Title: Myomectomy As an Alternative to Hysterectomy for Women Who Have Completed Childbearing: A Pilot Study
1Myomectomy 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
2Uterine 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)
3Why 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)
4Hysterectomy Risks
- Ureteral injury (0.1 - 0.5)
- Changes in libido (25-33) and orgasm
- Depression
- Decreased time to ovarian failure
5Patient 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
6Exclusions
- Patient desires fertility
- Patient declines uterine conservation
- Abnormal cervical or uterine histology
- Medical contraindications to surgery
7Operative 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
8Results
- 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
9Conclusions
- 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
10The 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
11Since 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