Defining Success in Hysteroscopy Procedures

[Dr. Mark Hoffman]
My next question. You obviously have done this before, but you answered our next question of what conditions can be treated with hysteroscopy. It sounds like basically everything.

[Dr. Linda Bradley]
Well, I wouldn't say that. I'd like to first say, there's two roles to hysteroscopy. One is diagnostic and the other is therapeutic. When you do surgery, it is a minimally invasive surgery. When I went to one of the hospitals that I was first working only out of the main campus, the Cleveland Clinic, and then the city has grown. The Cleveland Clinic bought eight other community hospitals. Many of us were told, "It's getting so busy at the main campus. You need to move these outpatient types of procedures out."

I go to another smaller hospital to be unnamed. There were a group of doctors from another hospital that used to practice there that were gynecologists. I just asked. I said, "Oh, do you have hysteroscopy and the D&C equipment?" They said, "Oh, yes, all of our doctors do hysteroscopy and D&C." Something said, "Can you open a tray? Show me what it is." What those physicians did was basically put a hysteroscope in.

They didn't have a resectoscope. There wasn't maybe a tissue morcellator, but there were resectoscopes. They looked. They then took out the D&C, the curette, and scraped the heck out of the uterus and called it a day. That is not hysteroscopic surgery, okay? My definition of hysteroscopic surgery is an uninterrupted visualization and removal of pathology that's there. Uninterrupted. You look. I never, ever, ever put a curette in a woman's uterus anymore, ever, okay?

It would have been so rare. Why do it? Because you can see, nothing's blind. I know I haven't perped. I know I haven't missed a lesion. Especially for fibroids, the type 0s, yes, 1s and 2s, I know I have all of it taken out. I think that's important. It's very interesting. I haven't told this story, but that physician, the anesthesiologist, is now retired. I'm a little feisty sometimes. He says to me in the OR with a med student and a resident and a fellow and the nurses, "The patient's asleep."

He puts his hands on his chest and says to me, "Young lady, I've never seen anybody take this long to do a hysteroscopy D&C." I kept my cool. Patient awakened and I said, "Dr. So-and-so, I want to speak with you. Do you have an office on this floor?" I went into his office, I closed his door, and I said, "Don't you ever speak to me in this fashion around my colleagues and peers and students. If you have something to say, please talk to me privately. We're both adults."

I said, "I don't play peekaboo hysteroscopy. I am not putting a scope in, then taking it out, scraping around, maybe not even looking again." I said, "I'm doing surgery," and blah, blah, blah. I also said to him, "I don't ever want you to touch a patient of mine. I don't want to work with you and I don't want you to be assigned to any of my cases." I just started at this hospital that is Cleveland Clinic, but it was so rude and unprofessional.

I didn't do the kind of surgery that those other doctors at the other hospital do. I think that's where it could take a long time. I would have residents speak to me, "Oh, so-and-so could have done a vag hyst," and I said, "Yes, but no one's going to get into a ureter, not going to have to hystens. You're not going to need antibiotics. You're not going to need narcotics. They can have sex in a week." For small or large intracavitary pathology, the rest of the uterus and adnexa are fine. There's no other reason to take out the uterus. Tell me why I shouldn't spend an hour if it takes me that long that the patient goes, wakes up, goes to the recovery room an hour and a half, goes home, and is doing things in short order.

[Dr. Amy Park]
Linda, well, let me just ask you. I think you've eloquently described why people should be getting hysteroscopes and why we should be offering them. Can you just give insight into how you would advise trainees to gain the skills?

[Dr. Linda Bradley]
Be curious, listen. This first hysteroscope was done, I think, 154 years ago. It's just, how can you practice blindly?

[Dr. Amy Park]
How about the technical skills? Are there simulations? Are there ways to practice? Do you have to do a fellowship? Is this something we can pick up with time? How do you get better at this blind? You have to do some cervical dilation for operative hysteroscopy. How do you get familiar with managing fluid deficits and all the things? There's a lot that goes into it. It's not like when they're easy, they're easy. When they're hard, they're hard. That's how surgery is. How do you approach that? I'm curious about your thoughts too, Mark, because we're all involved in trainees. They're getting less and less time to learn.

[Dr. Linda Bradley]
You have answered it. Like I said, for myself, I just looked and said, "Oh, my God. I have to learn this." I had my first slide for almost every lecture. It's a picture of a hysteroscope. It's all red and we call it the Japanese flag sign. First 50 cases, all I saw was blood. I knew Jay Cooper, Adamyan, Phil Brooks, Dr. Loffer. I saw their pictures. I was like, "I am going to keep learning this."

Again, my training was self-instruction because we did not have anybody in Cleveland, residency for where I was at the other hospital, or at the Cleveland Clinic doing this. I just said, "This is not a big space to navigate." Now, if you asked me to do a sacrospinous fixation by myself, I'd be like, "Oh, my God." I think, now, you answered the question. One is simulation. Number two, we're going to both push our societies that we're active in. This year's AAGL meeting in November at Nashville, postgraduate courses.

