Uterine Conditions & Treatment When a woman faces a medical condition that affects her uterus, the hollow, muscular organ that holds and feeds a fertilized egg, the emotional impact can often be as challenging as the physical. These conditions include, but are not limited to, cervical and uterine cancers such as endometrial cancer, uterine fibroids, uterine prolapse, excessive bleeding and endometriosis. Treatment options are as varied as the conditions themselves, depending on individual circumstances. A woman’s age, health history, surgical history and diagnosis (benign or cancerous), all factor into the recommended course of action. Endometriosis, also known as endometrial hyperplasia, is a condition in which the endometrial tissue grows outside the uterus, causing scarring, pain, and heavy bleeding. It can often damaging the fallopian tubes and ovaries in the process. A common organic cause of infertility, endometriosis can be treated with medications such as lupron for endometriosis that lowers hormone levels and decreases endometrial growths. While such medications often relieve associated symptoms, a patient should understand the potential side effects before pursuing this treatment regimen. For endometrial cancer, also known as uterine cancer and more common among women after menopause, standard treatment options include hormone therapy, radiation therapy, chemotherapy and hysterectomy (surgical removal of the uterus). Three of these — radiation therapy, chemotherapy and hysterectomy — are also used to treat cervical cancer. For benign (non-cancerous) conditions like menorrhagia (heavy menstrual bleeding), non-surgical treatments like hormone therapy or minimally invasive ablative therapies may offer relief. For fibroids, uterine-preserving myomectomy – a surgical alternative to hysterectomy — may be an option. Hysterectomy

For most uterine conditions, if available non-surgical treatments fail to relieve symptoms, many women choose a more certain result with elective hysterectomy. Each year in the U.S. alone, doctors perform about 600,000 hysterectomies, making it the second most common surgical procedure.1 While symptoms such as chronic pain and bleeding often point a woman and her doctor toward hysterectomy as the preferred treatment choice, life-threatening conditions such as cancer or uncontrollable bleeding in the uterus often necessitate a hysterectomy and follow-up treatment. While hysterectomy is relatively safe, always ask your doctor about all treatment options, as well as their risks and benefits, to determine which approach is right for you. And if hysterectomy is recommended or required, you owe it to yourself to learn about da Vinci Hysterectomy, a robot-assisted, minimally invasive surgery that for many women has potential as the safest and most effective treatment available. 1.Center for Disease Control. Keshavarz H, Hillis S, Kieke B, Marchbanks P. Hysterectomy Surveillance — United States, 1994–1999. Morbidity and Mortality Weekly Report. Surveillance Summaries. July 12, 2002. Vol. 51 / SS-5. Page 1. www.cdc.gov/mmwr/PDF/ss/ss5105.pdf

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. For additional information on minimally invasive surgery with the da Vinci® Surgical System visit www.davincisurgery.com



Fibroids & Treatment Options Uterine fibroids* are benign (non-cancerous) tumors occurring in at least one quarter of all women.1 They can grow underneath the uterine lining, inside the uterine wall, or outside the uterus. Many women don’t feel any symptoms with uterine tumors or fibroids. But for others, these fibroids can cause excessive menstrual bleeding (also called menorrhagia), abnormal periods, uterine bleeding, pain, discomfort, frequent urination and infertility.2 Treatments include uterine fibroid embolization – which shrinks the tumor – and surgery. Surgical treatment for uterine tumors most often involves the surgeon removing the entire uterus, via hysterectomy.3 While hysterectomy is a proven way to resolve fibroids, it may not be the best surgical treatment for every woman. If, for example, you hope to later become pregnant, you may want to consider alternatives to hysterectomy like myomectomy. Myomectomy is a uterine-preserving procedure performed to remove uterine fibroids. Types of Myomectomy Each year, roughly 65,000 myomectomies are performed in the U.S.4 The conventional approach to myomectomy is open surgery, through a large abdominal incision.5 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. Menorrhagia is extensive menstrual bleeding. While myomectomy is also performed laparoscopically, this approach can be challenging for the surgeon, and may compromise results compared to open surgery.6 Laparoscopic myomectomies often take longer than open abdominal myomectomies, and up to 28% are converted during surgery to an open abdominal incision.7 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. * Uterine fibroids are also called fibroids, uterine tumors, leiomyomata (singular – leiomyoma) and myomas or myomata (singular – myoma) 1.Newbold RR, DiAugustine RP, Risinger JI, Everitt JI, Walmer DK, Parrott EC, Dixon D. Advances in uterine leiomyoma research: conference overview, summary, and future research recommendations. Environ Health Perspect. 2000 Oct;108 Suppl 5:769-73. Review. 2.National Institutes of Health: Fast Facts about Uterine Fibroids. www.nichd.nih.gov/publications/pubs/fibroids/sub1.htm#where 3.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. 4.Lumsden MA.Embolization versus myomectomy versus hysterectomy: Which is best, when? Hum Reprod. 2002; 17:253-259. Review. 5.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. 6.Kristen A. Wolanske, MD; Roy L. Gordon, MD. Uterine Artery Embolization: Where Does it Stand in the Management of Uterine Leiomyomas? Part 2. Appl Radiol33(10):18-25, 2004. Medscape.10/27/2004. 7.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. 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. For additional information on minimally invasive surgery with the da Vinci® Surgical System visit www.davincisurgery.com





