Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Presenters

Eric Coon, Ricardo Quinonez, Alan Schroeder

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.

The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.

The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.

Key Takeaway

The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Presenters

Eric Coon, Ricardo Quinonez, Alan Schroeder

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.

The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.

The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.

Key Takeaway

The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Presenters

Eric Coon, Ricardo Quinonez, Alan Schroeder

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.

The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.

The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.

Key Takeaway

The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?

James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Presenters

Dan Hale, MD, FAAP, and Elisabeth Schainker, MD, FAAP, The Floating Hospital for Children at Tufts Medical Center, Boston

Summary

"Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high-quality and sustainable program,” said Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals that programs should review before starting and also periodically after established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine were used as a starting point for program self-evaluation. These “building blocks” include:

• Establish the rationale for the program and include all stakeholders;

• Financial expectations; • Define scope of practice;

• Nursing and referral physician collaboration;

• Assess staffing and workload expectations;

• Referral base; and

• Basic code and emergency preparedness.

Ongoing program development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (emergency, radiology, surgery, etc.);

• Newborn medicine care;

• Internal group clinical practice guidelines;

• Co-management of surgical or specialty patients;

• Transfers from other hospitals or continuing care from tertiary care centers;

• Pediatric code teams and rapid response teams;

• Advanced code and emergency preparedness and mock code training; and

• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program. The essentials of a successful distributed network of multiple hospitalist program site were also described. After assuring the fundamentals are present at each site, transparency and institutional alignment are imperative.

Key Takeaways

1. It is important to understand several fundamental elements of hospitalist programs and address goals before starting a program.

2. For existing programs, it is important to review the fundamentals periodically and provide program maintenance.

3. After a program is established and fundamentals are in place, other important advance practices can be added on. These include ongoing collaboration, advanced emergency planning, staff education, and clinical practice guidelines.

4. For a multiple site or distributed program, high level collaboration and transparency is essential.

Dr. Hale is a past member of Team Hospitalist and is a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

ANSWER

Admittedly, this is a bit of a trick question—but with a good teaching point to make. A course of oral fluconazole (choice “a”) is futile, since there’s no reason to think this problem is yeast-driven and since the patient has already demonstrated a lack of response to topical imidazoles.

Punch biopsy (choice “b”) would be a good choice, but not in this area, where it could quickly become a bigger problem than the one the patient presented with. Sutures would not likely hold the biopsy wound together, and resultant infection is all too likely.

A KOH test to detect fungal or yeast elements (choice “c”) is unlikely to shed any light on the problem, given the lack of response to antifungal creams. Finally, there’s no reason to suspect a bacterial origin, so oral antibiotics such as cephalexin (choice “d”) would be useless (and had already been tried unsuccessfully).

The correct answer is none of the above (choice “e”).

DISCUSSION

This case illustrates why dermatology seems so maddeningly difficult to the uninitiated. Any experienced derm provider would know the correct diagnosis, lichen sclerosus et atrophicus (LS&A), because it presents in such a distinctive way (in limited locations, predominantly in women) and because the differential is so limited. But if you’ve never heard of LS&A, you’re unlikely to diagnose it, let alone know how to treat it.

LS&A is an inflammatory condition of unknown origin that affects the upper epidermis. It can present in extragenital locations (particularly shoulders and legs) but is far more common in genital areas. As exhibited in this case, it presents with well-defined pigment loss, which is especially easy to see in patients with darker skin.

Although more commonly seen in women, LS&A can occur in men, usually manifesting on the penile glans and distal foreskin of uncircumcised patients. The dry atrophic changes seen on the glans can lead to stenosis of the urethral meatus and, proximally, to adhesions (phimosis) of the foreskin. (This condition was termed balanitis xerotica obliterans [BXO] long before its pathologic process was determined to be identical to LS&A’s. Tissue specimens obtained during circumcisions performed for chronic phimosis often yield evidence of BXO.)

In women, untreated chronic LS&A can lead to sclerotic changes in and around the urethra and labia minora and can cause introital stenosis. This case is a bit atypical; LS&A more often manifests in perivaginal and perirectal areas, where the intense hypopigmentation produces a classic “figure eight” appearance.

The differential includes lichen simplex chronicus, psoriasis, lichen planus, contact/irritant dermatitis, and seborrhea. Often, biopsy is necessary and appropriate to settle the issue, other factors being equal.

