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Vaginal hysterectomy is an alternative to abdominal hysterectomy when a woman has a normal-sized or only slightly enlarged uterus. Because no abdominal incisions are made, the patients tend to leave the hospital in 1-2 days. Women typically take 4 weeks off work.
Laparoscopically Assisted Vaginal Hysterectomy
This procedure was introduced in the late 1980s so a woman with a larger uterus could avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.
Total Laparoscopic Hysterectomy
This procedure was developed to allow the woman with an enlarged uterus to avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The vagina is entered from above instead of through the vagina. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.
Laparoscopic Supracervical Hysterectomy (LSH)
LSH is the least painful form of hysterectomy, with the fastest recovery, ever described. Women who have LSH can go home the day of the surgery up to 90% of the time. Office workers are back to work in as few as 4 days, typically 4-6 hours. Most take 1-2 weeks off. Full recovery and return to exercise takes about 3-5 weeks. Women in physical jobs that require heavy lifting(more than 50 pounds) mostly need 6 weeks.
Since the cervix is left the vaginal and pelvic floor anatomy is not altered.
Whether LSH is less likely to create sexual and bladder dysfunction compared to traditional forms of hysterectomy is controversial. A randomized controlled trial did not show a difference in sexual and bladder function 12-18 months after open total abdominal hysterectomy compared to LSH. No study has 15-20 year outcome data which might be when differences show up.
A study about pelvic prolapse repair reported fewer complications when the LSH was performed compared to Total laparoscopic hysterectomy.
Laparoscopic Intrafascial Hysterectomy (LIH)
LIH is similar to LSH for post op recovery. The difference is how the cervical canal is treated.
Critics of LSH focus on continued risk of cervical cancer and post operative cervical bleeding, either cyclic or random. The pap smear has virtually eliminated cervical cancer but dealing with an abnormal PAP is stressful and costly. Cervical bleeding problems also make for an unhappy patient.
During the LIH procedure a donut hole like incision is made to remove the cervical canal. The cervical tissue is closed with suture. Reducing the risk of cervical cancer along with bleeding while still leaving the pelvic floor anatomy, nerve supply and blood flow as close to normal as possible is the purpose of LIH.
Laparoscopic myomectomy with endometrial ablation
For the woman who does not accept hysterectomy, but would like to terminate menstrual flow, the uterine lining can be removed at the same time as laparoscopic myomectomy.
Uterine artery embolization(UAE)
This procedure was first described in the mid 1990’s. A catheter is inserted into the femoral artery at the top of the leg and guided to the uterine arteries with fluoroscopy(live X-ray). Polyvinyl chloride particles are infused until blood flow no longer can be detected. The ischemic insult causes fibroids to shrink. Collateral blood supply saves the uterus from complete necrosis. The majority of women are satisfied with their outcome.
A comparative study of UAE and open abdominal myomectomy has been published. In the three years after UAE 35% of patients underwent a second surgical procedure, as opposed to 3% in the open myomectomy patients. A case series with 5 year follow up reported a 25% second intervention rate. One UAE expert has indicated 60% of woman seeking the procedure had no problem with hysterectomy they were just trying to avoid open abdominal surgery.
There are now studies in the medical literature that have compared Laparoscopic Supracervical Hysterectomy and Laparoscopic Myomectomy to UAE. Patients had similar recovery times. More importantly, patients were more satisfied with laparoscopic surgery than UAE.
MRI-guided high intensity focused ultrasound
This has been approved by the FDA. The procedure cannot treat more than 1-2 fibroids at a time in a 2-3 hour procedure. This is cost ineffective and typically is not covered by insurance. The patient with the larger uterus and multiple fibroids would require 2 or more procedures.
Uterine artery occlusion
This is described as a laparoscopic procedure to accomplish the same end result as UAE,
This was described around 1990 as a laparoscopic procedure to shrink fibroids tumors. It was the first laparoscopic alternative to hysterectomy. To shrink the fibroid, either a laser fiber or a bipolar cautery needle was inserted many times into different locations throughout the tumor. The fibroid got smaller over the next several weeks. Patients wanted laparoscopic myomectomy once we were able to offer it. They wanted the fibroids out and gone.
Laparoscopic radio frequency alblation(LRFA)
This is a new, FDA approved, laparoscopic procedure to accomplish the same end result as myolysis, LFRA may result in better outcomes than myolysis because only one insertion is made. More studies are needed to understand its benefit. It may be difficult to get covered by insurance since it is new. It is an alternative to hysterectomy if laparoscopic myomectomy is not an available option.
