Alternatives to Hysterectomy

Duncan Turner MD, MBBS,

FACOG,
October 28th 1998
Santa Barbara,California
 HYSTERECTOMY

• 600,000 per year in USA

• 35% chance by 60
• Traditional Surgery
– 3 days in hospital
– 6 weeks of recovery

• Total Cost: $15,000 + loss of productivity

 TOPICS

• Alternatives to Hysterectomy
• Alternatives to Traditional Hysterectomy
• Why?
– New Treatments
– New Surgeries
– You Have A Choice
 Definitions

• Hysterectomy
– Removal of Uterus, With/Without Ovaries

• Subtotal Hysterectomy
– Removal of Uterus Without Cervix, With/Without Ovaries

• Approaches
– Abdominal (Laparotomy)
– Vaginal
– Endoscopic (Laparoscopic)
The Uterus
 Definitions

• Endoscopy: Looking through a narrow tube

• Types of Endoscopy
– Hysteroscopy - into uterus via vagina
– Laparoscopy - into the abdomen
– Cystoscopy - into bladder
– Others
 Cost of laparotomy

• $5,000 - $15,000
• 3 Days in Hospital
• Significant Pain
• 6 Weeks of Recovery
 Cost of laparoscopy

• $4,000 - $15,000
• Outpatient or Inpatient
• 3 Hours to 2 Days in Hospital
• 3 Days to 3 Weeks Recovery
 Cost of hysteroscopy

• $2000
• Outpatient
• <3 Hours in Surgery Center
• 1-2 Days of Recovery
 The Conditions

• Abnormal Uterine bleeding

• Fibroids
• Endometriosis
• Prolapse
• Chronic Pelvic Pain
• Cancer and Precancerous Conditions
 ABNORMAL UTERINE
BLEEDING

• Prolonged, Irregular or Heavy Bleeding

• 30% of Hysterectomies
• 200,000 a Year
 Causes of A.U.B.

• Hormonal Irregularity
• Growths in Uterus
• Cancer and Precancerous Conditions
• Bleeding Disorders
 Investigation and Treatment

• Nothing
• Ultrasound and Biopsy to Rule Out Cancer
or Precancerous Conditions
• Hormonal Therapy
• D and C
• Hysteroscopic Therapy
• Hysterectomy
 Hormonal Therapy for A.U.B.

• Birth Control Pill

• Adjustment of Current Therapy
• Other Hormones
 D and C for A.U.B.

• Traditional Treatment
• Blind Procedure
• Good for Biopsy
• No Evidence of Therapeutic Benefit
 Hysteroscopic Treatment of
A.U.B.
• Visual Procedure
• Removal of Growth
– Good for Biopsy
– Very Accurate
• Endometrial Ablation
– Destruction of Lining Tissue by
• Laser
• Electricity
• Hot Water Balloon
Thermachoice
Thermachoice VS Electrocautery

• Improvement at 12 months
– 85% vs 89%

• Hysterectomies by 12 months
– 2% =

• Repeat Ablations by 12 months

– <1% =

• Complications
– 4% vs 6%
 Benefits of Thermachoice

• Effective
• Simple
• Safe
• Short Procedure
• Local or General Anesthetic
• 85% Successful
 Hysterectomy for A.U.B.

• Traditional
• Laparoscopic
• With or Without Ovaries or Cervix
• 100% Successful
 Fibroids
• Non-cancerous Growths of Uterine Muscle
• 35% of Women
• 30% of Hysterectomies
• Can Cause:
– Bleeding
– Pain
– Pressure
– or Nothing
 Treatment of Fibroids

• Nothing
• Hormonal Therapy
• Destruction
• Removal
• Hysterectomy
 Hormonal Therapy for Fibroids

• Side Effects
• Temporary
• Expense
• Can be Utilized Before Surgery
 Destruction of Fibroids

• Blocking Blood Supply

– (EMBOLIZATION)

• SURGERY
– Laser
– Electricity
– Freezing
 Removal of Fibroids

• Individual -
– Traditional or Endoscopic
– Hysteroscopic or Laparoscopic

• Total -
– Hysterectomy
– Subtotal Hysterectomy
– Traditional or Laparoscopic
 Endometriosis

• Endometrial Tissue in Abnormal Places:

• On Ovaries, Uterus, Bowel
• Can Cause:
• Pain
• Infertility
• Growths
 Treatment of Endometriosis

• Nothing
• Hormonal
• Excision
• Cutting of Nerve Supply
• Hysterectomy
 Hormonal Therapy for
Endometriosis

• Birth Control Pills

• Progesterone
• Danazol
• Lupron
• Side Effects
• Expensive
 Excision of Endometriosis

• Traditional Surgery
• Laparoscopic Surgery
• Better Visualization
• More Precise Surgery
• Nerve Supply May Be Cut
• Hysterectomy May Not Be Necessary
 PROLAPSE
• Loss of Support of:
• Uterus
• Bladder
• Vagina
• Rectum
• Because of:
• Childbirth
• Genetics
• Chronic Increase in Pressure
 PROLAPSE

• Resulting in:
• Protrusion of Structures
• Pain and Pressure
• Urinary Incontinence
• Urinary Retention
 Non-Surgical Treatment of
Prolapse

• Pessary
• Kegel Exercises
• Weights
• Electrical Stimulation
• Biofeedback Therapy
 Surgical Treatment of Prolapse

• Vaginal
• Abdominal
• Laparoscopic
• Does not Have To Include
HYSTERECTOMY
 CHRONIC PELVIC PAIN

• Debilitating Pain - Chronic

• No Obvious Cause
• Pain With Intercourse
• Pain With Periods
 Treatment of Chronic Pain

• Hormones
• Pain Killers
• Diagnostic/Therapeutic Surgery
– Microlaparoscopy
– Smaller Instruments
– Quicker Recovery

• Traditional Surgery
 PRECANCEROUS
CONDITIONS of UTERUS

• Hormonal Therapy
• Observation
• Hysterectomy
 PRECANCEROUS
CONDITIONS of the CERVIX

• Freezing
• Conization
– Office of Out Patient Surgery Center

• Hysterectomy - Traditional or Laparoscopic

 CONCERNS REGARDING
MANAGED CARE

• Underutilization vs Overutilization
• Diminished Freedom to Choose
 SUMMARY

• Alternatives Exist
• Treatment Should be Suited to the
Individual
• A Minimally Invasive Approach is Almost
Always Available
• Be Part of the Decision Making Process