TREATMENT/PROGNOSIS

The patient was given a prescription for clobetasol 0.05% ointment for twice-daily application Monday through Friday (and no application for two consecutive days—in this case, the weekend—per week). Studies have established the efficacy and safety of this treatment regimen.

In a month or two, application can be reduced to once or twice a week to control the condition.

ANSWER

Admittedly, this is a bit of a trick question—but with a good teaching point to make. A course of oral fluconazole (choice “a”) is futile, since there’s no reason to think this problem is yeast-driven and since the patient has already demonstrated a lack of response to topical imidazoles.

Punch biopsy (choice “b”) would be a good choice, but not in this area, where it could quickly become a bigger problem than the one the patient presented with. Sutures would not likely hold the biopsy wound together, and resultant infection is all too likely.

A KOH test to detect fungal or yeast elements (choice “c”) is unlikely to shed any light on the problem, given the lack of response to antifungal creams. Finally, there’s no reason to suspect a bacterial origin, so oral antibiotics such as cephalexin (choice “d”) would be useless (and had already been tried unsuccessfully).

The correct answer is none of the above (choice “e”).

DISCUSSION

This case illustrates why dermatology seems so maddeningly difficult to the uninitiated. Any experienced derm provider would know the correct diagnosis, lichen sclerosus et atrophicus (LS&A), because it presents in such a distinctive way (in limited locations, predominantly in women) and because the differential is so limited. But if you’ve never heard of LS&A, you’re unlikely to diagnose it, let alone know how to treat it.

LS&A is an inflammatory condition of unknown origin that affects the upper epidermis. It can present in extragenital locations (particularly shoulders and legs) but is far more common in genital areas. As exhibited in this case, it presents with well-defined pigment loss, which is especially easy to see in patients with darker skin.

Although more commonly seen in women, LS&A can occur in men, usually manifesting on the penile glans and distal foreskin of uncircumcised patients. The dry atrophic changes seen on the glans can lead to stenosis of the urethral meatus and, proximally, to adhesions (phimosis) of the foreskin. (This condition was termed balanitis xerotica obliterans [BXO] long before its pathologic process was determined to be identical to LS&A’s. Tissue specimens obtained during circumcisions performed for chronic phimosis often yield evidence of BXO.)

In women, untreated chronic LS&A can lead to sclerotic changes in and around the urethra and labia minora and can cause introital stenosis. This case is a bit atypical; LS&A more often manifests in perivaginal and perirectal areas, where the intense hypopigmentation produces a classic “figure eight” appearance.

The differential includes lichen simplex chronicus, psoriasis, lichen planus, contact/irritant dermatitis, and seborrhea. Often, biopsy is necessary and appropriate to settle the issue, other factors being equal.

TREATMENT/PROGNOSIS

The patient was given a prescription for clobetasol 0.05% ointment for twice-daily application Monday through Friday (and no application for two consecutive days—in this case, the weekend—per week). Studies have established the efficacy and safety of this treatment regimen.

In a month or two, application can be reduced to once or twice a week to control the condition.

ANSWER

Admittedly, this is a bit of a trick question—but with a good teaching point to make. A course of oral fluconazole (choice “a”) is futile, since there’s no reason to think this problem is yeast-driven and since the patient has already demonstrated a lack of response to topical imidazoles.

Punch biopsy (choice “b”) would be a good choice, but not in this area, where it could quickly become a bigger problem than the one the patient presented with. Sutures would not likely hold the biopsy wound together, and resultant infection is all too likely.

A KOH test to detect fungal or yeast elements (choice “c”) is unlikely to shed any light on the problem, given the lack of response to antifungal creams. Finally, there’s no reason to suspect a bacterial origin, so oral antibiotics such as cephalexin (choice “d”) would be useless (and had already been tried unsuccessfully).

The correct answer is none of the above (choice “e”).

DISCUSSION

This case illustrates why dermatology seems so maddeningly difficult to the uninitiated. Any experienced derm provider would know the correct diagnosis, lichen sclerosus et atrophicus (LS&A), because it presents in such a distinctive way (in limited locations, predominantly in women) and because the differential is so limited. But if you’ve never heard of LS&A, you’re unlikely to diagnose it, let alone know how to treat it.

