Interview With..

Interview with... Stefano Bettocchi

 The history of the hysteroscopy and Prof. Bettocchi are linked forever. The vaginoscopic approach as well as his 5 mm hysteroscope were the first step of the modern hysteroscopy.

 How did you developed the vaginoscopy approach?

  The vaginoscopic approach was developed in ’92 as an answer to my experience abroad and to the need to overcome the shortage of anaesthetists we used to have; actually in those days we still had to access the operating theatres for the anaesthesia and due to the shortage of anaesthetists and the growing number of patients, we decided to find a way to hysteroscopy and finally strip down our patients’ discomfort. Back then, there were more and more nuns accessing our institute and this fact motivated us even more to find a non-invasive access to the cervical canal.

   The first vaginoscopies were executed even before to develop an outpatient procedure, when the hysteroscopies were still executed with CO2, so just imagine how difficult it could be to do vaginoscopies with gas! Only during the following years, with the new hysteroscopes, we could use the liquid and so standarise the technique to make it reproducible.

You have design some new devices for hysteroscopy, do you have any other tool in mind?

  Yes, actually we have many projects going on, but, actually, for the company it is impossible to manage all them at the same time, so we are now prioritising them and I hope you will see something new very soon. Anyway, the latest innovations have been the Integrated Hysteroscope (B.I.O.H.) and the amazing suction/irrigation device (pump) called Hysteromat E.A.S.I.

There is a growing interest in hysteroscopy, what can we do to promote the hysteroscopy?   

  Well, non-enthusiasts commonly consider hysteroscopy just a secondary and minor procedure. So we shall first of all "convert" them and make them to understand that they are in front of a very important and valuable procedure. Furthermore, hysteroscopy is in the hands of the youngest gynaecologists who consider this technique suitable for them against laparoscopy; then we shall try to have an effect on the young blood!

In your opinion, which is the best way to become a skilled hysteroscopist?

Definitely not the do-it- yourself. In fact many colleagues, due to the lack of skilled hysteroscopists, they rely just on info they can obtain during some congresses and courses and on their own "attempts"; they try their own luck. Well, we should make sure we have experts in each country so that we can have experts everywhere able to teach; we can not limit the teaching task to super-experts coming from abroad.

Has hysteroscopy reached its limits?

I don’t think so. The clinical pathologies are well defined because we know the uterine cavity very well, but we have to keep working on the improvement of the technology to solve even more rapidly and efficiently these pathologies

Please give us your future reflections in regards to hysteroscopy.   

As I have just said, my reflections are not just based on pathologies, but on what we should do in order to standardise these procedures and research new procedures for our daily activities.

I personally think that this question can be of interest for too many people. Do you have any advice for the young physician who is starting out in the world of surgery?

  First of all, I would suggest him to be passionate: passion can make the difference. The young physician should learn and listen to experts but, at the same time he should not be passive in the learning process. He should try to be innovative also when he is onlyvrepeating activities he has learned or seen from experts. This is my own story, I could have been a clone of my maestro, but I was always looking for new solutions in my reality.

 So, do respect your teaching experts, but always look for something new discovering and sometimes overcoming your limits!

Interview with... Osama Shawki

To talk about Dr. Shawki is to talk about “the art of hysteroscopy”. He is one of the most relevants hysteroscopists in the world with global influence

  

What is your vision regarding the application of Office Hysteroscopy in Modern Gynaecology?

 My dear friends, we have to face the unpleasant fact that gynaecologists are amongst the least technologically adept of medical specialties. If we look at Ophthalmology, ENT or even our neighbours – Dentists; all have now recruited cutting edge optics to their standard practice. Office gynaecology equipment is still the same ancient, antiques used for the past hundred years with a shiny new lamp and electronic chair added.

 We are also the only specialty still performing blind sampling. As reported in multiple statistics, 100% of urologists are performing cystoscopy compared to only 15% of gynaecologists performing hysteroscopy.It is high time for a revision and reassessment in the practice of gynaecology. Office hysteroscopy uses a diameter less than that of theuterine sound and utilizes high definition optics making it the mostbeneficial modern technology in practice. In my personal opinion, theequipment is very affordable but there are major pitfalls in equipment designand technology, which diminish enthusiasm for the procedure.

