Harry Reich, MD
It is a privilege to be able to come here to speak to you about sex and endometriosis. It is great to be with some of my old friends, I see one in the front row over there. You can see they sneak around. Over there in the corner is Tamer enjoying himself and the guy across from him is Arnaud Wattiez who is at WebSurg in Strasbourg and does the most teaching I think in the world. He did about five years with the robot and he says we can chuck it in our specialty. It is a great device for the urologist but not for the gynecologist. There is really nothing that the expert gynecologist could do better with a robot.
Having said that, to make myself clear, I do have to echo what Padma said, we do have the technology but it is very well hidden. And we certainly have technology that does not depend on millions and millions of dollars. That having been said we get to the endometriosis part of the lecture.
I am going to try to speed this up because we all know we have a lot of things to do this evening.
The present treatment of endometriosis in much of our country and I guess in much of the world, but you see lots of different skill levels in other countries, believe me, especially like France and Italy. But present treatment was mentioned by Voltaire back in the 1700s when he said, “The art of medicine consists in amusing the patient while nature cures the disease”. Well, nature does not really cure endometriosis. If it is there at menopause it is still there when the patient is 80 years old, it is just not as active. It does not have that urge that keeps it going at such an active level. But when we talk about endometriosis and dysparunia let us face it, the cul-de-sac is right there behind the vagina, right in front of the anterior rectum. So, one gets a reputation for doing a lot of these cases, most of your cases involve the rectum and the vagina, the rectovaginal septum. It was good of CY to show us some of the bladder stuff that can be tough too. But this is not really the mystery disease most of the time. I was interested that David said that he does not do rectovaginal exams because I believe you have to do rectovaginal exams. I believe the patient is getting short-changed if they do not have a rectovaginal exam because the surgeon or the doctor can put his finger behind the cervix and lift it up and you can feel the uterosacral ligaments quite far back and you can feel the anterior rectum and it gives you a roadmap of where to operate; to what to excise when you do your primary surgery – so much for the rectovaginal exam.
Now we are going to get into what is wrong with the laparoscopic treatment of endometriosis. You saw beautiful surgery with CY, really great cases and long time consuming. My son, who incidentally just bought a ticket for $500 to the Charlie Sheen thing in the next week or two, he is a bariatric surgeon and he is in New Jersey and today he will do five or six lap bands and yesterday he did four. Probably the lowest fee that they get – everything is insurance, insurance covers everything you have in this type of surgery - the lowest fee he will get will be probably higher than the highest fee that a gynecologic laparoscopic surgeon will get from the insurance company. As a result, unfortunately for women, most of the people who do a lot of these extensive cases cannot or do not take insurance. I think that is one of the major reasons for that.
There is a case in Philadelphia, it is an ongoing case of Medicare fraud, where the orthopedic surgeon was doing four different patients, hip replacements, at the same time or four different patients knee replacements at the same time. I guess you can do that in other specialties. You could actually have three or four fellows start them off each in a different room doing the same hip operation. The reimbursement is phenomenal, much higher than a gyn person would get. It is disturbing. What CY, what David and what most of us who do extensive endo we could never do that. I remember I had a fellow for two years and she never could get past 15 minutes on difficult endometriosis operations. C’est la vie. What is wrong with this whole situation - a lot of different things. Some of these are repeat slides from last year because the questions still are high on my list. Why are the ovaries removed at hysterectomy? For the money! A good surgeon could take the endometriosis and preserve the ovaries in almost every case. Why is present day total laparoscopic hysterectomy a rip off? Because, well it is not done that often, people go the supracervical route and very commonly leave all the endometriosis behind. The other thing is if you look at ureteral injuries you will see in the present day it is like three per hundred and about 30 years ago it was three per 10,000. We have to train our people and we have to try to find people who are trained before you have any type of surgery. And, why do so many endometriosis patients have no endometriosis? Well, it is because the surgeons are biopsying, if they biopsy, which most of the time they do not, they just look and they see brown stuff and they say this patient has endometriosis. Now brown stuff in almost all cases, the majority, is the product of retrograde menstruation. They are white blood cells filled up with hemosiderin. Half the biopsy when the pathology report comes back, hemosiderin-like macrophages, it does not mean endometriosis. You have to have endometriosis glands or stroma in there to call the patient an endometriosis patient.
