Uterine fibroids are the most common benign tumor of the female reproductive tract. Approximately 30–70% of reproductive-age women have uterine fibroids. Although the majority of women are asymptomatic, uterine fibroids can cause multiple symptoms; most commonly heavy menstrual bleeding. Other symptoms include bleeding between periods and infertility concerns. As fibroids grow, bulk symptoms occur, such as pelvic pressure and pain, frequent urination, occasional urinary retention and also bowel changes.
In the past, when fibroid symptoms became unbearable, hysterectomy was the procedure of choice. If fertility was a concern, myomectomy, that is, fibroid removal from the uterus, was performed. Even with a laparoscopic approach, major complications are seen in 1–2% of patients undergoing either procedure. Over the past 10 years, several other options have become popular in the treatment of symptomatic uterine fibroids. These include the following:
| • | Medical treatment, such as the use of a gonadotropin-releasing hormone agonist (GnRH), which creates a hypoestrogenic state and allows temporary fibroid size reduction, as well as cessation of menstrual flow. The resultant amenorrhea enables treatment of anemia secondary to profound menstrual blood loss. During treatment, many patients complain of symptoms secondary to this hypoestrogenic state. If noted, estrogen and progesterone can be added to the treatment regimen. Moreover, fibroid growth will ensue once the GnRH agonist is stopped; | ||||
| • | Treatment via the interventional radiologist – uterine artery embolization. Fibroid reduction is noted to be 35–40%. In terms of symptom improvement, bleeding reduction is noted in 90% of patients, while 80% will note reduction in bulk-related symptoms. Unfortunately, uterine artery embolization is noted to have a 33% fibroid recurrence rate. Uterine artery embolization should not be used in women interested in future fertility and is associated with an incidence of post-procedure menopause, particularly in patients in their mid-40s. Moreover, embolization misadventure can occur. | ||||
At the 35th Annual Global Congress of Minimally Invasive Gynecology of the AAGL, new techniques for the treatment of symptomatic uterine fibroids were presented. Although the studies were small, they nevertheless provide an eye to the future on the minimally invasive treatment of symptomatic uterine fibroids.
Magnetic resonance-guided focused ultrasound
The first study on the treatment of symptomatic uterine fibroids, presented at the 35th Annual Congress of the AAGL, came from the Lahey Clinic (MA, USA). It involved the use of magnetic resonance-guided focused ultrasound surgery (MRgFUS). In this technique, magnetic resonance imaging (MRI) is used to target and control the noninvasive focused ultrasound thermal ablation of uterine fibroids. MRgFUS was approved by the US FDA for treatment of symptomatic fibroids in 2004.
Raffaele Bruno and colleagues initially prospectively evaluated over 25 pre- or post-menopausal women with symptomatic uterine fibroids who were to undergo MRgFUS. Patients completed a uterine fibroid symptom severity questionnaire (UFS-QOL) before and after treatment. Enrollment required symptomatic uterine fibroids scoring a minimum of 18 on the symptom severity questionnaire. Gynecologic examination and prior MRI confirmed a definitive diagnosis of uterine fibroids. Patients were evaluated at 3, 6 and 12 months after treatment.
The authors reported on the 19 patients who had returned for their 1-year follow-up. Starting at the 3-month evaluation, approximately 60% of patients demonstrated a significant decrease of at least ten points on the symptom severity score of UFS-QOL. The decrease was also evident in patients at 12 months. The average decrease at 3 and 12 months was 11 and 10 points, respectively. MRI follow-up confirmed a reduction in size or volume of the treated fibroids. No serious adverse events were reported. Thus, in the short term, MRgFUS appears to be a safe and effective nonsurgical alternative for treating symptomatic uterine fibroids in women interested in uterine preservation and avoiding major surgery. The authors acknowledged that more long-term follow-up is necessary to evaluate the persistency of these results.
Fibroid cryotherapy
From the University of Mississippi Medical Center (MS, USA) came a report describing a non-FDA-approved technique of fibroid cryoablation using both MRI-directed and laparoscopically assisted approaches.
Bryan D Cowan and colleagues presented the outcome of two studies; the first involving 12 women treated with MRI-guided 2- and 3-mm cryoprobes, as well as a separate evaluation of 20 patients treated with laparoscopically assisted 17 gauge cryo needles (Galil Medical). In all patients, the treatment strategy was to devitalize the fibroid by freezing the tumor. Primary goals were safety, fibroid volume reduction and quality of life (QOL) improvement.