 Our mission is to spread out proper training and reconstruction of equipment design to provide optimal easy practice and make it a standard procedure inevery gynaecologist's office.

 

What is your role in training?

 It is my pleasure to have travelled to 56 countries training people from huge metropolitan capital cities to the most humble, low key villages; deprivedeven of electricity! Meeting and training thousands of colleagues of differentraces and cultures.My ultimate pleasure is seeing them providing the highest standards inpractice. You can look at me as the Mahatma Ghandi, both of us yielding special sticks that spread peace and love. The difference being that his is made of wood and mine is of a special alloy.

  I am proud that you are fulfilling this mission through raising awareness by this wonderful newsletter. I have concrete belief that we can achieve moreand more in the next period.

 

 You seem to oppose most mainstream concepts regarding Uterine Septums, what is your take on the matter?

  Actually, I am against the term septum resection/removal as in fact septum should never be considered abnormal additional tissue to be taken out. Old concepts of Strassman Operation, which described it as a foreign tissue to beexcised, are now refunded. In my opinion, this was a mutilating reduction metroplasty, losing approximately 1/3 of the uterus.

My vision through seeing thousands of septums and observing the response of the tissues when cut by scissors or electrocautery is that the septum is merely stretched myometrial fibers fused in the midline. Old concepts of it being a fibrous, avascular tissue are corrected now by histological assessment and color Doppler studies- it is a actually richly vascular muscle tissue.

I feel very surprised to still see opinions on resection, you simply release the fibers and the tissues retract leaving no residual extra redundancies. I invite all colleagues to access my library on Youtube collecting hundreds of cases of multiple varities.

You are always criticizing the low number of hysteroscopists compared to laparoscopists. What is the explanation?

  Definitely the number of gynae laparoscopists is greater than hysteroscopists. There is an obvious unsatisfaction in the performance of hysteroscopy. In Laparoscopy the surgeon operates in the huge abdominal cavity with the privilege of multiple trochars, instruments, camera man, uterine manipulator, suction irrigation etc to provide optimal view. In comparison, Hysteroscopy is performed in a very restricted cavity with difficult accessibility to all walls and limited number of additional instruments.

Ironically the main mass concept is that hysteroscopy skills are simpler than those of laparoscopy. Assuming that performing dilatation of the cervix or IUD application is the same as introduction of a hysteroscope. What happens is most beginners don’t get proper orientation and direction from experts. This leads to unsatisfactory view and awkward mobility. I know for sure that many colleagues, who are great laparoscopists,actually started their career as hysteroscopists! We have to face the fact that every gynaecologist should be able to perform hysteroscopy but this requires effort and training to improve and grasp the fine techniques. 

What is your opinion on new technology such as Morcellators for polyps and myomas?

 Technology will never stop providing safer, easier options for intrauterine surgery. However, wise minds should calibrate advantages vs cost added. Definitely morcellators do a very nice job eating up small polyps and Type 0 myomas but in my opinion such pathology can be dealt with very nicely with standard resectoscope with negligible time difference. Putting in mind the cost of the high end technology vs standard resectoscope, I believe the 1st option the patients pays for the technology, whilst the second pays for the surgeons’ skills. There is a place for both, but me personally, in this phase of my life, I handle any pathology with scissors and resectoscope.

Rumors are spreasing that you have your own line of equipment for hysteroscopy; can you enlighten us?

 My dear friends, let me bring the surprise soon. I have developed a total solution for intrauterine surgery including innovative sheaths, HD optics providing pristine crystal clear images, and a state of the art fluid management system that defies all taboos responsible for poor vision. Stay tuned!

Interview with ... Dr. Attilio Di Spiezo Sardo

 Dr. Attilio Di Spiezio is a world recognized gynecologist who characterizes by his observations and research without limits. With the publication of his new book "State of the Art Hysteroscopic Approaches to Pathologies of the Genital Tract" he culminates a long journey into the world of hysteroscopy, which has led him to be recognized as a pioneer of modern hysteroscopy with the highest level of international appreciation.

  At the beginning of the book, you give a tribute to those gynecologists who had accompanied you on your training. In your opinion, how important is the figure of the Mentor?

