Dr. Voicu Simedrea: "In Romania, at present, 500,000 women suffer from endometriosis"
Dr. Voicu Simedrea is an OB/GYN Doctor and founder of EndoInstitute in Timișoara, specialized in endometriosis surgery, a disease encountered more and more often in fertile women, which, left untreated, can lead to severe complications that affect the vital organs, and also to infertility. By everything he did, he succeeded to spread the information about endometriosis and has been organizing for the medical team for the last 4 years in Timișoara a conference that focuses on this condition. He draws attention to the fact that intense pain in the gynecological area should not be overlooked, and that the anamnesis is very important in establishing the diagnosis. Following the recent partnership between EndoInstitute and Columna Medical Center in Bucharest, Dr. Simedrea also offers consultations at the clinic in Bucharest.
What made you choose medicine and what does your professional career so far look like?
I chose medicine subconsciously as my mother really loved the idea of me becoming a doctor. And slowly, slowly she instilled in me throughout my education, first of all, the idea that we have a duty to do good to our fellow men and that our fellow men are basically good, which is not necessarily always correct and true.
My professional career was a winding one… After graduating from the Faculty of Medicine and Pharmacy in Timișoara, I was initially haunted by the idea of immigrating to the United States, which is why I took one of the two exams for the recognition of the doctor’s degree in the United States, as well as the foreign language exam I actually passed. Later, I entered the residency exam and I took a surgical specialty that suited me. I decided to abandon the idea of immigration because it would have taken me a long time to specialize in a surgical department in the States. I was lucky enough to start the residency program at the Second Surgery Clinic of the Timișoara County Hospital, where the professor was the great surgeon, Dr. Bordoș Doru. I had the pleasure to discover his work and to learn perhaps from the best surgeons I have known until now.
After graduating from the surgery and oncology surgery internship, I attended the gynecology internship at the Victor Popescu Hospital in Timișoara. I could not occupy any position in the state system because unfortunately the state system was and is still closed for people who want to access it through the front door. Seven years of volunteering at the Military Hospital in Timișoara followed, and after that, a private hospital was opened in Arad, where I practically coordinated the activity for one year. I was then appointed head of a department at the Atena Private Hospital in Timișoara, Head of Gynecology, then Head of Obstetrics-Gynecology, where I worked for 4 years. I grew from a surgical point of view, I diversified the part of minimally invasive interventions, I also had some international firsts, I practically matured as a doctor. After that me and a few colleagues from Timisoara joined and initiated the Premier Hospital project. For a year and a half we have been carrying out our activity in a new location with an area of 5,000 sq.m., with 6 operating and delivery rooms, with everything we need to carry out / perform high-performance surgeries.
What are the gynecological diseases you treat most often?
Given my predominantly surgical vocation, I focused on the performance of gynecological surgery. I have always been concerned about what’s new in the gynecological surgery area, I have been delighted and obsessed with the thought that this surgery can be performed by methods that are as little invasive as possible, with as little trauma for the patient; I was fascinated by the experiences I had watching Prof. Betochi performing outpatient hysteroscopy or Prof. Brătilă performing vaginal surgery. And I understood that this is actually the path I need to follow, the path of minimally invasive surgeries. I first started treating benign pathology with laparoscopy, and then I moved on to treating oncology pathology, genital cancers by using minimally invasive methods and this last stage came naturally, i.e. is the culmination of a journey and from my point of view the most complicated surgery in gynecology, which is the endometriosis surgery.
I say complicated because it involves mixed teams of surgeons and it is very important to put together such a team because it involves the art of trusting each other and respecting each other's work and expertise. I think this is the key to success in endometriosis surgery. In a nutshell, I currently specialize in endometriosis surgery and have over 100 cases of operated advanced endometriosis per year, with colorectal resections, bladder resections, etc. And in addition to that, I also do oncology surgery and reproductive surgery.
