Melanie Cole, MS (Host): Welcome to Health Talk, presented by the Valley Health System. I'm Melanie Cole. And today, we're talking about minimally invasive options for hysterectomy, and principally utilizing the vaginal approach or vNOTES. Joining me today is Dr. Lamarr Tyler. He's an obstetrician-gynecologist with Intermountain Health, and he's on the medical staff at the Valley Health System.

 Dr. Tyler, thank you so much for joining us today. So, before we get into vNOTES and hysterectomy, tell us a little bit about this procedure, the evolution of it, and what are some of the main reasons that a woman might even need a hysterectomy?

Lamarr Tyler, DO: Sure. So, I think that's really the first question is, does the patient need a hysterectomy? And most common reasons are things like abnormal uterine bleeding, uterine fibroids, endometriosis, adenomyosis. These are all benign conditions, but they can truly cause a lot of debilitating symptoms in patients' lives.

Once patients are done with childbearing, if these symptoms are really bothersome and they've failed other medical options or other conservative options, then hysterectomy becomes a reasonable approach to taking care of these issues. In that ring, we try to make sure we find the least invasive option for hysterectomy.

Traditionally, when I was in training, we only had two options. That was a vaginal approach and open approach. Nowadays, we are offering a lot of minimally invasive technologies, primarily with things you may have heard about using a laparoscope or a robot. But the vaginal approach has always been the least invasive option for hysterectomy. And unfortunately, it's become a lost skill set amongst most gynecologists. And this is where vNOTES comes into play, because now we can use the same technology with a laparoscope, but now we use it vaginally. So, it allows us to visualize the same procedure during the vaginal approach, which means we have no abdominal incisions, means you have less pain, quicker recovery, less bleeding.

Melanie Cole, MS: Wow. It really is amazing in how things circle back around. So, tell us a little bit more about the vNOTES procedure, how it differs from what we think of as—I mean, obviously, Doctor, traditional hysterectomy has evolved over the years, as you said, and from an open procedure to a minimally invasive procedure. How is this different because we're going through the vaginal orifice? Tell us a little bit about the benefits, and I'd like you to even talk about the benefits to you, to the surgeon.

Lamarr Tyler, DO: Absolutely. So, NOTES is just an acronym. It means Natural Orifice Transluminal Endoscopic Surgery, which means that we're now using the body's own natural openings to do surgery. Traditional vaginal hysterectomy was actually quite challenging to do, because you really couldn't visualize what you were doing. We had to really develop a special skill set to be able to understand the anatomy and complete the surgery vaginally. With vNOTES, we have a special access platform that now allows us to insert the laparoscope vaginally and the operating instruments vaginally and complete the procedure that way from the bottom-up versus the top-down.

Most important thing is that you simply are using the vaginal area. It's completely scarless, which means you have no abdominal scars. And then, the lack of scars means you have less pain, less bleeding, quick recovery, and more importantly, nowadays, we can also get the adnexa, which is primarily the ovaries and the tubes, which is very important in patients. We now know that most ovarian cancer starts in the fallopian tube. So, if a patient's having a hysterectomy removing the uterus, we generally also take out the tubes as well to help reduce their risk of ovarian cancer if the ovaries are left inside too.

Melanie Cole, MS: Is this an outpatient surgery? Do you spend the night in the hospital? Tell us a little bit about the procedure itself.

Lamarr Tyler, DO: So, 95% of all my hysterectomy cases go home the same day. So, this is an outpatient procedure. So, I'm generally trying to accomplish this procedure with the vNOTES approach. And I would say that roughly 50-60% of these case, the cases of patients that I see can be done in this manner. If not, then I use the laparoscope traditionally, either robotically or what we call straight-stick laparoscopy, and we use that through the abdominal approach. All three approaches do allow you to go home the same day.

The key issue is trying to find the least invasive option for approaching the patient's pathology. And as I said before, without any scars, that truly enhances the patient's recovery. So, this truly is an outpatient procedure.

