Endometriosis - treatment tailored to the patient's expectations. Episode 55

Monika Rachtan
Hi, Monika Rachtan. I would like to welcome you very warmly to the next episode of the programme "Po Pierwsze Patient". Despite the fact that there is a lot of talk about endometriosis in the media, not only on the internet but also on television, it turns out that for some patients this diagnostic odyssey can take up to 8 years. I will be talking to Dr Maciej Pliszkiewicz today about why this happens. Good morning, doctor. Your doctor is a specialist in gynaecology and obstetrics, but primarily specialises in the surgical treatment of endometriosis at the Medicover Hospital in Warsaw.

Maciej Pliszkiewicz
Correct.

Monika Rachtan
Your doctor is an obstetrician gynaecologist, he is also a gynaecological oncologist, but he mainly specialises in the surgical treatment of endometriosis. Doctor, I would like to ask you what this patient pathway should look like from the appearance of the first symptoms of endometriosis to the diagnosis and to the start of treatment? What should it look like, but also what does it currently look like?

Maciej Pliszkiewicz
What should it look like? We can guess. A patient comes to the doctor, reports a number of symptoms, reports her complaints. On the basis of these complaints, we can already draw some conclusions as to whether or not we are dealing with this disease. The patient should then be examined in the chair, and an ultrasound examination should also be performed. On this basis, we should be able to tell the patient what we are dealing with, so that it is ideal. However, the most common situation, at least until now, as the situation has fortunately changed a little, was that the patient came to the doctor and said she had painful periods, painful bowel movements, pain when she held her urine for a longer time, pain during intercourse, painful ovulation, pain before menstruation and a few other things. She is examined by a colleague who finds that there is basically nothing wrong with her and says that it is the way she is, or that she has it that way, or that if she gets pregnant and gives birth it will pass.

Monika Rachtan
And is it true that it is such a beauty that you will pass, that you have it like that? However, is it worth digging into this diagnosis here and trying to find the cause of these complaints that the patient is talking about?

Maciej Pliszkiewicz
Well, it is worth digressing, because, of course, there is pain. Let's face it, the first few hours of menstruation in a patient who has not given birth can cause some pain, this can be accepted as some element of physiology. But if these complaints are long-lasting, repetitive, are coupled with the menstrual cycle and do not improve over time, but actually worsen, as is usually the case, then pain complaints do not come from nowhere, and they certainly do not come from what patients sometimes hear, that they make themselves up to be ill. Even today I was talking to a colleague who had a patient whose doctor had now recently told her that she had invented endometriosis, because it is such a popular disease now, and she was fine, and it turned out that she had a tumour in her rectum.
Monika Rachtan
Doctor, what does this scrambling, this diagnostics, look like? What kind of tests are performed here? Well, because there is an examination in the armchair, we have an ultrasound, which is probably performed in most private practices, because I do not know what it is like in public health care, because I have not had the opportunity to use the advice of a gynaecologist on the National Health Fund. On the other hand, these two tests are performed, and can the doctor already tell from them whether he is dealing with endometriosis? Are any additional diagnostic tests needed?

Maciej Pliszkiewicz
Well, for people who deal with this disease, who above all have some elementary experience in diagnosis, this is usually enough. We can say that a well-gathered history, i.e. asking a series of questions that we ask each patient. We can say that a well-gathered history, i.e. asking a series of questions that we ask each patient, already gives us a clue as to whether or not we are dealing with this disease. It can be said that 90% we get the answers to the question of whether the patient has the disease or not just by talking to the patient, without even touching her in the chair. This is such a first element. On the other hand, it is useful to know what questions to ask, because if we ask what ails you, and you ask a, because it hurts me. However, this is not enough.

Monika Rachtan
So what should come next?

Maciej Pliszkiewicz
We, as doctors, should drill down, we should ask this patient a series of questions that will allow us to find out whether we are really dealing with a situation that should be suspected of endometriosis or not. A long time ago I made such a list of eight questions, modified a little bit in the meantime, but I started using it 15 years ago, when I started dealing with patients with endometriosis. Such 15 questions, the answers to which give me basically 90-95% certainty.

Monika Rachtan
What kind of questions are these?

Maciej Pliszkiewicz
The first question is about continuous pain. Because if the pelvic pain, the pain in an area of the body is constant and changes in intensity depending on the phase of the menstrual cycle, then something is not right. This is one element. The second element is pain occurring before menstruation begins. Contrary to appearances, pain occurring before menstruation is one of the most characteristic symptoms for endometriosis, although its absence does not mean that it is not there. Neither does the presence of this symptom mean that it is always there. On the other hand, it is indeed a symptom that is quite characteristic of menstrual pain. As I have already mentioned, a few hours of pain on the first day of menstruation may be present. On the other hand, if the menstrual pain, that associated with menstrual bleeding, drags on for three or four days, it causes the patient to have to leave work, to have to leave school as a young girl, to be unable to function normally, to be unable to get up, to go to the bathroom or to the kitchen, and to die with an apology. For those first three or four days of the cycle, well that's an obvious indicator that something is not right.

Maciej Pliszkiewicz
Another element is the pain associated with ovulation. Ovulation itself, of course, can be felt by a woman in different ways. It can be pelvic discomfort, some slight prickling in the ovaries. But if the patient in the period around ovulation dies of pain again.

Monika Rachtan
And is it the kind of pain you get with your period or would we describe it differently?

Maciej Pliszkiewicz
This varies. It depends on the patient. Every woman will have a slightly different pain pattern. Some perovulatory patients have very severe low back pain, for example. Other patients will just have menstruation-like pain, i.e. diffuse pelvic pain. There are patients who will have numbness in the limbs, for example, and there are patients who will have no symptoms during the periovulatory period or will have other symptoms, such as pain during bowel movements. And now yes is pain with bowel movements characteristic of endometriosis? No. But if this pain is coupled with the phases of the cycle, if this pain occurs for example just before and during menstruation or perovulatory, then a red light should go on for us that something is up. This is also such a symptom that is quite characteristic of rectal bleeding. Of course, if the patient has haemorrhoids or if she has an anal fissure once treated, she may have bleeding from the anus. This is nothing surprising. But if there is no history of diseases that can give such bleeding, then again the light should go on. With that said, again, the fact that rectal bleeding occurs is not always a sign of bowel disease.

