Laparoscopic Ultrasound-Guided Radiofrequency Ablation of Uterine Fibroids

[Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroid: A retrospective study]

OBJECTIVE

To assess clinical and radiological efficacy and safety of laparoscopic ultrasound-guided radiofrequency ablation of uterine leiomyomas.

MATERIAL AND METHODS

Thirty-three patients with symptomatic uterine leiomyomas FIGO type 2 to 7, have undergone a laparoscopic ultrasound-guided radiofrequency ablation at Croix Rousse University Hospital Center (Hospices civils de Lyon) and at Saint-Vincent de Paul Hospital in Lille, between June 2020 and December 2022. The characteristics of each myoma and the symptoms were assessed with pelvic MRI and with Higham score, SSS and HRQL scores preoperatively and at 6 months.

RESULTS

A total of 54 fibroids have been treated in 33 patients. We observed a significant decrease of the volume 6 months after the surgery, on average 21mL (55.97 vs. 74.37mL, 95% CI [7.13-34.88], P=0.001). The maximum diameter of each fibroid was also significantly reduced on average 11.78mm (41.89 vs. 52.06, 95% CI [8.83-14.73], P<0.05). We noticed a significant decrease of the NRS for dysmenorrhea on average 2.79 points (2.1 vs. 4.89, 95% CI [1.14-4.42], P<0.05). There was also a trend to improvement of menorrhagia, assess by Higham score. Indeed, 70.8% of the patients had menorrhagia. Menorrhagia was improved of 108,3 points with an average Higham score before surgery of 197.3 versus 87.9 after surgery (95% CI [47.9-168.8], P=0.001). Concerning UFS-QOL score: the symptom severity score (SSS) decreased on average 33 points, testifying of symptom improvement (27.04 vs. 60.89, 95% CI [22.92-43.39], P<0.001) and the HRQL score increased on average 20 points testifying quality of life improvement (65.57 vs. 42.7, 95% CI [15.83-37.85]. P<0.001). No severe adverse event has been reported.

CONCLUSION

In this first French study about radiofrequency ablation. We confirm its efficiency for improvement of symptoms and quality of life but other study is mandatory to confirm the safety of this procedure in particular in patients with a wish to conceive.

Comparison of computer simulations and clinical treatment results of magnetic resonance guided focused ultrasound surgery (MRgFUS) of uterine fibroids

Purpose

Magnetic resonance‐guided focused ultrasound surgery (MRgFUS) can be used to noninvasively treat symptomatic uterine fibroids by heating with focused ultrasound sonications while monitoring the temperature with magnetic resonance (MR) thermometry. While prior studies have compared focused ultrasound simulations to clinical results, studies involving uterine fibroids remain scarce. In our study, we perform such a comparison to assess the suitability of simulations for treatment planning.

Methods

Sonications (N = 67) were simulated retrospectively using acoustic and thermal models based on the Rayleigh integral and Pennes bioheat equation followed by MR‐thermometry simulation in seven patients who underwent MRgFUS treatment for uterine fibroids. The spatial accuracy of simulated focus location was assessed by evaluating displacements of the centers of mass of the thermal dose distributions between simulated and treatment MR thermometry slices. Temperature–time curves and sizes of 240 equivalent minutes at 43°C (240EM₄₃) volumes between treatment and simulation were compared.

Results

The simulated focus location showed errors of 2.7 ± 4.1, −0.7 ± 2.0, and 1.3 ± 1.2 mm (mean ± SD) in the anterior–posterior, foot–head, and right–left directions for a fibroid absorption coefficient of 4.9 Np m^–1 MHz^–1 and perfusion parameter of 1.89 kg m^–3 s^–1. Linear regression of 240EM₄₃ volumes of 67 sonications of patient treatments and simulations utilizing these parameters yielded a slope of 1.04 and a correlation coefficient of 0.54. The temperature rise ratio of simulation to treatment near the end of sonication was 0.47 ± 0.22, 1.28 ± 0.60, and 1.49 ± 0.71 for 66 sonications simulated utilizing fibroid absorption coefficient of 1.2, 4.9, and 8.6 Np m^–1 MHz^–1, respectively, and the aforementioned perfusion value. The impact of perfusion on peak temperature rise is minimal between 1.89 and 10 kg m^–3 s^–1, but became more substantial when utilizing a value of 100 kg m^–3 s^–1.