Melanie Cole, MS: That really is amazing. Now, tell us a little bit about patient selection, Doctor, because this is not available for everybody. Are there certain contraindications, whether it's obesity or certain cancers? Are there any contraindications?

Lamarr Tyler, DO: So actually, believe it or not, the obese patient is actually a great candidate for this procedure because now you are minimizing the risk of having to go through a lot of the adipose tissue to get to the target organ, which is the uterus. So, the vaginal area is actually the quickest access point to get into the pelvic area.

The patient selection comes down to uterine size, uterine mobility, patient's previous experience of vaginal deliveries. But we are also doing some procedures to patients who had C-sections and who never had any children before. So, the really limiting factor for me is can I get in the bottom portion of the vagina? Because then, I can insert gas into the abdominal cavity, and that makes the top portion of the vagina easier to open up.

Once that happens, then I have a access platform that I'm able to put into the vagina. This now allows me to put trocars or instruments through that platform without having to make incisions in the abdomen and do the surgery in that manner. Certain cancers, we have to be very careful of things like cervical cancer and endometrial cancers. Those are ones we typically would avoid doing this approach for. And patients that may have advanced endometriosis may also be a contraindication.

Melanie Cole, MS: Then, how do you make this decision with patients? And talk about shared decision-making and how you explain these procedures versus what we think of as traditional hysterectomy.

Lamarr Tyler, DO: Yeah, I think the best way to have this discussion, I truly agree with a shared decision process, because that's really the way to go. I like to use the benefit of my knowledge and my skill set to explain to patients what their disease pathology is, and then what are some of their approaches to treatment, whether it be conservative observation, medication, and obviously hysterectomy.

In choosing hysterectomy, a lot depends on the patient's history. A patient who's had children, as I mentioned previously, is perfectly a candidate for a vaginal approach, especially if they had them done vaginally. But a C-section is not a contraindication for this being done. Uterine size is very important. So if you've got a really large, bulky uterus, that may make it difficult to do it vaginally. Somebody who may have a very narrow vaginal area who hasn't had children, that can be quite challenging as well.

But that being said, all patients who present for hysterectomy, I would tell you that in proper patient selection and proper evaluation with imaging, 60% of these patients can be done with a vNOTES approach.

Melanie Cole, MS: Wow. Thank you so much for telling us all of this. Now, Dr. Tyler, we think of certain medications we've heard about over the years that have been, you know, initiated for one disease, and then we start using them for another. Do you see other conditions that could be treated with vNOTES? And where do you see this going?

Lamarr Tyler, DO: Yeah. So basically, patients that may have ovarian cysts who don't need a hysterectomy, you can treat that. We are able to do tubal ligations that can be done through the vaginal approach. Patients that may have even an ectopic pregnancy, for instance, we can treat that with the vaginal approach. So, there are a lot of these things that we traditionally do with laparoscopic incisions in the abdominal area that we can now do in the vaginal area using this vNOTES approach.

Melanie Cole, MS: Dr. Tyler, do you have any final thoughts? I'd like you to give your best advice for women that are considering hysterectomy and learning about all of the different options available. What would you like them to know about what you're doing at the Valley Health System and vNOTES?

Lamarr Tyler, DO: I recommend that they really become really informed and do their research. If they're talking to their provider about hysterectomy, ask them why they're doing the approach that they're recommending. And if they're recommending a robotic or laparoscopic approach, then ask them can they do this vaginally, okay? And they can reference vNOTES and do their research online. And more importantly, they can reach out to the providers here at Valley Health who are providing this great procedure to seek consultation.

Melanie Cole, MS: Thank you so much, Dr. Tyler, for joining us today and really sharing your incredible expertise for our listeners. And to learn more about this and other healthcare topics at the Valley Health System, please visit valleyhealthsystemlv.com. That concludes today's episode of Health Talk with the Valley Health System.

We'd like to invite our audience to download, subscribe, rate, and review Health Talk on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.

Disclaimer: Physicians are independent practitioners who are not employees or agents of the Valley Health System. The system shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks with any surgical procedure. Please talk with your physician about these risks to find out if this procedure is right for you.