While there are a range of non-invasive treatment options are available to women to relieve symptoms of benign conditions or to slow the growth of gynecologic cancers, surgery remains the accepted and most effective treatment option for a range of gynecologic conditions. These include, but are not limited to, cervical and uterine cancer, uterine fibroids, endometriosis, uterine prolapse and menorrhagia or excessive bleeding. 

Uterine Fibroid Embolization

Fibroids are benign (non-cancerous) growths of muscle tissue on or inside the uterus. Uterine fibroid embolization shrinks a fibroid by cutting off its blood supply. The procedure is done through a catheter (a long, thin, flexible tube) placed into a blood vessel through a small incision. The procedure is often done by a specially trained doctor called an interventional radiologist.

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Open Surgery

Open abdominal surgery or laparotomy refers to any surgical operation in which the abdomen is opened to access or inspect the organs of the abdominal cavity.

Traditionally, surgeons perform the majority of gynecologic surgery using an “open” approach, which is through a wide (6-12 inch) abdominal incision below the navel and through the abdominal muscle wall.

The skin incision can be either transverse (horizontal) or vertical. The transverse incision is usually an inch or so above the pubic bone. This type of incision is also known as a “bikini” incision. This is the most common type of incision used during C-section.

Open abdominal surgery can be painful, involving heavy pain medications, risk of infection, significant blood loss and increased risk for transfusion. After surgery, a long recovery (often 6 weeks) is usually necessary. In addition, many patients are not happy with the scar left by the incision.

While minimally invasive surgery (laparoscopy) has been available for two decades now for many routine gynecologic procedures, most complex hysterectomy, myomectomies and sacrocolpopexies are performed using open surgery. This is because conventional laparoscopic technology can’t provide surgeons the visualization, precision, dexterity and control required to handle challenges like large uteri, multiple adhesions from prior pelvic surgery.

Fortunately, today the vast majority of complex gynecologic conditions – from endometriosis to uterine fibroids, prolapse, heavy menstrual bleeding and cancer – can now be treated effectively without a big incision — with da Vinci ® Surgery.

da Vinci Surgery for gynecologic conditions requires only a few small incisions, so you can get back to life faster — within days rather than the usual weeks required with traditional surgery. Also, surgeons using the da Vinci System can operate using minimally invasive techniques on a wider range of women — even those with large uteri, high BMIs and adhesions due to prior pelvic procedures like C-section.

da Vinci Surgery enables physicians to perform the most precise, minimally invasive gynecologic surgery available today. If you have been told you aren’t a candidate for minimally invasive surgery and that you need open surgery to resolve a gynecologic problem, it may be time to ask your doctor about da Vinci Surgery.

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Minimally Invasive Surgery

Approximately 20 years ago, surgeons began practicing a new approach to performing surgery, an approach that came to be known as minimally invasive surgery, or MIS. During this era, tiny cameras in instruments called endoscopes or laparoscopes were introduced. These visual and surgical aids could be inserted in the patient’s body through small ports.

Although revolutionary in its positive effect on patient trauma and recovery times, MIS encountered significant technical drawbacks. The surgeon operated using a standard 2D monitor instead of looking at his or her hands. The resulting image flattened the natural depth of field, and the fixed-wrist instruments limited his/her dexterity. The lack of 3D visualization of the operative field, the poor ergonomic design and reduced control were major roadblocks to further progress. As a result, this type of MIS turned out to be suitable for a narrow range of surgical procedures.

In the late 1990s, another evolutionary stage in the development of surgical technique was achieved with the application of robotics to surgical technology. At the forefront of this new era, Intuitive Surgical introduced the da Vinci ® Surgical System. The da Vinci System features wristed instruments with seven degrees of freedom, three-dimensional, intuitive visualization and ergonomic comfort. These innovations created the preconditions for minimally invasive solutions to complex procedures in a wide range of surgical specialties. Today, Intuitive Surgical’s products continue to enable a new generation of surgical advancements, providing benefits to surgeons, hospitals and patients.

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Myomectomy

Each year, roughly 65,000 myomectomies are performed in the U.S.1 The conventional approach to myomectomy is open surgery, through a large abdominal incision.2 After cutting around and removing each uterine fibroid, the surgeon must carefully repair the uterine wall to minimize potential uterine bleeding, infection and scarring. Proper repair is also critical to reducing the risk of uterine rupture during future pregnancies.

