Expulsion of Fibroids to the Endometrial Cavity after Magnetic Resonance Imaging-guided High Intensity Focused Ultrasound Surgery (MRgFUS) Treatment of Intramural Uterine Fibroids

Delayed expulsion of a large fibroid after transcervical radiofrequency ablation: A case report

Fibroids are the most common type of benign uterine tumor, which occur up to 68.6% of women. Hypermenorrhea is the most common symptom with a general prevalence of 40%-54%, followed by dysmenorrhea and low abdominal pain. Transcervical fibroids ablation was developed as a minimally invasive, incisionless treatment of fibroids in a short time. This method is safe and effective with an excellent record of safety. We present the case of a 40-year-old woman, who attended in our fibroid excellence center. She reported severe hypermenorrhea and dysmenorrhea. Family planning was definitely completed. Using vaginal ultrasonography a FIGO 2-5 fibroid of 5 cm in diameter was detected. Different treatment options were discussed: medical treatment, laparoscopic fibroidectomy, hysterectomy, and transcervical radiofrequency ablation with Sonata System. Because of advantages of transcervical radiofrequency ablation (minimal invasive treatment without incision, effectivity of method, short surgical time) the patient decided on this method. Three months later, the patient came to the first follow up. She reported a significant improvement of hypermenorrhea. A vaginal ultrasonography was carried out. The fibroid changed its position from FIGO 2-5 to FIGO 2. The patient was very satisfied with the result. After 2 months, she attended in our department again because of severe clear vaginal discharge. She had no bleeding, no pain as well as no fever. We examined her immediately. A fibroid expulsion was detected. The fibroid was removed vaginally. There was no severe bleeding during the operation and the fibroid could be removed completely. The surgery time was 25 minutes.

A Retrospective Analysis of the Treatment of Cesarean Scar Pregnancy by High-Intensity Focused Ultrasound, Uterine Artery Embolization and Surgery

Objective: This study aims to retrospectively analyze the clinical curative effects of surgery, uterine artery embolization (UAE), and high-intensity focused ultrasound (HIFU) in order to provide the theory and evidences for selecting the optimal treatment for cesarean scar pregnancy (CSP).

Methods: Women with CSP were treated with surgery (laparoscopic, hysteroscopy, and hysteroscopy–laparoscopic surgery), UAE combined with curettage, and HIFU combined with curettage. The general conditions and therapeutic effects, including vital signs during the operation, discomfort of discharge, cure rate, total blood loss, decline in the rate of hCG, and hospital stay, were compared and analyzed.

Results: For the 154 CSP patients, the cure rate of surgery (n = 95) was 97.89%, the cure rate of UAE (n = 32) was 43.74%, and the cure rate of HIFU (n = 27) was 70.37%. The difference was statistically significant (P < 0.05). Furthermore, the hCG level of surgical patients quickly declined, whereas HIFU slowly declined. The difference between the decline rate of hCG and mean hospitalization time was statistically significant (P < 0.05). UAE was good for CSP with gestational age <60 days and diameter of gestational sac <40 mm. Furthermore, HIFU was well for CSP patients with a gestational age of <55 days and a gestational sac diameter of <30 mm. Surgery was suitable for any type of these cases.

Conclusion: CSP patients with short gestational age and small gestational sac can be treated with surgery, UAE, and HIFU, and achieve safe and effective therapeutic effects. Surgery is also a good choice for CSP for patients with a long gestational age, a large gestational sac diameter, high levels of hCG, or an ample blood supply.

Gonadotropin-releasing Hormone Agonist Plus Aromatase Inhibitor in the Treatment of Uterine Leiomyoma in Near Menopause Patient: A Case Series Study

Objectives

There are many drugs for of symptomatic fibroids. Gonadotropin-releasing hormone (GnRH) agonists are the well known drugs. Also, aromatase inhibitors are effective. All published studies surveyed the effect of one of these two drugs. In this study as the first study decided to evaluate the effectiveness of the combination of GnRH agonists + aromatise inhibitor on the uterine fibroids.

Methods

A cross-sectional prospective case series study was performed on 10 known cases of uterine fibroids late perimenopause, at least 3 myomas >5 cm, abnormal uterine bleeding and anemia due to fibroids, candidate for hysterectomy, no tendency to surgery. A single dose of Diphereline 11.25 mg, SR plus 2.5 mg of Letrozole daily for 4 weeks with add-back therapy + calcium carbonate were used. The second dose of Diphereline 11.25 mg, SR was used 3 months after the first injection. The patients were followed until 3 years.

Results

The mean age of the study group was 49.90 ± 1.66. The mean fibroid size reduced from 15.05 ± 57.20 cm to 13.56 ± 39.39 cm (P = 0.012) and fibroid volume reduced from 72.78 ± 110.6 to 50.96 ± 64.2 (P = 0.116). There was no signification changes in the serum level of hormones at the end of six months. Eight cases were menopause at the end of the study and hypoestrogenism symptoms did not happened in none of the cases until the end of 24 months. Except in one case, there was no need to do surgery on others.

Conclusions

Combination of Diphereline + Letrozole probably could prevent surgery in cases that have multiple fibroids, perimenopause, anemic and candidate for surgery.

Outcome of magnetic resonance-Guided focused ultrasound surgery (MRgFUS) for FIGO class 1 fibroids

OBJECTIVE

Intracavitary uterine fibroids and fibroids that distort the uterine cavity are associated with excessive vaginal bleeding and infertility. While intracavitary fibroids smaller than 4 cm are usually treated safely by operative hysteroscopy, larger fibroids may require multiple surgeries or more extensive surgery with possible damage to the integrity of the uterine wall. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive approach for treating uterine fibroids, mainly the intramural type. We present the outcome of MRgFUS treatment for intracavitary fibroids (FIGO class 1) in cases that could not be treated by hysteroscopy due to either fibroid size or patient refusal. (Canadian Task Force II-1).

STUDY DESIGN

A retrospective cohort study from a single tertiary referral center. A total of 68 patients were treated by MRgFUS for symptomatic uterine fibroids from January 2013 to December 2016. Six of them had FIGO class 1 fibroids. Adverse effects and short- and long-term outcomes (quality of life issues and need for additional surgical intervention) were assessed during ambulatory clinic visits and by phone interviews.

RESULTS

The mean ± SD fibroid volume on MRI screening was 86.3 ± 60.9 cm³. Six of those patients underwent the procedure (mean age 40.5 ± 5.6 years, range 33-48). The follow-up duration was 24.1 ± 12.0 months. Four patients were not interested in future fertility and did not undergo additional treatment, while the two who planned to conceive underwent another surgical intervention (one underwent operative hysteroscopy after reduction of fibroid size and the other underwent laparoscopic myomectomy).

CONCLUSION

This preliminary study shows that MRgFUS can be a feasible treatment option for FIGO class 1 uterine fibroids. Shrinkage of fibroids by MRgFUS can obviate or facilitate subsequent surgical intervention in selected cases.