Greenville Health System (GHS) surgeons offer a range of treatments to meet women's health care needs.
Alternatives to Hysterectomy
“We lean toward conservative management of a patient’s condition when we are treating a woman of childbearing age or a woman who otherwise wants to keep her uterus, even when a problem exists that a hysterectomy would solve,” said Laura Wang, M.D., FACOG, a gynecologist with GHS.Beyond medicinal therapies, including birth control pills, some surgical procedures that can prevent or delay a hysterectomy include myomectomy, uterine artery embolization and endometrial ablation.
Myomectomy. With this operation, the surgeon cuts away large uterine fibroids (myomas), common noncancerous tumors of the uterine musculature, without removing the uterus, so that a woman can maintain her ability to bear children. Removal of the fibroids tends to weaken and scar the uterine wall, so future deliveries may have to be performed by cesarean section. Myomectomy may not be recommended for women who do not desire future fertility or who are menopausal.Traditionally a myomectomy is performed through a large incision in the abdominal wall, but some patients are candidates for laparoscopic fibroid tumor removal. A laparoscopic myomectomy is performed while the patient is under general anesthesia and her abdomen is inflated with carbon dioxide gas via a tiny incision. The surgeon inserts the laparoscope through the navel and examines the internal organs, then incises the outer coating of the uterus and muscular wall to remove the fibroid.
After the fibroid is removed from the uterus, it is cut into small pieces with a morcellator, and the pieces are removed through one of the ports or through an incision in the vagina. Following laparoscopic myomectomy, most women leave the hospital within 24 hours. Recovery takes about two weeks. In contrast, abdominal myomectomies require a hospital stay of three to four days and a recovery period of four to six weeks.
Uterine artery embolization. This minimally invasive hysterectomy alternative preserves the uterus but is not advised for women who want to become pregnant. Sometimes called uterine fibroid embolization, the operation blocks the arteries carrying blood to the uterus as well as the fibroids. Interventional radiologists perform the procedure. First, they place a catheter through a large artery in the groin and then they thread the catheter through the blood vessels until it reaches the uterine arteries. Next they inject plastic particles about the size of grains of sand through the catheter to block the uterine arteries and subsequently decrease the blood supply to the fibroid(s). Patients usually are hospitalized overnight for pain control. Over time, the size of the fibroids decreases because their blood supply is blocked. The procedure typically relieves heavy menstrual blood loss as well as pelvic pressure and pain caused by large fibroids.
Endometrial ablation. This operation, which also is not recommended for women who want to bear children, can reduce or stop abnormal uterine bleeding by using electrical energy, heat or cold to destroy the endometrium (tissue lining the inside of the uterus). Following is one example of how the procedure can be performed: The surgeon inserts a narrow tube called a hysteroscope vaginally into the uterus and then uses the tube’s tiny camera to view the uterine cavity on a monitor while other instruments passed through the hysteroscope destroy the tissue. There are a number of other methods for accomplishing the operation. Complications can include recurrent symptoms that ultimately lead to hysterectomy to control dysfunctional bleeding.
Hysteroscopic SterilizationFor women who desire permanent sterilization but do not want to undergo an abdominal operation, GHS offers the Essure® Micro-Insert System. The first FDA-approved hysteroscopic approach to tubal sterilization, Essure requires no incision or general anesthesia and can be performed in approximately 30 minutes in an outpatient setting.
Hysteroscopic sterilization works by “plugging up” the fallopian tubes to prevent fertilization. Two small coil implants (the micro-inserts) are positioned through the body’s natural pathways (vagina, cervix and uterus) in each fallopian tube. Each one expands upon release, anchoring itself inside the tubes. Over time, the implants trigger scar tissue to grow around them, permanently blocking the tubes.
Laser Vaginal Rejuvenation®Age, childbirth and other issues can cause the vagina to stretch and its supportive muscles to lose tone and control, diminishing sexual gratification. Laser Vaginal Rejuvenation (LVR®) is a one-hour outpatient surgical procedure that addresses these issues. LVR can decrease the internal and external vaginal diameters as well as build up and strengthen the perineal body – the area immediately outside the vagina and above the anus.