Conclusions

The results of this study suggest that perfusion, while in some cases having a substantial impact on thermal dose volumes, has less impact than ultrasound absorption for predicting peak temperature elevation at least when using perfusion parameter values up to 10 kg m^–3 s^–1 for this particular array geometry, frequencies, and tissue target which is good for clinicians to be aware of. The results suggest that simulations show promise in treatment planning, particularly in terms of spatial accuracy. However, in order to use simulations to predict temperature rise due to a sonication, knowledge of the patient‐specific tissue parameters, in particular the absorption coefficient is important. Currently, spatially varying patient‐specific tissue parameter values are not available during treatment, so simulations can only be used for planning purposes to estimate sonication performance on average.

Percutaneous High Frequency Microwave Ablation of Uterine Fibroids: Systematic Review

Uterine fibroids are the most common benign pelvic tumor of the female genital tract and tend to increase with age; they cause menorrhagia, dysmenorrhea, pelvic pressure symptoms, back pain, and subfertility. Currently, the management is based mainly on medical or surgical approaches. The nonsurgical and minimally invasive therapies are emerging approaches that to the state of the art include uterine artery embolization (UAE), image-guided thermal ablation techniques like magnetic resonance-guided focused ultrasound surgery (MRgFUS) or radiofrequency ablation (RF), and percutaneous microwave ablation (PMWA). The purpose of the present review is to describe feasibility results and safety of PMWA according to largest studies available in current literature. Moreover technical aspects of the procedure were analyzed providing important data on large scale about potential efficacy of PMWA in clinical setting. However larger studies with international registries and randomized, prospective trials are still needed to better demonstrate the expanding benefits of PMWA in the management of uterine fibroids.

Radiofrequency Ablation of Uterine Fibroids: a Review

Laparoscopic, ultrasound-guided radiofrequency ablation (RFA) is a new, FDA-cleared uterine sparing, outpatient procedure for uterine fibroids. The procedure utilizes recent technological advancements in instrumentation and imaging, allowing surgeons to treat numerous fibroids of varying size and location in a minimally invasive fashion. Early and mid-term data from multi-center clinical trials have demonstrated safety and efficacy, with resolution or improvement of symptoms and significant volume reduction. Re-intervention rates for fibroid symptoms have been low. The procedure is well tolerated with a typically uneventful and rapid recovery requiring NSAIDs only for postoperative pain. While post RFA pregnancy data are limited, the results are promising.

Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy

Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.

Thermal ablative treatment of uterine fibroids

In addition to surgical methods of treating uterine fibroids, numerous non-invasive treatments have been developed. Many of these involve the use of hyperthermia, the heating of tissue by a variety of methods. These include the use of lasers, radiofrequency, microwave energy and high intensity focused ultrasound, guided by both ultrasound and magnetic resonance imaging. In this review we examine the technology behind these treatment modalities and review the current evidence for their use.

Laparoscopic radiofrequency fibroid ablation: phase II and phase III results

BACKGROUND AND OBJECTIVES

To review phase II and phase III treatments of symptomatic uterine fibroids (myomas) using laparoscopic radiofrequency volumetric thermal ablation (RFVTA).

METHODS

We performed a retrospective, multicenter clinical analysis of 206 consecutive cases of ultrasound-guided laparoscopic RFVTA of symptomatic myomas conducted on an outpatient basis under two phase II studies at 2 sites (n = 69) and one phase III study at 11 sites (n = 137). Descriptive and exploratory, general trend, and matched-pair analyses were applied.

RESULTS

From baseline to 12 months in the phase II study, the mean transformed symptom severity scores improved from 53.9 to 8.8 (P < .001) (n = 57), health-related quality-of-life scores improved from 48.5 to 92.0 (P < .001) (n = 57), and mean uterine volume decreased from 204.4 cm(3) to 151.4 cm(3) (P = .008) (n = 58). Patients missed a median of 4 days of work (range, 2-10 days). The rate of possible device-related adverse events was 1.4% (1 of 69). In the phase III study, approximately 98% of patients were assessed at 12 months, and their transformed symptom severity scores, health-related quality-of-life scores, mean decrease in uterine volume, and mean menstrual bleeding reduction were also significant. Patients in phase III missed a median of 5 days of work (range, 1-29 days). The rate of periprocedural device-related adverse events was 3.5% (5 of 137). Despite the enrollment requirement for patients in both phases to have completed childbearing, 4 pregnancies occurred within the first year after treatment.

