Hysterectomy

Hysterectomy is resorted to when fertility is no longer desired and/or if the patient is between 42-50 and wants a definitive treatment for her uterine tumor/s. Hysterectomy is also to be performed in a patient in the perimenopause or menopausal age where cancer is either suspected or verified. The surgery may be done by traditional open surgery, laparoscopy or robotic surgery. However, in the last decade, minimally invasive surgery by laparoscopy or robotic surgery has largely replaced open surgery in centers where the machine is available and where credentialed gynecologists are present to perform the surgery.

Laparoscopy reaches its technical limits depending on the experience and skill of the laparoscopist as well as the technical difficulty of a case, like massive adhesions plus economic considerations for the patient. Surgeons with much experience in removing very large uteri will not hesitate to remove uteri with myomas of over 7 cm; whereas, the average laparoscopic surgeon may use 5-7 cm as a limit, beyond which, they will prefer to first shrink the mass with GNRH antagonists or ulipristal acetate, or just perform an open surgery. Laparoscopy requires instilling carbon dioxide gas into the abdominal cavity to better see the entire area up to the liver and diaphragm, while under general anesthesia. Because of this, certain subsets of patients with morbid obesity or cardiovascular symptoms cannot tolerate this set up and may be better with an open procedure.32

There is data that shows that post-operative pain intensity among post robotic hysterectomy patients is less compared to post laparoscopic hysterectomy patients. This may be because with lap surgery, the pivot point of the lap instruments is the abdominal wall itself, whereas robotic instruments pivot at a remote, fixed center of motion away from the abdominal wall, thereby decreasing the injury to the anterior abdominal wall itself.33 Some authors, though, found no difference in pain or narcotic use post-op between patients who underwent a laparoscopic hysterectomy vs robotic hysterectomy. 34

In conclusion, myomas are benign tumors that afflict over half of women in their reproductive age presenting with various symptoms of pain, bleeding, pressure on the bladder and rectum. Treatment may be conservative or definitive, medical or surgical depending on the size, location of tumor, age of patient and desire for fertility.

