February 19, 2009 Radisson Hotel Longmont, Colorado

Transcription

1 February 19, 2009 Radisson Hotel Longmont, Colorado

2 NEW TREATMENTS FOR UTERINE FIBROIDS AND HEAVY BLEEDING Understanding the Options

3 Presented jointly by Boulder Community Hospital and the Thayer Group for Women s Care, P.C.

4 david o. thayer m.d. Board Certified in Obstetrics and Gynecology Fellow of the American College of Obstetrics and Gynecology Private practice in Boulder 23 years Surgical privileges at Boulder and Foothills Hospitals, Longmont Surgery Center, Longmont United Hospital, and Medical Center of the Rockies in Loveland Involved with teaching of Interns/Residents, Nurse Practitioners, Physician Assistants, Nurses, Medical Assistants Donate time and/or patient care to People s Clinic; Mante, Mexico; Children s Hospital; BVWHC; and Rebuilders THAYER GROUP FOR WOMEN S CARE, P.C.

5 Thayer Group for Women s Care, P.C. Care Providers Pam Chandler, WHP,CNM Tamara Lester, WHCNP Myself -Kate Harding, RNC -Linda Cohen, CNM Specialize in Women s Health, Preventative Health, Gynecology, and Health Education - for all ages of women. Special interest in the evaluation and treatment of menopause, hormonal imbalances, bleeding issues, fibroid tumors, and reproductive/pelvic pain. Focus on Minimally Invasive Surgery,and non-surgical treatment First Robotic gyn surgery in Boulder County

6 Goals Define fibroids. Define abnormal bleeding. Discuss the issues involved with each. Discuss treatments - both medical and surgical. Discuss the newer approaches, and the exciting new field of Robotic surgery. Allow time to answer questions.

7 The Uterus & Reproductive Organs Uterus (womb) Endometrium Myometrium Fallopian Tube Fallopian Tube Fallopian tubes Ovary Myometrium Ovary Ovaries produce eggs, and - female hormones Cervix opening of uterus Endometrium Cervix Vagina Vagina birth canal davincisurgery.com A number of diseases and conditions that gynecologists treat affect various sites in the female reproductive system. Before I discuss these further, let s quickly review the female reproductive system and its major organs. The uterus is the muscular organ pictured here in the center of the diagram. The uterus is where the embryo and then the fetus develop during pregnancy. At the top end of the uterus or womb are the fallopian tubes which deliver the fertilized eggs to the uterus for implantation. The ovaries are the reproductive organs which contain the eggs and also produce hormones. When an egg is fertilized, it travels down the fallopian tubes to the uterus. The myometrium is the muscular wall of the uterus while the endometrium is the uterine lining that is shed every month during a menstrual cycle, unless of course a pregnancy develops. At the bottom end of the uterus is the cervix or the mouth of the uterus, which opens into the vagina or birth canal.

8 Lateral View tail bone Bladder Uterus Vagina Rectum pubic bone davincisurgery.com

9 Fibroids Technical name is uterine leiomyomas. Most common solid pelvic tumors in women % of all women may develop fibroids. Benign tumors in much the same sense that skin moles are tumors. Most can be followed. Some become symptomatic. Leading cause of hysterectomies. Hysterectomy is curative and eliminates recurrence. There are a number of alternatives for treatment.

10 Types of fibroids based on their location Common Benign tumors Vary by size & location Intramural Subserosal Submucosal Pedunculated davincisurgery.com Let s talk a little bit more about fibroids. Fibroids or the medical term leiomyomas are very common. They are almost always benign and they arise from the muscular wall of the uterus. They can grow in different parts of the uterus and they can vary in size, location, and severity of symptoms. They can be as small as a pea or as big as a melon or even larger. Pedunculated fibroids are when the fibroid comes off of a stock that is attached to the uterus. Subserosal fibroids usually bulge out from the outer aspect of the uterine wall, whereas submucosal fibroids bulge in towards the uterine cavity or the endometrial cavity. Fibroids within the myometrium or the muscular wall itself are usually called intramural fibroids. Different types of fibroids can result in different types of symptoms. The most common symptoms of fibroids overall are heavy periods or irregular bleeding, difficulty getting pregnant or a sense of urinary urgency from the fibroids pushing on the bladder. Fibroids can also cause a bulging sensation in your pelvic area and they can also cause pain, particularly pain with intercourse.