You specialized in endometriosis and have drawn attention to this condition…
I was surprised that so many patients came to my office or arrived on the operating table with this disease that we knew very little about and that there was very little talk about it at the time. Five years ago, in the gynecology area in Romanian, it seemed to me that there was a discrepancy between the incidence of the disease, which was very high, and the concerns of the medical body in relation to this disease. And then I decided that, with the launch of my platform that increased awareness and tried to confirm the idea of minimally invasive surgery, to draw attention to the disease. I was lucky that a very well-informed and professional journalist was present at the press conference and he wrote a very good and successful article about endometriosis. Since then we have tried to make constant efforts and to inform both patients and the medical body about endometriosis. We informed the patients through interviews, through TV shows, through the blog that exists on the endometriosis.ro website, and on the EndoInstitute website. For the medical staff, we organized the first conference that mainly focused on endometriosis. And this conference is already in its fourth edition and it takes place every year in Timisoara and we bring first-hand speakers in this field.
How does the disease manifest itself and what are the main symptoms that send the patient to the doctor?
The first symptom of the disease is pain. Pain during menstruation at first, during ovulation, then it becomes chronic pelvic pain of high intensity that requires analgesic treatment and often keeps the patient in bed. The pain also occurs during sexual intercourse, it is accompanied by nausea, vomiting, general discomfort. Digestive disorders that are intensified by menstruation or ovulation occur: diarrhea, pain during defecation, altered stools. Pain may also be present when urinating along with a burning sensation. Endometriosis is also a cause of infertility. All of these symptoms should make the patient see a doctor. She needs to keep in mind this: although she is told this, it is not normal to have extremely intense pain throughout her life, menstrual pain, ovulation pain, or chronic pelvic pain. The pain should be investigated.
What are the diagnostic methods?
Endometriosis is diagnosed quite easily if the doctor is knowledgeable and empathetic, if he or she listens to the patient, if he or she gives her the chance to expose her usually a long history of the disease and if he or she examines her thoroughly, with expertise and experience. The diagnosis of endometriosis is based on the anamnesis, on what the patient tells the doctor, on the clinical examination (valve examination, bimanual palpation, an examination by touch). A transvaginal ultrasound examination is performed – this is an extremely useful method to detect endometriosis in the small pelvis, both in the anterior and middle and posterior compartments. If these examinations indicate an advanced phase of the disease, stage 3 or 4 of the disease, then we are entitled to request additional and more expensive examinations, but they also give us information about the rest of the abdominal cavity, such as the pelvic MRI with endometriosis protocol, a virtual colonoscopy, a urology CT scan. The idea that endometriosis should be diagnosed by laparoscopy is wrong. At present we have the possibility / obligation to diagnose the disease and to stabilize it by non-invasive methods, not by surgery. The surgeries are reserved for advanced cases of the disease and have a therapeutic role, not a diagnostic-related one.
How many stages of the disease are there?
There are 4 stages of the disease according to the rASF classification – the American Fertility Society classification, revised. In stages 1 and 2 of the disease, we are dealing with an incipient phase, which is not extended beyond the genital tract. But stage 3 of the disease involves, in addition to the genital tract, the adjacent organs as well, but to a lesser extent, and may be accompanied by infertility. Stage 4 of the disease is the most advanced, in which we always find lesions of deep endometriosis, which affect vital organs such as the bladder, intestine and in which infertility almost inevitably occurs in addition to the low quality of life.
In Romania, there are very few doctors specialize in endometriosis and often the disease is incorrectly diagnosed. What are its complications and also the risk groups?
I am not aware of the activity of all the colleagues in the country, I am not able to evaluate and judge, I just want to say that as far as we, EndoInstitute, as a center of excellence in endometriosis, have operated over 450 cases so far, and over 1,500 consultations have been performed. We do not operate everything we see, we operate only 20-25% of the evaluated cases. The surgery is reserved only for serious cases, i.e. 78.8% of the cases we operated on are cases in stages 3 and 4, basically, 65% of them are stage 4.
The problem with endometriosis in Romania is the diagnosis. There is high diagnostic latency. In German-speaking countries, it seems that there is a diagnostic latency of 7-8 years. In Romania, it is probably over 10-12 years old. And then, during all this time when the disease is not diagnosed, it can get complicated, and thus it becomes a case that requires multidisciplinary management, special attention, consuming medical and social resources. The key to success in managing this disease would be, from my point of view, a well-developed screening system.
The risk group for this disease is represented by girls who have great pain from the first menstruation, who have a family history of estrogen-dependent diseases, such as endometriosis, endometrial cancer, breast cancer, fibroids. These patients should be evaluated before they develop / show clinical disease. The complications of endometriosis are to be feared, starting with the loss of the fertile capacity and continuing with serious damages of the vital organs, as I said. There are many women who have lost their kidneys due to this disease, women who wear a colostomy bag for their entries lives.