For the woman who feels comfortable with hysterectomy is it a good procedure. No woman should be told hysterectomy is her only option.
There are several forms of hysterectomy:
The abdominal hysterectomy is the most common approach to hysterectomy in the United States. About 60-70% of hysterectomies are abdominal. Hospital stay is 2-4 days, and patients typically take 6 weeks off work. Full recovery may take up to a year.
First described in 1972, endometrial ablation is an alternative to hysterectomy for abnormal uterine bleeding.
Endometrial Resection Ablation (ERA)
The same scope used for hysteroscopic myomectomy and polypectomy is used to remove the uterine lining, thus eliminating menstrual flow. Return to work is also 2-3 days and complete recovery is one week on average. The average woman waits 4 weeks to return to work after a vaginal hysterectomy. Three randomized controlled trials comparing ERA to vaginal hysterectomy concluded, overall, patients were equally satisfied with their surgery after one year or more.
ERA is considered the gold standard of endometrial ablation.
A pencil sized(5mm) scope placed through the base of umbilicus(belly button) sends a video image to the monitoring screen while the myomectomy is completed using 3 small access ports(trocars) just above the pubic bone. The 2 side ports are for pencil size instruments. The 12 mm trocar site is for suturing the uterus closed and fibroid morcellation.
This form of myomectomy is outpatient instead of 2-4 days in hospital. We have reported return to work is possible in 10 days for our average patient, not 6 weeks. The average woman who has laparoscopic myomectomy states she feels fully recovered in 3 weeks. This is 3 weeks before the open woman returns to work.
Centers that specialize in laparoscopic surgery have reported that more than 95% of hysterectomies for benign disease could be done laparoscopically instead of open.
Women can successfully get pregnant after myomectomy. The procedure has been described in the medical literature for over 100 years. Myomectomy is safe when performed by an appropriately trained physician. Return to work is usually 6 weeks. Complete recovery can take longer.
A complete and thorough evaluation is important to the success of any surgery. Women who have multiple fibroids or other pathology may want to consider other minimally invasive approaches.
When medical therapy fails or is not an option hysterectomy may be recommended.
If a woman does not feel ready she should seek information on alternatives.
We are strive to make you aware of all reasonable options. No woman should be told hysterectomy is her only option for a benign problem.
About the uterus:
The uterus is a muscle with a cavity inside where the fetus grows until the muscle contractions of labor force the cervix to dilate for delivery. The cervix is a fibrous tissue attached to the muscle of the uterus. It is very tough and is attached to the rest of your fibrous tissue pelvic supports. The cervix is as much a part of the vagina and pelvic supports as it is the uterus.
The cervical canal is a glandular lined connection to help sperm move from the vagina into the uterine cavity and up through the tubes to fertilize the egg. The area where the glands of the cervical canal meet the squamous cells of the vagina is the location for the HPV virus infection that causes cervical cancer.
Alternatives to Hysterectomy
All women’s medical societies recognize a woman’s right to choice. Regardless of age a woman with fibroids can have myomectomy. Prolapse repairs do not require hysterectomy. For bleeding problems endometrial ablation is a well-established alternative to hysterectomy.
When abnormal bleeding is caused by fibroids or polyps growing into the uterine cavity they can be removed with minimal discomfort. Women are back to work in 2-3 days and all normal activities in one week on average. Hysteroscopic surgery will correct the bleeding problem with less pain and risk than hysterectomy. This is especially important for the woman who wants to maintain fertility.
ERA is a sub-specialty procedure. It is the most effective alternative to hysterectomy to stop bleeding.
In the last several years devices have been developed to make endometrial ablation easier so general OB/GYN’s can offer this less invasive, less painful treatment for abnormal bleeding to their patients. These devices use various forms of energy to destroy the uterine lining.
Global ablation is a less invasive, less painful alternative to hysterectomy.
If you want the “State of the Art” for ablation you should contact us.
Fibroids that are too large for hysteroscopic myomectomy can be removed without the need for hysterectomy. Myomectomy should be discussed with each patient. Not all women want or are ready for a hysterectomy.
Surgical alternatives to hysterectomy for fibroids include:
Open abdominal myomectomy
Through a 4-8 inch abdominal incision fibroids are removed and the uterus is closed with suture.