   The Mentor by definition is  someone who imparts wisdom to and shares knowledge with a less experienced colleague. The Mentor has an invaluable role in medicine and mostly in endoscopic surgery where you need not only to acquire psychomotor skills but also surgical competencies. While psycomotor skills can be acquired on inanimate models, for surgical competencies you  need a Mentor who can speed up your learning curve, reducing the unavoidable complications at the beginning of your "endoscopic trip". I owe much of my career to all my  Mentors who have guided my "endoscopic hand" since I was a medical student. 

  Does the development of assisted reproduction technology have contributed to the advancement of hysteroscopy?

  I think so.  In the last years, the entire gynecological community, including those working in "infertility centers", had to recognize that  the uterine cavity and its inner layer, the endometrium, are fundamental for the implantation of the embryo. However, despite hysteroscopy is generally recognized as the gold standard technique for the  evaluation of the uterine cavity and treatment of its relevant pathological disorders, its use as a routine procedure in the infertility work-up is still under debate as there is no consensus on its efficacy and effectiveness in improving the prognosis of infertile couples. 

  I found really interesting the chapter on Hysteroscopic Outpatient Metroplasty To Expand Dysmorphic Uteri. (HOME-DU technique), could you give us a brief summary?

  The new classification system of Müllerian anomalies developed by the ESGE/ESHRE CONUTA working group has dedicated a specific interest to those uteri, named "dysmorphic", characterized by a normal outline but with an abnormal lateral wall’s shape of the uterine cavity    ( i.e. T-shaped uterus and tubular-shaped/infantilis uteri).  These uteri are associated with infertility and pregnancy loss and in the previous American Fertility Society classification were included in class VII and mainly related to diethylstilbestrol-related (DES) exposure. However clinical experience has shown that these uteri are more common than expected, mostly diagnosed in young infertile patients with no history of DES exposure.  

  When faced with a tubular uterine cavity or an increased smooth muscle component on the walls of a ‘T’ shaped uterus, the literature reports success with a resectoscopic technique designed to improve the volume and the morphology of the uterine cavity. The technique involves the use of a hooked loop which is meticulously guided by the surgeon placing parallel longitudinal incisions along the main axis of the uterine cavity. The aim is to decrease the centripetal force of muscle fibers and of any fibro-muscular rings that have contributed to the stenosis, and to promote a consecutive increase in the volume of the uterine cavity.

  Recently, our group has developed a new outpatient technique yielding an increase in volume and an improved morphology of both T-shaped and tubular uterine cavities (Hysteroscopic Outpatient Metroplasty To Expand Dysmorphic Uteri: the HOME-DU technique). The novelty relies in the fact that such a technique combines the surgical principles of traditional resectoscopic surgery with the latest innovations of minimally invasive operative hysteroscopy and bipolar technology. The technique involves two incisions of 3–4 mm in depth made with a 5-Fr bipolar electrode along the lateral walls of the uterine cavity in the isthmic region, followed by additional incisions placed on the anterior and posterior walls of the fundal region up to the isthmus . The operation ends with the application of an anti-adhesive gel. Preliminary data on a cohort of 30 patients showed a significant increase in the volume of the uterine cavity, with a substantial improvement in uterine morphology. This resulted in an improvement of the reproductive outcomes with a clinical pregnancy rate of 57% and a live birth rate of 71% at mean follow-up of 15 months.

  As Prof Nappi coded, hysteroscopy has sometime become the "Cinderella" of gynecology. Has the prime time of hysteroscopy arrived yet?

   I think so! The number of gynecologist performing diagnostic and operative hysteroscopy is rapidly increasing all over the world and many technical and technological innovations continue to be reported in the hysteroscopy field. "Hysteroscopy Newsletter" is an example of the need to "give voice" to such a growing number of endoscopic surgeons, who are specifically focused on hysteroscopy.

Has hysteroscopy reached its limits? What do you foresee as the future of hysteroscopy?

   Absolutely not! The limits of hysteroscopy are still far! Indeed there are many aspects of the uterine cavity which still need to be completely elucidated. I am thinking about endometrial receptivity, embryo implantation, uterine congenital anomalies, the progression from hyperplasia to carcinoma, the endocervical canal…. All the technological improvements which could help us to investigate and treat these and other unknown aspects/conditions of the uterine cavity will represent the "future" of hysteroscopy!   

