NHMRC awards “Ten of the Best” to QCGC Research Trial that reduced surgical complications for women needing a hysterectomy

Last month, the NHMRC recognised and awarded our Queensland Centre for Gynaecological Cancer Research’s ‘Imagine’ Trial with inclusion amongst their “Ten of the Best ” research projects .

Here I would like to share with you the backstory and the mindset from which the ‘Imagine’ trial developed.

When I trained, vaginal and open hysterectomies were the only known surgical approaches to remove a uterus. Total Laparoscopic Hysterectomy (TLH) was emerging slowly. Robotic surgery was largely unknown at that time.

I was training in TLH with one of my mentors, the late Tony McCartney interstate. I have many very fond memories of that time, but the most vivid memory that has not left me,?is when Tony and I saw patients post-operatively on the ward.

“Our TLH patients were sitting upright in bed, had lipstick on, just enjoyed dinner and there was always a bit of a good chat going on”

The contrast between these scenes and what we regularly saw from the more invasive traditional approaches was striking and deeply motivating to us as surgeons who want the very best for our patients.

However, around the same time, a large prospective, randomized trial was published that showed an unacceptable rate of ureteric injuries in the TLH arm. Nevertheless, our retrospective data showed very good outcomes and no signs of an increased risk of intraoperative complications.

Tony wanted me to push on and spread the word about TLH. He wanted me to give talks, show video clips and help other O&G’s to become great TLH surgeons.

But our own lack of published data bothered me. I remember saying to Tony, “If we can’t quantify that TLH is better than open or vaginal hysterectomy - what’s the point believing in it and promoting it?” This was the moment when it became a mission for me, and I doubled down on my question.

“If we don’t show that our better procedure is indeed better, we are actually doing ourselves and humanity a disservice”

Saying that out loud to Tony, who was an eminent surgeon, was risky for me, his trainee. Tony had just offered me his kingdom and I was saying, “It’s not good enough. We need better”.

?

I proposed a clinical trial to Tony; a trial that compared the then standard of hysterectomy in endometrial cancer (open surgery) with TLH. We made sure our surgeons were hand-picked, passed a stringent trial accreditation process and could deliver a meticulous surgical procedure. The trial enrolled almost 800 patients and we saw clearly that the numbers were very much in favour of TLH.

“However, despite good data, hundreds of gynaecologists in the community did not take up TLH.”

We heard about all sorts of problems, including suturing the vagina. Together with my friend and colleague Anusch Yazdani , I started a laparoscopic workshop. We all loved it but only a small cohort of course participants switched from open surgery to TLH. As a consequence, our RANZCOG trainees did not get exposed to TLH, let alone taught it. A vicious circle.

We surveyed thousands of patients, of which many told us that they wanted a laparoscopic hysterectomy but their gynaecologist would not support it.

At QCGC Research, we formed a team consisting of gynaecologists, nurses, policy makers, marketing people, health economists and other professions. We interviewed and surveyed hundreds of gynaecologists and only then did a clear picture start to emerge: Gynaecologists did not feel supported to change from open to laparoscopic.

They told us that workshops don’t cut it; that it is very hard to take out time from a busy schedule to retrain; that training needs to ascertain their hospital’s support; that training must involve not only them but their entire surgical team, including nurses and anaesthetists.

Again, we could have described the barriers of TLH uptake and left it at that. However, I wanted a measurable change.

“I wanted a change in clinical practice that I could prove was effective”.

We addressed those unmet needs, bundled them together and delivered an intervention trial. We picked 11 gynaecologists from 4 hospitals, monitored their surgical outcomes from the beginning throughout surgical training and 6 months after training. We compared their outcomes with the outcomes of the gynaecologists who also wanted to participate but who we were unable to accommodate.

For data capture and clinical outcomes analysis, all participating gynaecologists utilised SurgicalPerformance .

In our trial, the rate of TLH procedures increased from 24% at baseline to 70% and that rate remained stable even 6 months after the trial finished.

Surgical complications decreased from 13.5% at baseline to 6.4% during the training and decreased further to 4.2% 6 months after the training finished.

The results have also shown that the experienced gynaecologists who exposed themselves to training a new surgical method, enjoyed their training.

In 2023/2024, more than half of all hysterectomies are done via minimally invasive surgery

As a result of the trial, women’s suffering? and recovery times have been greatly reduced, which is fantastic. Additionally, it is hugely gratifying to see that now even junior colleagues in training are being expertly taught best-practice laparoscopic hysterectomy.

National Health and Medical Research Council (NHMRC) awarding the ‘Imagine’ trial for its surgical leadership with inclusion in their “10 of the Best” is the icing on top of already satisfying empirical results.

The reference for the Imagine publication is: Aust N Z J Obstet Gynaecol 2023; 1–7.

The most important learnings from implementing a surgical innovation can be found here .

To join the growing number of responsible surgeons who capture their surgical and patient-reported outcomes using SurgicalPerformance, click here .