LOUISVILLE Consumer-driven healthcare, a model of care that puts the patient at the center, has become the rallying cry across healthcare industries and organizations in the U.S. in response to the Affordable Care Act and the rapidly changing dynamics of medicine. The model is not just about putting decision-making power into patients’ hands. Equally as critical is providing services that are in the best interests of patients and educating patients on their choices. Baptist Health is one health system in Louisville that has teamed up with physicians to put this principle into practice – particularly when it comes to minimally invasive surgery (MIS) for women.
The HHS Office on Women’s Health cites hysterectomy as the second most common surgical procedure for women in the U.S. behind c-section. One in three women will have a hysterectomy by age 60, yet, it’s simply not something people talk about. Minimally invasive options for hysterectomy have been around for decades, but in 2008 it was estimated that 70 percent of hysterectomies were still done with a large abdominal incision.
One partial cause for the lag may be reimbursement rates that are lower for MIS than open hysterectomy, even though advanced technology makes MIS technically more difficult. Says Rebecca Booth, MD, gynecologist and co-managing partner of Women First of Louisville, PLLC, the largest OB/GYN group serving Baptist Health Louisville, “Nonetheless, we are devoted to these strategies and hope that the trend will be reversed in the future to encourage other surgeons to adopt these techniques.”
The good news is the trends are changing.
Louisville on the Forefront
Until the late 1980s, surgical options were limited to open hysterectomy through an abdominal incision and transvaginal hysterectomy (TVH), the first minimally invasive approach. It was in 1989 that the first laparoscopic hysterectomy was published. “By 1991, when I started in my practice, we were offering laparoscopic-assisted vaginal hysterectomy (LAVH). I saw from early on in my surgical practice the advantage of how well patients do with minimally invasive surgery compared to open surgery,” says Lori Warren, MD, gynecologic surgeon with Women First.
Warren has since become a champion of minimally invasive gynecologic surgery. In practice since 1991, she has for the past 10 years specialized in gynecology, specifically focusing on MIS techniques and treatment of prolapse and urinary incontinence. She is also the co-director of the minimally invasive gynecologic surgery fellowship program at the University of Louisville (U of L), which means, “Every time I’m in the OR, I have the opportunity to share MIS with other surgeons,” she says. Beyond the fellowship, she has been involved locally, nationally, and internationally with educational programs to help other doctors learn laparoscopic techniques. Last fall, she visited Saudi Arabia on the invitation of the Ministers of Health to teach MIS in a hospital in Riyadh.
Heath Brown, MD, OB/GYN with Baptist OB/GYN Associates, did his residency at U of L when TVH and LAVH were the only minimally invasive techniques available. “The problem with those procedures is that they were limited to women who anatomically had enough access to the uterus. Women who had not had children would often be precluded from those approaches,” Brown says.
Brown, who grew up in Birmingham, Ala., put down roots in Louisville after his residency because he loved the community. He has been practicing OB/GYN for 20 years, and in fact, when he decided to add MIS techniques to his practice, he turned to Warren as a resource. “Warren has been instrumental in training not only new physicians but also seasoned ones in minimally invasive techniques, so they may adopt those practice for their own patients,” he says.
Brown has been employed by Baptist Medical Associates for the last three years. His practice, Baptist OB/GYN Associates, has five providers and two main offices in Louisville and Shelbyville.
Unlike Kentucky’s many poorly ranked disease states, Booth says, “Louisville has always been on the forefront of minimally invasive gynecologic surgery, and actually, the University of Louisville was a leader in training OB/GYN residents in these techniques in the mid-80s.”
Since 1990, more advanced technology and instrumentation have paved the way for the advent of total laparoscopic hysterectomy (TLH), supracervical hysterectomy, and robotic hysterectomy.
In 2008 Baptist Health Louisville acquired the da Vinci® robotic system which is used as another MIS approach to hysterectomy. The system may be of benefit in difficult cases and incidences of gynecologic cancer.
The MIS Advantage
As in other specialties, the benefits of gynecologic MIS are evident. “I very rarely have to open a patient,” says Warren. “The difference between seeing a patient after a vaginal hysterectomy or laparoscopic hysterectomy compared to open surgery is really paramount.”
According to Booth, “Laparoscopic approaches allow the opportunity for much less post-operative pain and quicker recovery, generally less blood loss, and shorter hospital stays. This can translate to less time off work and lower rates of post-operative complications.”
Booth is in her 26th year of practice, having started at Women First in 1989, one year after its inception. She has spent the last 10 years focused on gynecology with an interest in MIS and hormonal wellness. With 11 physicians and 11 physician extenders, Women First is an independent, full-service OB/GYN practice that sees an average of 350 patients a day. Baptist Health Louisville is currently the only major hospital they admit to.
Brown posits the benefits of MIS can have additional implications for a woman’s future pelvic health. “When you perform a hysterectomy, depending on the method you choose, you degrade or compromise to a degree some of the supporting structures of the female anatomy,” he says. Open hysterectomy, TVH, and LAVH require cutting through the uterosacral ligaments to release the uterus. “The invention of minimally invasive techniques of late has given us the opportunity to preserve those upper structures and keep them intact to decrease the risk of vaginal prolapse down the road,” says Brown.
Another rare complication of abdominal approaches is the shortening of the vagina, which can affect the quality and comfort of intercourse. “Minimally invasive techniques work at the highest possible margin for transecting the cervix so you preserve vaginal length as optimally as anyone can,” Brown says.