11 Fibroid problems Growth of individual fibroids or volume of the uterus. Abnormal bleeding - heavier or prolonged. Anemia. Pelvic pressure or pain. Bladder pressure, increased urinary frequency. Back pain. Sense of rectal fullness. Increased abdominal girth. Fertility or fecundity issues. Pain with intercourse.

12 Abnormal bleeding Defined by amount of flow, duration of flow, frequency of flow, or bleeding that occurs at times other than during a mense (intramenstrual flow) In our practice, we tend to have patients track a menstrual calender that visually shows when a person bled, and also the amount. In order to understand abnormal bleeding, you need to understand how mother nature regulates normal flow.

13 Menstrual Calendar January February [29] March April May June July August September October November December

14 Menstrual bleeding Menstrual bleeding is a natural process that cleanses the uterine lining each cycle, to allow fresh endometrium for implantation of a pregnancy. If pregnancy does not occur any given cycle, the body sluffs the old endometrium, and allows for the rebuilding of new and fresh tissue. Normal bleeding during a complete menstrual cycle should not exceed 2 ounces total. Thats four tablespoons total. Maximum. All days combined. Surprised?

15 Menstrual cycles Complicated system of control The ovaries produce hormones which actually cause growth of the endometrium. Ovaries receive their orders of what to produce via signal hormones ( FSH and LH) from the pituitary gland, near the base of the brain.

16 Normal menstrual cycle

17 Menstrual Cycles 6 ideal months FSH ESTROGEN PROGESTERONE LH The solid red represents estrogen. The solid dark green represents progesterone. The dotted lines represent FSH and LH

18 Abnormal bleeding Causes of abnormal bleeding are extensive, and management is based on the cause. Most common cause is hormonal fluctuations - variations in the complex system of control - i.e. hormone imbalance. When you realize how complex the natural system of control actually is, it s easy to understand how it can get out of control. In fact, it s harder to understand how most cycles are as regular as they are. Menstrual life consists of phases.

19 Stages and phases Where you are in your hormonal life influences your regularity and flow

20 Perimenopause 6 months Erratic hormones = erratic bleeding and erratic symptoms for example, this woman in perimenopause will have very abnormal bleeding

21 Abnormal bleeding Besides hormonally caused bleeding there are a number of pathologic conditions that will lead to abnormal bleeding. Fibroid tumors Endometrial polyps Adenomyosis Endometrial Hyperplasias Precancerous or cancerous growths

22 Abnormal bleeding Correct diagnosis is critical to safety and appropriate treatment. Treatment will vary depending on the cause. Diagnosis is pieced together like a jigsaw puzzle, based on history, exam and tests such as ultrasound imaging or biopsies.

23 Fibroids and Bleeding Fibroids can be the cause of bleeding, but not all fibroids will cause bleeding,( or any problem for that matter). I want to demonstrate this concept because its important Many women are undergoing surgery that is not appropriate because the exact cause of the bleeding has never been elucidated

24 Fibroids can be innocent let this large oval represent all women All Women

25 Fibroids can be innocent Abnormal Bleeding This smaller circle represents women with abnormal bleeding most women obviously do not have abnormal bleeding All Women

26 Fibroids can be innocent Abnormal Bleeding The brown now represents women with fibroids. Fibroids All Women

27 Fibroids can be innocent The intersection represents women with both fibroids and abnormal bleeding. Abnormal Bleeding but just because you now have fibroids doesn t mean your fibroids are CAUSING the bleeding. Fibroids All Women

28 Fibroids can be innocent The point is that not all fibroids cause bleeding Abnormal Bleeding And not all bleeding is caused by fibroids B l e e d i n g a c t u a l l y caused by fibroids Fibroids All Women

29 Hysterectomy will cure your bleeding regardless of the cause. Period.

30 For those that subscribe to the one size fits all this is a perfect fit!

31 For many years we had no better solutions and major surgery was the only way out of these miserable problems. Today you are blessed with many options - enough to make your head spin. How does one decide?

32 Options Subdivided into medical treatments and surgical treatments. Surgical treatments can be further divided into standard open procedures, verses minimally invasive surgeries.

33 Alternatives to Hysterectomy -medical treatments Oral contraceptive pills can sometimes effectively control excess flow. Non-steroidal anti-inflammatory pills (Advil, Ibuprofen, Aleve) may reduce pain and pressure symptoms. An IUD containing progesterone can sometimes control flow in correctly chosen women. Another class of drugs, aromatase inhibitors, show promise, but are not FDA approved, and again are temporary.