  Do you have any advice for the young physician who is starting out in the world of surgery?

  Yes, I have! Follow your talent, achieve an excellent training and continually update during you career. But above all, keep in mind that the endoscopic training consists of 4 phases [didactic (i.e. theoretical knowledge), laboratory (i.e. training on inanimate models to simulate real procedures), observational (i.e. observation of real-time procedures) and preceptorship (i.e. performing a surgical procedure under direct supervision)] each of which is equally important. In other words, don’t  be anxious to go straightaway to the operating room, but wait for the proper time to do it!

 

Interview with... Ivan Mazzon

 To talk about Dr. I. Mazzon is to talk about innovation in hysteroscopic myomectomy. His “cold loop” technique is something that all ginecologists should know. He is the head of the department of the “Arbor Vitae” endoscopic centre in Rome

You were the first in use the term “cold loop myomectomy” . Do you think that the technique is well known?

 At the beginning of nineties, for the first time I presented the “cold loop” hysteroscopic myomectomy at the National Congress of the Italian Society of Gynecologic Endoscopy. In the following years, this technique was spread among Italian endoscopic surgeons and nowadays the majority of Endoscopic Centres in Italy, routinely performing hysteroscopic myomectomy, utilizes “the cold loop technique” for the treatment of G1 and G2 myomas. Until now, outside Italy few Centres in USA, Belgium, Germany, England, South America know and perform such technique. Unfortunately, only in the last years I started to publish data about the cold loop technique in international Journals and probably for this reason the technique is still not utilised in all over the world. Nevertheless, I am noticing an international growing interest on the cold loop hysteroscopic myomectomy.

Can you make a brief resume of the technique and its advantages?

 The technique is articulated in two phases:

1) Slicing the Intracavitary Component of the Myoma

The intracavitary component of myoma is removed using the conventional slicing technique powered by monopolar or bipolar current (in pure cutting mode). When the cleavage plane between the myoma and myometrium is identified, the slicing has to be stopped. In order to identify the correct cleavage plane between myoma and myometrium, it is very important to reach accurately the plane of the endometrial surface: remaining above or falling below of such plane makes it difficult to recognize the correct dissection plane.

2) Enucleation of the Intramural Component of the Myoma

The electric cutting loop is subsequently replaced with a not electrified cold loop (mechanical loops of Mazzon; Karl Storz, Tuttlingen, Germany). Usually, it is better to start with the “straight cold loop” (the most atraumatic), which is inserted into the cleavage plane and applied repeatedly along the surface of the myoma. In this way, the connective fibers anchoring the myoma to the pseudocapsule are disconnected by blunt dissection. In case of wide and tough fibro-connectival bridges, it is useful to resort to the “rake-shaped” or to the “knife-shaped” cold loops. In this way, the intramural component of myoma is progressively detached from the myometrium and becomes an endocavitary neoformation, safely removable by slicing. In case of myomas of large volume, it is possible to repeat for more times this phase.

The main objective of the “cold loop hysteroscopic myomectomy” is to avoid the contact of the electrical cutting loop with the myometrium: in this way it is possible to achieve efficacy and safety.

a – the tissues are preserved from the thermal injury caused by the electric energy. In this way, the myoma, the myometrium and the cleavage plane between myoma and pseudocapsule are easily distinguishable;

b – uterine perforation with the electrical thermal loop is virtually eliminated;

c – avoiding the damage of the healthy myometrium, the risk of haemorrhage and post-surgical intrauterine synechiae is reduced. Indeed, haemostatic contraction of the myometrium is maintained and the fibrous reaction caused by the thermal injury is avoided;

d – the thickness of the free myometrial margin loses its importance;

e – the chance to accomplish the treatment of G1 or G2 myomas in only one surgical step is greatly improved; only the achievement of a critical value limit in absorption of distension media could need the interruption of the procedure and so the scheduling of a new surgical step to complete the treatment.

Which are the limits of the single step hysteroscopic myomectomy?

 Theoretically, every submucous myoma may be removed hysteroscopically in only onesurgical step. Nevertheless, the limit is determined by the absorption of the distension media and such limit may significantly change according to the surgeon experience. The surgeons should treat only submucous myomas that really are able to remove.