You have your simulators. Again, you hope that you can start with someone that's doing something so that the blind is not leading the blind. I think how I did this decades ago would probably be more frowned upon. That's how it happened. I would say now, hopefully, there is a champion at someone's institution, residency, or fellowship that they can try to spend more time in. The Cleveland Clinic, we have a tracking program where the residents may spend more time in a certain area.

I do think the coursework, just going to lectures, looking at what's possible is beneficial. You're right. We're not talking today about fluid management. There are particulars, things to do, know Trendelenburg, the different fluid management systems. There's a whole cottage industry around being safe. I don't know what trainees-- if they're allowed to go to other places to observe. Basically, nowadays, it's finding a mentor. Then it's like an apprenticeship, watching, learning, and then doing.

[Dr. Mark Hoffman]
I agree with what you're saying. I also think that we have more opportunities in training than we realize. I think one of the things I noticed specifically with hysteroscopy, I was always fascinated by it. I loved it. They're my favorite cases. I think when you do a really tough hysteroscopic case and you just walk away and there's no incision to close, they go home and like ibuprofen and Tylenol.

You just feel like you've done something really special for them. I think people think of hysteroscopic cases as though that's an intern case or a second-year case because hysterectomies and majors are really what I need to be doing in my upper levels. I think these are cases that can be really challenging. These are cases in which there is a definite skill to hysteroscopy. There's absolutely a skill, just sometimes on the difficult case to get in.

I see all the time where I'll be with a resident. They'll start the case and they grab a dilator. I'm like, "Whoa, stop. Get that away." They'll take the giant operative scope. I say, "There's a diagnostic scope right there. Put it together. You know how to use it." They're still having trouble. "There's an outer sheath. Take the outer sheath off. Just take off the outflow. You've got a tiny, little scope. Walk right in."

They go, "Oh, wait. We didn't have to put a clamp on. We didn't dilate." All of a sudden, you walk in there and the cavity goes posteriorly. You go, "Oh, wait, it's a good thing we looked because you would have perforated anteriorly while you were dilating." This idea that you're going to dilate blindly because I can't get my scope in, it is an art like all of surgery. There is a nuance. There is a skill set that I think we have too low an expectation for advanced hysteroscopy.

We have too low an idea about what it can be. I think that one of the reasons why I was trying to find you at meetings is because I want to know how I can do more. I think about the operative hysteroscopy that I want to talk about in just a second. It's just as simple as the diagnostic part of it. Just getting there sometimes on the tough hysteroscopes where I can see where someone would perforate where the disaster happens. You got to see it ahead of time and know how to prevent that.

I do think challenging our chiefs to really continue with hysteroscopy for four years, not just, "Oh, this is a junior-level case." I think that's something that is important. Hysteroscopic myomectomy has, I think, five different variables all happening at once, right? You've got the camera rotation. You've got the rotation of the actual device, which is above the camera. Below, you've got the instrument rotation. You've got the instrument in and out, plus you've got a pedal. There's four to five or six different things moving at once.

You've got to keep your horizon. It's not a straightforward procedure. It sounds like, "Oh, camera, cutting device, simple." There is absolutely a skill. That's just for a MyoSure. The resectoscope is a whole other thing. It takes doing a lot of these like any skill. My feeling is you have to understand how valuable it is, but also understand what the potential is to know how hard to work to get there and not settle for a low bar, not settle for, "Oh, I can throw a scope at it. That's no big deal."

[Dr. Linda Bradley]
People used to ask me, do I do vagis? The answer would be yes, but I did the easiest ones. You couldn't be overweight. You couldn't have had a C-section. You had to have a baby. I just did and I'm embarrassed as a gynecologist to say that I would make a referral, like yesterday was a very interesting day. This patient had two C-sections. I met her in the office because there was postmenopausal bleeding again, but it took two hours for me to get her cervix dilated. I know I can do it, I got frustrated, but she has gone two to three years of bleeding. We can't get in. It's so tucked up and underneath her. Probably the uterus was stuck to her abdominal wall. Yes, that was not an easy case. Once we got in, it was easy, but the whole challenge for a topic expert is getting into that cervix and several people had taken her to the OR and couldn't get in.

Then I also, the way our practice is, I'm considered a consultant. People fly all over the country, have had two procedures, have had a uterine perf and complete resection, and they've just got something that needs to come out. I'm always feeling like, I've got to do this and I will just work until I get in. Sometimes it just doesn't work, but luckily it's not that often.
Yes, I agree. This is a skill you'd have to keep doing the easy cases because sometimes easy is a little bit harder than a moderate heart and then a super heart. I would tell anybody who's just starting, you shouldn't start with someone that you're getting referred. If you're finishing fellowship and training, you haven't done that much work with somebody.