myomectomy
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  • 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. 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)
  • 3. 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
  • 5. 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
  • 6. Exclusions:
    • Patient desires fertility
    • Patient declines uterine conservation
    • Abnormal cervical or uterine histology
    • Medical contraindications to surgery
  • 7. 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
  • 8. 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
  • 9. 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
  • 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. “ 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