34 Alternatives - medical A class of drugs known as GnRH agonists can temporarily shut off normal estrogen production and allow fibroids to shrink. They are approved only for temporary use and are quite expensive. The fibroids tend to re-grow after treatment, so use is usually limited to preoperative therapy. Antiprogesterone agents, ( Mifepristone ), effectively reduce the growth, but may increase the risk of endometrial cancer. Bleeding that does not respond to one of these treatments may require surgery. The lack of simple, safe and long term medical treatment means that most problematic fibroids will require surgical intervention.

35 Surgical Alternatives to Hysterectomy Bleeding issues Remove internal (submucosal or pedunculated) fibroids via Hysteroscopy. Hysteroscopic removal of polyps. Treat noncancerous bleeding with endometrial ablation. Adenomyosis may respond to ablation.

36 Surgical Alternatives to Hysterectomy Pain or Masses (including Fibroids) May require diagnostic surgery. Removal of a fibroid is referred to as a myomectomy. Myomectomy leaves the uterus intact, and allows future childbearing. Multiple fibroids can be removed.

37 Limitations of Myomectomy The risk of recurrence of fibroids is real and significant. Intraoperative risks can lead to unplanned hysterectomy. Blood loss can lead to transfusion. Studies differ, but I believe the surgical risks are slightly higher than actual hysterectomy. Should be reserved only for women who have need of future fertility, to justify the risks.

38 Methods of Myomectomy Simplest surgery is hysteroscopic removal - only applies to intracavitary fibroids of suitable size and location. Abdominal myomectomy is most common, and the recovery is longer and slower than hysterectomy. Standard of care for several decades and method most doctors were trained to do. Laparoscopy (MIS) has been used but the technique is very difficult. Along with increasing difficulty comes a higher risk of complications. Few laparoscopic surgeons possess the skills to accomplish this procedure. Slightly more think they have the skills. :(

39 Uterine Artery Embolization This is a technique performed by interventional radiologists. A transcutaneous catheter is placed into the femoral artery, and fed into the uterine vessels. A slurry of microsphere particles is released into the vessels supplying the fibroid(s) resulting in devascularization and eventually involution (partial death of the fibroid with shrinkage and cessation of further growth). Moderate failure rate, moderate relapse rate. Not intended for future pregnancies, but many reported. Acceptable option for well selected candidates.

40 Focused Ultrasound Surgery MRI-guided focused ultrasound therapy is a relatively new modality being studied to damage the fibroid using high energy ultrasound, focused from outside the body into the center of a fibroid, causing cellular damage and ultimately shrinkage. Unknown long term outcomes. Mild to moderate short term successes so far. Stay tuned.

41 Robotic assisted surgery A sophisticated tool, this advancement allows more precise control of advanced laparoscopic instruments. Allows formerly difficult maneuvers to be done routinely. Should ultimately reduce the risks associated with more difficult procedures. Myomectomy now becomes viable as a MIS procedure. More complicated hysterectomies can be performed. Women are now candidates, that formerly would have been turned away.

42 Myomectomies are feasible for selected patients. Hysterectomies are sometimes the better alternative, but now they are not so onerous. We perform MIS hysterectomies as an outpatient procedure in almost all cases. We frequently recommend supracervical hysterectomies, because we feel this better supports the pelvic floor, preventing later prolapse or incontinence problems.

43 Hysterectomy Facts Most common female surgery Definitive solution for many uterine conditions 650,000 procedures annually Most performed through abdominal (open) incision Advances in minimally invasive surgery (MIS) for hysterectomy More GYN surgeons performing MIS for hysterectomy davincisurgery.com Some important things to know about hysterectomy are that it s the most common surgical procedure performed on women. This is because it is the definitive solution for many types of common gynecologic conditions. About 650,000 hysterectomies are performed annually in the United States alone. Most of these are still performed through abdominal incisions, either up and down between the belly button and the pubic bone or across, what many women refer to as a bikini incision. Due to recent advances in minimally invasive approaches to hysterectomy, more and more gynecologic surgeons are performing these types of procedures either vaginally or using what s called a laparoscopic approach.

