David Blair Toub, M.D.

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Hysterectomy A Reappraisal

• David Blair Toub, M.D.
• Department of Obstetrics and Gynecology
• Pennsylvania Hospital, Philadelphia, PA

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• Although it is unusual for myomectomy to be
  technically implausible, the procedure may be
  difficult, time-consuming, and associated with a
  substantial complication rate...Hysterectomy
  usually is a simpler procedure than multiple
  myomectomy, as well as the procedure to which
  most gynecologists are more accustomed.
• Te Linde, Operative Gynecology, Seventh Edition

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Hysterectomy

• 600,000/year, mostly TAH
• 33 of women have hysterectomies by age 60
• Rates vary by geography, patient race, and
  physician gender/age
• Mortality (benign) 10/10,000

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Potential Complications

• Blood loss
• Genitourinary
• Sexual
• Ovarian failure
• Depression?
• CVD?

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Benefits of Retained Uterus

• Orgasmic Potential Retained
• Risk to Ureters Minimized
• Decreased Blood Loss
• Fertility Potential

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TOP 10 LISTReasons to do a hysterectomy

• 10. Size gt 12 Weeks
• 9. Rapid Growth
• 8. To Prevent Future Problems.
• 7. Pelvic Relaxation
• 6. Endometrial Hyperplasia in Older Patient

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TOP 10 LISTReasons to do a hysterectomy

• 5. Incidental to BSO
• 4. DUB
• 3. Pelvic Pain
• 2. TOA

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And the 1 Reason

• Symptomatic Fibroids, Fertility Undesired

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Alternatives to Hysterectomy

• Myomectomy
• Open
• Laparoscopic
• Hysteroscopic

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Open Myomectomy Hemostasis Techniques

• The older approach Speed!
• Vasopressin
• Uterine ischemia tourniquet /- Bulldog vascular
  clamps

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Suggestions for Open Myomectomies

• Preoperative endometrial sampling if gt35
• Autologous blood donation
• Exposure (Maylard incision helpful)
• Minimize uterine incisions - intentional
  Classical hysterotomy with uterine reconstruction
• Know when to quit
• Liberal use of frozen section
• Meticulous hemostasis and closure of dead space
• Adhesion prevention

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Case Study

• 42 yo G6 P6 , s/p tubal ligation with chronic
  hypermenorrhea and anemia due to fibroids.
  Initial uterine size over 20 weeks.
• U/S uterus 17x14x11, multiple fibroids (6 cm
  maximum size). EMBx benign.
• Pt opted for myomectomy. After 3 months of
  GnRH-a, uterine size reduced to 16 weeks.
• At Xlap, 33 fibroids removed via Maylard incision
  using a tourniquet and Bulldog clamps for
  hemostasis. EBL 175 cc. Pt d/cd to home on POD3

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Pilot Study Myomectomy as an Alternative to
Hysterectomy in Women Who Do Not Desire Fertility

• 14 patients, age 26-50
• Fibroid totals 1-42 (largest single aggregate
  weight 1473g)
• Mean EBL 165 cc (range 35-750cc)

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Alternatives to Hysterectomy

• Endometrial Ablation
• Myolysis
• Progestins
• ?Photodynamic Therapy
• Kegel exercises (or pessary in selected patients)
• GnRH Agonists (adjunctive)

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GnRH Agonists

• Decreases fibroid size by up to 50 after 3
  months
• Long-term use limited by osteopenia
• Decreases blood loss pre- and intraop

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Appropriate Indications for Hysterectomy

• Gynecologic Cancers
• Symptomatic Procidentia
• Life-Threatening Hemorrhage
• Patient Declines Alternative Measures

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Excuses, Excuses

• Myomectomy
  
• adhesions
• fibroid recurrence
• high blood loss intraop
• Ablation
• CA risk
• failure to learn procedure

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Conclusions

• Alternatives to hysterectomy exist
• Commonly-held indications for hysterectomy are
  often more subjective than substantiated by
  science
• Physician bias or inexperience with new surgical
  techniques may explain why hysterectomy is
  recommended more often than conservative measures

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Conclusions

• Hysterectomy should be a last resort, and used
  only when specific indications exist and after
  discussions with the patient.

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• The uterus has but one function-reproduction.
  After the last planned pregnancy, the uterus
  becomes a useless, bleeding, symptom-producing,
  potentially cancer-bearing organ and therefore
  should be removed.
  
• Wright, Obstet Gynecol 33560, 1969

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• Since cure without deformity or loss of
  function must ever be surgerys highest ideal,
  the general proposition that myomectomy is a
  greater surgical achievement than hysterectomy is
  incontestable.
• Bonney, 1931