Overview of Hysterectomy and Myomectomy
Hysterectomy is the most frequent intervention in gynaecology.
What do you have to know when an hysterectomy is proposed or planned
Besides the technical aspects it is important to discuss indication, removal of ovaries and also the choice of techniques.
Is de indication correct without better alternatives ?
The indications vary with the country and vary with the gynaecologist. The wide differences in life time risk ( Belgium has a life time risk of 35%, 50% in USA, 17% in Sweden) cannot be explained by differences in women.
Some gynaecologist easily perform an hysterectomy ; others have more restraint.
The problem is that an hysterectomie indeed solves all bleeding disorders and it cures almost all causes of pelvic pain such as myoma’s, adenomyosis, pelvic varices, a painful retroversion, and even deep endometriosis when the ovaries are removed. Often it is performed together with other surgery such as pelvic floor repair. With a better diagnosis often alternatives exist which are less invasive, such as hysteroscopic surgery. Moreover the introduction of laparoscopic surgery introduced other better techniques : important is to choose the best technique for the individual patient
What are correct indications ?
A uterus larger than 14 weeks= more than 1 kilo.
A fibroma with complaints as pain, blood loss and bowel or bladder problems.
Cancer of the cervix or the uterus
Total prolaps
Which indications for hysterectomy should be doubted
* Menorrhagia only. If the uterus is normal and without any other pathology, menorrhagia is an indication for an endometrial ablation. If the cause is a submucous myoma of a polyp, this should be treated by hysteroscopy which is mudh less invasive.
* Irregular bleeding often is induced by hormonal treatment such as oral contraception (7%), a continuous combined therapy after menopause or progestagens only (Mirena, Lutenyl, Orgametril). This obvious is not an indication for an hysterectomy.
*Pelvic pain : first a diagnosis then a therapy ! To miss a diagnosis is not an indication. Adenomyosis should be used carefully as an indication for hysterectomy since the diagnosis is generally not that certain, and since the relationship between adenomyosis and pain is highly variable. Too often the potenial diagnosis of adenomyosis is used as an alibi to perform an hysterectomy.
What is always wrong ?
Hysterectomy and leaving endometriosis. Unfortunately this occurs rather frequently .
Which are the alternatives for an hysterectomy
Medical treatment (if only Hormonal disorders), hysteroscopic surgery as endometrial ablation and polypectomy or myomectomy, laparoscopic muyomectomy, laparoscopic treatment of specific causes of pelvic pain as pelvic congestion, adhesions, endometriosis, adenomyosis etc.
Which technique will be used for the hysterectomy
The actual standard is a Laparoscopic Hysterectomy, total or subtotal because of the many advantages of the laparoscopic hysterectomy in comparison with an abdominal hysterectomy. Abdominal hysterectomy for uteri less than 800 grams is history and was no longer performed by me since 1996.
A vaginal hysterectomy can be an option . However it should be discussed clearly whether in case of severe prolaps a vaginal hysterectomy should be performed (with a recurrence rate of over 30%) or a subtotal laparoscopic hysterectomy ( and a promontofixation) See pelvic floor for more details.
What to do for a uterus of more than 1 kilo ? . TLH can be done for uteri up to 1500 gram, but requires special expertise.
Do we remove Ovaries after 50 years ? This remains controversial. Elements to consider are : a risk of 1/200 for an ovarian cancer, women with ovaries live longer, ovaries after menopause still produce hormones, especially androgens which are difficult to replace.
What are indications for a Myomectomy
Small myoma’s in the uterus often associated with bleeding disorders should be removed by hysteroscopy.
Smaller myoma’s in the wall can easily be removed by laparoscopy.
Also larger myoma’s of more than 8 cm can be removed by laparoscopy but this is technically more difficult than an hysterectomy and special laparoscopic expertise is necessary. The same holds true for multiple myoma’s. In women looking for a baby, however a unique myoma certainly can be operated by myomectomy. The operability of multiple myoma’s depends on the expertise of the surgeon.