CONCLUSIONS

RFVTA does not require any uterine incisions and provides a uterine-sparing procedure with rapid recovery, significant reduction in uterine size, significant reduction or elimination of myoma symptoms, and significant improvement in quality of life.

Ultrasound-guided radiofrequency ablation of symptomatic uterine fibroids: short-term evaluation of effect of treatment on quality of life and symptom severity

OBJECTIVE

To evaluate the feasibility of ultrasound-guided radiofrequency ablation (USgRFA) for the treatment of women with symptomatic uterine fibroids in relation to volume of fibroid.

METHODS

Forty-three women with symptomatic fibroids underwent USgRFA for treatment of uterine fibroids. Improvements in fibroid symptoms and quality of life were measured by the Uterine Fibroid Symptom and Quality of Life questionnaire scores at baseline and 3, 6 and 9 months after the intervention, and analyzed in relation to baseline fibroid volume. Volume reduction of fibroids was measured and the frequency of adverse events and re-interventions was recorded.

RESULTS

Following USgRFA, mean Symptom Severity Scores (SSS) decreased from 60.7 ± 17.8 to 31.2 ± 19.5, corresponding to an improvement of 48.6%. The total Health-Related Quality of Life (HRQOL) score improved by 46.4% from 55.6 ± 20.9 to 81.4 ± 16.6. There was no correlation between fibroid volume at baseline and improvement in SSS and HRQOL scores. Fibroid volume was reduced in all patients, by a mean of 69.7 ± 19.4%. Two (4.7%) patients underwent hysterectomy. No adverse events occurred.

CONCLUSION

USgRFA reduces fibroid symptom and size even in patients with larger fibroids. USgRFA is a promising new treatment for fibroids in gynecological settings and should be further investigated.

Ultrasound-guided radiofrequency thermal ablation of uterine fibroids: medium-term follow-up

Previous studies have shown that radiofrequency thermal ablation (RFA) of uterine fibroids through a percutaneous ultrasound (US)-guided procedure is an effective and safe minimally invasive treatment, with encouraging short-term results. The aim of this study was to assess the results in terms of volume reduction and clinical symptoms improvement in the midterm follow-up of fibroids with a diameter of up to 8 cm. Eleven premenopausal females affected by symptomatic fibroids underwent percutaneous US-guided RFA. Symptom severity and reduction in volume were evaluated at 1, 3, 6, 9, and 12 months. The mean symptom score (SSS) before the procedure was 50.30 (range 31.8-67.30), and the average quality of life (QOL) score value was 62 (range 37.20-86.00). The mean basal diameter was 5.5 cm (range 4.4-8) and the mean volume was 101.5 cm(3) (range 44.58-278 cm(3)). The mean follow-up was 9 months (range 3-12 months). The mean SSS value at the end of the follow-up was 13.38 (range 0-67.1) and the QOL 90.4 (range 43.8-100). At follow-up the mean diameter was 3.0 cm (range 1.20-4.5 cm), and the mean volume was 18 cm(3) (range 0.90-47.6 cm(3)). In 10 of 11 patients we obtained total or partial regression of symptoms. In one case the clinical manifestations persisted and it was thus considered unsuccessful. In conclusion, US-guided percutaneous RFA is a safe and effective treatment even for fibroids up to 8 cm.

Image-guided thermal therapy of uterine fibroids

Thermal ablation is an established treatment for tumors. The merging of newly developed imaging techniques has allowed precise targeting and real-time thermal mapping. This article provides an overview of the image-guided thermal ablation techniques in the treatment of uterine fibroids. Background on uterine fibroids, including epidemiology, histology, symptoms, imaging findings, and current treatment options, is first outlined. After describing the principle of magnetic resonance thermal imaging, we introduce the applications of image-guided thermal therapies, including laser ablation, radiofrequency ablation, cryotherapy, and in particular, magnetic resonance-guided focused ultrasound surgery, and how they apply to uterine fibroid treatment.