Statistics on endometriosis show that there are currently more than 150 million women in the world suffering from this disease; in Romania, the number of patients is 500,000, of which 10% develop the serious form of the disease – deep infiltrative endometriosis, i.e. we have 50,000 patients suffering from the serious form of the disease, so there is a great need for specialists, not only surgeons but also specialists in assisted human resources, endocrinologists, psychologists, gastroenterologists.
What is the contribution of technology in diagnosing and treating endometriosis?
Technology influences the development in any of the surgical branches, and it would be inconceivable today to operate without using technology. As for the surgical treatment, as I said, it is minimally invasive… so we depend on various tools that allow us access to small holes in the abdominal cavity. It is very important to benefit from the contribution of technology, but first and foremost, and this is I want to emphasize, we need people. The human factor is essential. I have visited endometriosis surgery centers with a long tradition, where the diagnosis was made with an absolutely basic ultrasound scanner, Prof. Keckstein used to make some absolutely incredible ultrasound scauns, he saw lesions that were very difficult to detect. I think that up to a point technology helps us a lot, but on the other hand, it could raise the costs of the intervention a lot, and it is not always justified.
From my point of view, endometriosis surgery should be minimally invasive, but at least at present robotics does not bring additional benefits in terms of lowering the complication rate, the length of hospital stay, the recovery, instead, it adds to the costs and I believe that at the moment, in Romania, it is not yet feasible as a method, although of course, it is desirable.
What gynecological investigations are mandatory for the age groups of 20-30, 30-40, 40-50, and 50+?
If we talk about general gynecological investigations and we do focus on endometriosis, in this case, there are many things to mention here.
For the age groups of 20-30 / 30-40, we include the cervical cancer screening, the Pap test, an HPV infection pattern and if the pattern is negative it can be postponed to the next determination 5 years after the first testing. We need to evaluate the ovarian reserve, the tubal status, the uterus, the uterine cavity, a breast ultrasound scan after the age of 30.
For the patients aged between 40 and 50 years, family history also matters. Those with cases of ovarian or breast cancer in their families should be screened for those cancers, a mammogram after the age of 40, possibly BRC testing, but this is still prohibitively expensive, and also transvaginal ultrasound scans to check the ovaries. In principle, after the age of 50, we no longer have problems with endometriosis.
How much time did you spend in an operation?
10 hours during which we replaced three surgery teams of assistants and anesthetists…
Tell us more about the single-port total hysterectomy
The single-port total and sub-total hysterectomy are two national premieres that we presented 5-6 years ago. It is an alternative to laparoscopic hysterectomy on selected cases, i.e. where we can afford to apply this method, an additional aesthetic benefit is conceived, meaning that the patient will have a single umbilical incision where we insert both the optic camera and all the working instruments, we skeletonize / disconnect the uterus and appendages, and extract them vaginally.
The total hysterectomy is indicated only if the patient has an ancillary pathology or if the uterine pathology involves the removal of the appendages, but the standard gold method is the vaginal hysterectomy, something that has been welcomed by the American Association / College of Gynecology long ago. The single-port hysterectomy is made a little more interesting: as I told you before, we disconnect the uterus, but the uterine body is sectioned and morselled – which means that it is extracted in small pieces through the umbilicus, the maneuver being monitored with the optical camera that is introduced through the remaining cervical abutment. They are feasible methods for selected cases, they offer only an additional aesthetic benefit. From the point of view of postoperative evolution, postoperative pain, etc., it is comparable to laparoscopic hysterectomy; in terms of costs, the queen is the vaginal hysterectomy.
What do you think is your most important professional success?
I believe that the most important thing I managed to keep, not to gain, is that I did not lose my humanity. I managed not to forget that this job is primarily for and about the people. And, if I had to add something else, I have not lost my interest in self-improvement, in what’s new, and I have always tried to push my limits during all these years.
What advice do you have for the students who would like to follow in your footsteps?
The only advice I can give to young people from my experience is to do this job with love, joy, and the satisfaction that they basically do a good thing. Schopenhauer said, "The work of art is a generally valid good — that is, something whose positive value no one can dispute". From this point of view, I believe that medicine is a work of art.
This interview was published in the magazine "Galenus"