Maciej Pliszkiewicz
It's also sometimes patients, sometimes it's difficult to explain to a patient that she has rectal bleeding during menstruation, but she doesn't have a disease in her bowel.

Monika Rachtan
It's such a big concern because there's already some oncology coming up and thoughts that it could be some kind of cancer.

Maciej Pliszkiewicz
Maybe oncology does not, but indeed such oncological vigilance occurs and patients are afraid of it. This needs to be remembered and needs to be explained. Even if we have intestinal disease, endometriosis in the gastrointestinal tract, these patients also need to be reassured, because it is not cancer as such. It is not, it is not cancer, is it? It is a disease that has certain characteristics of proliferative diseases, because it grows, because it has the characteristic of being able to destroy tissues, so it has certain characteristics. However, it is not a cancer.

Monika Rachtan
What else does these questions raise?

Maciej Pliszkiewicz
Another question is pain during intercourse. If these pains during intercourse occur, this is already a warning signal. If they depend on the position or phases of the cycle, this is additional information. Of course, you can always say, well, but there may be, for example, a situation in which there is a certain inappropriateness between partners. Of course, yes, but that is a margin. Generally speaking, a little jokingly, but in fact seriously, when I talk to patients I tell them that two things in a woman's life should not hurt. The gynaecological examination and intercourse. If they hurt, it means that something is wrong and it is worth dabbling.

Monika Rachtan
We as women, as young girls, often do not have such awareness. Probably such a conversation with a gynaecologist for many young girls, because endometriosis doesn't apply to, let's say, 30 year olds, I mean it also applies, but not only, who can easily talk about such problems, but it also applies to young girls for whom such a visit and talking about painful intercourse can be a challenge, it can be difficult, but also from what the doctor said, I thought to myself that in order to answer these eight questions of the doctor, you have to know yourself very well. You have to observe yourself, you have to know yourself. Well, because it would be difficult for me, for example, to associate pain in my loins precisely with ovulation, I need to know first of all when I have it. And I think that not all girls know when.

Maciej Pliszkiewicz
And not all women feel it either.

Monika Rachtan
So here you actually have to observe yourself, and it is probably worth it. When we come to the gynaecologist, when we report any problems, we should do such a month of observation in order to precisely answer the specialist's questions.

Maciej Pliszkiewicz
On the one hand, yes, and on the other hand, to be honest, I have not yet encountered a situation where a patient would not be able to answer most of these questions. Yes, most patients do, however, and even young girls. A mother comes in with her 16-year-old daughter who suffers from very painful periods. She asks these questions. She answers without missing a beat.

Monika Rachtan
How old was the youngest girl you diagnosed with endometriosis?

Maciej Pliszkiewicz
Recognise that 15 years old. Operate, the 17-year-old was the youngest patient I operated on for this reason.

Monika Rachtan
So here again we have living proof that this is not a disease of 25, 30 year old girls only. But also younger girls can get sick, and that it's worth it, I think, first of all for mothers to listen to these symptoms to deal with this pain as soon as possible, because it's beautiful to become a woman without such ailments.

Maciej Pliszkiewicz
In the case of girls, however, there is a bit of a problem, because while in the case of an adult woman we have a certain arsenal of medicines and methods of treatment which we can, in principle, implement immediately, right, not all medicines can be used in the case of young girls, because they are in the process of growing, because we can't always examine them either, because their parents or they themselves are reluctant to do so, because there are, one could say, a few such limitations in the care of adolescent girls with suspected endometriosis, but this is our role and our headache to deal with.

Monika Rachtan
Many women, many couples these days are affected by infertility. Can it also be a result of endometriosis? And if the doctor starts treating endometriosis in a woman, is this chance of her being able to get pregnant and have a baby in the future higher?

Maciej Pliszkiewicz
This is a complex problem, i.e. there is no simple answer to this question. Regarding the issue of infertility, it is now thought that 40 to 50% of female infertility is endometriosis. Is it fair to say that out of 10 women with infertility who would be here now, half of them are likely to have endometriosis. That is the scale of the problem. On the other hand, I will add here such a thing, which is completely unrelated to endometriosis, and I will say it because I observe. Let's call it a great reluctance among the partners of women who have problems getting pregnant to examine themselves.

Monika Rachtan
It is such a taboo subject that the gentlemen say, however, I am not affected?

Maciej Pliszkiewicz
This is how it happens. Whereas of course it's not about pointing the finger, but it's about men also being aware that in partner infertility 30 to 40% cases, it's a problem on the man's side. So I have this rule of thumb if a couple comes in who are trying to get pregnant, which doesn't work out, sort of no matter what we plan. I don't take a step forward. If they both don't get tested, do I just require the man to have a semen test done as well. What it takes for it to be done. Because we need to know where we stand. The point is to avoid a situation in which we abuse a woman for 10 years with treatments, stimulation, medicines, this way, that way, inseminations, in vitro, God knows what, so that in the end it turns out that the man simply has no sperm. And I know such situations.

Monika Rachtan
When you have a conversation like this, when the doctor starts it, do men often have such resistance to start this diagnosis?

Maciej Pliszkiewicz
Certainly not verbal and certainly not, not such that, no, I'm not going to do anything. No, certainly not. But what happens when they leave the office, I don't know anymore.

Monika Rachtan
It seems to me, however, that this awareness is growing in society. When a child comes into the world, more and more often we both take care of that child. We take on this responsibility of looking after the child. Both the man and the woman. So I think when it comes to trying to get pregnant, this awareness is increasing. So I take it that such a diagnosis can be safely started for both men and women during a joint visit to the gynaecologist's surgery? Here it is not necessary to go to some other specialist who is dedicated to the man.

Maciej Pliszkiewicz
Of course, we order tests. However, if it turns out, for example, that there is also a problem in a man, because we have a reduced quality of semen, because there are some abnormalities in the parameters of the seminogram, then, of course, we refer such a man to an andrologist, to a urologist with experience in this area, because this is not our area, is it? So we are already pointing such a person in the direction in which he can go to help himself.

Monika Rachtan
We have already said a few words about the symptoms. The doctor also said about the diagnosis, that already on the basis of the history he is able to determine in 90 per cent whether to suspect endometriosis, whether afterwards some further diagnostic examination is performed to confirm this diagnosis. In fact, is an interview and these two examinations at the surgery sufficient?

