Tamer Seckin: I am Dr. Tamer Seckin. We are in Osaka, Japan ISGE 2007 Annual Meeting. I have a guest who everybody is familiar with, Professor Togas Tulandi. Today he is going to talk about myomectomies. He has a recent article in The New England Journal of Medicine. The name of the article is “Is Myomectomy Obsolete?” Togas, nice having you here today.
Togas Tulandi: Thank you sir. The title is Treatment of Uterine Fibroids, “Is Myomectomy Obsolete?”
Tamer Seckin: How did you get to this title?
Professor Togas Tulandi: There was a paper in New England actually there was a paper that was about to be published. So, the editor of New England Journal asked me to write an editorial on the same subject, so I thought because they were pushing embolization, I thought this was a good chance for us to talk about treatment of uterine fibroids whether myomectomy is obsolete.
Tamer Seckin: All right, I am asking you the question again “Is Myomectomy Obsolete?”
Togas Tulandi: It is not. Uterine-artery embolization is an alternative option to hysterectomy. For myomectomy, myomectomy is still a good surgery, for young females with symptomatic fibroids and who would like to have a baby in the future. The reason is uterine-artery embolization is associated with increased premature labor, increased miscarriages, and maybe increase in postpartum bleeding due to placenta accrete. So, women who are to conceive should be offered myomectomy rather than uterine-artery embolization.
Tamer Seckin: And how about new technologies coming up with respect to high frequency ultrasound treatment of fibroids.
Togas Tulandi: The focused ultrasound is still brand new. There was one side effect of skin burn; however, the procedure itself is brand new. So, we do not know how good it is especially for women who wants to conceive.
Tamer Seckin: Since as an endosurgeon and myomectomy specialist, would you like to give some experience, opinions about the techniques that you perform for laparoscopic myomectomy, stitching, amount of trocar you use and in specimen removal.
Togas Tulandi: I do three punctures for any surgery, in the umbilical and two lateral secondary trocar’s, for any surgery including myomectomy. The criteria for myomectomy should be – depends on the surgeons’ experience and preference. I think most people will take criteria of myoma of more than 5 cm with a total number three, depends on surgeon. This is not surgery for everybody. Laparoscopic myomectomy should be done by surgeons who know how to do laparoscopic surgery. They have to do it like they do it by laparotomy, otherwise it might end up with uterine rupture. So, suturing by laparoscopy is an expertise that it is needed by a surgeon before they do laparoscopic myomectomy.
Tamer Seckin: How about bleeding control, are you a pitocin favorite person or do you use other techniques for it?
Togas Tulandi: No, I use vasopressin routinely, very dilute 1 in 20.
Tamer Seckin: Any complications with it?
Togas Tulandi: We had one brachycardia, which we published a while back, but that is about it. But every time you inject vasopressin you should inform the anesthesiologist.
Tamer Seckin: And your preference for specimen removal; multiple, single, size, morcellator versus colpotomy or laparoscopic assistance, minilaparotomy.
Togas Tulandi: I do everything using morcellator and I use a 2 cm morcellator from right secondary trocar. Colpotomy depends on the size of the fibroid. It would be very difficult and you might have to morcellate a large specimen anyway.
Tamer Seckin: How about fibroids that are very calcified.
Togas Tulandi: Very calcified fibroids, you need a good motor whereas I am using electric morcellator and the morcellator is very sharp.
Tamer Seckin: And how about necrosed and degenerated, liquefied fibroids.
Togas Tulandi: Well it is easier certainly to morcellate, it is softer.
Tamer Seckin: Coming back to the previous question for a hysterectomy alternative, probably embolization is a good…
Togas Tulandi: Is a good alternative.
Tamer Seckin: Good and favorable alternative for many who does not want the surgery. For tuitive purposes only myomectomy has an irreplaceable place…
Togas Tulandi: At the moment I think myomectomy is still the best.
Tamer Seckin: And even it is multiple in good hands, myomectomy is a good procedure. I think there will be coming new, I saw that AAGL is doing a new study group giving their experience with myomectomy, pregnancies that have post myomectomy pregnancies. I think new material is going to be soon out there.
Togas Tulandi: Maybe I should mention that laparoscopic hysterectomy versus embolization, if you do embolization, 10% of patients will comeback and they might bleed again, they might have pain again, and they do require further treatment such as hysterectomy. If you do hysterectomy, that is the end of it. The complications are different, complication of hysterectomy is postop complication that we expect. Complication of myomectomy could be bleeding again, pain again, and that is latent. So it is different complications. We expect the complication due to surgery for embolization 10% of patients will comeback. So that is the difference.
Tamer Seckin: Last question for young endosurgeons from all over the world who we aim to have members in the future and who are already, I would like you to give your advice how to improve your skills with respect to the future endosurgeons and their endosurgery career. From the myomectomy aspect, you already said suturing, but there is a prolonged learning curve, myomectomy is probably the most if not difficult, technically difficult procedure in endoscopic surgery, tell them to cut their learning curve, how can they do safely.
Togas Tulandi: Laparoscopic suturing as you said is a most difficult technique to learn. So they have to start from maybe suturing ovarian cyst, start slowly, but also learn at home using this black box, learn how to suture. With time they will get better, and they will be comfortable, but not for everybody. Some people cannot learn suturing no matter how hard they try.
Tamer Seckin: Dr. Tulandi, thank you very much.
Togas Tulandi: Thank you Tamer.