LS&A is an inflammatory condition of unknown origin that affects the upper epidermis. It can present in extragenital locations (particularly shoulders and legs) but is far more common in genital areas. As exhibited in this case, it presents with well-defined pigment loss, which is especially easy to see in patients with darker skin.

Although more commonly seen in women, LS&A can occur in men, usually manifesting on the penile glans and distal foreskin of uncircumcised patients. The dry atrophic changes seen on the glans can lead to stenosis of the urethral meatus and, proximally, to adhesions (phimosis) of the foreskin. (This condition was termed balanitis xerotica obliterans [BXO] long before its pathologic process was determined to be identical to LS&A’s. Tissue specimens obtained during circumcisions performed for chronic phimosis often yield evidence of BXO.)

In women, untreated chronic LS&A can lead to sclerotic changes in and around the urethra and labia minora and can cause introital stenosis. This case is a bit atypical; LS&A more often manifests in perivaginal and perirectal areas, where the intense hypopigmentation produces a classic “figure eight” appearance.

The differential includes lichen simplex chronicus, psoriasis, lichen planus, contact/irritant dermatitis, and seborrhea. Often, biopsy is necessary and appropriate to settle the issue, other factors being equal.

TREATMENT/PROGNOSIS

The patient was given a prescription for clobetasol 0.05% ointment for twice-daily application Monday through Friday (and no application for two consecutive days—in this case, the weekend—per week). Studies have established the efficacy and safety of this treatment regimen.

In a month or two, application can be reduced to once or twice a week to control the condition.

Vaginal hysterectomy is the preferred route to benign hysterectomy because it is associated with better outcomes and fewer complications than the laparoscopic and open abdominal approaches.^1,2 Yet, despite superior patient outcomes and cost benefits, the rate of vaginal hysterectomy is declining.

According to the Nationwide Inpatient Sample, the use of vaginal hysterectomy declined from 24.8% in 1998 to 16.7% in 2010.³ In fact, more than 80% of surgeons in the United States now perform fewer than five vaginal procedures in a year.⁴

The increasing use of other minimally invasive routes, such as laparoscopy and robotics, indicates that most practicing surgeons and recent graduates are choosing these approaches over the vaginal route. In only 3 years, the rate of laparoscopy increased by 6% and robotics increased by ­almost 10%.³

Many surgeons assume that vaginal hysterectomy exists in a state of suspended animation, with nothing much changed in the way it has been performed over the past few decades. Further, vaginal surgery is difficult to teach and learn, given limitations in exposure and visualization, difficulty in securing hemostasis, and challenges in the removal of the large uterus and adnexae. As a result, vaginal hysterectomy often is thought, erroneously, to be indicated only in procedures involving a small and prolapsing uterus.

To increase the rate of vaginal hysterectomy, we can benefit from experience gained in laparoscopy and robotics—whether we are teachers or learners—while maintaining patient safety and containing costs.

In this article, I describe common challenges in vaginal hysterectomy and offer tools and techniques to overcome them:

• achieving and enhancing ergonomics, exposure, and visualization
• the need to work in a long vaginal vault
• the task of securing vascular and thick tissue pedicles when the introitus and vaginal vault are narrow.

The vaginal approach is less costly
Vaginal hysterectomy costs significantly less to perform than other approaches. At a tertiary referral center, vaginal hysterectomy costs approximately $7,000 to $18,000 per case less than laparoscopic, abdominal, and robotic hysterectomy.⁵ With declining use of vaginal hysterectomy and increasing use of more costly approaches, we face a health-care crisis.

Residents are inadequately trained to perform vaginal hysterectomy
Data reveal that not only are our recent graduates inadequately prepared to perform vaginal hysterectomy, but national health-care dollars and resources are depleted when surgeons choose to perform more costly approaches. As a result, many eligible patients end up deprived of the benefits of a single, concealed, and minimally invasive procedure.

The increase in laparoscopic and robotic approaches to hysterectomy has affected residency training. National case log reports from the Accreditation Council of Graduate Medical Education show that the number of vaginal hysterectomies performed by residents as “primary surgeons” decreased by 40%, from a mean of 35 cases in 2002 to 19 cases in 2012.⁶ A recent survey found that only 28% of graduating residents were “completely prepared” to perform a vaginal hysterectomy, compared with 58% for abdominal hysterectomy, 22% for laparoscopic hysterectomy, and 3% for the robotic approach.⁷

The rate of vaginal hysterectomy will continue to decline if we perform it in the same manner it was done 30 years ago. The current generation of practicing gynecologists and graduates is choosing to perform the procedure laparoscopically or robotically because of the advantages these technologies provide. It is time that we incorporate features from these minimally invasive approaches to streamline vaginal hysterectomy while maintaining patient safety and containing costs.