44 Myomectomy Facts 40,000 procedures performed annually Most performed through abdominal (open) incision Number and size of fibroids may require complete removal of uterus (hysterectomy) Advances in minimally invasive surgery (MIS) for myomectomy More GYN surgeons performing MIS for myomectomy If uterine and/or fertility preservation is desired davincisurgery.com Myomectomies are also quite common. About 40,000 procedures are performed in the United States every year. Most of these procedures are performed through abdominal incisions. Sometimes if there are many fibroids or the fibroids are very large, a hysterectomy maybe required. Some gynecologic surgeons have begun performing myomectomies with minimally invasive surgical approaches. Myomectomies are indicated if you are still trying to get pregnant and a minimally invasive surgical approach offers many advantages for a shorter recovery.

45 Surgical Approaches to Hysterectomy Open (abdominal) surgery Minimally invasive surgery (MIS) Vaginal surgery Conventional laparoscopic surgery da Vinci Hysterectomy (robot-assisted surgery) davincisurgery.com Now that we have talked about some common gynecologic conditions and their various treatment options, let s discuss some of the approaches that are available when surgery is needed. As I alluded to earlier, if you need a hysterectomy, it can be done with a traditional approach, an open abdominal incision; this incision maybe vertical or transverse. Now, however, many physicians are offering minimally invasive surgery for hysterectomy. A minimally invasive approach could be vaginal with conventional laparoscopy or robotically with the da Vinci Surgical System.

46 Minimally Invasive Surgery (MIS) Reduced blood loss Fewer complications Shorter Hospital stay Faster recovery Less scarring Circa davincisurgery.com There are many advantages to minimally invasive surgery. These include reduced blood loss, fewer complications, a shorter stay in the hospital, a faster recovery, and less scarring.

47 da Vinci Surgery Double-click to view video Surgeon has Improved visualization Better instrumentation, surgical control & precision Better surgical dexterity for complex aspects of procedure Easier & faster suturing Better ergonomics davincisurgery.com In addition to the number of many benefits to the patient, there are many benefits to me the surgeon as well. These include improved visualization, better control of the instruments, improved surgical dexterity for complex aspects of the operation, easier and faster suturing, and I m more comfortable while I m operating.

48 Vision System Surgeon immersed in 3D image of the surgical field davincisurgery.com Rather than a two-dimensional flat image, I am immersed in a three-dimensional image of the surgical field.

49 The Surgeon Directs the Instruments Surgeon directs precise movements of the instruments using Console controls davincisurgery.com I direct the instruments at all times while controlling the arms on the console. Even small or very precise movements of my hands are transmitted to the instruments inside the patient s abdomen in real time.

50 Wrist and Finger Movement Conventional minimally invasive instruments are rigid with no wrists EndoWrist Instrument tips move like a human wrist Allows surgeon to operate with increased dexterity & precision davincisurgery.com Conventional laparoscopic instruments are rigid and do not have the ability to rotate like a human wrist. The EndoWrist instruments, part of the da Vinci Surgical System, move like a human wrist with seven degrees of freedom. This allows me to operate with increased dexterity and precision.

51 Small Instruments, Small Incisions EndoWrist Instruments fit through dime-sized incisions A wide range of instruments are available davincisurgery.com These EndoWrist instruments fit through small dime-sized incisions or keyhole incisions. A wide range of instruments are available to perform almost any type of task that might be required.

52 Robot-Assisted Surgery Access Open Vertical Incision Open Transverse Incision da Vinci Surgical Incision davincisurgery.com This slide shows a picture of the typical configuration of these small keyhole incisions that might be used for access to perform a robotic-assisted surgery.

53 Potential Patient Benefits Benefit Incision size Pain or discomfort Hospital stay Recovery Return to normal activities Open Surgery Long incision with visible scaring Weeks 3-5 days 4-6 weeks Weeks da Vinci Surgery 4-6 dime-sized incisions with minimal scaring Days 1-2 days 1-3 weeks Days davincisurgery.com When you compare the benefits of different surgical approaches, you can see that the da Vinci Surgical System offers many advantages. In general, smaller incisions result in less scarring, less pain, a shorter hospital stay, shorter recovery, and quicker return to normal activities.

54 Goals? We ve defined fibroids and the inherent problems. We ve discussed normal vs. abnormal bleeding and causes. We ve reviewed both medical and surgical treatments for both problems. We ve described the newer MIS procedures-hysteroscopic, Laparoscopic, and the newest addition, davinci Roboticassisted surgeries. Time now for questions.

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56 Thank you!