All three of the physicians agree that the approach they choose depends upon the patient. Says Booth, “The approach is always individualized depending on the size of the uterus, the need for ovarian conservation, the patient’s habitus, and the patient’s preferences.”
At Women First, physicians typically encourage women to conserve normal ovaries, unless there is a genetic history of cancer or the ovaries are abnormal, until age 65, at which point there is no proven benefit to ovarian conservation.
Removal of fallopian tubes and the cervix are also discussion points with patients. Brown says bilateral salpingectomy was not common practice until a couple of years ago but has been widely adopted because of new studies suggesting cancers occurring in the abdomen of women later in life may frequently originate from the fallopian tubes rather than the ovaries. “It’s our common practice, even when ovaries stay behind, that we remove the tubes to increase women’s health and decrease the risk of malignancy later in life,” he says.
The supracervical hysterectomy, preserving the cervix, provides quicker recovery and shorter hospital stays for patients who are at low risk for cervical cancer and dysplasia.
The Technology behind the Technique
As a vocal proponent of MIS, Warren keeps tabs on the nation’s progress. She estimates in 2008 only roughly 30 percent of hysterectomies were done using a MIS technique with 70 percent being open surgeries. Today, while exact numbers are hard to come by, she estimates those numbers have improved with 60 percent of procedures done with one of the minimally invasive approaches and 40 percent open. She credits the upward trend of MIS to the advent of robotic techniques and the resurgence of vaginal hysterectomy.
One complication in the pursuit of optimizing MIS has been the controversy of morcellation. Surgeons used morcellation to cut tissue into smaller pieces so it could be removed through smaller incisions or the vagina. However, in November 2014, the FDA issued a warning against the use of power morcellators in laparoscopic hysterectomy and myomectomy for the treatment of fibroids. The concern is that uterine fibroids could contain an unsuspected sarcoma, and the use of a power morcellator could potentially spread the cancer.
Brown says, “We try to do every hysterectomy now in a minimally invasive fashion.” However the FDA warning has decreased Baptist OB/GYN Associates laparoscopic rates from 90-95 percent several years ago to about 80 percent today because it precludes his practice from removing large fibroids minimally invasively using morcellation.
Women First estimates 90 percent of their hysterectomies are still done laparoscopically. Warren is taking a very cautious but informed approach, and says Baptist Health is certainly following the warnings but has also been supportive in allowing doctors to use their best judgement based on the clinical picture of the patient. “If a patient would like to keep her cervix and is not having a hysterectomy for fibroids, I’m still offering a supracervical hysterectomy because the risk of sarcoma in a uterus that doesn’t have a fibroid is really zero,” says Warren. Baptist Health does ensure patients are well-informed and uses a special consent form in these cases.
Warren believes the future for morcellation will be better devices that utilize the morcellator within a containment system inside the body so that cells are not spread.
There are tools that have been pivotal in the development of newer MIS techniques in a much less controversial way. “One of the biggest tools that revolutionized our basic minimally invasive interventions is the harmonic scalpel,” says Brown. Utilizing ultrasonic vibration to cut and cauterize tissue, the instrument can be introduced into the abdomen though a small five-millimeter incision where previous techniques required a large incision with clamps and suturing.
While these surgeons agree minimally invasive techniques are usually in the best interest of the patient when surgery is warranted, the development of in-office techniques in the field mean that the best interest of the patient may be to avoid surgery altogether. “The use of IUDs, specifically the Mirena®, and endometrial ablations have significantly reduced the need for hysterectomy in patients,” says Booth.
Women First is currently in an expansion to offer other procedures in-office, such as hysteroscopy, treatment of cervical lesions, and tubal sterilization procedures.
Women’s Services at Baptist Health Louisville
Minimally invasive hysterectomy is just one component in a comprehensive Baptist Health Louisville Women’s Services program, which also offers minimally invasive procedures for incontinence and heavy menstrual bleeding; women’s imaging services such as digital mammography and breast MRI; a lymphedema clinic; a Women’s Health Physical Therapy Program; and mother and baby care.
“What they’ve really been able to do with gynecology is team-building, where they have skilled nurses that are really familiar with gynecologic procedures, and that makes a big difference,” says Warren.
Booth describes Baptist Health as “extremely cooperative with surgeons” and says, “Our practice has been on the forefront of changing this dynamic [toward MIS] for the last 26 years, and Baptist has been our partner all the way, which in this economic time is really unique.”
Brown concurs, “Baptist is pretty good about procuring the latest tools for intervention. They have the routine armamentarium for performing MIS and have been receptive to acquiring new equipment.”
Pass the Pearls
As a champion of gynecologic MIS, Warren has started a nonprofit organization to educate women about their treatment options called Pass the Pearls. The organization’s website, www.passthepearls.com, includes a physician finder tool called “String of Surgeons,” where physicians across the country can add themselves to the directory if they perform MIS.
Warren also works with HysterSisters, a woman-to-woman hysterectomy support organization. They have partnered together to create Hysterectomy Awareness Month in May and have set up the website www. hysterectomy.org to support the cause.
“When you’re a surgeon, it’s a lifetime of learning,” says Warren. “If I did only the surgeries I trained with in residency, I wouldn’t have any surgeries to do. It’s been an exciting evolution for me and to get to share that with others is really gratifying. Most gratifying is to see the benefits to patient care. The surgeries I do today are much improved compared to the techniques I trained with in my residency.”
In the end, that penchant for lifelong learning and educating others comes back full circle, and the beneficiary is clear – providing treatment options in the best interest of patients.