Challenges: Ergonomics, exposure, and visualization
In conventional vaginal surgery, the surgeon often is the person who has the best and, sometimes, the sole view. Two bedside assistants are required to hold retractors during the entire case, which can lead to fatigue and muscle strain. Poor lighting also can greatly limit visualization into the pelvic cavity.

Both laparoscopy and robotics provide a well-illuminated and magnified view, with three-dimensional images now available in both platforms. This view is projected to overhead monitors for the entire surgical team to see. Magnification of the pelvic anatomic structures and projection to an external monitor facilitate teaching and learning, better anticipation of the surgical and procedural needs, and overall patient safety.

From robotics, where ergonomics is exemplified, we also learn the importance of surgeon comfort during the procedure.

Solution #1: A self-retaining retractor
A self-retaining system such as the Magrina-Bookwalter vaginal retractor (Symmetry Surgical, Nashville, Tennessee) (FIGURE 1)

Solution #2: Seat the surgeon for an optimal view
With the patient in the lithotomy position and her legs in candy cane stirrups, the surgeon can be seated on a high chair so that the operative field is at the approximate level of the assistants’ view (FIGURE 2)

Solution #3: Illuminate the cavity
The deep pelvic cavity can be easily illuminated using a lighted suction tip, a flexible light source (as part of the cystoscopy set) held with a Babcock clamp (FIGURE 3), or a malleable illuminating mat taped to the retractor blades (such as Lightmat surgical illuminator, Lumitex, Inc., Strongsville, Ohio).

Solution #4: Project the image
Cameras attached to an overhead boom or operating room light handles (FIGURE 4) and an external telescope with integrated illumination, such as a standard cystoscope or VITOM Exoscope (Karl Storz, El Segundo, California) (FIGURE 5) provide both magnification and projection of the procedure to an overhead monitor.

Glass technology (Google, Mountain View, California) also has been utilized in surgery and can be a good application of simultaneous projection and recording of the procedure to an external monitor (­FIGURE  6). Google Glass is a wearable computer with an optical head-mounted display. The device, similar to eyeglasses, is voice-activated, thereby allowing the surgeon to record the procedure hands-free. Simultaneous projection to an external monitor allows the entire team in the operating room to be aware of the flow of the procedure.

Challenge: Working in a narrow vaginal vault
Without correct instrumentation, this challenge can be especially daunting. Laparoscopy and robotics have changed the way we perform pelvic surgery by providing advanced instrumentation.

Solution #5: Adapt your instruments
Modified vaginal instruments can be used to facilitate a case. Watch the accompanying VIDEO on the use of improved vaginal instruments during morcellation.

Among the instruments adaptable for vaginal surgery:

• curving, articulating instruments
• long, curved, and rounded knife handles, which allow for better ergonomics during prolonged morcellation
• modified long retractors and use of a single long vaginal pack provide retraction of loops of bowel and easy access to secure pedicles deep in the pelvis.

All of these instruments are available through  Marina Medical in Sunrise, Florida.

Challenge: Securing vascular and thick tissue pediclesA narrow introitus and vaginal vault can be difficult to manage during vaginal surgery. Another challenge is a uterus that is large or deformed by multiple fibroids.

Solution #6: Vaginal incision
A simple superficial 2- to 3-cm incision on the distal posterior aspect of the vaginal wall can widen the introitus and vault to facilitate the procedure (FIGURE 7)

Solution #7: Vessel-sealing tools
The use of energy is integral to laparoscopy and robotics for dissection and securing vessels. In a meta-analysis that included seven randomized controlled trials, advanced vessel-sealing devices proved useful in vaginal surgery by decreasing blood loss and operative time.⁸

In the setting of a difficult vaginal hysterectomy with a narrow introitus and large uterus, the use of vessel-sealing technology allows the surgeon to skeletonize the uterine arteries while allowing progressive descensus to secure the upper pedicles.

In my experience, the use of an advanced vessel-sealing device, compared with traditional clamp-cut-tying technique, facilitated successful completion of vaginal hysterectomy in 650 patients with relative contraindications to the vaginal approach, such as nulliparity, a uterus weighing more than 250 g, and a history of cesarean delivery (Mayo Clinic data; yet unpublished).

