What's new in the other journals?
- These snippets are extracts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at email@example.com or visit the website www.getjass.com.
There are a number of ways of removing a woman's uterus for benign conditions and the choice of operations continues to expand. The latest contender is robotic surgery, where the woman has instruments introduced into her abdomen laparoscopically that are mechanically moved (robotically) by the surgeon who sits at a console in theatre viewing the action on a screen. All manipulations are controlled remotely using devices on the ‘dash-board’.
Basically, it is a sophisticated form of laparoscopic surgery. The term robotic is a bit of a misnomer as the surgery is not carried out by a robot but by a highly trained surgeon using servo-systems that give considerable manoeuvrability and access but lack ‘feel and tension’ sensitivity.
Laparoscopic techniques offer various advantages and disadvantages to the patient, surgeon, hospital and instrument-makers and the introduction of robotics takes the debate of ‘advances’ to new levels. The levels are possibly better outcomes for women, ingenious developments of technology and new scientific frontiers on the one hand but greater start-up costs, longer operating times, extensive learning curves and more complicated equipment on the other.
It is already the focus of debate in academic circles, especially in the USA where most robotic surgery is being carried out. At present the only platform approved by the Food and Drug Administration is that of the Intuitive Surgical Company which makes the ‘da Vinci®’ robotic system. At the start of 2012, over 2000 systems had been sold, most of them in the USA. The cost of installing the system is between $1.25 million and $2.5 million. Instruments that are typically disposed of after ten operations cost $1300 to $2300.
Hysterectomies were the most frequently performed operation by robotic assistance in 2011. There were 125 000 performed that year, which is more than the number of robotically assisted prostatectomies, which appear to have advantages over conventional prostate removal techniques.
The prediction is that there will be many more robotically assisted operations in the near future with the drivers being:
- Our innate fascination with new technology
- It is becoming the symbol of the provision of advanced care
- It is being hailed as a success story of ingenuity and progress
- The manufacturers wish to sell their products and direct-to-consumer advertising allows direct access to buyers in the USA
- Institutions and individuals who have bought the equipment need to promote robotic operations to justify the initial outlay and lower the costs per procedure
- Having purchased a robotic platform the surgeons need to improve their technique through frequent use
- By honing their skills through regular use they climb the learning curve, presumably offering faster operating times with fewer complications
- In the long-term there is money to be made by carrying out and hosting expensive operations
For these reasons, robotic hysterectomy is here to stay.
But two points remain unaddressed—those of cost and patient outcomes. The costs can be quantified, with Wright et al. (JAMA 2013;309:689–98) calculating that it costs around $6700 per laparoscopic hysterectomy compared with $8900 per robotic operation. This difference of over $2200 per procedure would add billions to healthcare budgets if robotic operations replaced conventional techniques. It would be different if robotic operations gave better results, or the time taken in theatre was less, or recovery times were shorter, or better cosmetic results were on offer—as then a case could be made for pursuing robotic surgery. Unfortunately no such evidence yet exists.
Editorials in the BMJ and JAMA (Paul et al. BMJ 2013;346:f1573; Wiessman and Zinner JAMA 2013;309:721–2) both call for randomised trials and comparative effectiveness research to ensure that more complex and expensive treatments have a strong evidence-base of better outcomes for them to be adopted.
Until such time as robotic hysterectomies are of proven benefit to women do they not represent surgical swagger rather than acting in the patients’ best interests?
Source : Drawn from Wright et al. JAMA 2013;309:689–98
Smoking is a cultural habit. Each country seems to have a different attitude towards tobacco but these views are being consolidated as people become aware of the medical and social hazards of tobacco use. Australia has led the way with legislation on branding while New Zealand has the ultimate aim of making the whole country smoke-free.
UK citizens have reduced their smoking over the last 40 years, in men from 51% to 21% and in women from 41% to 19%. The Dutch have not been as successful in giving up, with smoking increasing from 25% to 26% last year.
