050 and it really again runs on from your excellent talk you gave here which, by the way, is on the website and can be accessed.  Looking forward to 2050, do you think that abdominal hysterectomies will still be performed in any number and if they are going to reduce or disappear, how do you think that would come about and sort of the technologies that may be on the horizon to help them?

 

Peter J. Maher: Thanks again Michael.  I think that hysterectomy as an operation will become less and less common.  I think that improved drug technology, we have the Mirena now and that has had an actual impact on the incidence of hysterectomy.  It is interesting when I first started performing endometrial ablation in 1999 and I felt that that would have a very, very big impact on the hysterectomy rates.  It is probable that we have saved what I believe probably 7 out of 8 patients having an unnecessary hysterectomy using endometrial ablation.  But it is interesting that there was a publication in Australia probably about 10 years ago looking at the impact of endometrial ablation on the global hysterectomy rate and it had no impact at all. The same number of hysterectomies were being done. 

 

Another interesting fact is that in 1972, the incidence of hysterectomy in Australian population was about 40% of all women reaching menopause had a hysterectomy and today thats down to about 19%.  I think the reasons for that are multiple. I think that the majority of women these days prefer to explore other alternatives such as, for example, myomectomy in particular and conservative surgery for endometriosis.  I can remember that the operation that was recommended for endometriosis was hysterectomy and BSO and I still see patients today that have been to the local doctor and have been told to have a baby very quickly and then have a hysterectomy whereas we know because of our interest in endometriosis that you know you can, in fact, perform resection procedures and the patient can retain their uterus for a lot longer period.

 

I think that the other situation that is a little bit disconcerting to me as the father of two girls is that the training these days of young specialists is not what it used to be, and I think that patients or doctors, surgeons, gynecologists are more and more opting for conservative medical procedures because they haven’t had the exposure and thus they do not have the confidence to perform these difficult operations.  I think that gynecologists unless training is altered, any difficult case that come along will be referred from a general gynecologist to the oncologist and I think that even today we are seeing that in our hospital that whereas I was young and I had a difficult case, I would seek the advice from one of my senior consultants.  Whereas today the young people if they get into trouble they then seek my advice, which I would freely give, but they seek the oncologist’s advice because they think that they have the surgical expertise to do it.

 

I think that also in the future, the reason that laparoscopic hysterectomy has not taken on, is basically its difficult to learn.  Gynecologists are still performing obstetrics, and as a result of poor training, it does have an unacceptably high complication rate.  I think in the right hands laparoscopic hysterectomy is as safe as any other operation.  I think that what may happen in the future is that with the advent now of robotic surgery that there may be a place for people to be able to perform those procedures using the robot.  The problem with the robot is that it is extremely expensive and that was always one of the arguments against laparoscopic hysterectomy in its own right that it was too expensive.  It was published in 1993 in Australia by Hirsch in the Australian Institute of Health that in fact laparoscopic hysterectomy in Australia was cheaper than abdominal hysterectomy.  In those days it was costing about $2900 for laparoscopic hysterectomy and abdominal hysterectomy was $3500.  So laparoscopic hysterectomy in all its forms in Australia has never been a cost issue.  It has really been more complication issue.  It has been a time issue.  So it may happen I think in the future that gynecology per say is going to alter quite dramaticall.  I think that gynecologists will become more office based.  I think that the  pretenders of gynecology will part company at some stage and I think that there will be a specific group of surgical gynecologists.  It will be almost like the old general surgeon.  They did not know very much about medicine as such and sought the advice of a physician to make sure the patient was well enough and had no medical problems that he recognized by name only and he would send the patient to a physician and then he would operate   If he had any complications that were not surgical afterwards such as spiritual or whatever he would get the physician back there.  And I think that gynecology will become like that.  I think that there will be pure surgical gynecologists, there will be office-based gynecologist, and there will be menopausal gynecologists, et cetera.

 

So, I think in 50 years’ time that the hysterectomy rate will continue to fall.  I think that probably the laparoscopic hysterectomy rate at best will probably get to 25%.  I think that the majority of surgeries will be performed if necessary by vaginal hysterectomy because it is quite interesting in that when we started performing laparoscopic hysterectomy all those years ago, everybody suddenly became a vaginal hysterectomies and everybody started to say, “Oh!  but my patients go home in two days.”  Well I know from reviewing the Medicaid down here in Australia that the vaginal hysterectomy the patient’s are in hospital for 8.9 days this is back in 1992 and the abdominal patients are in hospital for 8.7 days.  So their in hospital for the same time and the reason for that of course is that the majority of vaginal hysterectomies are done if excessive prolapse would be.  And it is still certainly in our hospital most common for patients to have abdominal hysterectomy unless they have prolapse.  So I think that advances in medicine per say will see a drop in hysterectomy.  The lack of training matter I guess patients will result in people becoming less experts in the operation and therefore the incidence of hysterectomy in the general gynecological population will decrease.  There will be a small group of gynecological surgeons that do all the cases.

 

Michael C. East: Thank you Peter.  Just a reminder that Peter’s excellent talk is on the website.  Peter, thank you very much for talking to us today.  I’m signing off.