I-46: Radiofrequency Ablation of Uterine Fibroids

Uterine fibroids are benign solid tumors that are present in the majority of women. While often asymptomatic, fibroids can result in abnormal uterine bleeding, pelvic pressure, pain, subfertility, dyspareunia and other symptoms. Submucous and intramural fibroids are most associated with heavy menstrual bleeding; subserosal fibroids are more often innocuous unless sufficiently large so as to contribute to bulk symptoms. Many fibroids contain elements of more than one fibroid type; that is, fibroids may have submucous and subserosal components and may be transmural. Fibroids are the most common benign female reproductive system tumor and remain the leading benign indication for hysterectomy in many developed country. Classic treatment options for symptomatic fibroids include hysterectomy and myomectomy. More recently, uterine artery embolization (UAE) has been demonstrated to be safe and effective, but the impact of this treatment modality upon fertility remains to be determined. Despite the availability of suitable management choices for fibroids, there remain unmet needs. Hysterectomy does not preserve the uterus and fertility, and represents major surgery with the risk of significant complications. Uterine artery embolization is not currently recommended for women who desire future fertility, and fibroid recurrence is a possibility, with approximately 20% of patients subsequently requiring hysterectomy. Myomectomy, which may be performed via laparotomy, laparoscopy, hysteroscopy or occasionally the vaginal route, preserves the uterus and fertility, but like UAE is not definitive therapy for many women. There has been considerable interest in the use of various forms of energy to heat and ablate uterine fibroids, including radiofrequency energy, focused ultrasound and microwaves. Unlike uterine artery embolization, which results in tissue infarction with disruption of cell membranes and spillage of intracellular contents, hyperthermic ablation results in thermal fixation, which preserves cellular architecture, as well as coagulative necrosis Radiofrequency ablation (RFA) has been extensively researched as a treatment option for uterine fibroids. Medical devices utilizing radiofrequency energy are widely available and familiar to physicians. There is an established history of treating hepatocellular carcinomata and other soft tissue malignancies with radiofrequency ablation. In the case of uterine fibroids, the presence of coagulative necrosis after treatment with RF energy can result in volume reduction of the myoma and symptomatic relief The use of radiofrequency energy has a demonstrable ability to successfully and safely ablate a range of fibroid volumes. Earlier management with RF ablation has been limited by the lack of concurrent imaging and the need for multiple fibroid punctures resulting in serosal injury, adhesions and potential myometrial disruption during pregnancy. More recent volumetric techniques, in concert with sonography, minimize the need for multiple punctures through fibroids; in the case of transcervical or transvaginal RF ablation, the serosa is entirely avoided Hyperthermic fibroid ablation results in thermal fixation and coagulative necrosis within the fibroid. When a sufficient percentage of a fibroid has been ablated, a reduction in fibroid volume and associated symptoms can be realized. Such symptomatic relief 11 appears to be durable, but additional, longer studies are required to more fully ascertain the reintervention rate after RF ablation of uterine fibroids. The emerging clinical literature base indicates that patients will reliably experience significant reductions in fibroid volumes and symptoms as a result of radiofrequency ablation.