While myomectomy is also performed laparoscopically, this approach can be challenging for the surgeon, and may compromise results compared to open surgery. 3Laparoscopic myomectomies often take longer than open abdominal myomectomies, and up to 28% are converted during surgery to an open abdominal incision.4 Myomectomy can be a uterine-preserving alternative to open abdominal hysterectomy.
da Vinci ® Myomectomy

A new category of minimally invasive myomectomy,da Vinci ® Myomectomy , combines the best of open and laparoscopic surgery. With the assistance of the da Vinci® Surgical System — the latest evolution in robotics technology — surgeons may remove uterine fibroids through small incisions with unmatched precision and control. Among the potential benefits of da Vinci Myomectomy as compared to traditional open abdominal surgery are:

  • Opportunity for future pregnancy
  • Significantly less pain
  • Less blood loss
  • Fewer complications
  • Less scarring
  • A shorter hospital stay
  • A faster return to normal daily activities

da Vinci Myomectomy is performed with the da Vinci Surgical System, which allows your surgeon to perform a minimally invasive, yet remarkably precise, comprehensive reconstruction of the uterine wall, regardless of the size or location of your fibroids. The unique level of control and precision provided by da Vinci can also help your surgeon provide the most precise and thorough reconstruction possible, helping to prevent possible uterine rupture (tearing) during future pregnancies.

As with any surgery, these benefits cannot be guaranteed, as surgery is both patient- and procedure-specific. While myomectomy performed using the da Vinci Surgical System is considered safe and effective, this procedure may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.

* Uterine fibroids are also called fibroids, uterine tumors, leiomyomata (singular – leiomyoma) and myomas or myomata (singular – myoma)

1. Lumsden MA. Embolization Versus Myomectomy Versus Hysterectomy: Which is Best, When? Hum Reprod. 2002; 17:253-259. Review.
2. Becker ER, Spalding J, DuChane J, Horowitz IR. Inpatient Surgical Treatment Patterns for Patients with Uterine Fibroids in the United States, 1998-2002. J Natl Med Assoc. 2005 Oct;97(10):1336-42.
3. Wolanske KA, Gordon RL. Uterine Artery Embolization: Where Does it Stand in the Management of Uterine Leiomyomas? Part 2. Appl Radiol 33(10):18-25, 2004. Medscape.10/27/2004.
4. Advincula AP, Song A, Burke W, Reynolds RK. Preliminary Experience with Robot-Assisted Laparoscopic Myomectomy. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):511-8.

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Hysterectomy Options

Physicians perform hysterectomy – the surgical removal of the uterus – to treat a wide variety of uterine conditions. Each year in the U.S., doctors perform approximately 600,000 hysterectomies, making it the second most common surgical procedure for women.1

Types of Hysterectomy

There are various types of hysterectomy that are performed depending on the patient’s diagnosis. All hysterectomies involve removal of the uterus. What can vary are which additional reproductive organs and other tissues that may be removed. Types of hysterectomy include:
Partial or subtotal hysterectomy: This procedure, also known as a supracervical hysterectomy, involves removing the uterus, but leaves the cervix intact. This decision is often based upon patient preference. Some women feel that leaving the cervix intact will preserve sexual function following surgery. 2
Total hysterectomy: This procedure involves removing the uterus and the cervix. The vagina remains entirely intact. This is the most common type of hysterectomy performed.
Removal of lymph nodes: For hysterectomies performed for malignant conditions – such as uterine, cervical, or ovarian cancer – the surgeon will also remove certain lymph nodes. This procedure is often referred to as a lymph node dissection or lymphadenectomy. Lymph nodes will be removed in certain areas, depending upon the location and extent of the disease. Lymph node removal also helps your surgeon determine the extent or stage of your cancer, and can guide further adjuvant treatment, such as radiation therapy or chemotherapy.
Removal of the fallopian tubes and ovaries: These organs may or may not be removed during your hysterectomy procedure. This will depend upon your condition, age, and other factors. Often, the ovaries and fallopian tubes are left intact. 3 Removal of the ovaries is called an oophorectomy. Removal of fallopian tubes and ovaries is called a salpingo-oophorectomy.
Radical hysterectomy: This procedure removes the uterus and cervix
Total hysterectomy: This procedure is most often performed for cervical cancer, and involves removal of the uterus, tissues next to the uterus, the upper part (about 1 inch) of the vagina, and pelvic lymph nodes. The fallopian tubes and ovaries may also be removed.

Approaches to Hysterectomy

Surgeons perform the majority of hysterectomies using an “open” approach, which is through a large abdominal incision. An open approach to a hysterectomy requires a 6-12 inch incision.

A second approach is vaginal hysterectomy, which involves the removal of the uterus through the vagina, without any external incision or subsequent scarring. Surgeons most often use this minimally invasive approach if the patient’s condition is benign, when the uterus is a normal size and the condition is limited to the uterus.