  1. Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol. 2004;104(2):393-406.
  2. Jacoby VL et al. Racial and ethnic disparities in benign gynecologic conditions and associated surgeries. Am J Obstet Gynecol. 2010;202(6):514-21.
  1. Islam MS et al. Uterine leiomyoma:available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab. 2013;98(3):921-34.
  2. Bohlmann MK et al. Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different. Reprod Biomed Online. 2010;21(2):230-6.
  3. Int J Womens Health. 2017; 9: 607–617. Published online 2017 Sep 5. doi: 10.2147/IJWH.S138982Copyright/License
  4. Peitsidis P, Koukoulomati A. Tranexamic acid for the management of uterine fibroid tumors: a systematic review of the current evidence. World J Clin Cases. 2014;2(12):893–898. [PMC free article] [PubMed]
  5. Shabaan MM, Ahmed MR, Farhan RE, Dardeer HH. Efficacy of tranexamic acid on myomectomy-associated blood loss in patients with multiple myomas. A randomized controlled clinical trial. Reprod Sci. 2016;23(7):908–912. [PubMed]
  6. Senol T, Kahramanoglu I, Dogan Y, Baktiroglu M, Karateke A, Suer N. Levonorgestrel-releasing intrauterine device use as an alternative to surgical therapy for uterine leiomyoma. Clin Exp Obstet Gynecol. 2015;42(2):224–227. [PubMed]
  7. Jiang W, Shen Q, Chen M, et al. Levonorgestrel-releasing intrauterine system use in premenopausal women with symptomatic uterine leiomyoma: a systematic review. Steroids. 2014;86:69–78. [PubMed]
  8. Tosun AK, Tosun I, Suer N. Comparison of levonorgestrel-releasing intrauterine device with oral progestins in heavy menstrual bleeding (HMB) cases with uterine leiomyoma (LNG-IUD and oral progestin usage in myoma uteri) Pak J Med Sci. 2014;30(4):834–839.[PMC free article] [PubMed]
  9. Hoellen F et al. Therapeutic drugs in the treatment of symptomatic uterine broids. Expert Opin Pharmacother. 2013;14(15):2079-85.
  10. Schmidt T et al. Modi cations of laparoscopic supracervical hysterectomy technique signi cantly reduce postoperative spotting. J Minim Invasive Gynecol. 2011;18(1):81-4.
  11. Donnez J et al. Long-term treatment of uterine fibroids with ulipristal acetate. Fertil Steril. 2014;101(6):1565-73.e1-18
  12. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/esmya-ulipristal-acetate—mhra-safety-alert/
  13. Gupta JK et al. Uterine artery embolization for symptomatic uterine broids. Cochrane Database Syst Rev. 2012;5:CD005073.
  14. Fennessy, Fiona; Fischer, Krisztina; McDannold, Nathan; Jolesz, Ferenc; Tempany, Clare (2015). “Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy”. International Journal of Women’s Health. 7: 901–12. doi:10.2147/IJWH.S55564. PMC 4654554 . PMID 26622192.
  15. Stewart, Elizabeth A.; Gostout, Bobbie; Rabinovici, Jaron; Kim, Hyun S.; Regan, Lesley; Tempany, Clare M. C. (2007). “Sustained Relief of Leiomyoma Symptoms by Using Focused Ultrasound Surgery”. Obstetrics & Gynecology. 110 (2, Part 1): 279–87. doi:10.1097/01.AOG.0000275283.39475.f6. PMID 17666601.
  16. Zimmermann A et al. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health. 2012;12:6
  17. Bohlmann MK et al. Hysteroscopic findings in women with two and with more than two first-trimester miscarriages are not significantly different. Reprod Biomed Online. 2010;21(2):230-6
  18. 18. Capmas P et al. Surgical techniques and outcome in the management of submucous fibroids. Curr Opin Obstet Gynecol. 2013;25(4):332-8
  19. Aguilar HN, Mitchell BF. Physiological pathways and molecular mechanisms regulating uterine contractility. Hum Reprod Update. 2010;16(6):725-44.
  20. Hucke J et al. Hysteroscopy in infertility–diagnosis and treatment including falloposcopy. Contrib Gynecol Obstet. 2000;20:13-20.
  21. 21. Donnez J et al. Unusual growth of a myoma during pregnancy. Fertil Steril. 2002;78(3):632-3
  22. Bettocchi S et al. The destiny of myomas: should we treat small submucous myomas in women of reproductive age? Fertil Steril. 2008;90(4):905-10.
  23. Cravello L et al. [Results of hysteroscopic myomectomy]. Gynecol Obstet Fertil. 2004;32(9):825-8
  24. Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am. 2006;33(1):145-52.
  25. Sunkara SK et al. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and metaanalysis. Hum Reprod. 2010;25(2):418-29
  26. Yan L et al. Effect of fibroids not distorting the endometrial cavity on the outcome of in vitro fertilization treatment: a retrospective cohort study. Fertil Steril. 2014;101(3):716-21.
  27. Yoshino O et al. Myomectomy decreases abnormal uterine peristalsis and increases pregnancy rate. J Minim Invasive Gynecol. 2012;19(1):63-7.
  28. Parker WH et al. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol. 2010;17(5): 551-4.
  29. Rooma S, Madhumati Sanjay, B. Rupa, and Samita Kumari. Robotic surgery in gynecology. J Minim Access Surg. 2015 Jan-Mar; 11(1): 50–59. doi: 10.4103/0972-9941.147690 PMCID: PMC4290120 PMID: 25598600
  30. Nezhat C, Lavie O, Hsu S, Watson J, Barnett O, Lemyre M. Robotic-assisted laparoscopic myomectomy: A retrospective matched control study. Fertil Steril. 2009;91:556–9. [PubMed]
  31. Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol. 2009 Dec:201(6):566.e1 5. Doi:10.1016/j.ajoj.2009.05.049.Epub2009 Aug 15.
  32. Hoellen F et al. Hybrid approach of retractor-based and conventional laparoscopy enabling minimally invasive hysterectomy in a morbidly obese patient: case report and review of the literature. Minim Invasive Ther Allied Technol. 2014;23(3):184-7
  33. Chiu LH, Chen CH, Tu PC, et al. Comparison of robotic surgery and laparoscopy to perform total hysterectomy with pelvic adhesions or large uterus. J Minim Access Surg 2015;11:87-93 .
  34. Turner TB, et al. Postoperative Pain Scores and Narcotic Use in Robotic-assisted versus Laparoscopic HysterectomyJ Minim Invasive Gynecol. 2015 Sept-Oct