Myomectomy As an Alternative to Hysterectomy for Women Who Have Completed Childbearing: A Pilot Study

1
Myomectomy As an Alternative to Hysterectomy for
Women Who Have Completed Childbearing A Pilot
Study

• David Blair Toub, M.D.
• Dept of Obstetrics and Gynecology
• Pennsylvania Hospital

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Uterine Fibroids

• 33 of all benign hysterectomies
• Generally treated by myomectomy or other
  conservative measures in women who desire
  fertility, hysterectomy in older women
• Definitively treated by hysterectomy
• Regress after menopause (51.8 years)

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Why Is Myomectomy Not Preferred?

• Reputation as bloody operation
• Fibroid recurrence is possible risk
• Adhesion formation
• Wallach 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)

4
Hysterectomy Risks

• Ureteral injury (0.1 - 0.5)
• Changes in libido (25-33) and orgasm
• Depression
• Decreased time to ovarian failure

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Patient Population

• Women with symptomatic fibroids (n 14)
• 11 s/p TL , 3 with undesired fertility
• Age range 26 - 50 (mean 38.4 years)
• Endometrial sampling done if IMB and 35
• Autoblood encouraged
• GnRH-a if corpus 16 weeks

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Exclusions

• Patient desires fertility
• Patient declines uterine conservation
• Abnormal cervical or uterine histology
• Medical contraindications to surgery

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Operative Technique

• Maylard or vertical incision
• Tourniquet placed around uterine arteries and
  Bulldog clamp across uteroovarian lig
• Minimize number of hysterotomies
• Classical hysterotomy if multiple myomata
• Vasopressin not employed

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Results

• Mean EBL 165 cc (35-750)
• 1 - 42 fibroids removed (maximum total weight
  1473 g)
• No PRBCs required
• BSO performed in 2 patients
• All uteri preserved, with significant relief of
  symptoms in 13 / 14 patients
• 3 wound seromas, 1 UTI

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Conclusions

• Myomectomy is a feasible alternative to
  hysterectomy regardless of fertility status
• Blood loss compares favorably with hysterectomy
  when appropriate techniques are utilized
• A randomized, prospective study comparing
  hysterectomy with myomectomy in this patient
  population is warranted

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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
33560, 1969
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Since cure without deformity or loss of
function must ever be surgerys highest ideal,
the general proposition that myomectomy is a
greater surgical achievement than hysterectomy
is incontestable. Bonney, 1931