We must change with the times
The rate of vaginal hysterectomy will continue to decline unless we modify our technique to incorporate new technology. The current generation of practicing gynecologists and recent graduates are choosing the laparoscopic and robotic approaches because of the advantages these technologies offer. It is time we incorporate relevant features from these minimally invasive approaches while maintaining patient safety and containing costs by performing vaginal hysterectomy whenever possible. A willingness to change and ability to think outside the usual box will help us train new generations of vaginal surgeons who can bring back vaginal hysterectomy as the preferred route to the benign hysterectomy.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected]

Vaginal hysterectomy is the preferred route to benign hysterectomy because it is associated with better outcomes and fewer complications than the laparoscopic and open abdominal approaches.^1,2 Yet, despite superior patient outcomes and cost benefits, the rate of vaginal hysterectomy is declining.

According to the Nationwide Inpatient Sample, the use of vaginal hysterectomy declined from 24.8% in 1998 to 16.7% in 2010.³ In fact, more than 80% of surgeons in the United States now perform fewer than five vaginal procedures in a year.⁴

The increasing use of other minimally invasive routes, such as laparoscopy and robotics, indicates that most practicing surgeons and recent graduates are choosing these approaches over the vaginal route. In only 3 years, the rate of laparoscopy increased by 6% and robotics increased by ­almost 10%.³

Many surgeons assume that vaginal hysterectomy exists in a state of suspended animation, with nothing much changed in the way it has been performed over the past few decades. Further, vaginal surgery is difficult to teach and learn, given limitations in exposure and visualization, difficulty in securing hemostasis, and challenges in the removal of the large uterus and adnexae. As a result, vaginal hysterectomy often is thought, erroneously, to be indicated only in procedures involving a small and prolapsing uterus.

To increase the rate of vaginal hysterectomy, we can benefit from experience gained in laparoscopy and robotics—whether we are teachers or learners—while maintaining patient safety and containing costs.

In this article, I describe common challenges in vaginal hysterectomy and offer tools and techniques to overcome them:

• achieving and enhancing ergonomics, exposure, and visualization
• the need to work in a long vaginal vault
• the task of securing vascular and thick tissue pedicles when the introitus and vaginal vault are narrow.

The vaginal approach is less costly
Vaginal hysterectomy costs significantly less to perform than other approaches. At a tertiary referral center, vaginal hysterectomy costs approximately $7,000 to $18,000 per case less than laparoscopic, abdominal, and robotic hysterectomy.⁵ With declining use of vaginal hysterectomy and increasing use of more costly approaches, we face a health-care crisis.

Residents are inadequately trained to perform vaginal hysterectomy
Data reveal that not only are our recent graduates inadequately prepared to perform vaginal hysterectomy, but national health-care dollars and resources are depleted when surgeons choose to perform more costly approaches. As a result, many eligible patients end up deprived of the benefits of a single, concealed, and minimally invasive procedure.

The increase in laparoscopic and robotic approaches to hysterectomy has affected residency training. National case log reports from the Accreditation Council of Graduate Medical Education show that the number of vaginal hysterectomies performed by residents as “primary surgeons” decreased by 40%, from a mean of 35 cases in 2002 to 19 cases in 2012.⁶ A recent survey found that only 28% of graduating residents were “completely prepared” to perform a vaginal hysterectomy, compared with 58% for abdominal hysterectomy, 22% for laparoscopic hysterectomy, and 3% for the robotic approach.⁷

The rate of vaginal hysterectomy will continue to decline if we perform it in the same manner it was done 30 years ago. The current generation of practicing gynecologists and graduates is choosing to perform the procedure laparoscopically or robotically because of the advantages these technologies provide. It is time that we incorporate features from these minimally invasive approaches to streamline vaginal hysterectomy while maintaining patient safety and containing costs.

Challenges: Ergonomics, exposure, and visualization
In conventional vaginal surgery, the surgeon often is the person who has the best and, sometimes, the sole view. Two bedside assistants are required to hold retractors during the entire case, which can lead to fatigue and muscle strain. Poor lighting also can greatly limit visualization into the pelvic cavity.