I enjoyed the talks earlier on why pain relief may not be a sufficient outcome variable and I certainly agree with that. Many gynecologists today with these patients to get around the low fees of the insurance companies will bring the patient in and will work through a whole bladder work up first. They will do all these bladder filling tests, potassium solutions, the different solutions, all these are billable. The worst one I heard is that some doctors will actually inject the uterosacral ligament nodules and call it neurolysis, but all this reimburses a lot more than laparoscopic surgery. Somehow we try to do a lot about it with our peers but we do feel that it is important for women to let the world know that this is all happening and it has been happening for a very long time with this condition.
I am going to push through this thing time-wise. Medical treatment never works. When we say pelvic reconstruction it could be by laparoscopy or by laparotomy but I have never seen anybody do by laparotomy well. When I trained in Boston, at Harvard, at Peter Bent Brigham Hospital and Boston Hospital for Women Robert Kistner was the greatest, and he would mobilize the ovaries and take out the endometriosis wall and do a presacral neurectomy and a uterine suspension. All the cul-de-sac stuff that some of the videos that CY showed you just never even got touched in those days by the best. The other thing that I try to tell some of the doctors in the audience is the endometriosis wall is it going to prevent endometriosis from coming back in the ovary? There is always endometriosis usually on the pelvic side wall, usually overlying the ureters, it must be removed also with a separate biopsy. As you can see the treatment with hysterectomy, I believe, is a poor choice because even if you do a hysterectomy you still have to remove the endometriosis, I believe. Usually intrafascial dissection leaves endometriosis on the rectum and vagina and today we have a lot of endometriosis patients who have supracervical hysterectomies, leaving all the disease behind. The hysterectomy like I said, and I have heard David say this so often too, it is often associated with taking out the ovaries and the normal part of the uterus while leaving behind the disease. We must first remove the endometriosis then do the hysterectomy.
I will show a little bit of my experience with endometriosis when I was at Columbia where over an 18 month period of time we looked at all the patients signed up with endometriosis and most of the treatment, except for my cases, was by laparotomy. There were 76 hysterectomies and 20 of these were supracervical hysterectomies. Why? They were supracervical because they were the most difficult cases. You would think it would be the opposite. But again, surgeons have to operate by the time and keep it moving that way. At Columbia, as I say here “no laparotomies were done to excise endometriosis”, maybe it is changed today but the last time I was there, which was this past June, they were talking about doing all this surgery and they had no mention of a laparoscope, all they mentioned was the robot. So, they are high-tech, I guess that is what you have to do in this world.
My diagnostic approach has been to remove the disease and David and I fight about this a little bit because all these different colored lesions to me endometriosis is something always surrounded by scar tissue, white fibrotic tissue. It might be big, it might be small but there is some fibrotic tissue because endometriosis to cause pain has to have done something to the body. If you see different peritoneal lesions, and I should have asked David the question on the teenage girls that is a very hard diagnosis, but after many, many cases you get an idea of just a little bit of roughening of the cul-de-sac. A lot of those will come back as positive biopsies. You can sometimes diagnose it but we could spend a whole hour talking about that one. The first part of most of these cases is taking down bowel adhesions from previous surgery because previous surgery using cautery causes adhesions. I try to do most of my cases without cautery, minimal cautery or micro bipolar cautery. I use scissors and I try to cut where it will not bleed. I believe that is the best technique. As you see in that slide midway down poor reimbursement for complex endometriosis surgery is a major, major problem. Plus, when you operate on the bowel or bladder, even though it is indicated, your chances of getting sued are much more elevated. As I also say office patient visits pay approximately 20 times what could be made in an operating room when you are an endometriosis surgeon. Our situation in the United States is a little difficult but here is something I want to stress, endometriosis, like I said, is almost always surrounded by fibromuscular tissue and it represents a longstanding inflammatory response. It is like if you cut your finger, you get inflammation around there and a scab forms and scar tissue is left behind at the end. But this happens month and month after month with endometriosis. Again, it is often missed at diagnostic laparoscopy if the surgeon looks for brown lesions instead of the white fibrotic ones, I always like to emphasize that. I think the big transition between cancer surgeons maybe doing some cul-de-sac dissections and what we did came at AAGL. In 1985 I presented, Camran Nezhat presented and a bunch of them presented about deep endometriosis. These were the type of cases that we were presenting back in 1985 where you could see endometrioma being drained and then excised. We did publish that and then a few years later in 1988 we presented on retrocervical deep fibrotic endometriosis causing cul-de-sac obliteration. At the second, I think, Endometriosis Association meeting I had a debate with Robert Franklin on doing this laparoscopically or through the laparoscope. He said, “Boy this new generation is equating the laparoscope to their penis”. That is what you have to put up with when you are debating in our specialty years ago. Notice I said it is not deep infiltrating endometriosis, everyone is still using that term infiltrating and it is not cancer, it is not infiltrating. It is deep fibrotic endometriosis with no signs of true invasion. It is DFE not DIE, D-I-E. Think about that sometime and when you do approach it clinically you could usually pick it up with a biopsy forcep, get under it and it is gone. It will not come back, that is the magic of it, it will not come back. It is not a malignancy but it does require advanced training as for cancer surgery. Basically, you look behind the uterus, you see that fibrotic tissue, you excise it, send it to the pathologist, the pathologist under the microscope will see fibromuscular tissue surrounding glands and stroma. And if you look at the bowel and that is removed you will see it sometimes in the muscle wall and rarely in the mucosa of the bowel but that is how you make the diagnosis with a pathological diagnosis.
