However women need to be made aware about the high rates of further intervention required following the procedure.
MRgFUS MRgFUS scanning to locate the fibroid and focus high intensity ultrasound beams on to a point within the fibroid results in tissue heating and subsequent necrosis. Its advantages are that it is low cost, non-invasive and requires no general anaesthesia or hospitalisation. Because it is an ambulatory procedure, recovery time is approximately one to two days. Large or multiple fibroids and pedunculated fibroids are considered relative contraindications to this treatment. The presence of bowel loops or abdominal wall scars in the projected pathway of the ultrasound beam may preclude use of the technique. Common symptoms during the procedure are lower abdominal pain, leg pain and buttock pain. The main drawback of the technique is high rates of further surgical or radiological interventions required.
There have been a number of reports of pregnancies following MRgFUS with reassuring pregnancy outcomes; however, further evidence is needed before recommending the procedure to women planning to conceive.
Evidence A pilot, randomised, placebo-controlled trial evaluated the feasibility of a full-scale placebocontrolled trial of magnetic resonance-guided focused ultrasound for fibroids in premenopausal women with symptomatic uterine fibroids. 7 Twenty women with a mean age of 44 years(± standard deviation 5.4 years) were enrolled, and 13 were randomly assigned to MRgFUS and seven to placebo. Four weeks after treatment, all participants reported improvement in the uterine fibroid symptoms and health-related quality of life score( UFS-QOL): a mean of 10 points in the MRgFUS group and 9 points in the placebo group( for difference in change between groups). By 12 weeks, the MRgFUS group had improved more than the placebo group( mean 31 points and 13 points, respectively). The mean fibroid volume decreased 18 % in the MRgFUS group with no decrease in the placebo group at 12 weeks. Two years after MRgFUS, 4 of 12 women who had a follow-up evaluation( 30 %) had undergone another fibroid surgery or procedure. 7
A study compared the long-term outcomes after UAE versus MRgFUS for symptomatic uterine fibroids. 8 Seventy-seven women( median age, 39.3 years; range, 29.2 – 52.2 years) with symptomatic uterine fibroids, equally eligible for UAE and MR-g high-intensity focused ultrasound underwent treatment( UAE, n = 41; MRgFUS, n = 36) from 2002 to 2009. Re-intervention was significantly lower after UAE( 12.2 %) than after MRgFUS( 66.7 %) at long-term follow-up( p < 0.001). Improvements in symptom severity and quality of life scores was significantly better after UAE resulting in a significant lower re-intervention rate compared to MRgFUS. 8
Another study of 119 women comparing outcomes of treatment between volumetric MRgFUS and UAE for uterine fibroids. 9 Both procedures resulted in significant symptom relief and quality of life improvement. UAE had a stronger positive effect on the clinical outcomes. Re-intervention rate after MRgFUS was significantly higher than after UAE. 9
Other minimally invasive techniques Ultrasound-guided high-intensity focused ultrasound ablation is a new non-invasive treatment of uterine fibroids. The technique allows a check on the immediate efficacy of the procedure and if viable residual tissue is detected, there is the option to repeat the ablation immediately. 3 Transcervical intrauterine sonography with radiofrequency ablation of the fibroids is yet another novel approach being investigated. A graphical interface delineates the boundaries of ablation and thermal spread so that thermal injury to the serosa as well as adhesions and injury to bowel or bladder can be minimised. A recent study looked into the effectiveness in day clinics of microwave endometrial ablation( MEA) on transcervical microwave myolysis for patients with menorrhagia caused by submucosal fibroids. 10 Thirty-five outpatients( average age 44.8 ± 5.2 years( mean ± SD), range 34 – 58) with a single submucosal fibroid that was 4 – 7cm( 5.5 ± 2.1cm) in size underwent MEA with transcervical microwave myolysis using a specifically developed transabdominal ultrasound probe attachment for transcervical puncture. The mean operation time was 27.9 ± 13.6 min. The fibroids had shrunk by 56.2 % at three months and 73.8 % at ≥six months after the operation. Blood haemoglobin levels had increased significantly at three months( 10.2 ± 2.0 vs. 12.7 ± 1.2; p < 0.001). 10 Further clinical trials are needed to better define the role and limitations of these techniques for treatment of symptomatic uterine fibroids.
Conclusions Many uterine fibroids are asymptomatic and require no intervention. While myomectomy and hysterectomy have been the traditional definitive treatments for symptomatic uterine fibroids, not all women wish to have a surgery and many would like to retain their uterus. Non-surgical treatment options for symptomatic fibroids include pharmacologic as well as radiologically guided interventions. Radiologically guided procedures such as UAE and ablation by highintensity focused ultrasound are newer treatment modalities that should be tailored to women’ s age, general health, fibroid size / symptoms, fertility and their individual wishes.
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