Both laparoscopy and robotics provide a well-illuminated and magnified view, with three-dimensional images now available in both platforms. This view is projected to overhead monitors for the entire surgical team to see. Magnification of the pelvic anatomic structures and projection to an external monitor facilitate teaching and learning, better anticipation of the surgical and procedural needs, and overall patient safety.

From robotics, where ergonomics is exemplified, we also learn the importance of surgeon comfort during the procedure.

Solution #1: A self-retaining retractor
A self-retaining system such as the Magrina-Bookwalter vaginal retractor (Symmetry Surgical, Nashville, Tennessee) (FIGURE 1)

Solution #2: Seat the surgeon for an optimal view
With the patient in the lithotomy position and her legs in candy cane stirrups, the surgeon can be seated on a high chair so that the operative field is at the approximate level of the assistants’ view (FIGURE 2)

Solution #3: Illuminate the cavity
The deep pelvic cavity can be easily illuminated using a lighted suction tip, a flexible light source (as part of the cystoscopy set) held with a Babcock clamp (FIGURE 3), or a malleable illuminating mat taped to the retractor blades (such as Lightmat surgical illuminator, Lumitex, Inc., Strongsville, Ohio).

Solution #4: Project the image
Cameras attached to an overhead boom or operating room light handles (FIGURE 4) and an external telescope with integrated illumination, such as a standard cystoscope or VITOM Exoscope (Karl Storz, El Segundo, California) (FIGURE 5) provide both magnification and projection of the procedure to an overhead monitor.

Glass technology (Google, Mountain View, California) also has been utilized in surgery and can be a good application of simultaneous projection and recording of the procedure to an external monitor (­FIGURE  6). Google Glass is a wearable computer with an optical head-mounted display. The device, similar to eyeglasses, is voice-activated, thereby allowing the surgeon to record the procedure hands-free. Simultaneous projection to an external monitor allows the entire team in the operating room to be aware of the flow of the procedure.

Challenge: Working in a narrow vaginal vault
Without correct instrumentation, this challenge can be especially daunting. Laparoscopy and robotics have changed the way we perform pelvic surgery by providing advanced instrumentation.

Solution #5: Adapt your instruments
Modified vaginal instruments can be used to facilitate a case. Watch the accompanying VIDEO on the use of improved vaginal instruments during morcellation.

Among the instruments adaptable for vaginal surgery:

• curving, articulating instruments
• long, curved, and rounded knife handles, which allow for better ergonomics during prolonged morcellation
• modified long retractors and use of a single long vaginal pack provide retraction of loops of bowel and easy access to secure pedicles deep in the pelvis.

All of these instruments are available through  Marina Medical in Sunrise, Florida.

Challenge: Securing vascular and thick tissue pediclesA narrow introitus and vaginal vault can be difficult to manage during vaginal surgery. Another challenge is a uterus that is large or deformed by multiple fibroids.

Solution #6: Vaginal incision
A simple superficial 2- to 3-cm incision on the distal posterior aspect of the vaginal wall can widen the introitus and vault to facilitate the procedure (FIGURE 7)

Solution #7: Vessel-sealing tools
The use of energy is integral to laparoscopy and robotics for dissection and securing vessels. In a meta-analysis that included seven randomized controlled trials, advanced vessel-sealing devices proved useful in vaginal surgery by decreasing blood loss and operative time.⁸

In the setting of a difficult vaginal hysterectomy with a narrow introitus and large uterus, the use of vessel-sealing technology allows the surgeon to skeletonize the uterine arteries while allowing progressive descensus to secure the upper pedicles.

In my experience, the use of an advanced vessel-sealing device, compared with traditional clamp-cut-tying technique, facilitated successful completion of vaginal hysterectomy in 650 patients with relative contraindications to the vaginal approach, such as nulliparity, a uterus weighing more than 250 g, and a history of cesarean delivery (Mayo Clinic data; yet unpublished).

We must change with the times
The rate of vaginal hysterectomy will continue to decline unless we modify our technique to incorporate new technology. The current generation of practicing gynecologists and recent graduates are choosing the laparoscopic and robotic approaches because of the advantages these technologies offer. It is time we incorporate relevant features from these minimally invasive approaches while maintaining patient safety and containing costs by performing vaginal hysterectomy whenever possible. A willingness to change and ability to think outside the usual box will help us train new generations of vaginal surgeons who can bring back vaginal hysterectomy as the preferred route to the benign hysterectomy.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected]

Vaginal hysterectomy is the preferred route to benign hysterectomy because it is associated with better outcomes and fewer complications than the laparoscopic and open abdominal approaches.^1,2 Yet, despite superior patient outcomes and cost benefits, the rate of vaginal hysterectomy is declining.