Hysterectomy Physicians perform hysterectomy – the surgical removal of the uterus – to treat a wide variety of uterine conditions. Each year in the U.S. alone, doctors perform approximately 600,000 hysterectomies, making it the second most common surgical procedure.1 Types of Hysterectomy There are various types of hysterectomy that are performed depending on the patient’s diagnosis: Supracervical hysterectomy – removes the uterus, leaves cervix intact

Total hysterectomy – removes the uterus and cervix

Radical hysterectomy or modified radical hysterectomy – a more extensive surgery for gynecologic cancer that includes removing the uterus and cervix and may also remove part of the vagina, fallopian tubes, ovaries and lymph nodes in order to stage the cancer (determine how far it has spread). Approaches to Hysterectomy Surgeons perform the majority of hysterectomies using an “open” approach, which is through a large abdominal incision. An open approach to the hysterectomy procedure requires a 6-12 inch incision. When cancer is involved, the conventional treatment has always been open surgery using a large abdominal incision, in order to see and, if necessary, remove related structures like the cervix or the ovaries. A second approach to hysterectomy, vaginal hysterectomy, involves 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 (non-cancerous), when the uterus is normal size and the condition is limited to the uterus. In laparoscopic hysterectomy, the uterus is removed either vaginally or through small incisions made in the abdomen. The surgeon can see the target anatomy on a standard 2D video monitor thanks to a miniaturized camera, inserted into the abdomen through the small incisions. A laparoscopic approach offers surgeons better visualization of affected structures than either vaginal or abdominal hysterectomy alone. While minimally invasive vaginal and laparoscopic hysterectomies offer obvious 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) 2

Thick adhesions due to prior pelvic surgery, such as C-section 3

Severe endometriosis 4

Non-localized cancer (cancer outside the uterus) requiring more extensive tissue removal, including lymph nodes With laparoscopic hysterectomy, surgeons may be limited in their dexterity and by 2D visualization, potentially reducing the surgeon’s precision and control when compared with traditional abdominal surgery. da Vinci Hysterectomy A new, minimally invasive approach to hysterectomy, da VinciHysterectomy, combines the advantages of conventional open and minimally invasive hysterectomies – but with far fewer drawbacks. da VinciHysterectomy is becoming the treatment of choice for many surgeons worldwide. It is performed using the da Vinci System, which enables surgeons to perform surgicall procedures with unmatched precision, dexterity and control. Read about what may be the most effective, least invasive approach to hysterectomy . 1.Center for Disease Control. Keshavarz H, Hillis S, Kieke B, Marchbanks P. Hysterectomy Surveillance — United States, 1994–1999. Morbidity and Mortality Weekly Report. Surveillance Summaries. July 12, 2002. Vol. 51 / SS-5. Page 1. www.cdc.gov/mmwr/PDF/ss/ss5105.pdf 2.Harmanli OH, Khilnani R, Dandolu V, Chatwani AJ. Narrow pubic arch and increased risk of failure for vaginal hysterectomy. Obstet Gynecol. 2004 Oct;104(4):697-700. 3.Paparella P, Sizzi O, Rossetti A, De Benedittis F, Paparella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004 Sep;270(2):104-9. Epub 2003 Jul 10. 4.Johnson N, Barlow D, Lethaby A, Tavender E, Curr L, Garry R. Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.BMJ. 2005 Jun 25;330(7506):1478. Review. 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. For additional information on minimally invasive surgery with the da Vinci® Surgical System visit www.davincisurgery.com



da Vinci Hysterectomy If your doctor recommends hysterectomy, you may be a candidate for da Vinci Hysterectomy, one of the most effective, least invasive treatment options for a range of uterine conditions. da Vinci Hysterectomy is performed using the da Vinci™ Surgical System, which enables surgeons to perform with unmatched precision and control – using only a few small incisions. For most patients, da Vinci Hysterectomy can offer numerous potential benefits over traditional approaches to vaginal, laparoscopic or open abdominal hysterectomy, particularly when performing more challenging procedures like radical hysterectomy for gynecologic cancer. Potential benefits include: Significantly less pain

Less blood loss

Fewer complications

Less scarring

A shorter hospital stay

A faster return to normal daily activities Moreover, da Vinci provides the surgeon with a superior surgical tool for dissection and removal of lymph nodes during cancer operations, as compared to traditional open or minimally invasive approaches.1 da VinciHysterectomy also allows your surgeon better visualization of anatomy, which is especially critical when working around delicate and confined structures like the bladder. This means that surgeons have a distinct advantage when performing a complex, radical hysterectomy involving adhesions from prior pelvic surgery or non-localized cancer, or an abdominal hysterectomy. 2 As with any surgery, these benefits cannot be guaranteed, as surgery is both patient- and procedure-specific. While radical hysterectomy or abdominal hysterectomy performed using the da Vinci Surgical System are considered safe and effective, these procedures may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits. 1.Boggess JF. da Vinci® Hysterectomy for Endometrial Cancer with Staging. Presented at ISI WWSSM 1/06. 871391_rev B_dVH Endometrial Cancer Presentation

2. UNC Department of Obstetric & Gynecology Health & Healing in the Triangle Vol 8 No 3 pp 22-23.