Maciej Pliszkiewicz
Examination and ultrasound and ultrasound again. Women know best themselves what a gynaecological examination usually looks like. It lasts 15 seconds, 20 seconds.

Monika Rachtan
Not likely to last more than a minute.

Maciej Pliszkiewicz
Exactly. What are we able to assess at this time? We are not able to tell much, whether the uterus is in forward or backward flexion, whether there is resistance in the ovarian projection. And that's basically it. By contrast, a gynaecological examination, a true gynaecological examination, should allow us to assess the entire pelvis both from the bladder side and from the bowel side, that is, from the rectovaginal recess. We can examine the ligaments, we can examine the bladder-uterine zipper, we can check uterine mobility. Whether I have any masses somewhere, abnormalities. All these things can be examined in the chair. Before we had a situation where there was an ultrasound machine in practically every surgery. Well, the patient was examined. And it wasn't like the ultrasound machine was standing next to it. The patient had to be examined and this examination was also sufficient to make a diagnosis in most situations. Sometimes it is enough to insert a speculum. And here I also raise awareness, because it still happens, and not infrequently at all, that a patient comes in with complaints of pain, spotting after intercourse, pain syndrome. The various symptoms we have talked about. The patient sits down on the chair, I put on the gynaecological speculum, I open the gynaecological speculum and it turns out that the patient has a large endometrial tumour behind the cervix, such a tumour visible immediately with the naked eye.

Maciej Pliszkiewicz
And I ask if you know that you have a tumour there. What kind of tumour? I for such circumstances have a camera in my wardrobe, I take a picture, I show such a tumour.

Monika Rachtan
Well, yes, it is difficult for a woman to believe.

Maciej Pliszkiewicz
Patients, unfortunately, very often, are not examined thoroughly, which is due to a number of factors. This is due to the fact that it hurts the patient to be examined, so the doctor does not want to add to her suffering.

Monika Rachtan
This shortens the study.

Maciej Pliszkiewicz
He will shorten this examination, he will not fully open the speculum, he will not significantly move the uterus so that it does not hurt the patient. Either in this examination or in this examination he will limit himself to looking at the cervix, because that is enough to take a cytology, but he will no longer look behind this cervix or somewhere on the sides. And last week I had a patient who found out from me that she had, firstly, a tumour in her vagina and, secondly, that she had a tumour in her bowel. And she is under regular gynaecological care. So we also try to train colleagues, we do all sorts of courses and so on. So that such things happen as rarely as possible, because such a patient circulates between doctors. A colleague in the team has a patient who has visited 47 doctors.

Monika Rachtan
And none found endometriosis in her?

Maciej Pliszkiewicz
And at 47, she was found to have endometriosis.

Monika Rachtan
That is to say that it is not such a beauty, only that it is there after all.

Maciej Pliszkiewicz
In general, to say that it is such a beauty that the patient hurts to the point of unconsciousness, well I think it is misguided.

Monika Rachtan
How long should a decent gynaecological examination like the one you mentioned a moment ago last?

Maciej Pliszkiewicz
It depends on the circumstances, because sometimes the illness is so obvious that I only need this minute or two, and sometimes it is the case that you actually have to look for the illness. So here there is no such thing that one or another time is needed. The whole visit should give us enough time so that we don't have to rush and so that we can actually look at everything so that we are convinced that we have looked at everything that is needed. The same applies to the ultrasound. In a classic gynaecological ultrasound, we assess the uterus, we assess the ovaries, we look at the urinary bladder, because it is next to it, and most often that is the end of the gynaecological examination, the ultrasound. However, the possibilities of ultrasound. The possibilities of both the apparatus and our diagnostic capabilities are enormous at this point. We are able to view the ureters. We are able to look at the sacro-uterine ligaments, we are able to look at, check what the mobility of the organ looks like, what the mobility of individual elements of the reproductive organ looks like. We are able to find, find deep ligamentous changes in the rectovaginal septum. We are able to assess quite a large section of the large bowel. We are able to see the disease there.

Maciej Pliszkiewicz
Sometimes, if there is a little, let's say, a favourable anatomical situation, it sometimes happens that we find the disease even in the small intestine with the help of ultrasound, nothing more. Again, however, this takes time. It also requires skill, of course, it requires dressing with the disease. And again, we also organise ultrasound courses. In the sense of ultrasound diagnosis. And it is precisely for this purpose. And as the Americans say "It's not rocket science". If you know what you are looking for, you are likely to find it. Examples are, colleagues from all over Poland come to us for training. Of course, there is the theoretical part. Then there are handson examinations, typical ultrasound examinations of patients, whom we invite to these courses and whom we thank. We really thank the ladies for their cooperation. These are patients who make themselves available to us so that we doctors can learn. It's not such an obvious thing, is it? And it's very often the case that a few days, a week go by after the course and we get feedback from one, second colleague, third, fourth colleague. Listen, this week I found two tumours in my rectum.

Maciej Pliszkiewicz
And he says, is it because they've only just come to me now, or have I not seen this before? Well the answer is impossible to give, but it's a motivator for us to do further editions of these courses on the one hand, and on the other hand it's an example of the fact that you can really learn this. And it really isn't that complicated.

Monika Rachtan
But also that an experienced doctor, who has been dealing with endometriosis patients for many years, is able to pick up such changes. And that if the patient sees that she has been to the 1st, 2nd, 3rd, 4th, 5th, 7th gynaecologist and still does not have a diagnosis, she clearly sees that these symptoms occur in her, then it is necessary to find a doctor who specialises in diagnosing and treating endometriosis. And to such a one, because, unfortunately, not everyone as you doctor will be able. As you said, the doctor will be able to find this disease. But we have already said a lot about this diagnosis, about these visits, about symptoms. And now I would like to ask about treatment. Is there any such gold standard treatment for endometriosis? Your doctor specialises in surgical treatment, but is it always the case that a patient must have surgical treatment in order to talk about treating, not curing, endometriosis?

