GP frustration over depression therapies
Dr Kevin Cooper outlines innovations in his field
1. New ablation techniques for heavy periods
More than 50 per cent of hysterectomies are still carried out for dysfunctional uterine bleeding (normal uterus) despite the fact that an effective minor surgical option, endometrial ablation, is available which produces high levels of satisfaction. It also enables many women to avoid a hysterectomy in the long-term.
Originally these techniques were performed under a general anaesthetic, but newer, second-generation ablative techniques are now available that are equally effective in reducing or stopping menstrual flow.
These are quicker, safe, easy to learn, and can be performed as day cases under local anaesthetic if desired. The likely outcome is light menstrual loss, although up to 50 per cent will become amenorrhoeic depending on what technique is utilised. Two of these microwave endometrial ablation and the endo-thermal balloon have been extensively evaluated and fulfil NICE recommendations (class A). Many other second-generation devices exist which are likely to be effective but require complete evaluation before being accepted into widespread use.
All women who require surgical treatment of dysfunctional uterine bleeding should have access to this treatment in both the NHS and private sector.
Uterine fibroids or leiomyomata are the commonest benign tumours affecting women. They are present in up to 50 per cent of uteri in the over-40s.
While most remain small and symptomless, they can cause considerable morbidity, through pressure and menstrual problems.
Uterine artery embolisation (UAE) is a new treatment. The uterine arteries are canulated via the femoral vessels on each side and under radiological control, synthetic particles are deposited to occlude the vessels.
Preliminary observational data suggests it is effective in relieving the symptoms associated with uterine fibroids in up to 85 per cent of women.
After one year up to 50 per cent reduction in volume can be achieved. Menstrual problems seem to respond better then pressure symptoms. This minimally invasive technique does not need general anaesthetic and appears to reduce hospital stay and recovery time compared with myomectomy or hysterectomy.
UAE has class B recognition from the Safety and Efficacy Register of New International Procedures (SERNIP) although a multicentre randomised trial has been completed in Scotland which will be assessed by NICE. Treatments have to be registered for long-term audit but the procedure should be available in centres with an interventional radiologist.
3. Anatomical and mesh repairs of prolapse
Symptomatic prolapse is a very common condition and while pelvic floor exercises and physiotherapy can lead to an improvement in up to 33 per cent of cases, many require surgical correction. Traditionally all anterior and posterior vaginal prolapses were treated by midline 'repairs'.
This approach is only effective in midline defects which make up under 40 per cent of vaginal hernias. The defects can also be detachment from the lateral vaginal wall, from the perineal body or a combination.
Also, if the patient's own fascia is of poor quality then mesh or graft may be necessary, as for inguinal hernia repair.
Mesh, which should be monofilament, can also be used to facilitate vault repair, laying mesh from the back of the vagina and vault to the sacrum (sacrocolpopexy) or the ischial spines (sacrospinous mesh colpopexy).
Lateral wall detachments require re-attachment to the pelvic side walls with permanent sutures, as midline repairs will cause further detachment.
As more women present at an earlier age with symptomatic prolapse it is critical they are properly assessed by a surgeon who has the capability to undertake the correct procedure.
Anatomical repair aims to recreate a well-supported vagina of normal length and capacity. If the traditional midline repair, with removal of redundant tissue, is undertaken for everyone then at best only a proportion of women will be cured but with a shortened and narrowed vagina. At worst there will be failure in the mid- to long-term, dyspareunia, loss of self-esteem and a requirement for further surgery.
Post-operatively the tissues will take 12 weeks to regain about
80 per cent of their original strength and lifestyle modifications will be required to avoid prolonged increases in intra-abdominal pressure. Up to 10 per cent of women who have a vaginal mesh repair will have extrusion of a portion of mesh, usually minor.
Discharge or bleeding should alert to this possibility and most mesh erosions are amenable to correction by trimming, often under local anaesthetic.
Randomised trials are under way to evaluate these techniques and results should be awaited before recommending use of mesh for routine prolapse repair.
It is likely to be available only in centres with urogynaecology specialists.