In laparoscopic hysterectomies, the uterus is removed using instruments inserted through small tubes into the abdomen, resulting in 3-5 small incisions in the abdomen. One of these instruments is an endoscope – a small miniaturized camera – which allows the surgeon to see the target anatomy on a standard 2D video monitor. A laparoscopic approach offers surgeons better visualization of affected structures than either vaginal or abdominal hysterectomy.

You may encounter shorthand abbreviations describing different approaches to hysterectomy. Some of these are as follows:
Total Laparoscopic Hysterectomy (TLH): The uterus and cervix are removed using laparoscopic instrumentation through 3-5 small incisions made in the abdomen.
Laparoscopic Supracervical Hysterectomy (LSH): The uterus is removed, but the cervix is left in tact, using laparoscopic instrumentation through 3-5 small incisions made in the abdomen. The uterus is removed through one of the small incisions using an instrument called a morcellator.
Total Vaginal Hysterectomy (TVH): The uterus and cervix are removed through an incision deep inside the vagina. This is often the surgical approach to treat uterine prolapse.
Total Abdominal Hysterectomy (TAH): The uterus and cervix are removed through a large abdominal incision. The incision size can vary from 6-12 inches, depending upon the patient’s condition.

While minimally invasive vaginal and laparoscopic hysterectomies offer important potential advantages to patients over open abdominal hysterectomy – including reduced risk for complications, a shorter hospitalization and faster recovery – there are inherent drawbacks. With vaginal hysterectomy, surgeons are challenged by a small working space and lack of view to the pelvic organs. Additional conditions can make the vaginal approach difficult, including when the patient has:

A narrow pubic arch (an area between the hip bones where they come together) 4
Thick adhesions due to prior pelvic surgery, such as C-section 5
Severe endometriosis 6
Non-localized cancer (cancer outside the uterus) requiring more extensive tissue removal, including lymph nodes

With laparoscopic hysterectomies, surgeons may be limited in their dexterity (since the instruments are straight and rigid) and by 2D visualization, both of which can potentially reduce the surgeon’s precision and control when compared with traditional abdominal surgery.

da Vinci® Hysterectomy

One in three women in the U.S. will have a hysterectomy before she turns 60. 1While no woman wants to face surgery, today the vast majority of gynecologic conditions – from endometriosis to uterine fibroids, heavy menstrual bleeding to cancer – can now be treated effectively without a big incision. With da Vinci ® Surgery, a hysterectomy requires only a few small incisions, so you can get back to life faster – within days rather than the usual weeks required with traditional surgery.

da Vinci Surgery enables gynecologists to perform the most precise, minimally invasive hysterectomy available today. For most women, da Vinci Hysterectomy offers numerous potential benefits over traditional open surgery, including:

  • Significantly less pain 4
  • Minimal blood loss and need for transfusion 5 , 6
  • Fewer complications 6 , 7
  • Shorter hospital stay 6 , 7
  • Quicker recovery and return to normal activities 3 , 4
  • Small incisions for minimal scarring
  • Better outcomes and patient satisfaction, in many cases 5

Surpassing the limits of conventional laparoscopic surgery, da Vinci is revolutionizing gynecologic surgery for women. No wonder more and more women are choosing da Vinci Surgery for their hysterectomy.

If you have been putting off surgery to resolve a gynecologic problem, it may be time to ask your doctor about da Vinci Surgery.

1. http://medical-dictionary.thefreedictionary.com/partial+hysterectomy
2. http://www.merck.com
3. http://www.merck.com/mmhe/sec22/ch252/ch252f.html?qt=pain%20during%20intercourse&alt=sh
4. Boggess JF. Robotic Surgery in Gynecologic Oncology: Evolution of a New Surgical Paradigm. J Rob Surg 2007 1:31-3
5. Payne TN , et al. A Comparison of Total Laparoscopic Hysterectomy to Robotically Assisted Hysterectomy: Surgical Outcomes in a Community Practice. J Minim Invasive Gynecol. 2008 May-June;15(3):286-91

Non-Surgical Options
Radiation Therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Hormone Therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. The presence of some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery or radiation therapy are used to reduce the production of hormones or block them from working.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. Chemotherapy can be either systemic, reaching cancer cells throughout the body via the bloodstream, or regional, targeting cancer cells in specific body parts or areas. The method chosen depends on the type and stage of the cancer being treated.1

1.http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/Patient/page4

While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.

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Uterine prolapse treatment

Surgical Options

Hysterectomy
Uterine prolapse may be treated by removing the uterus in a surgical procedure called hysterectomy. This may be done through an incision made in the vagina (vaginal hysterectomy) or through the abdomen (abdominal hysterectomy). Hysterectomy is major surgery, and removing the uterus means pregnancy is no longer possible.

