Less Invasive Alternatives To Hysterectomy

Over the past 25 years, advances in gynecologic surgery have caused a steady decline in the number of hysterectomies (removal of the entire uterus) performed in the US.

Now: A variety of new surgical techniques are giving women even more options for treating abnormal uterine bleeding and fibroid tumors.

ABNORMAL UTERINE BLEEDING

This condition typically occurs in women over age 45. It results from a high level of estrogen that is not balanced by progesterone. Ovulation does not occur, but the lining of the uterus (endometrium) thickens and is then shed incompletely and irregularly, causing bleeding.

In the past, abnormal uterine bleeding was treated with complete hysterectomy.

Alternatives to hysterectomy…

Endometrial ablation. This approach, which requires no incision and is performed on an outpatient basis, stops uterine bleeding in up to 80% of women.

How it works: A hysteroscope (a thin, lighted telescope) is introduced through the vagina and cervix into the uterus. An electric current or laser is then used to heat and destroy the endometrium. Scar tissue may develop, which is likely to impair a woman's ability to become pregnant. Other potential risks include perforation of the uterine wall and injury to adjacent structures, such as burns to the bowel.

Thermal balloon ablation. This newer technique appears to be as effective as endometrial ablation, and it typically has fewer risks. However not all hospitals have the equipment that is required to perform thermal balloon ablation.

How it works: A balloon placed in the uterus and filled with fluid is heated until it destroys the endometrium without damaging surrounding tissue.

UTERINE FIBROIDS

Up to 40% of hysterectomies are performed to remove uterine fibroids. Although the cause of these tumors is unknown, recent research has linked them to a genetic mutation. Fibroids are almost always benign and often produce no symptoms.

However, fibroids can cause extremely heavy or frequent menstrual flow (sometimes leading to anemia). . .chronic pain. . .bloating...pressure on the bladder and other internal organs...infertility. ..and/or abdominal swelling. In these cases, surgery is often the best solution. Procedures to consider...

Myomectomy. Currently the preferred treatment for women who want to keep their reproductive options open, this procedure removes fibroids but retains the woman's uterus to allow for pregnancy.

How it works: A surgeon makes an abdominal incision, cuts the fibroid out and repairs the wall of the uterus with sutures.

Laparoscopic myomectomy. This procedure is less invasive than standard myomectomy, but it may not be advisable if the fibroid is too large.

How it works: A laparoscope (a thin, lighted viewing tube) and other instruments are introduced through a small (less than one inch) abdominal incision. The fibroids are cut into fragments small enough to be removed through the abdominal incision or another small incision made through the vaginal wall. Most women can sustain a pregnancy following laparoscopic myomectomy. However, there is increased risk for uterine rupture at delivery because the laparoscopic closure of the uterine muscle may not be as effective as in a standard myomectomy.

In one out of three women who receive standard or laparoscopic myomectomy, fibroid tumors eventually recur.

Hysteroscopy. An even less invasive technique than laparoscopic myomectomy, hysteroscopy is now being used for some submucous fibroids, which protrude inside the uterine cavity. (Many fibroids are embedded in the uterine muscle.)

How it works: After the cervix is dilated, a hysteroscope is passed through the cervix into the uterus, which is inflated with gas or fluid to give a better view. Because dilation is painful, local or regional anesthesia is usually administered. With hysteroscopy, fibroids are removed with an electrosurgical tool that burns the tissue so that the fibroids can be removed in pieces. The procedure, which requires no incision, is performed on an outpatient basis, and recovery occurs within two to three days.

High-frequency ultrasound. This is a promising experimental procedure.

How it works: While the patient lies in a magnetic resonance imaging (MRI) scanner, a doctor uses the MRI image to aim heat-producing, high-frequency ultrasound beams at the tumor to destroy it.

The patient is awake throughout high-frequency ultrasound, and no incisions are required. Currently available at The Johns Hopkins Hospital in Baltimore, Brigham and Women's Hospital in Boston and Mayo Clinic in Rochester, Minnesota, this procedure has been found to be safe and effective in preliminary studies.

NEW HYSTERECTOMY OPTIONS

Despite the availability of newer treatments, up to 600,000 women each year still choose a hysterectomy for their gynecologic condition.

Reason: A hysterectomy provides a permanent cure for abnormal uterine bleeding and fibroid tumors and eliminates risk for uterine cancer.

Newer, less-invasive types of hysterectomy have sharply reduced hospitalization—to just two to three days for many patients—and hastened recovery to as little as a week.

Supracervical hysterectomy. The uterus, but not the cervix, is removed through an abdominal incision. This surgery has fewer complications than total hysterectomy, but it still leaves a woman at risk for cervical cancer.
Laparoscopic hysterectomy. The uterus is removed using a laparoscope inserted through a small abdominal incision.
Vaginal hysterectomy. The uterus is removed through an incision inside the vagina.

The procedure includes removal of the cervix and also the uterus. It can only be performed on fibroids that are small enough to pass through the vagina. Yaginal hysterectomy can also be performed with laparoscopic assistance.