1. david blair toub, m.d. David Blair Toub, M.D. Department of Obstetrics and Gynecology Pennsylvania Hospital, Philadelphia, PA Hysterectomy: A Reappraisal

2. david blair toub, m.d. “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.” “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

3. david blair toub, m.d. Hysterectomy: 600,000/year, mostly TAH 600,000/year, mostly TAH 33% of women have hysterectomies by age 60 33% of women have hysterectomies by age 60 Rates vary by geography, patient race, and physician gender/age Rates vary by geography, patient race, and physician gender/age Mortality (benign) = 10/10,000 Mortality (benign) = 10/10,000

4. david blair toub, m.d. Potential Complications: Blood loss Blood loss Genitourinary Genitourinary Sexual Sexual Ovarian failure Ovarian failure Depression? Depression? CVD? CVD?

5. david blair toub, m.d. Benefits of Retained Uterus: Orgasmic Potential Retained Orgasmic Potential Retained Risk to Ureters Minimized Risk to Ureters Minimized Decreased Blood Loss Decreased Blood Loss Fertility Potential Fertility Potential

6. david blair toub, m.d. TOP 10 LIST: Reasons to do a hysterectomy 10. Size > 12 Weeks 10. Size > 12 Weeks 9. “Rapid Growth” 9. “Rapid Growth” 8. “To Prevent Future Problems.” 8. “To Prevent Future Problems.” 7. Pelvic Relaxation 7. Pelvic Relaxation 6. Endometrial Hyperplasia in Older Patient 6. Endometrial Hyperplasia in Older Patient

7. david blair toub, m.d. TOP 10 LIST: Reasons to do a hysterectomy 5. Incidental to BSO 5. Incidental to BSO 4. DUB 4. DUB 3. Pelvic Pain 3. Pelvic Pain 2. TOA 2. TOA

8. david blair toub, m.d. And the #1 Reason:  Symptomatic Fibroids, Fertility Undesired

9. david blair toub, m.d. Alternatives to Hysterectomy: Myomectomy: Open Open Laparoscopic Laparoscopic Hysteroscopic Hysteroscopic

10. david blair toub, m.d. Open Myomectomy Hemostasis Techniques: The older approach: Speed! The older approach: Speed! Vasopressin Vasopressin Uterine ischemia: tourniquet +/- Bulldog vascular clamps Uterine ischemia: tourniquet +/- Bulldog vascular clamps

11. david blair toub, m.d. Suggestions for Open Myomectomies: Preoperative endometrial sampling if >35 Preoperative endometrial sampling if >35 Autologous blood donation Autologous blood donation Exposure (Maylard incision helpful) Exposure (Maylard incision helpful) Minimize uterine incisions - intentional Classical hysterotomy with uterine reconstruction Minimize uterine incisions - intentional Classical hysterotomy with uterine reconstruction Know when to quit Know when to quit Liberal use of frozen section Liberal use of frozen section Meticulous hemostasis and closure of dead space Meticulous hemostasis and closure of dead space Adhesion prevention Adhesion prevention

12. david blair toub, m.d. Case Study: 42 yo G 6 P 6, 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/c’d to home on POD#3

13. david blair toub, m.d. Pilot Study: Myomectomy as an Alternative to Hysterectomy in Women Who Do Not Desire Fertility 14 patients, age 26-50 14 patients, age 26-50 Fibroid totals: 1-42 (largest single aggregate weight 1473g) Fibroid totals: 1-42 (largest single aggregate weight 1473g) Mean EBL 165 cc (range 35-750cc) Mean EBL 165 cc (range 35-750cc)

14. david blair toub, m.d. Alternatives to Hysterectomy: Endometrial Ablation Endometrial Ablation Myolysis Myolysis Progestins Progestins ?Photodynamic Therapy ?Photodynamic Therapy Kegel exercises (or pessary in selected patients) Kegel exercises (or pessary in selected patients) GnRH Agonists (adjunctive) GnRH Agonists (adjunctive)

15. david blair toub, m.d. GnRH Agonists: Decreases fibroid size by up to 50% after 3 months Decreases fibroid size by up to 50% after 3 months Long-term use limited by osteopenia Long-term use limited by osteopenia Decreases blood loss pre- and intraop Decreases blood loss pre- and intraop

16. david blair toub, m.d. Appropriate Indications for Hysterectomy: Gynecologic Cancers Gynecologic Cancers Symptomatic Procidentia Symptomatic Procidentia Life-Threatening Hemorrhage Life-Threatening Hemorrhage Patient Declines Alternative Measures Patient Declines Alternative Measures

17. david blair toub, m.d. Excuses, Excuses: Myomectomy: adhesionsadhesions fibroid recurrencefibroid recurrence high blood loss intraophigh blood loss intraopAblation: CA riskCA risk failure to learn procedurefailure to learn procedure

18. david blair toub, m.d. Conclusions: Alternatives to hysterectomy exist Alternatives to hysterectomy exist Commonly-held “indications” for hysterectomy are often more subjective than substantiated by science 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 Physician bias or inexperience with new surgical techniques may explain why hysterectomy is recommended more often than conservative measures

19. david blair toub, m.d. Conclusions: Hysterectomy should be a last resort, and used only when specific indications exist and after discussions with the patient.

20. david blair toub, m.d. “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 33:560, 1969 Wright, Obstet Gynecol 33:560, 1969

21. david blair toub, m.d. “Since cure without deformity or loss of function must ever be surgery’s highest ideal, the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable.” “Since cure without deformity or loss of function must ever be surgery’s highest ideal, the general proposition that myomectomy is a greater surgical achievement than hysterectomy is incontestable.” Bonney, 1931