Maciej Pliszkiewicz
Definitely not. I mean, if we look at the overall number of patients with endometriosis, it can be said that a large proportion of these patients are treated, because if they present themselves with painful menstrual periods, even if the doctor who is treating them does not find a significant disease, he tries to help the woman. For example, he will offer hormone therapy, which, even if it does not contain the optimal substance, offers the possibility of alleviating the pain. And these patients are nevertheless cared for to some extent, and if they do not have a significant illness, i.e. an illness that threatens them in some way, such as a critical bowel stricture or urinary infiltration, that is, things that can be very detrimental to their health. This is able to function. It may not be the optimal management, but it is nevertheless some kind of management. On the other hand, it is not the case that every one of these women requires surgical treatment. I would say the opposite. And it is both the data, the literature and my own experience that, in fact, the need for surgical treatment affects maybe 5, maybe 10% of these women.

Maciej Pliszkiewicz
Most of these can be managed conservatively, i.e. without resorting to surgical intervention.

Monika Rachtan
And what determines that this operation should be carried out? And what does the whole process of surgical treatment for endometriosis look like in general?

Maciej Pliszkiewicz
Or the process of treatment at all? I would call the process not so much the process of treatment as the management of the disease. Because if we talk about treatment, we assume that we are going to cure something. This disease cannot be cured, so I prefer the term management. But that is a detail. The most important thing, in fact, in the whole management of this disease is firstly to recognise that it is there. Well, we have already talked about that. But the second and most important element is to identify the patient's priorities, because it's not a question of what I want. It is a question of what this patient wants. Because we will deal differently with a woman who is in pain and who wants to improve her quality of life. We will deal differently with a woman who has been trying for a pregnancy for four years and is able to get pregnant. Yes, and we will deal even differently with a patient who has such an intense pain syndrome plus a wish for pregnancy. And all this has to be combined somehow for her to achieve her goal. So you could say that the only standard in treatment is to match our management to the patient's preferences, to her priorities.

Maciej Pliszkiewicz
So this treatment should be individualised each time. You can't say stiff, the standard has to be this and that. Of course, if we look at how female patients from the National Health Service are treated, it can be assumed that most of them are treated very similarly, that is, most often with hormonal drugs, mostly or preferentially leg-based. This is the kind of chemical that is known to be there for, apart from the fact that it can block ovulation, because it is in contraceptive drugs. It also has the characteristic that it shows an inhibitory effect on the proliferation of the cells of these abnormal endometrial cells, the ideal cells, and therefore it can be said that it slows down the disease process somewhat. It doesn't cure, it doesn't stop, it doesn't reverse, it doesn't make the disease disappear, but it slows it down. And it can provide the patient with an improved quality of life.

Monika Rachtan
That is to say, this pain may disappear, it may diminish.

Maciej Pliszkiewicz
It will diminish, it may disappear. In some patients it is sometimes the case that they stop having pain at all. But again, the response to these drugs is also individual. There are women who will be offered hormone therapy and it will have no effect. And then we have to adjust to that and we have to see what we can do next.

Monika Rachtan
Such hormone therapy also has some of its side effects, which the patient must take into account when deciding on this type of treatment.

Maciej Pliszkiewicz
Can any drug treatment have side effects? It's not that these patients routinely or very often have a side effect, but certainly a disadvantage of contraceptive drugs or a disadvantage of hormonal drugs is that the libido drops. Although some patients have a big problem with this and report this as the main cause. Some patients report vaginal dryness. Well, because we are blocking the pulsatile secretion of oestrogens, therefore the vaginal mucosa functions less well. These are the most common things, so to speak. Of course, there are patients who, because of hormone treatment, may have mood disorders or may even have disorders of a depressive nature. There are patients who will have migraines, these headaches. There are patients who will have, for example, some cardiovascular disorders. This is actually rare, fortunately. But they can. In very rare cases, hormone therapy can lead to thrombosis and then, one could say, this is already a serious complication which, on the one hand, requires the discontinuation of medication and, on the other, in a sense prohibits us from returning to these drugs. These are patients with whom we have quite a serious problem, because sometimes we do not have much to treat them with.

Maciej Pliszkiewicz
But it's the case that we have to tell all of this and it's the patient who ultimately decides whether she's going to go to the pharmacy, whether she's going to buy the drugs, and if she buys the drugs, whether she's going to take them, right? So we tell what can happen, what needs to be looked at. But the final decision is made by the patient.

Monika Rachtan
I think about the fact that often patients do not have this conversation with their doctor. Or it's the doctor who doesn't talk to them, and the moment they get these drugs, they go home, read the leaflet, they end up on a shelf in a cupboard, and they continue to suffer. And that this conversation just with the doctor and telling yourself about these side effects, about their frequency, about the likelihood that they will occur, is very important, because it makes the patient feel safe, she knows what to expect, she knows what to look out for. Therefore, if the doctor does not talk to you, does not ask you what decision you want to make with regard to treatment, it is worthwhile for you to courageously ask this yourself before you decide to go to the pharmacy, buy the drugs and then, as I said, put them back on the shelf. But doctor, I asked about surgical treatment and the indications for surgical treatment, because we already know that it is not for everyone. That it is rather used in more difficult cases, if I am inferring correctly.

Monika Rachtan
Please tell me what determines clinically that a patient is a candidate for surgery?

Maciej Pliszkiewicz
Yes. First of all, it is the patient who decides no matter what, because it is the patient again who signs the consent, the informed consent for the surgical treatment that we can propose. But when it comes to this side, this strictly medical side, there is certainly an indication for surgical treatment. There are conditions where the patient's health and sometimes even life is at risk. Because if we have a patient who has a critical stenosis of the bowel, who has a lesion in the small bowel that causes her to start having obstructive conditions, new ones, these are patients who are at risk of obstruction. At the point when this obstruction happens to them. Because it can happen to them. And we have quite a few patients among our patients who have undergone such a thing. This gastrointestinal obstruction is a life-threatening condition. This is a patient who comes to the ED with severe, severe pain. A CT scan, which is then routinely performed, shows features of gastrointestinal obstruction. The patient is opened, because then we no longer have subtlety. Laparoscopy is that, elective treatment, we are only saving the patient's life, so such a patient has her abdomen opened. And depending on what the situation is, either the fragment that is obstructed colloquially speaking is removed respectfully.