Midterm outcome of radiofrequency thermal ablation for symptomatic uterine myomas

BACKGROUND

Over the past decade an increasing demand for uterine-sparing treatment to manage symptomatic uterine myomas has become apparent in women's health care. A preliminary report showed that radiofrequency ablation (RFA) of uterine fibroids under laparoscopic guidance was a safe and effective minimally invasive approach with encouraging short-term results. The purpose of this study was to evaluate the midterm outcomes of radiofrequency ablation (RFA) of uterine myomas in terms of durability of symptom control and level of health-related quality of life.

METHODS

Consecutive women with symptomatic uterine myomas, no plans for future pregnancy, and who declined hysterectomy were offered RFA ablation of uterine fibroids under laparoscopic guidance. Only 25 patients who completed at least the one-year follow-up assessment were included in the study group. Follow-up evaluations were scheduled at 1, 3, 6, 9, and 12 months and thereafter annually following the procedure. Improvement in myoma-related symptoms and impact on quality of life were assessed using a validated questionnaire (UFS-QOL).

RESULTS

The median number of myomas treated per patient was 1 (range = 1-3). The median baseline volume of the dominant myoma was 76.8 cm3 (range = 14.8-332.8). No intraoperative or postoperative complications occurred. The median follow-up time was 24 months, with nine women completing three years of follow-up. The median reduction in myoma volume was 68.8% and 77.9% at six months and one year, respectively. No further change in fibroid size was observed at two years and three years. One year after the procedure, one woman (4%) underwent hysterectomy for recurrence of fibroid-related symptoms. Quality-of-life measures showed significant and durable improvement compared with baseline.

CONCLUSIONS

RFA of symptomatic fibroids seems a valuable alternative to major surgery, with durable symptom relief for most patients and a low chance of recurrence at midterm.

Percutaneous Image-guided Radiofrequency Thermal Ablation for Large Symptomatic Uterine Leiomyomata after Uterine Artery Embolization: A Feasibility and Safety Study

PURPOSE

To evaluate the feasibility and safety of percutaneous image-guided radiofrequency ablation (RFA) performed with moderate sedation for large symptomatic uterine leiomyomata.

MATERIALS AND METHODS

Women with large (>5 cm in diameter) symptomatic subserosal and/or intramural uterine leiomyoma were recruited for a prospective study. Patients underwent percutaneous RFA following UAE. RFA using 5 cm treatment diameter expandable needle electrodes connected to a 460 kHz monopolar RF generator, which was performed with a target temperature and power set at 85 degrees C and 150 watts respectively, with a target temperature ablation time of 10 minutes. Patients were assessed for complications in perioperative and post-procedure periods at 24 hours and 1 month, and for symptom improvements at 6 months.

RESULTS

Thirty-five patients (mean 43.8 years +/- 6.2) were recruited. RFA targeting ablation size and temperature was achieved in 97% of the patients (34/35). There were no immediate percutaneous RFA-related complications. There was a self-limiting delayed drainage via the transabdominal RFA access track in one patient (2.9%), a urinary tract infection in one patient (2.9%) and post-embolization/post-ablation symptoms in three patients (8.6%). The mean transformed symptom severity score (SSS) as a part of the uterine fibroid symptom and quality of life (UFS-QOL) assessment shows that the improvements at 1 month were 24.3 points ( P < 0.001) and at 6 months were 40.4 points ( P < 0.001). Mean volume reduction of leiomyomata was 286.8 cm(3) or 56.5% ( P = 0.0015).

CONCLUSIONS

Percutaneous image-guided RFA as adjunctive to UAE under moderate sedation is feasible, and appears safe without significant morbidity in the treatment of large uterine leiomyomata.

New Treatments for Uterine Fibroids

Since the introduction of uterine artery embolization as a minimally invasive treatment option for uterine fibroids, there has been a great deal of effort made toward developing other options for these patients. These options approach the problem differently, either with direct targeting of individual fibroids, organ-wide targeting of multiple fibroids, and systemic therapy to address the problem of fibroids using a hormonal approach. This review will focus on the different techniques and different philosophies that have been applied to the treatment of fibroids during the past decade.