How important are the courses and the “hands on” training in hysteroscopy?

 Since over 20 years I organize courses in which the “hands on training” has great importance. They are fundamental in order to know correctly the instruments and the surgical gesturing. The courses and the “hands on trainings” should always come first to the learning pathway during the clinical practice.

You have published some books and atlas in DVD. Can hysteroscopy be improved with the use of audiovisual aids?

 Books, atlas, DVD and all multimedia instruments are important to build the necessary knowledge in hysteroscopy but, as usual, they may be insufficient without an adequate training during courses or in Endoscopic Centres setting with a tutoring carried out by expert surgeons.

Do you have any advice for the young physician that is starting out in the world of gynecologic minimally invasive surgery?

 Being a minimally invasive surgery, the great fault, (and in the same time the most frequent) is to consider the hysteroscopic surgery as a procedure extremely easy to accomplish and therefore to believe that it requests a “minimal” training commitment. Unfortunately, a bad use of such surgery may be characterized by serious complications. There are several reports in the scientific literature about it. As for all surgical techniques, it is necessary a correct learning pathway, which allows a real knowledge of the uterus anatomy and the uterine cavity (the diagnostic hysteroscopy has a fundamental role), a suitable comprehension of the instrumentations utilised and an adequate learning curve. I believe that only in this way the hysteroscopic surgery can be performed with efficacy and safety.

Interview with ... Elizabeth Stewart

Dr. Stewart primary research interests are minimally invasive therapies for uterine fibroids and the genetics of uterine leiomyomas. Her clinical practice is devoted to uterine fibroid treatment in women who want future fertility and infertility diagnosis and treatment.

After more than 150 publications in different medias. What's your reflection about myomas?

Myomas are much more complex and varied than we give them credit for. To me it is like the 19th century concept of cancer: cancer is cancer and there is no need to understand the type. Only when you understood differences in prognosis and pathophysiology did it make sense to differentiate a thyroid cancer from a lymphoma and an ER+PR+ breast cancer from a triple negative one. I think because we’ve relied too much on hysterectomy, we consider all fibroids the same. I think in the next decade we will understand better the molecular subtypes of myomas and our current way of making decisions will seem pretty primitive.

 Laser, miniresectoscopes, intrauterine morcellator, "cool loop" technique, pseudocapsula.... , are times changing in the "myoma world"?

 One of the great advances over the course of my career has been innovation in surgical equipment and technology. When I was an intern, Ob Gyn’s were doing laparoscopy and General Surgeons were not. So if a woman was seen in the emergency room with a question of PID vs. appendicitis, we would do the laparoscopy and if we saw a ruptured appendix they would do an open appendectomy. Ob Gyns are great surgical innovators and often ahead of their time. We are seeing this now with fibroids.

Is there a growing interest about myomas?

There is a growing interest and I believe it is fueled by the increasing number of alternative to hysterectomy. When all you do is hysterectomies, myomas are much less interesting.

Has the debate about myomas and fertility finished or there are more things to know?

It has barely begun. I believe the genetic and biologic heterogeneity of fibroids makes some fibroids detrimental for fertility and others not. Thus one 3 centimeter FIGO type 3 fibroid may be very detrimental to fertility based on some factor it is secreting or storing and another one of the same size and location doesn’t play a role at all.

Do you think that the future treatment of leiomyomas will be only medical?

No, I think there will always be surgical therapy. It is hard to treat anything effectively when it is 10 centimeters or greater. However, I hope medical therapy will be able to be used for prevention and early intervention so we will see far fewer of these large fibroids.

You are also expert in adenomyosis. Do you think that this entity is usually underdiagnosed?

I do. Again, since we have few options other than hysterectomy people, don’t make the effort to establish its importance. I believe it accounts for more pelvic pain and heavy menstrual bleeding than we suspect. I also believe undiagnosed concomitant adenomyosis accounts for many failures of alternatives to hysterectomy for fibroids.

Do you have any advice for the Young fellow Who is beginning in the world of surgery?

Yes, develop your surgical skills by doing as many cases as you can. However, you also need to be able to walk away from those carefully honed skills and learn new techniques. You have to keep up with the times. When the general surgeons started doing laparoscopic cholecystectomies, the experts at open procedures who didn’t want to change got left behind.