At 6 months, MRI-treated patients showed 66% fibroid volume reduction. Ten (out of 12) patients showed improvement or resolution of symptoms; some experienced mild pain post-treatment, which resolved spontaneously. Patients were discharged from the hospital within 24 h. One patient returned for hysterectomy 1 year after cryoablation and one patient underwent emergency surgery for a lacerated fibroid-associated vessel.
In the laparoscopically assisted cryotherapy group, no intra- or post-operative adverse events occurred. Patients reported no significant post-treatment pain. The SSS–UFS–QOL (Spies 2002) instruments detected significant aggregate improvement in questions related to bleeding and bulk symptoms. Fibroid volume reduction at 3 months (30 fibroids) and 6 months (14 fibroids) was 57.1 and 81.6%, respectively.
The authors speculated that in the future, with advances in cryoablation technology and sonographic visualization, cryoablation could be performed in the office.
Transvaginal Doppler: guided temporary uterine artery occlusion
The next study, authored by George Vilos and colleagues (University of Western Ontario, Canada) assessed the feasibility, safety and efficiency of the non-FDA-approved technique of Doppler-guided, temporary uterine artery occlusion using the FlowStat™ system in women with symptomatic uterine fibroids.
Under general or conscious sedation with a paracervical block (n = 17) or epidural analgesia (n = 13), hysteroscopy and dilation and curettage were carried out and the uterine arteries were occluded using the vascular clamp under Doppler guidance. Following device placement, the patients were transferred to the recovery area and the occlusion was maintained for a period of 6–9 h.
Patients were prescreened prior to treatment using the Ruta Menorrhagia Severity Scale, ultrasound and/or MRI at baseline and at 3 and 6 months to assess fibroid and uterine volumes. Uterine arteries were successfully occluded in all 30 patients. In one patient, the clamp was dislodged and removed after an adverse anesthesia event. Significant reduction in menorrhagia was noted; 81% of women reported a 15% or greater Ruta score at 6 months (an average reduction of 51%). In this group, the corresponding average reductions in uterine and dominant fibroid volume were 24 and 45%, respectively. Two patients developed hydronephrosis and were subsequently treated with urethral stents. As a result of these adverse events, the bladder is now filled prior to the procedure.
Hysteroscopic morcellation
Hysteroscopic resectoscopy has been the gold standard for removal of symptomatic uterine fibroids within the cavity of the uterus over the past 25 years. Unfortunately, owing to the low learning curve, risk of uterine perforation, inadvertent bowel burns, pulmonary embolism and complications secondary to fluid absorption, use of the hysteroscopic resectoscope has been limited to 5–10% of all practicing gynecologists. Recently, a hysteroscopic morcellation system (Smith & Nephew) has gained FDA approval for the treatment of uterine fibroids within the cavity of the uterus and endometrial polyps. In this operative hysteroscopy system, electrical energy is converted to mechanical energy. A rotary blade resects the fibroid. Immediately, the resultant fibroid chips are suctioned from the field of view. Since this is a mechanical system, the risk of burns related to electrosurgery, as well as pulmonary embolism due to vapor created at electrosurgery are eliminated. Furthermore, saline is used as the distension medium. This negates the risk of hyponatremia associated with monopolar hysteroscopic resectoscopy, which requires a nonionic distension media.
In a randomized, controlled multicenter study that included the author (Charles E Miller, University of Chicago, IL, USA), hysteroscopic morcellation was compared with conventional loop resectoscopy for the removal of endometrial polyps and fibroids within the uterine cavity. A total of 167 lesions were treated in 97 patients. Of these, 94 lesions in 48 patients (73 polyps, 21 fibroids) were treated via hysteroscopic morcellation. The remaining 73 lesions (51 polyps, 22 myomas) were removed in 49 patients treated by conventional loop resectoscopy.
The operating time for the morcellation technique was 10.2 min and the mean fluid deficit for these procedures was 313 ml. The operative duration for the loop resection was 12.7 min, with a fluid deficit of 232 ml. Essentially, the operating time and the fluid deficit were similar between patients in both the hysteroscopic morcellation and the loop resectoscopy group. Thus, hysteroscopic morcellation is an effective technique for the treatment of endometrial polyps and fibroids contained in the uterine cavity. It can be offered as a safe alternative to conventional hysteroscopic resectoscopy.
Conclusion
Both now and in the future, the physician will have multiple surgical and nonsurgical minimally invasive modalities with which to treat symptomatic uterine fibroids. While the operating room or the radiologic suite will continue to be used, many of these patients will alternatively be treated in the office.