Maciej Pliszkiewicz
The bowel is burned, for example, in cases of obstruction on the sieve. Most often, however, these patients have anastomoses performed. But if it is, for example, a low bowel obstruction? The patient will have an emergent stoma, it will be a stoma that is designed to save life, to encase the problem. And then only then will it be possible to start thinking about how to manage the patient in a planned way. So certainly advanced disease in the digestive tract is such a medical indication for surgical treatment. The second situation is when we have a disease that in some way presses on the urinary tract. That is, when we have lesions obstructing the outflow of urine from the kidney. In this disease, this is a significant problem, as these changes do not appear quickly, because, for example, in lithiasis we have sand in the kidney, small deposits. This goes into the urine because the patient gets acute. Patients too, of course, but in this situation we are talking about women. She gets acute renal colic pain, lands in the ED. It is known that there is an emergency situation, we know something is going on, we have a problem.

Monika Rachtan
Growing confidently.

Maciej Pliszkiewicz
Endometriosis. The disease grows slowly. It's not a disease that grows fast. It grows slowly, so it slowly, slowly, slowly, slowly, slowly tightens that urinary shoe. Slowly, slowly obstructing the outflow of urine. What can happen? It can happen. A situation such that a patient comes in, says I have such, such complaints. We actually already quite routinely, on the occasion of a gynaecological examination, ultrasound, we also check what the kidneys look like. We apply a probe to the kidney. It turns out to be monstrous. Watery kidney.

Monika Rachtan
The standard when it comes to gynaecological surgeries in Poland is no.

Maciej Pliszkiewicz
On the other hand, it is worth doing. And of course it's nice to have the impulse to just do it. However, very often time does not allow for this. I understand this very well, because if there are a lot of patients, there is limited time per patient, it is impossible to do everything U all the same.

Monika Rachtan
But when it comes to gynaecological diagnostics, we rather talk about clinics that. About surgeries that function in private mode too.

Maciej Pliszkiewicz
But as I say, we are all learning. And it's not as if anyone here has eaten all their brains and knows everything. God forbid, it doesn't work like that. It is a disease in which everyone learns. The one who is just starting to learn and the one who has been doing it for a dozen years are also learning. And we change our behaviour based on what we learn too. And back to those kidneys if we have them. If we have a situation such that in the gynaecological examination in the chair we have features of deep disease, involving the cruciate ligaments, the magical ligaments, i.e. we have such lesions that have this in common that they pull the tissues also from the pelvic walls. Then, however, we should have the reflex to put the ultrasound probe to the abdomen and look at the kidneys. This is because in these situations it happens that indeed the urinary ones are also involved. I had this week, I had such a young, young patient. Maybe without any particular pain syndrome, but still. How to. As one asked a little bit of these questions, it turned out that a little bit of these discomforts are with such a rather large lesion Indeed, the magical cruciate ligaments.

Maciej Pliszkiewicz
And I say this reflex of putting the ultrasound to the abdomen and it turned out that in this patient there is urine stasis in the kidney, there is no large hydronephrosis there, the kidney is not destroyed, it does not look destroyed in the ultrasound. But that is the point, because it is early stage. If this patient came to the doctor in two or three years' time, it could turn out that there the kidney is already dead.

Monika Rachtan
And whether this.

Maciej Pliszkiewicz
The patient will not have symptoms because this process is very slow.

Monika Rachtan
And is this patient a candidate for surgical treatment?

Maciej Pliszkiewicz
While she is a potential candidate for surgical treatment, the decision must be made by her.

Monika Rachtan
You spoke to the doctor about changes in urine, water. You spoke to the doctor about changes in the bowel or still. Lesions and other clinical situations are indications for surgical treatment of endometriosis.

Maciej Pliszkiewicz
The patient's decision, i.e. a situation in which, for example. I will expand this statement a little bit. A situation where we have, for example, a woman who we are treating pharmacologically, we are trying to change the medication, to adapt to different, to different circumstances. The patient has changed her diet, changed her lifestyle, goes to physiotherapy. She is doing everything she can to improve her quality of life non-invasively, to reduce these pain complaints. And they continue to be exacerbated and continue to ruin her life, continue to make her daily life really dependent on her illness. That's when it's sometimes the case that such a patient says okay, stop, medication, cool, everything is fine. They help a little, but still this quality of life is not enough. I want us to do that, knowing that the disease is there. We are able to tell the patient that this operation has a chance of helping her. Of course. Can a situation arise where we, the patient, operate and it doesn't have an effect? Unfortunately, yes. Fortunately, this is a margin. On the other hand, if such an operation is carried out properly, this is an important aspect.

Maciej Pliszkiewicz
It is indeed the case that more than 95% patients get an improvement in terms of the extent of their pain.

Monika Rachtan
We will talk more about this operator experience in a moment, but the doctor has been working in the operating theatre for fifteen years with endometriosis patients.

Maciej Pliszkiewicz
This is more or less what we already know.

Monika Rachtan
Does the doctor operate alone or is there some sort of larger team here that.

Maciej Pliszkiewicz
When it comes to the operation itself, there is always a staff of people at the operation. It's always the cameraman, myself or someone, one of us. There is always an assistant, that is, there is a person who is an assistant and at the same time runs the camera. If we are talking about classical laparoscopy. There is an anaesthetist. There is an aesthetic, that is, a nurse or a nurse anaesthetist. Numerous is the instrumentarium, that is, the person who is with us, washed sterile for the operation, who gives us the instruments, changes the instruments, cleans these instruments, etc., etc., etc. Instrumentarium so called dirty is an ugly saying, but it is the other term, more appropriate. It is volatile, because we send her somewhere for something all the time and she flies around this operating theatre as well. In any case, this one does not touch the patient, it does not touch the patient. On the other hand, if, for example, we need an extra tool or some instrument, she goes to the storeroom, brings the open one, gives the instrument to the one that is with us. There is a whole staff of people at the operating table. And now it's like this. Assisting operator. Well it depends on what we are dealing with.

Maciej Pliszkiewicz
Most often, in this type of operation, we have an experienced person as the operator and a less experienced person, a learner, who assists. But there comes a point when we swap, when this person assists, they have already watched these operations so much that with simpler cases they are able to take over the role of the operator and then the person with experience stands in as an assistant on a training basis. This is simply how medical training is done, because there is no other way to do it.

