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myomectomy

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    myomectomy myomectomy Presentation Transcript

    • 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
    • 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)
    • 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)
    • Hysterectomy Risks:
      • Ureteral injury (0.1 - 0.5%)
      • Changes in libido (25-33%) and orgasm
      • Depression
      • Decreased time to ovarian failure
    • 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
    • Exclusions:
      • Patient desires fertility
      • Patient declines uterine conservation
      • Abnormal cervical or uterine histology
      • Medical contraindications to surgery
    • 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
    • Results:
      • Mean EBL 165 cc (35-750)
      • 1 - 42 fibroids removed (maximum total weight 1473 g)
      • No PRBC’s required
      • BSO performed in 2 patients
      • All uteri preserved, with significant relief of symptoms in 13 / 14 patients
      • 3 wound seromas, 1 UTI
    • 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
    • “ 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
    • “ 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