1. Alternatives to Hysterectomy
Duncan Turner MD, MBBS, FACOG,
October 28th 1998
Santa Barbara,California

2. HYSTERECTOMY 600,000 per year in USA 35% chance by 60
Traditional Surgery
3 days in hospital
6 weeks of recovery
Total Cost: $15,000 + loss of productivity

3. TOPICS Alternatives to Hysterectomy
Alternatives to Traditional Hysterectomy
Why?
New Treatments
New Surgeries
You Have A Choice

4. Definitions Hysterectomy Subtotal Hysterectomy Approaches
Removal of Uterus, With/Without Ovaries
Subtotal Hysterectomy
Removal of Uterus Without Cervix, With/Without Ovaries
Approaches
Abdominal (Laparotomy)
Vaginal
Endoscopic (Laparoscopic)

5. The Uterus

6. Definitions Endoscopy: Looking through a narrow tube
Types of Endoscopy
Hysteroscopy - into uterus via vagina
Laparoscopy - into the abdomen
Cystoscopy - into bladder
Others

7. Cost of laparotomy $5,000 - $15,000 3 Days in Hospital
Significant Pain
6 Weeks of Recovery

8. Cost of laparoscopy $4,000 - $15,000 Outpatient or Inpatient
3 Hours to 2 Days in Hospital
3 Days to 3 Weeks Recovery

9. Cost of hysteroscopy $2000 Outpatient <3 Hours in Surgery Center
1-2 Days of Recovery

10. The Conditions Abnormal Uterine bleeding Fibroids Endometriosis
Prolapse
Chronic Pelvic Pain
Cancer and Precancerous Conditions

11. ABNORMAL UTERINE BLEEDING
Prolonged, Irregular or Heavy Bleeding
30% of Hysterectomies
200,000 a Year

12. Causes of A.U.B. Hormonal Irregularity Growths in Uterus
Cancer and Precancerous Conditions
Bleeding Disorders

13. Investigation and Treatment
Nothing
Ultrasound and Biopsy to Rule Out Cancer or Precancerous Conditions
Hormonal Therapy
D and C
Hysteroscopic Therapy
Hysterectomy

14. Hormonal Therapy for A.U.B.
Birth Control Pill
Adjustment of Current Therapy
Other Hormones

15. D and C for A.U.B. Traditional Treatment Blind Procedure
Good for Biopsy
No Evidence of Therapeutic Benefit

16. Hysteroscopic Treatment of A.U.B.
Visual Procedure
Removal of Growth
Good for Biopsy
Very Accurate
Endometrial Ablation
Destruction of Lining Tissue by
Laser
Electricity
Hot Water Balloon

17. Thermachoice

18. Thermachoice VS Electrocautery
Improvement at 12 months
85% vs 89%
Hysterectomies by 12 months
2% =
Repeat Ablations by 12 months
<1% =
Complications
4% vs 6%

19. Benefits of Thermachoice
Effective
Simple
Safe
Short Procedure
Local or General Anesthetic
85% Successful

20. Hysterectomy for A.U.B. Traditional Laparoscopic
With or Without Ovaries or Cervix
100% Successful

21. Fibroids Non-cancerous Growths of Uterine Muscle 35% of Women
30% of Hysterectomies
Can Cause:
Bleeding
Pain
Pressure
or Nothing

22. Treatment of Fibroids Nothing Hormonal Therapy Destruction Removal
Hysterectomy

23. Hormonal Therapy for Fibroids
Side Effects
Temporary
Expense
Can be Utilized Before Surgery

24. Destruction of Fibroids
Blocking Blood Supply
(EMBOLIZATION)
SURGERY
Laser
Electricity
Freezing

25. Removal of Fibroids Individual - Total - Traditional or Endoscopic
Hysteroscopic or Laparoscopic
Total -
Hysterectomy
Subtotal Hysterectomy
Traditional or Laparoscopic

26. Endometriosis Endometrial Tissue in Abnormal Places:
On Ovaries, Uterus, Bowel
Can Cause:
Pain
Infertility
Growths

27. Treatment of Endometriosis
Nothing
Hormonal
Excision
Cutting of Nerve Supply
Hysterectomy

28. Hormonal Therapy for Endometriosis
Birth Control Pills
Progesterone
Danazol
Lupron
Side Effects
Expensive

29. Excision of Endometriosis
Traditional Surgery
Laparoscopic Surgery
Better Visualization
More Precise Surgery
Nerve Supply May Be Cut
Hysterectomy May Not Be Necessary

30. PROLAPSE Loss of Support of: Uterus Bladder Vagina Rectum Because of:
Childbirth
Genetics
Chronic Increase in Pressure

31. PROLAPSE Resulting in: Protrusion of Structures Pain and Pressure
Urinary Incontinence
Urinary Retention

32. Non-Surgical Treatment of Prolapse
Pessary
Kegel Exercises
Weights
Electrical Stimulation
Biofeedback Therapy

33. Surgical Treatment of Prolapse
Vaginal
Abdominal
Laparoscopic
Does not Have To Include
HYSTERECTOMY

34. CHRONIC PELVIC PAIN Debilitating Pain - Chronic No Obvious Cause
Pain With Intercourse
Pain With Periods

35. Treatment of Chronic Pain
Hormones
Pain Killers
Diagnostic/Therapeutic Surgery
Microlaparoscopy
Smaller Instruments
Quicker Recovery
Traditional Surgery

36. PRECANCEROUS CONDITIONS of UTERUS
Hormonal Therapy
Observation
Hysterectomy

37. PRECANCEROUS CONDITIONS of the CERVIX
Freezing
Conization
Office of Out Patient Surgery Center
Hysterectomy - Traditional or Laparoscopic

38. CONCERNS REGARDING MANAGED CARE
Underutilization vs Overutilization
Diminished Freedom to Choose

39. SUMMARY Alternatives Exist
Treatment Should be Suited to the Individual
A Minimally Invasive Approach is Almost Always Available
Be Part of the Decision Making Process