Hot Topics in Gynaecology

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Hot Topics in Gynaecology

• Tal Jacobson
• RANZCOG NZ ASM
• 30 August 2 September 2006
• Paihia

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• New Ideas
• New Products
• New Techniques
• New Technology

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From the Birthplace of the Nation to the Future
of the Nation
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Changes in training

• Shorter training
• Shorter hours
• Greater patient expectations
• Greater litigation
• More service commitments
• Pressure on theatre time
• More subspecialisation

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Training

• Competency Based
• Time
• Number Based
• Apprenticeship

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Training Models
Numbers
Apprenticeship
Time
Competence
Assessment
Training
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www.anatomy.tv
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www.anatomy.tv
www.anatomy.tv
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• Infertility
• PGD
• Sex Selection
• Chlamydia / PID
• Cloning and Stem Cells

• Menorrhagia
• TCEA
• OPD Hysteroscopy
• Fibroids

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The Future of Gynaecology

• The Generalist Gynaecologist
• The Specialist Gynaecologist
• The Medical Gynaecologist
• The Surgical Gynaecologist
• The Managing Gynaecologist
• The Academic Gynaecologist
• The Office Gynaecologist
• The Teaching Gynaecologist
• The Retired Gynaecologist
• The Suspended Gynaecologist

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PGD

• First birth following PGD for single gene
  disorder 1990.

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FISH F-PCR
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PGD / PGS

• Single gene defects
• Duchenne muscular dystrophy
• Cystic fibrosis 
• Spinal muscular atrophy  
• Beta-thalassaemia
• Sickle cell disease
• Tay-Sachs
• Gaucher disease 

• Cancer predisposing mutations
• Retinoblastoma  
• Familial polyposis coli  
• Chromosomal abnormalities
• Aneuploidy
• Translocations  
• Structural
• Late onset  
• Huntington's disease 
• Myotonic dystrophy

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Isolation of Fetal Cells

• Transcervical Cell (TCC) samples using an
  aspiration catheter
• Maternal Serum
• Techniques
• PCR
• FISH
• Laser capture micro-dissection
• As early as 5 weeks

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• Systematic review meta-analysis
• 2 RCTs - 437 women
• Women with stage 1 2
• Laparoscopic resection/ablation or destruction
  of all visible implants versus diagnostic
  laparoscopy
• Pregnancy rate _at_ 9 or 12 months
• Pregnancy RR 1.4 (95CI 1.1 to 2.0)

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Poppy seed oil or surgery is lipiodol a more
effective fertility treatment than laparoscopic
endometriosis surgery?

• Neil Johnson
• Wendy Hadden
• Larry Chamley
• Cindy Farquhar
• - The University of Auckland
• - Fertility Plus
• - National Womens Health
• _at_ Auckland Hospital

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Poppy seed oil or surgery Lipiodol as a
fertility treatment versus laparoscopic
endometriosis surgery?
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Endometriosis 6-month follow-up
 
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FLUSH Trial

• RCT Lipiodol versus no intervention
• Unexplained
• Total n158 Endo n62
• Endometriosis population
• Treatment Control similar demographics
• Age 34
• 4.5 yrs infertility
• P0 gt75
• Previous laparoscopic treatment endo 50
• Previous IVF 40
• Agreement to 6 month FU

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• Cervix
• HPV Vaccination
• Liquid Based Cytology

• Surgery
• Adhesions
• Laparoscopy
• Pain pump
• Endometriosis
• Patient Care Pathways

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Liquid Based Cytology

• Thin Prep
• HPV, Chlamydia gonorrhoea can be tested from
  the same collection pot

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HPV Vaccine

• 1930s Papanicolou
• 1990s HPV testing
• HPV 16 and 18 assoc with 70 of all Cervical Ca
• 2000s HPV Vaccine
• Prophylactic vaccine
• Therapeutic vaccine

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Prophylactic vaccine

• HPV L1 VLPs (virus like particles)
• Safe
• Well tolerated
• Highly Immunogenic
• RCT HPV-16 L1 VLP vaccine 100 efficacy
• NEJM 2002 3471645-51

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• Quadravalent HPV- 6 / 11/ 16 / 18 (Gardasil)
• 100 effective as a prophylactic vaccine
• 90 reduction in persistent infection or disease
• HPV 6 11 associated with wart virus but not
  cervical cancer - therefore treatment also
  decreases abnormal smears

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Therapeutic Vaccines

• Several current strategies
• Safe
• Well tolerated
• Immunogenic
• Not yet shown to be effective

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Implementation

• Age group?
• 12-15
• Female / Male / Both?
• How long is immune response?
• How will it influence the screening programme?

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SCAR 1

• Surgical and Clinical Research (SCAR) group
• Retrospective
• 54,380 patients who had undergone open surgery
• 1 in 3 patients readmitted at least twice for
  problems potentially related to adhesions over
  the following 10 year period.
• 5.7 of admissions directly attributable to
  adhesions
• 3.8 required surgical intervention.
• Ellis H et al. Lancet 1999 353 147680.

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SCAR 2

• 20,046 patients
• Laparoscopic procedures with a high risk of
  adhesion formation 1.3 risk of a readmission
  as a direct consequence of adhesions.
• Lower AM et al Hum Reprod 2004 19187785.

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Adhesions

• SCAR 12
• Spraygel
• Interceed
• Temperature
• Humidity
• 02 levels
• Fluids
• Adept

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Adhesions

• Pneumoperitoneum adhesion forming mechanisms
• Peritoneal hypoxia
• Ischaemia
• Peritoneal temperature
• Desiccation

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Adhesions

• Laparoscopy adhesion forming mechanisms
• Peritoneal hypoxia Addition of 2-4 O2
  decreases adhesion rate
• Ischaemia
• Peritoneal temperature adhesion formation is
  less at lower BBT
• Desiccation increases adhesion formation
• Humidification decreases adhesion formation

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Surgical technique

• Gentle tissue handling 
• Haemostasis
• Irrigation 
• Avoiding infection 
• Minimise foreign body material
• Minimise Suturing 
• Minimise Diathermy

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Intraoperative

• Humidification
• Add 2-4 O2

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Pharmacological Agents

• Solid barriers
• Interceed
• Seprafilm
• Surgiwrap
• Gel Barriers
• Spray Gel
• Intergel
• Liquid barriersAdept

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Spraygel
Intergel
Interceed /Seprafilm / Surgiwrap
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Saline Heparinised saline Dextran 70 Icodextran
(Adept)
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Ternamian EndoTIP
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Hysterectomy /- Ovarian Conservation?

• TAH for benign condition
• Who would recommend BSO at the same time in a
  woman aged-
• 40?
• 45?
• 50?
• 55?
• 60?
• 65?

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Analysis of health risks Parker et al Obstetrics
and Gynecology 2005 106219-26

• Comparison of 4 strategies
• Ovarian conservation
• Oophorectomy
• Use of Estrogen therapy
• Non use of Estrogen therapy

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Risk of Death by Age 80 for non HRT users as a
function of age at oophrectomy
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Saline Instillation Sonography
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Integrated Digital OR
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Robotics
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Thank You

• Dr Graham Parry
• Assoc Prof Neil Johnson