The data on smoking show that there are methods of reducing cigarette consumption. Legislation on smoke-free environments, duties on tobacco and media campaigns all have an effect on smoking rates. Probably the best example of these effects in action is in New York City where the last decade has seen a dramatic drop in smokers from the national average of 22–14% with the declines in percentages mirroring the authority's efforts in encouraging quitting (Farley et al. JAMA 2013;309:1221–3). New laws, new taxes and new attitudes can make communities react differently to smoking.
Half of all smokers die prematurely from tobacco-related causes. They live on average 10 years shorter than non-smokers. The medical profession should be understanding of smokers’ addiction but clear on their stance to assist smokers to quit in a compassionate way. Like being overweight, pointing out the error of somebody's ways is not the solution, neither is getting angry. Behavioural change is all about getting the person on your side, usually through empathy for the person's situation and using ‘motivational interviewing’ (Kaner and McGovern BMJ 2013;346:f1763). This is always a challenge but for doctors it is a professional duty to assist patients in this way and speak up about the dangers of smoking and engage in behaviour-change counselling.
So do we have an obligation to enquire and intervene about smoking in all our obstetric or gynaecological patients?
Pregnancy affords us an opportunity to make the opening gambit armed with data about the statistics of harm to the unborn child. This may give us the moral high-ground to encourage intervention but playing on a woman's guilt is a poor option unless it is followed through by positive cessation support. All antenatal efforts are directed towards the fetus's wellbeing so this is one of the clearest benefits that professionals and the expecting woman can achieve. The obligation is clear and failing to grasp the nettle is negligent. Here proper antenatal care can make a difference.
Any gynaecological patient should also have her smoking habits queried. Be the interaction with her at a check-up, a contraceptive visit or to deal with pathology, a proper consultation must include the prevention of ill health. The point is made by Fiore and Baker (JAMA 2013;309:1032–3) that all doctors know accurately the perils of cigarette smoking-so clinicians have a clear duty to ask, advise and follow through. Smoking is no longer a threat to be ignored.
Helping physicians get their cessation message across are two articles in JAMA. The first addresses the issue of quitting smoking and subsequent weight gain (Clair et al. 2013;309:1014–21). People do gain a mean of 4 kg in their first year of abstinence but they retain the reduction in risk of cardiovascular disease, the biggest danger of continued smoking. The second describes the opportunity afforded to quit when a woman is operated on (Khullar et al. JAMA 2013;309:993–4). The perioperative advantages are startling and of course the long-term gains are substantial.
Doctors seldom save lives but they can save patients money by not ordering ineffective screening and unnecessary investigations and they can improve the health of our patients who smoke by helping them to quit.
Hormone therapy after the menopause
After a decade of bad press menopause hormone therapy is now being rationally researched and reported. The two most important concepts that are being emphasised are the types of hormones used and the timing of treatment.
Estradiol via patch delivery is superior to conjugated equine estrogens, and micronised progesterone or a progestin (not medroxyprogesterone acetate, which might be deleterious) are the progestogens of choice. The timing of initiating use is as soon after the menopause transition as possible and continued to the age of 60 years, during which time the risks are small and the benefits in terms of symptom control and cardiovascular protection are greatest (Schierbeck et al. BMJ 2012;345:e6409).
Another aspect of the postmenopausal years that is being investigated is mental health-more precisely cognitive impairment and Alzheimer's disease. Davey in Women's Health (2013;9:279–90) explores the mechanisms whereby a wider approach plus menopause hormone therapy during the ‘window of opportunity’-the years from the menopause transition till the age of 60 years—may prevent or ameliorate mental deterioration. It seems that the time frames of atherosclerosis and cognitive decline run parallel so theoretically interventions to protect against one could work for the other. Such steps are a Mediterranean diet (possibly with added vitamin D), attention to sleep and depression, engaging with brain-stimulating activities and hormone therapy. An additional effect would be skeletal protection so the advantages of menopause hormone therapy may be further proven in the many studies underway.
What is clear is the intense attention that is being given to the latter third of women's lives. They are living longer and should grow old gracefully with informed support from their gynaecologist who should provide ongoing primary care in concert with General Practitioners.