Cure rates with Lupron therapy are near zero regardless of the disease stage. Cure rates with surgery, most of them are over 50 percent. Mine that I presented in 1988 was 33 percent. But we were not using all these modern instruments, I was still using cautery then I did not use the scissors like I do today. Cure rate does mean it requires another procedure and lots of biopsies of anything closely resembling the disease. What do we do on the bowel? We could try shaving lesions, we could try what I do, the disc excision quite a lot – maybe I will show you one of them quickly to end the talk. This is 1986 surgery. For this lady in this case we used some carbon monoxide laser but everything is stuck to the back of her uterus. I had a second look at her in 1989 and I saw no evidence of disease except for her anterior rectum. I believe that is the first time we did a discoid full thickness rectal resection. I am not going to get into that because you see too much laser and smoke and all that kind of stuff. These days I do not use that kind of technique but for the bowel I am very free to use a circular stapler. Here for instance is a bowel lesion you can see, CY knows, I use the same equipment in every case. The same scissors in use for over 20 years, same biopsy forcep with a nice little tooth on the end and most of the time I try to cut where it will not bleed. Now endometriosis does not bleed. The blood vessels are these tiny little neovascular vessels that have been stimulated there by this chronic inflammatory response. Note this curl up given 30 seconds to a minute and a half and the bleeding stops. You could come right across that and take much of the fibrosis off just with the simple scissors, without a fancy laser or fancy robot. As you can see the scissors cut better than robotic scissors I am sure, that I have seen anyway. The robot they are using they use a lot of what we call harmonic scalpel. That is an instrument that will heat up very easily to over 200 degrees sono-grade. I said 200 degrees sono-grade and it takes about a minute to cool down. Those of you who use that instrument, beware it is not helping things.
We will go now to something a little bit more aggressive before I finish I think. I am trying to hold this time right down. This is an old tape, this is from 1995 with a big endometriosis lesion where you will see some bleeding. Some of you who do not like blood close your eyes in about a minute. It does not seem to faze a surgeon too much. I think that is part of knowing what you doing when you do surgery – but notice the scissors is sticking on the deep fibrotic tissue and I am taking it out in chunks and I have a probe in the rectum. The scissors come across and the lesion itself goes right into the rectum. It is a full thickness rectal lesion. You can see the white rectal probe there as we enter the rectum and you can see the start of some bleeding there. So we have a hole in the rectum. One suture, well in this case we used two, and I believe that this is a really nice clean simplified technique to remove a rectal lesion. Put our two stitches in. We hold the sutures long and put the stapler up and this gives us a much nicer margin around the endometriosis area. You can see how the lesion is invaginated into the jaws of the stapler, the stapler is brought together again and the operation is done, just about done, one more minute. On lesions like this you have to do bowel resection. These are big especially when you look in with a sigmoidoscopy and you see this it means bowel resection. Rectosigmoid resection, well we are just in the early stages of doing these operations. We know excision works on bladder lesions, vaginal lesions, uterine lesions and ovarian lesions. We have never tried to excise rectum we tend to vacillate on that but I believe that may be our future. Last year’s speaker, Mauricio Abrao spoke extensively on that showing his data. Again, I mentioned earlier that I do not believe the number of endometriosis cases has increased. I think that we could just identify it better by biopsy. The future is hard to predict. Long term there may be a pharmaceutical agent to modify and eradicate endometriosis but I think that is very long term. We now know that excision works best. What will rectal resection become in our treatment? We are waiting for the answers.
I would like to thank you all and it is really nice to be involved with treating endometriosis, and sex.