Monika Rachtan
We, through this, get another doctor who is educated, learns from the best and realises this. And everything is done under the supervision of an older, more experienced colleague. So absolutely here, there are no worries about patient safety. Doctor, it's hard to get to a place that treats endometriosis surgically in just this way. Is this standard of care that you mentioned, that is, this team that accompanies the surgeon, is this a common phenomenon in Poland when it comes to treating endometriosis, Are there actually a few exceptional places in our country that specialise?

Maciej Pliszkiewicz
This is a difficult topic because, unfortunately, we have certain limitations in the, let's call it public space. However, although procedures related to the treatment of endometriosis are included in some kind of catalogue, true, there is no fooling ourselves. Gynaecology in general is nevertheless underfunded when it comes to public funding. That is simply the way it is. If we compare the prices of certain gynaecological procedures to cardiology or orthopaedics or ENT, then these other procedures are clearly better priced. I think gynaecology stands out a little. I worked in a public hospital for many years and have been working in a private hospital for over five years. Well, that's how it went and. And to be honest, I think it was a good one. Well, because we basically created a place that specialised in this. So it's fair to say that there are a few centres that are specialised in the treatment of endometriosis. In fact, because. because it is a certain philosophy on the one hand. On the other hand, it's a certain philosophy on the part of the management, and that's regardless of whether it's a public or private hospital.

Maciej Pliszkiewicz
The management has to want and the management has to agree that we do certain things a little differently. To create conditions, yes, well, such restrictions. I don't want to say this in such a way that anyone feels affected in any way, because that's not the point, but in a public hospital, the operating theatre works until some hour, usually until 3.15.30 p.m. If a procedure drags on after 3.30 p.m., everyone is already stamping their feet and wants to go home, because they've already run out of time. Because they are, after all, working 7 35 on a full-time basis. Our operating theatre works from 7.30 a.m. to 7 p.m. Of course, if I drag out an operation until 2 p.m., people are also stamping their feet. But we do work. We work 12 13 hours, not 7. So it's also a bit of a reduction in procedures from that. Within the framework within public funding. Well, because colleagues who would even like to do it or are training for it, are trying to gain knowledge, are going for training. Well they are nevertheless covered by some framework, some constraints that the organisation imposes.

Maciej Pliszkiewicz
So if 4 or 5 operations are to take place on a given day, there is no chance to build into such a surgical plan an operation that will by definition last a minimum of 3 hours or an average of 3 hours. Or an operation that can sometimes last 12 hours.

Monika Rachtan
Sure, these limitations of the system we all know, but at your hospital, however, the class of equipment that you use in your operations, that accompanies you, is very high. What are the benefits for patients of working with such state-of-the-art equipment? Do you offer patients?

Maciej Pliszkiewicz
Equipment is important, I mean equipment, Equipment on the one hand gives us comfort in our work. This working comfort translates into patient safety, that's for sure. On the other hand, a lot of centres have been subsidised at the moment. There is a lot more equipment. It is not that there is a gap. Yes, but in fact it is the case that we have, we have high-end equipment and this definitely helps us in this work, because it gives us better visualisation of the field, better control over what is happening in the surgical field. And that translates into patient safety. It translates into the range of procedures that we can perform. So certainly this aspect of such instrumental equipment is important. Maybe, maybe I'll put it this way sometimes in conversations, sometimes it manifests itself. There is a thread that comes up that a, well, because I work in a private hospital, therefore you have such and such equipment. This is not quite true, because I know public centres that are equipped just as well, and sometimes even better. So it's not a question of this equipment not being there, we have it.

Maciej Pliszkiewicz
We have limitations in terms of funding, so we have limitations in terms of what we can offer the patient, because the reimbursement, you could say financial reimbursement for the procedure done will not cover the cost. And I understand perfectly well hospital directors who say to their colleagues, listen, you cannot do these procedures, because this procedure will cost the hospital 20 000, and the fund will pay for it 5, for example. That is putting the safety, the financial security of the hospital at risk. So I understand that perfectly well too.

Monika Rachtan
Well, yes, it is understandable that such procedures are expensive. It is incomprehensible that the National Health Fund pays too little for them. But perhaps we should look at ourselves and think about how much we want to pay for our health in Poland, because we keep complaining that we pay too much. It turns out that we are the country in Europe which spends relatively the least on health, as far as patients are concerned. So it would be worth considering what quality of care we expect. Is it the kind we saw in Forest Mountain, or the kind we often see in hospitals. And often it's not the ill will of directors or doctors.

Maciej Pliszkiewicz
I can only say one thing. We are functioning under the circumstances, under the conditions in which we are functioning. Everyone, whether in private or in public, is trying to help patients. And I do not have the slightest doubt about that. Health policy, on the other hand. I don't think there is a country in the world where health policy is run in a way that satisfies everyone. Because it can be said that modern medicine is expensive. Modern medicine must be expensive, because modern medicine is based on technologies that are simply expensive. However, there is no country in this world where this problem has been unequivocally well solved. This is because the needs will always be greater than the possibilities. And it does not matter whether it is Poland, whether it is Germany, whether it is the United States, whether it is the Netherlands, France or any other country in the world. It doesn't. There is no possibility of creating, at least for the time being, a system that will provide everything for everyone and at the same time not have to add to it. Because that would be the ideal one.

Maciej Pliszkiewicz
But unfortunately, it is not possible.

Monika Rachtan
A few months ago, the doctor obtained his Da Vinci certification. Why did the doctor decide to do this training? Is this what patients are looking for today?

Maciej Pliszkiewicz
The da Vinci robot. In general, robotics is likely to be the future of medicine. However, it also has its limitations. However, what needs to be said is that the da Vinci Robot, whether it be the da Vinci Robot or some other robotic tool, is a tool. It is a very modern tool. It is a very precise tool. It is a very, you could say, comfortable tool. It is, under the right conditions, a safe tool, but it is still a tool. Therefore, I am smuggling in a phrase to make it sound like the patient is operated on by a doctor.

Monika Rachtan
Behind the robot is a human being.

