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
100%
100%
85%
Reproductive Potential Maintained
Subsequent Procedures
Risk of Incontinence
10% 40% Increase
10%
15%
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