Myomectomy As an Alternative to Hysterectomy for Women Who Have Completed Childbearing: A Pilot Study David Blair Toub, M....
Uterine Fibroids: <ul><li>33% of all benign hysterectomies </li></ul><ul><li>Generally treated by myomectomy or other cons...
Why Is Myomectomy Not Preferred? <ul><li>Reputation as “bloody” operation </li></ul><ul><li>Fibroid recurrence is possible...
Hysterectomy Risks: <ul><li>Ureteral injury (0.1 - 0.5%) </li></ul><ul><li>Changes in libido (25-33%) and orgasm </li></ul...
Patient Population: <ul><li>Women with symptomatic fibroids (n = 14) </li></ul><ul><li>11 s/p TL , 3 with undesired fertil...
Exclusions: <ul><li>Patient desires fertility </li></ul><ul><li>Patient declines uterine conservation </li></ul><ul><li>Ab...
Operative Technique: <ul><li>Maylard or vertical incision </li></ul><ul><li>Tourniquet placed around uterine arteries and ...
Results: <ul><li>Mean EBL 165 cc (35-750) </li></ul><ul><li>1 - 42 fibroids removed (maximum total weight 1473 g) </li></u...
Conclusions: <ul><li>Myomectomy is a feasible alternative to hysterectomy regardless of fertility status </li></ul><ul><li...
“ The uterus has but one function- Reproduction. After the last planned pregnancy, the uterus becomes a useless, bleeding,...
“ Since cure without deformity or loss of  function must ever be surgery’s highest ideal,  the general proposition that my...
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myomectomy

  1. 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
  2. 2. Uterine Fibroids: <ul><li>33% of all benign hysterectomies </li></ul><ul><li>Generally treated by myomectomy or other conservative measures in women who desire fertility, hysterectomy in older women </li></ul><ul><li>Definitively treated by hysterectomy </li></ul><ul><li>Regress after menopause (51.8 years) </li></ul>
  3. 3. Why Is Myomectomy Not Preferred? <ul><li>Reputation as “bloody” operation </li></ul><ul><li>Fibroid recurrence is possible risk </li></ul><ul><li>Adhesion formation </li></ul><ul><li>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) </li></ul>
  4. 4. Hysterectomy Risks: <ul><li>Ureteral injury (0.1 - 0.5%) </li></ul><ul><li>Changes in libido (25-33%) and orgasm </li></ul><ul><li>Depression </li></ul><ul><li>Decreased time to ovarian failure </li></ul>
  5. 5. Patient Population: <ul><li>Women with symptomatic fibroids (n = 14) </li></ul><ul><li>11 s/p TL , 3 with undesired fertility </li></ul><ul><li>Age range 26 - 50 (mean 38.4 years) </li></ul><ul><li>Endometrial sampling done if IMB and ≥ 35 </li></ul><ul><li>Autoblood encouraged </li></ul><ul><li>GnRH-a if corpus ≥ 16 weeks </li></ul>
  6. 6. Exclusions: <ul><li>Patient desires fertility </li></ul><ul><li>Patient declines uterine conservation </li></ul><ul><li>Abnormal cervical or uterine histology </li></ul><ul><li>Medical contraindications to surgery </li></ul>
  7. 7. Operative Technique: <ul><li>Maylard or vertical incision </li></ul><ul><li>Tourniquet placed around uterine arteries and Bulldog clamp across uteroovarian lig </li></ul><ul><li>Minimize number of hysterotomies </li></ul><ul><li>Classical hysterotomy if multiple myomata </li></ul><ul><li>Vasopressin not employed </li></ul>
  8. 8. Results: <ul><li>Mean EBL 165 cc (35-750) </li></ul><ul><li>1 - 42 fibroids removed (maximum total weight 1473 g) </li></ul><ul><li>No PRBC’s required </li></ul><ul><li>BSO performed in 2 patients </li></ul><ul><li>All uteri preserved, with significant relief of symptoms in 13 / 14 patients </li></ul><ul><li>3 wound seromas, 1 UTI </li></ul>
  9. 9. Conclusions: <ul><li>Myomectomy is a feasible alternative to hysterectomy regardless of fertility status </li></ul><ul><li>Blood loss compares favorably with hysterectomy when appropriate techniques are utilized </li></ul><ul><li>A randomized, prospective study comparing hysterectomy with myomectomy in this patient population is warranted </li></ul>
  10. 10. “ 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
  11. 11. “ 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
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