Maciej Pliszkiewicz
Behind the robot is the man and the movement. The robot in the abdomen is the movement of my hand at the console. So the robot is just a de facto transfer of what the surgeon can do to the patient. Of course, it is a very precise tool. Among such advantages of robotics is that we have a perfectly still, perfectly motionless surgical field. How do we work? With two doctors at the operating table during a laparoscopy, there is always this hand moving somewhere. Something. This image can always change a little bit there. A little to the left, a little to the right during robotic surgery. The optics are controlled by the operator, because he presses the right button, sets the camera the way he wants and sees what he wants, the way I want, as close as I want, at the angle I want. So that's one advantage. The other advantage is that the operator is sitting.

Monika Rachtan
However, with 12-hour operations.

Maciej Pliszkiewicz
It may seem absurdly ridiculous, but when we operate laparoscopically, we are actually standing on one leg. Through the whole operation.

Monika Rachtan
Why on one?

Maciej Pliszkiewicz
This is because we control the other with energies.

Monika Rachtan
So it is actually physically necessary to be very fit to have such an operation. The operation doesn't always take two hours, because today the doctor was still telling us in the director's studio, when we were talking about operations, that the longest operation was more than 12 hours on one leg for 12 hours, well you can actually try it if you want to feel for a while like a surgeon who just operates laparoscopically.

Maciej Pliszkiewicz
I am not going to present here the strange positions we sometimes adopt, but it is true that this position can be extremely uncomfortable at certain moments of the operation. However, it is true that during the operation the surgeon sits at the console, has his elbows resting, and can adjust the height of the console so that he is comfortable and his spine does not hurt. This is not just doctor comfort. It translates into patient safety. Because if the doctor is not dramatically tired after three or four hours of surgery, he will work better. He will finish the operation faster and the operation will be safer for the patient. So, as I say, there are many advantages. But why, why? Why did I decide to do this training? Because I think it is, I think it is a tool to be able to offer the patient. It is not that the robot is needed for every operation. No, but there are some specific types of endometriosis surgery. When it seems that this robotics can maybe be very useful in a situation where we really need to, we need to get very deep into the neural structures, for example.

Maciej Pliszkiewicz
new indeed with the robot, with this stability of the image, with this precision of the tools, we can probably do more.

Monika Rachtan
Do you often get patients to your hospital who are already after some sort of first surgical or surgical experience?

Maciej Pliszkiewicz
The record holder was after 13 operations.

Monika Rachtan
And what then happens to such a patient? She was really tough.

Maciej Pliszkiewicz
You cannot talk about fixing. It's not like someone broke it and we fix it. It does not work like that. I mentioned at the beginning that a great deal depends on how the operation is carried out. That's what I'm going to say two words about now, because it's important. The idea behind the surgical treatment of endometriosis is that if we already operate, if we already decide to operate together with the patient, the aim of this operation is to remove all visible disease. The problem is that very often, for various reasons, part of this disease remains. And this is actually the problem. And it's not a question of someone messing something up, it's a question of the operation not being complete. If the operation is not complete, then we are basically guaranteed a recurrence of symptoms, or not even a cessation of those symptoms, and sometimes even an exacerbation of those symptoms. And, for example, using such a simplest example, which probably every woman has heard somewhere in her life. Ovarian cyst. Endometrial cysts of the ovary. That's really the tip of the iceberg in this diagnostic process too.

Maciej Pliszkiewicz
And an endometrial ovarian cyst alone is not a reason for a patient to have surgery, and certainly not a reason to just have an ovarian cyst removed. Why? Because endometrial ovarian cysts do not occur spontaneously. Never.

Monika Rachtan
That is, you have to look for this disease.

Maciej Pliszkiewicz
I will put it this way once I thought, it was 2000, probably 16, that I came across a patient with an isolated cyst. Endometriosis, however, is present. But I thought okay, I'll take sections from the peritoneum adjacent to the ovary. There was endometriosis there too. It wasn't visible, but it was visible, so they don't occur therefore and therefore, for example, just releasing the endometrial cysts of the ovary without excising the endometriosis, the superficial, the deep endometriosis that is in the pelvis will not have a good effect, i.e. it will have the effect that for a while these cysts will be gone, but the risk of recurrence of these cysts is very high and.

Monika Rachtan
The risk of returning to the hall.

Maciej Pliszkiewicz
Operative. But there is a second aspect which, I will talk about in the context of fertility, because repeated removal of ovarian cysts unfortunately takes its toll on the reproductive function, therefore. Also, we should not proceed in such a way that if we have a patient with a good cyst, we take it to the table, we release the cysts, in 3 months' time we take another cyst again. Because in this way we can lead to a situation where this woman will decide that she wants to get pregnant. Then she will no longer be able to.

Monika Rachtan
How should this situation be handled?

Maciej Pliszkiewicz
Again, there is no simple solution. But, but we accept as such a certain, let's say, standard when it comes to dealing with female patients. In any case, we try to strive for this. At the stage when a patient comes to us, we ask about pregnancy plans, because sometimes a patient comes to us and has no pregnancy plans, because, for example, she already has two children and is not planning more, well then it doesn't matter so much. But if a young girl comes to us, I don't know, 23 25 years old, she has unspecified pregnancy plans, she may not even have a boyfriend or husband. Who knows, maybe in 5, maybe in 10 years, maybe in 15, Or maybe not at all? I don't know. Yes it's in a patient like this that is the best candidate to have the disease. That's the best candidate to have ovarian function checked. And in such patients it is worthwhile to determine the AMH level. This is such an anti-Mullerian hormone. Alternatively, it is called Janikowo reserve. It is not exactly Janikowo Reserve, but this parameter correlates quite well indeed with this reproductive function of the ovary.

Monika Rachtan
It is important to discuss this with your doctor. If the doctor does not suggest us, to ask about the possibility of such a test. Doctor, there is a colloquial opinion that these very long and complicated operations require a long training process for the operator. Is this really the case?

Maciej Pliszkiewicz
Let me put it this way, training never ends. It's not like there's a learning curve and then it's Plato and we don't learn anything else. The thing about this disease is that no two cases are actually the same. It doesn't happen that we have the same picture in the abdomen. In two, three or as many patients. It doesn't always happen. Each time it is the case that this disease looks different. Therefore, for us, for the operators, every case is something new. That is one part of the answer. However, the other part of the answer. Perhaps I will use such an example from a discount workshop held some time ago at the hospital on Szaserów Street in the Military Medical Institute. He came to such a workshop. this is an American who is actually highly specialised in the treatment of endometriosis, in robotic surgery. Of course he showed, he did two or three demonstration surgeries there. Then he had a lecture and asked the question how long it takes to train an independent endometriosis operator. The statement from the floor was 2 years.

