Medical Device Daily Contributing Writer

WASHINGTON — A change in name and an aggressive mission launched the 36th Global Congress of Minimally Invasive (MIS) Gynecology at the Marriott Wardman Park hotel here last week.

That mission was characterized by an outcry to push for the education of women concerning new MIS procedures for gynecology, thus encouraging them to pursue alternatives to traditional surgical methods in this sector.

"Minimally invasive therapeutic and diagnostic techniques offer women safer and often more effective alternatives to traditional procedures for many gynecologic conditions," said Charles Miller, MD, president of AAGL (Cyprus, California), formerly the American Association of Gynecologic Laparoscopists. While endoscopic procedures have been readily adopted by other surgical specialties such as orthopedics and general surgery, that has not been the case in gynecology.

Marking a first for this annual meeting, the AAGL held an opening press conference to encourage all media to get the message out to women that they need to advocate for their own well-being by pursuing these alternatives.

Charles Miller, MD, clinical associate professor at the University of Chicago, opened the press conference by saying that the organization "has morphed." He noted the name change to AAGL and said, "We used to teach hysteroscopy and laparoscopy, and now we teach all minimally invasive gynecologic procedures.

We are no longer just endoscopists, and we are no longer just Americans. There are 1,300 physicians of the 4,500 members here, and they are from 58 different countries."

Miller said the AAGL was using the annual meeting to launch a public relations initiative "to educate women in order to empower them to move their own medical care forward, as well as to encourage their physicians to learn the new less-invasive procedures that will benefit them."

He added: "In the same time period that 80% of open surgical cholecystectomies were converted to laparoscopic procedures, only 15% of hysterectomies were converted to laparoscopic procedures."

This, he said, demonstrated his point that the adoption of innovative gynecologic surgeries lags considerably behind other surgical sub-specialties, even though less invasive techniques were developed by gynecologists.

"The new AAGL as a society is committed to making this change" Miller said.

A large reason for technology lag in gynecology, according to a panel assembled for the press conference, is the lack of demand from patients.

Another reason for the technological lag which inhibits the growth in women's pelvic surgery is delays in reimbursement — although comparable urologic procedures for men get double the payment.

Oftentimes these newer procedures can be moved from the operating room (OR) into the office, making it easier and less stressful for the patient. And decreased stress levels have been clinically shown to improve outcomes. However, reimbursement for performing these procedures in an office setting did not exist until recently and so they were not financially feasible.

A prime example of this is intrafallopian tube sterilization.

Though cleared by the FDA in 2002, reimbursement for it was not in place until 2005. Since then, the growth in this procedure has surged because it offers women an important alternative to permanent sterilization that eliminates going into an OR and having small incisions made in their abdomen. But prior to the establishment of reimbursement for this procedure, the unpopular alternative was self-pay.

Keith Isaacson, MD, medical director of minimally invasive gynecological surgery at Newton-Wellesly Hospital (Newton, Massachusetts), discussed other office-based minimally invasive gynecologic procedures that have become available and "should be offered as an alternative to conventional surgical procedures in order that the female patient can make an informed decision as to what suits her best."

For example, Isaacson said that "menorrhagia, or excessive uterine bleeding, has been the underlying reason for 200,000 of the 600,000 hysterectomies performed annually in the U.S. It also is the reason for 30% of all office visits."

But, he said, "Newer treatments for this condition, such as endometrial ablation, can be performed in an office and also produce successful results in a high percentage of women without undergoing a major surgery and loss of an organ." Endometrial ablation instruments are offered by several manufacturers, employing various forms of energy to destroy the uterine lining; these include heat, freezing, microwave energy and the use of a laser.

In addition to intrafallopian permanent sterilization and endometrial ablation that can be performed in an office setting, an in-office procedure for urinary stress incontinence also is available.

As just one example, Novasys Medical (Newark, California) offers an office-based procedure for mild-to-moderate stress incontinence, or involuntary leakage of urine upon coughing or sneezing. Its system uses small amounts of radio frequency energy to generate heat to firm the bladder neck and upper urethra tissue to stop urine leakage.

Only the more severe cases of stress urinary incontinence, along with pelvic organ prolapse, have been treated in the past, often because women were too embarrassed about the problem to seek help or because they assume it was part of the normal process of aging and nothing could be done about it.

Marie-Fidela Paraiso, MD, of the Cleveland Clinic, urged the media to "enlighten women that one, these symptoms, though not life-threatening, are life-changing, and two, should not be tolerated when there are minimally invasive ways to treat them."

Paraiso said that "one in nine of all women seek treatment for these conditions when close to 35% need it. Minimally-invasive surgical treatments have an 86% to 97% cure rate with few complications, and there are now even less-invasive procedures that could conceivably move into an office setting that early studies show an 83% to 93% cure rate."

The less-invasive procedures often involve the use of mini-slings.

"We are not just doing these procedures," Paraiso emphasized. "We are studying them and publishing about them. We need women to ask for them."

As if this information wasn't enough to disseminate, William Parker, MD, clinical professor at UCLA School of Medicine (Los Angeles), closed with one more plea for all women to have their tubes tied whenever they are undergoing any other type of abdominal surgery, such as an appendectomy or cholecystectomy. He cited studies that have demonstrated that women who have had a tubal ligation have a 50% reduction in ovarian cancer.

The new AAGL wants women to actively participate in their own gynecologic health and ask to be informed of all their options.