According to the Nationwide Inpatient Sample, the use of vaginal hysterectomy declined from 24.8% in 1998 to 16.7% in 2010.³ In fact, more than 80% of surgeons in the United States now perform fewer than five vaginal procedures in a year.⁴

The increasing use of other minimally invasive routes, such as laparoscopy and robotics, indicates that most practicing surgeons and recent graduates are choosing these approaches over the vaginal route. In only 3 years, the rate of laparoscopy increased by 6% and robotics increased by ­almost 10%.³

Many surgeons assume that vaginal hysterectomy exists in a state of suspended animation, with nothing much changed in the way it has been performed over the past few decades. Further, vaginal surgery is difficult to teach and learn, given limitations in exposure and visualization, difficulty in securing hemostasis, and challenges in the removal of the large uterus and adnexae. As a result, vaginal hysterectomy often is thought, erroneously, to be indicated only in procedures involving a small and prolapsing uterus.

To increase the rate of vaginal hysterectomy, we can benefit from experience gained in laparoscopy and robotics—whether we are teachers or learners—while maintaining patient safety and containing costs.

In this article, I describe common challenges in vaginal hysterectomy and offer tools and techniques to overcome them:

• achieving and enhancing ergonomics, exposure, and visualization
• the need to work in a long vaginal vault
• the task of securing vascular and thick tissue pedicles when the introitus and vaginal vault are narrow.

The vaginal approach is less costly
Vaginal hysterectomy costs significantly less to perform than other approaches. At a tertiary referral center, vaginal hysterectomy costs approximately $7,000 to $18,000 per case less than laparoscopic, abdominal, and robotic hysterectomy.⁵ With declining use of vaginal hysterectomy and increasing use of more costly approaches, we face a health-care crisis.

Residents are inadequately trained to perform vaginal hysterectomy
Data reveal that not only are our recent graduates inadequately prepared to perform vaginal hysterectomy, but national health-care dollars and resources are depleted when surgeons choose to perform more costly approaches. As a result, many eligible patients end up deprived of the benefits of a single, concealed, and minimally invasive procedure.

The increase in laparoscopic and robotic approaches to hysterectomy has affected residency training. National case log reports from the Accreditation Council of Graduate Medical Education show that the number of vaginal hysterectomies performed by residents as “primary surgeons” decreased by 40%, from a mean of 35 cases in 2002 to 19 cases in 2012.⁶ A recent survey found that only 28% of graduating residents were “completely prepared” to perform a vaginal hysterectomy, compared with 58% for abdominal hysterectomy, 22% for laparoscopic hysterectomy, and 3% for the robotic approach.⁷

The rate of vaginal hysterectomy will continue to decline if we perform it in the same manner it was done 30 years ago. The current generation of practicing gynecologists and graduates is choosing to perform the procedure laparoscopically or robotically because of the advantages these technologies provide. It is time that we incorporate features from these minimally invasive approaches to streamline vaginal hysterectomy while maintaining patient safety and containing costs.

Challenges: Ergonomics, exposure, and visualization
In conventional vaginal surgery, the surgeon often is the person who has the best and, sometimes, the sole view. Two bedside assistants are required to hold retractors during the entire case, which can lead to fatigue and muscle strain. Poor lighting also can greatly limit visualization into the pelvic cavity.

Both laparoscopy and robotics provide a well-illuminated and magnified view, with three-dimensional images now available in both platforms. This view is projected to overhead monitors for the entire surgical team to see. Magnification of the pelvic anatomic structures and projection to an external monitor facilitate teaching and learning, better anticipation of the surgical and procedural needs, and overall patient safety.

From robotics, where ergonomics is exemplified, we also learn the importance of surgeon comfort during the procedure.