Maciej Pliszkiewicz
To which Gabi replied in his typical manner I don't know such a genius. It can be assumed that it takes 5 7 years of regular surgery for endometriosis to reach a certain level. Let's call it, to reach that level of surgical independence so that. What we find in the abdomen is not really a significant surprise to us. One that will make us. We're going to wonder oh god what am I going to do. So this learning curve. She is quite a long one. I once, I read an article like that, which said that you can sustain the skills of an endometriosis operator by doing 13 15 operations a year. That was an article once. Whereas it seems to me that it is not a question of how many. It is not a question of numbers, it is a question of time. It is not a question of setting yourself a framework, because there are people who have a talent for this. There are people who have less talent for it. There are people who are very fit and there are people who are less fit. In fact, what matters most in all of this I think is an English word, a very fitting one, dedicated an such.

Maciej Pliszkiewicz
It's not about making sacrifices, but it is about commitment.

Monika Rachtan
I think that's a very good word.

Maciej Pliszkiewicz
Because. Well, because you have to be a bit passionate about this disease, you have to be a bit passionate about this surgery, all of this, in order to do it well. If we do it out of necessity, we're not going to do it well. Nothing that we do out of compulsion, out of necessity is, is not going to be done really 100 per cent well. You really have to have such a deep conviction, you have to want to do it. And I think we have this team of people who want to do it, both the older ones and the younger ones, because once upon a time, our boss said that to do this kind of surgery, you have to have, sorry, pimples on the brain, and I kind of agree with him. And I have that too. Also, you know, if. If a person hijacks an operation that might take 6 8 hours, that might have a risk of complications, that doesn't give us 100% certainty of success. I think that.

Monika Rachtan
What you see in a patient's abdomen is always some. I don't know if surprise is the right word, but you can't be sure before opening a patient what will be there and assume for yourself that.

Maciej Pliszkiewicz
Sure maybe not, but with a certain level of diagnosis and experience just at this stage of conversation with the patient, examination, examination, ultrasound, evaluation, at least an MRI scan, because an MRI scan is also very useful, but there are some limitations here, and in any case some important, significant things, then we usually have a pretty good idea of what we are going to be dealing with. There may be some minor things that may surprise us, but so that, for example, we assume good, this operation will take two hours, say, and then it takes eight. Such things are unlikely to happen.

Monika Rachtan
It means you have the kind of patients, Doctor, that will stay in your memory forever.

Maciej Pliszkiewicz
I think everyone has and in every department, whether an internist, a surgeon, a gynaecologist or an oncologist. I think they do. Because really, what is it? What pushes us to do it is, on the one hand, to want to help the other side, to get a fertility outcome at least. If a woman comes in who has been trying to get pregnant for 10 years, has undergone many IVF procedures, has had three operations, well, generally she is already losing hope of ever being able to be a mother. We operate on such a patient and then two or three months after the operation she calls or sends a positive pregnancy test.

Monika Rachtan
Then the patient comes under your care. As far as the management of the pregnancy is concerned, is that something you would rather not deal with?

Maciej Pliszkiewicz
Strangely enough, practically all the pregnant patients they manage are endometriosis patients. I don't know why.

Monika Rachtan
Perhaps because more than a thousand operations of advanced endometriosis have been carried out by the doctor and I think he has already conquered an eight-thousander in this field of surgery it.

Maciej Pliszkiewicz
You cannot say that. You know, it is the case that here you always, always have to keep a cool head, because there is no such thing as having seen everything. That kind of thinking always takes its toll. If, God forbid, someone thinks, and this is regardless of whether it is endometriosis or any other plot. O I have already seen everything, then fate will surely prove him otherwise. And that kind of thinking is just dangerous. On the other hand. On the other hand, of course, experience, experience matters. This translates, on the one hand, into what we are able to do in the operational field, this translates into the duration of the operation. It translates into the completeness of that operation. Of course it does. If someone has done ten operations, someone does a hundred operations, someone does 500 operations, well there are some differences. However, we work as a team, so a person who has done 10 or 15, or 30, or 50, or 100 of these operations, standing up to someone more experienced, they will do these operations just as well, because we watch over each other.

Maciej Pliszkiewicz
But if someone experienced is operating and they have someone younger with them, the younger one also watches over the older one. It's a team effort.

Monika Rachtan
Do patients still complain today that this pathway from suspecting the disease to diagnosis, to receiving help, is a long one? And what would your doctor advise women who suspect they have endometriosis, or who have been diagnosed with the disease and are at some early stage of treatment? How to proceed further? How to look for a specialist? What to look out for in order to receive this best specialist care?

Maciej Pliszkiewicz
Again, there are no simple, straightforward answers. Of course, it continues to happen that a patient comes in saying that she has been in pain for years. It has been ignored for years. Well, yes, the patient says I don't suppose it's that it's been ignored, but it's just that sometimes it's that colleagues spread their arms. We don't know what is hurting you. And then it's more honest to tell such a patient I don't know what's hurting you, you have to look further. And sometimes I get patients to whom their general practitioner says: "Ma'am, I don't know, maybe it's endometriosis, but I don't know. Look for a specialist. I have the highest respect for such colleagues, because these are people who on the one hand want to help the patient, and on the other hand, knowing their own limitations, say you need to look further, because maybe there is something more. And if. If a woman has such a doctor, she should stick with him, because he is a good doctor, a really good doctor. On the other hand, if. If we don't know what's going on, if we have a suspicion of endometriosis, well then you really just have to look for a specialist, look for someone who specialises in this area.

Maciej Pliszkiewicz
Certainly here. A big role is played by patient organisations that. Which keep registers, let's call it that way, of doctors who deal with this disease though. In any case, who are able in various places in the country to indicate to whom it is best to go, because this person already has some experience in this area, so you have to seek help.

Monika Rachtan
And I will conclude by adding that if. Dear girls, dear women, your doctor says that this is your beauty, then you should change your doctor and look for one who will be able to explain your pain. Today, my guest, but above all your guest, was Dr Maciej Pliszkiewicz. Thank you very much, doctor. This was the 'Patient First' programme. Monika Rachtan, thank you for your attention.