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