4. Tapes for stress incontinence
Stress urinary incontinence (SUI) affects up to 25 per cent of women, and most will have had a vaginal delivery. While in many the symptoms resolve or are a minimal problem following pelvic floor exercises, a significant proportion have their quality of life markedly affected and a surgical cure is sought.
Following urodynamic confirmation of SUI, surgical options can be discussed. The traditional gold standard is colposuspension, which achieves high long-term cure rates, but is relatively invasive unless performed laparoscopically.
Tension-free tapes are minimal access techniques that have become popular over the last five years in the UK. A permanent polypropelene tape is sited under the mid urethra which is not under tension. When intra-abdominal pressure is raised during a cough for example, the tape supports the mid urethra and prevents leakage.
The original tape procedure, TVT, has undergone rigorous evaluation, including a multicentre trial comparing it to colposuspension.
It has the advantage of being significantly quicker to perform with less intra- and post-operative morbidity. Specifically there are fewer problems with voiding and urgency in the short- and long-term that can be a problem following colposuspension. TVT has achieved Class A recommendation from SERNIP and NICE.
Obturator tapes are a newer development the tapes pass through the obturator fossa rather than behind the pubic bone. The advantage is that unlike TVT, the needles are not placed near the bladder avoiding injury to it, and cystoscopy is not required.
Outcomes seem similar to traditional TVT and one multicentre randomised trial has confirmed this. These procedures can be performed under general, regional or even local anaesthetic and are widely available.
5. Laparoscopic excision/ ablation for endometriosis
The aetiology of this condition is still poorly understood with theories including retrograde menstruation, embryonic rest cell activation and genetic predisposition. Early detection before structural damage has occurred is critical to successful management.
At laparoscopy minor disease should be treated with excision or if superficial with ablation. If there is more extensive disease, treatment should be deferred until the risks of surgery are fully discussed with the patient. Women who still have pain symptoms on drug therapy should be considered for surgery.
For extensive disease, advanced laparoscopic surgery may be necessary, but there are risks to the bowel, urinary tract and reproductive organs and this needs to be clearly discussed. If there is known bowel involvement then a colorectal surgeon should be involved in the management.
Excision of the disease can be achieved using electrocautery or a CO2 laser and specimens should be sent to pathology. Superficial disease or endometrioma (after deroofing and draining) can be treated by ablation, again using electrocautery or a variety of laser energy types.
If fertility is not desired then hysterectomy may be considered but existing endometriosis still requires treatment and a discussion with regards to ovarian removal is also required.
Laparoscopic surgical treatment of endometriosis is skilled surgery and there is a need for regional centres to serve the population, as it is not possible for such treatment to be available in all gynaecology units. The major advantages to the patient are clearance of disease with proven significant symptom relief, and the quick recovery afforded by laparoscopy. Although special expertise is necessary, laparoscopic excision of endometriosis is not a discrete new procedure and therefore does not call for a safety and efficacy decision by NICE.
Basic laparoscopic treatment for endometriosis should be available in any gynaecology unit, although advanced treatment should be in tertiary specialist regional centres only.
And on its way... four things we will hear more about over the next five years
four things we will hear more about over the next five years
A laser fibre is passed into the fibroid percutaneously under MRI guidance, resulting in a reduction in fibroid volume. The technique is currently being researched at St Mary's Hospital, London.
2Microwave treatment of endometriosis and fibroids
Microwave technology used for endometrial ablation could be adapted for treatment of endometriosis and fibroids.
Trials evaluating hysteroscopic tubal occlusion have been completed. Small metal coils are inserted into the proximal tube leading to fibrosis and irreversible sterilisation. Now available commercially.
4Gene therapy for menorrhagia and endometriosis
Gene mapping is under way to identify those implicated in endometriosis and menorrhagia. Once identified, blockage of gene action could lead to modification of the disease and symptoms.
The techniques and procedures described above are now commonly used throughout Europe and should be available to patients in the UK. If a technique is not available at a local hospital then referral to a specialist centre should be available to a patient who requires one of the above treatments. Four developments presently undergoing investigation are outlined in the box on the right, although apart from the sterilisation procedure it is difficult to know if any will become available.
Kevin Cooper is consultant gynaecologist, Aberdeen Royal Infirmary