Solution #1: A self-retaining retractor
A self-retaining system such as the Magrina-Bookwalter vaginal retractor (Symmetry Surgical, Nashville, Tennessee) (FIGURE 1)

Solution #2: Seat the surgeon for an optimal view
With the patient in the lithotomy position and her legs in candy cane stirrups, the surgeon can be seated on a high chair so that the operative field is at the approximate level of the assistants’ view (FIGURE 2)

Solution #3: Illuminate the cavity
The deep pelvic cavity can be easily illuminated using a lighted suction tip, a flexible light source (as part of the cystoscopy set) held with a Babcock clamp (FIGURE 3), or a malleable illuminating mat taped to the retractor blades (such as Lightmat surgical illuminator, Lumitex, Inc., Strongsville, Ohio).

Solution #4: Project the image
Cameras attached to an overhead boom or operating room light handles (FIGURE 4) and an external telescope with integrated illumination, such as a standard cystoscope or VITOM Exoscope (Karl Storz, El Segundo, California) (FIGURE 5) provide both magnification and projection of the procedure to an overhead monitor.

Glass technology (Google, Mountain View, California) also has been utilized in surgery and can be a good application of simultaneous projection and recording of the procedure to an external monitor (­FIGURE  6). Google Glass is a wearable computer with an optical head-mounted display. The device, similar to eyeglasses, is voice-activated, thereby allowing the surgeon to record the procedure hands-free. Simultaneous projection to an external monitor allows the entire team in the operating room to be aware of the flow of the procedure.

Challenge: Working in a narrow vaginal vault
Without correct instrumentation, this challenge can be especially daunting. Laparoscopy and robotics have changed the way we perform pelvic surgery by providing advanced instrumentation.

Solution #5: Adapt your instruments
Modified vaginal instruments can be used to facilitate a case. Watch the accompanying VIDEO on the use of improved vaginal instruments during morcellation.

Among the instruments adaptable for vaginal surgery:

• curving, articulating instruments
• long, curved, and rounded knife handles, which allow for better ergonomics during prolonged morcellation
• modified long retractors and use of a single long vaginal pack provide retraction of loops of bowel and easy access to secure pedicles deep in the pelvis.

All of these instruments are available through  Marina Medical in Sunrise, Florida.

Challenge: Securing vascular and thick tissue pediclesA narrow introitus and vaginal vault can be difficult to manage during vaginal surgery. Another challenge is a uterus that is large or deformed by multiple fibroids.

Solution #6: Vaginal incision
A simple superficial 2- to 3-cm incision on the distal posterior aspect of the vaginal wall can widen the introitus and vault to facilitate the procedure (FIGURE 7)

Solution #7: Vessel-sealing tools
The use of energy is integral to laparoscopy and robotics for dissection and securing vessels. In a meta-analysis that included seven randomized controlled trials, advanced vessel-sealing devices proved useful in vaginal surgery by decreasing blood loss and operative time.⁸

In the setting of a difficult vaginal hysterectomy with a narrow introitus and large uterus, the use of vessel-sealing technology allows the surgeon to skeletonize the uterine arteries while allowing progressive descensus to secure the upper pedicles.

In my experience, the use of an advanced vessel-sealing device, compared with traditional clamp-cut-tying technique, facilitated successful completion of vaginal hysterectomy in 650 patients with relative contraindications to the vaginal approach, such as nulliparity, a uterus weighing more than 250 g, and a history of cesarean delivery (Mayo Clinic data; yet unpublished).

We must change with the times
The rate of vaginal hysterectomy will continue to decline unless we modify our technique to incorporate new technology. The current generation of practicing gynecologists and recent graduates are choosing the laparoscopic and robotic approaches because of the advantages these technologies offer. It is time we incorporate relevant features from these minimally invasive approaches while maintaining patient safety and containing costs by performing vaginal hysterectomy whenever possible. A willingness to change and ability to think outside the usual box will help us train new generations of vaginal surgeons who can bring back vaginal hysterectomy as the preferred route to the benign hysterectomy.

WE WANT TO HEAR FROM YOU! Share your thoughts on this article. Send your Letter to the Editor to: [email protected]

Click here to register for PAGS 2014 December 4 to 6 at the Bellagio in Las Vegas

More from PAGS 2013:

Lichen sclerosis: My approach to treatment
Michael Baggish, MD

Click here to register for PAGS 2014 December 4 to 6 at the Bellagio in Las Vegas

More from PAGS 2013:

Lichen sclerosis: My approach to treatment
Michael Baggish, MD

Click here to register for PAGS 2014 December 4 to 6 at the Bellagio in Las Vegas

More from PAGS 2013:

Lichen sclerosis: My approach to treatment
Michael Baggish, MD