Types of Hysterectomies

Types of Hysterectomies • • • • • Total abdominal hysterectomy Total vaginal hysterectomy Laparoscopic assisted vaginal hysterectomy Laparoscopic hysterectomy Laparoscopic Supracervical hysterectomy Outcomes Comparison Acute Experience Hospitalization Recovery Abdominal Supracervical Resection Hysteroscopic Hysterectomy Hyst. / Ablation Myomectomy 2-3 days 4-6 weeks 1 day 2 weeks 6 hours 1 1-4 days 1, 2 6 hours 1-4 days Complications Costs 35% $10,000 10% $6,000 4% 1, 2 $5,000 3 4% $5,000 90% of AUB patients prefer treatments that are painless, require no large incision and allow a quick recovery. 4 1 2 3 4 Brumsted JR, Blackman JA, et.al., Fertility and Sterility, Vol. 65:2, 1996 Dwyer, ibid Brooks, PG, et.al., Journal of Reproductive Medicine, Vol. 39, No. 10, October 1994, Rand Corporation RAND Institute, AAGL 9/97 Long-Term Patient Outcomes Comparison Long-term Experience Abdominal Hysterectomy Supracervical Hysterectomy OPERA Procedur e SMART Procedure Complete / Near Absence of Complete Bleeding Subsequent Procedures 100% 100% 85% Reproductive Potential Maintained 10% 10% 15% Risk of Incontinence 40% Increase No No AUB: Life-Table Analysis (N=62) • FU (menopause)N 1 49 25 2 48 16 3 47 14 4 46 3 5 45 1 6 44 0 7 43 2 8 42 2 No further surgery (%) 100 Global 100 Global 91.3 R/A(?cryo) 91.3 R/A(?cryo) 91.3 R/A Fib/Adeno 91.3 R/A SCH 73.0 SCH SCH 48.6 SCH SCH Derman et al. Obstet Gynecol 1991:59-77. Alternatives to hysterectomy • Supracervical hysterectomy • Ablation of the endometrium • Resection/ablation in Operating room » » » » » Versa Point Electric loop, any instrument company Cryoablation Gynecare: tri-wire loop with morcellator Yag Laser • Pre-menopause: GnRH analog therapy + add-back Global Ablation: Technique & Equipment • Thermal Balloon: 170-190°F for 8-10 min – ThermaChoice® (Gynecare) – Cavaterm • Cryo-ablation – Soprano™ (Gynecare) • Bipolar:  2 min exposure – Novacept® • Heated fluid: 70°C for 3-4 min (local anesthesia) – EnAbl® (Innerdyne/U.S. Surgical) • Radiofrequency balloon – Vesta/DUB (Vesta Medical) • Photodynamic Therapy – Photofrin II • Microwaves: 8mm probe: 2 min 12 sec Indications for hysterectomy • • • • • • • • • • • • • • • • Endometriosis Abnormal uterine bleeding Fibroids Pelvic inflammatory disease Cancer of uterus, tubes or ovaries Severe pelvic adhesions Bilateral ovarian pathology Adenomyosis Pelvic congestion syndrome Intractable, recurrent dysmenorrhea or metrorrhagia Uterine anomalies Uterine prolapse Recurrent intrauterine polyps Uterine perforation Mentally retarded patient with no hygiene control Pregnancy – – – – Placenta increta, percreta, or acreta Atonic uterus Uterine perforation Ruptured uterus