GHS urogynecologist Jeffrey B. Garris, M.D., FACOG, FACS, performs LVR and the companion procedures of Designer Laser Vaginoplasty® (DLV®). DLV operations are intended to aesthetically enhance the vulvar structures. Dr. Garris was trained in both LVR and DLV by Los Angeles-based gynecologic surgeon David Matlock, M.D., who pioneered the procedures.
“Depending on a patient’s wishes, it’s possible to do laser vaginal rejuvenation surgery with or without surgery to correct urinary incontinence, pelvic floor prolapse or other problems,” said Dr. Garris
Vecchietti Procedure for Vaginal AgenesisEach year about one in 4,500 women is born with vaginal agenesis, a condition in which the vagina is absent or shorter than normal. Also known as Mayer-Rokitansky-Kuster-Hauser Syndrome, vaginal agenesis may occur in isolation or with the absence of the cervix and uterus. It usually is diagnosed in girls age 15 to 18 who have not yet begun to menstruate.
The laparoscopic Vecchietti procedure for addressing vaginal agenesis has been widely accepted in Europe since the 1980s but has remained less familiar in the United States. GHS is one of the few U.S. hospital systems to offer this procedure, which is performed by physicians of the Division of Reproductive Endocrinology & Infertility (REI), part of GHS –Department of OB-GYN. Paul B. Miller, M.D., FACOG, an REI specialist with the group, initiated the laparoscopic Vecchietti procedure in the Upstate.
Treatment Alternatives. The most commonly used alternatives to the Vecchietti procedure have some major drawbacks. Nonsurgical treatment involves the use of graduated dilators to expand and enlarge the tissue already present at the vaginal entrance. Patients use the dilator to apply pressure for 15 to 20 minutes a day. Creation of a neovagina with this method takes three to six months on average but can take up to a year if dilators are not used daily or properly.In the United States, the most common surgical treatment for vaginal agenesis performed by gynecologists is the McIndoe procedure. While the patient is under general anesthesia, the surgeon removes a skin graft from the buttocks and attaches it to a mold of a vagina. Then the surgeon makes an incision where the patient’s vagina started to develop and inserts the mold into this opening. Patients remain hospitalized for a week while the skin attaches, and then the mold is removed.
With the McIndoe procedure, there is a strong tendency for the graft to contract and close up the vaginal cavity. Preventing this stenosis requires conscientious use of dilators postoperatively. The operation also leaves patients with a permanent 10-inch scar at the graft site.
The Vecchietti Way. The Vecchietti procedure is another surgical treatment option for constructing a neovagina. It was developed in Europe in the 1960s as an open, abdominal operation and then evolved into a laparoscopic procedure in the 1980s.Using the laparoscopic Vecchietti approach, the surgeon places an acrylic bead about the size of an olive at the vaginal opening and connects it to a traction device on the anterior abdominal wall with strong sutures. Then every other day, the patient visits the physician’s office for tightening of the sutures around the device. This tightening pulls the bead inward by about one centimeter a day to create a vagina. This process takes approximately two weeks, and then the device and sutures are removed. For about two months following the procedure, patients who are not sexually active sleep at night with a firm foam rubber mold in the vagina.
“The Vecchietti procedure offers an option for young women with vaginal agenesis who find conservative treatment with dilators difficult or impossible or who show poor progress,” said Dr. Miller. “Understandably, there are some patients who simply can’t get the privacy needed for daily dilator use. For others, the prospect of self-dilation poses a great deal of emotional and psychological trauma.”
“The laparoscopic Vecchietti procedure is a safe, discreet option in which a neovagina can be created in a short amount of time – a week or so of progressive tightening of sutures instead of six months of dilator use,” he concluded. “And unlike the more commonly used McIndoe procedure, it does not involve the painful recovery, the longer operative time, the lengthy postoperative hospital stay and the skin graft that leaves a long scar.”