Vaginal vs. Abdominal Surgery
Doctors generally prefer to perform the surgical repair vaginally because it’s associated with less pain after surgery, faster healing and a better cosmetic result. However, vaginal surgery may not provide as lasting a fix as abdominal surgery. And if you didn’t have your uterus removed during surgery, prolapse can recur.

Laparoscopic Techniques
Laparoscopic and robotic operating techniques use smaller abdominal incisions, a lighted camera-type device (laparoscope) and specialized surgical instruments to offer a minimally invasive approach to abdominal surgery.

Uterine Suspension
Uterine suspension is a procedure that involves putting the uterus back into its normal position. This may be done by reattaching the pelvic ligaments to the lower part of the uterus to hold it in place. Another technique uses a special material that acts like a sling to support the uterus in its proper position. Recent advances include performing uterine suspension with minimally invasive techniques and laparoscopically (through small band aid-sized incisions) that decrease post-operative pain and speed recovery.4

Robotically-Assisted Surgery
Robotically-assisted laparoscopic surgery is an effective alternative to traditional surgery for treatment of vaginal vault prolapse, U.S. researchers report.

Robotic surgery involves the use of a device that helps speed up the repair and simplifies technically difficult aspects of vaginal vault prolapse surgery. A recent Mayo Clinic study of 30 women who had robot-assisted laparoscopic repair concluded that this method has the following advantages over traditional open surgical repair.1

1.”Robot Technology Improves Vaginal Prolapse Surgery,” U.S. Dept. of Health & Human Services, healthfinder.gov. URL: http://www.healthfinder.gov/news/newsstory.asp?docID=534003

Non-Surgical Options

There are a number of non surgical options that are available for you to discuss with your physician.

Kegel Exercises
Kegel ExercisesSpecial exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. To do Kegel exercises, tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscles tight for a few seconds and then release. Repeat. You may do these exercises anywhere and at any time. To see results, it is recommended that you repeat the exercise four times daily.

www.kegelexercises.com.

Vaginal Pessary
A pessary is a rubber or plastic doughnut-shaped device that fits around or under the lower part of the uterus (cervix), helping to prop up the uterus and hold it in place. A health care provider will fit and insert the pessary, which must be cleaned frequently and removed before sex.

Estrogen Replacement Therapy
ERT refers to a woman taking supplements of hormones such as estrogen alone or estrogen with another hormone called progesterone (progestin in its synthetic form).  ERT replaces hormones that a woman’s body should be making or used to make.1 Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, there are some drawbacks to taking estrogen, such as an increased risk of blood clots, gallbladder disease and breast cancer. The decision to use ERT must be made with your doctor after carefully weighing all of the risks and benefits.

1.”Estrogen Replacement Therapy (ERT),” National Institute of Child Health & Human Development.

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da Vinci® vs. Laparoscopy vs. Open Surgery

The following table displays patient outcomes for hysterectomy for benign gynecologic conditions. As you can see, da Vinci Hysterectomy shows measurable advantages as compared to both traditional open surgery performed through a large abdominal incision and conventional minimally invasive laparoscopic surgery (referred to as laparoscopy).

* Last 25 procedures **The percent of patients who required open abdominal surgery whose condition was not amenable to a minimally invasive approach using da Vinci (4%) or laparoscopy (20%).

What does the data mean to you?

•  da Vinci® Hysterectomy can reduce hospital stay, minimize blood loss, and reduce the risk of surgical complications compared to open abdominal surgery for benign gynecologic conditions.

•  When comparing the percent of patients who underwent open surgery for their hysterectomy, only 4% of them required open surgery with da Vinci compared to 20% with laparoscopy. This data demonstrates that da Vinci will enable gynecologists to treat even complex or more advanced conditions minimally invasively.

•  Unlike conventional laparoscopy, da Vinci allows gynecologists to treat patients with more advanced benign pathology, such as an enlarged uterus (e.g., due to fibroids) and pelvic adhesive disease (e.g., due to endometriosis or prior pelvic surgeries). This, in turn, will allow gynecologists to extend the benefits of minimally invasive surgery to more patient types.

•  Ultimately, da Vinci® Surgery will allow gynecologists to perform fewer open abdominal surgeries for hysterectomy, while improving patient outcomes and allowing patients to get back to their lives faster.

1. Payne TN, et al. A Comparison of Total Laparoscopic Hysterectomy to Robotically Assisted Hysterectomy: Surgical Outcomes in a Community Practice. J Minim Invasive Gynecol. 2008 May-June;15(3):286-91While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.

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