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OB-GYN and specialist in minimally invasive gynecology surgery Farinaz Seifi, MD, FACOG, Vice Chair of Gynecology and Gynecology Subspecialties and Associate Professor of Medicine at University of Maryland School of Medicine, delivers a grand rounds presentation focusing on fibroids. Dr. Seifi discusses various treatment options for fibroids, including alternative options to hysterectomy. She also shares tips for success in minimally invasive approaches to fibroids.

Overall, the presentation aimed to move providers away from defaulting to hysterectomy in cases of symptomatic fibroids. “To optimize fibroid treatment, treatment options should be individualized,” Dr. Seifi said. “As physicians are moving to a shared decision-making model, patients should be presented with all their options.”

About uterine fibroids

A fibroid is a benign solid pelvic tumor. The incidence of fibroids is very high, affecting up to 80% of African American women and 70% of white women by age 50. One in three women with fibroids have symptoms that affect their lives, including heavy menstrual bleeding, pelvic pain and pressure, recurrent pregnancy loss, urinary and bowel symptoms, and back pain. Fibroids tend to recur – according to one study, 53 % reoccur in five years (reoperation rate 7%), and 84 % recurrent rate after eight years (reoperation rate 16%).

The most common treatment for uterine fibroids that are causing symptoms is hysterectomy, if a woman’s childbearing is complete. As a result, 70% of women with symptomatic fibroids undergo hysterectomy, and of those, 38% are not given any other options to consider.

Myomectomy is performed 12.5% of the time. It is a more challenging procedure, with higher rates of intraoperative bleeding when compared to hysterectomy. But there are a range of new approaches and minimally invasive techniques for the treatment of fibroids. 

Minimally invasive options present compelling alternatives to hysterectomy

There are various minimally invasive treatment options for fibroids. They include: 

Hysteroscopic myomectomy – a quick procedure (30-40 minutes) appropriate for type 0-2 fibroid

Robotic or laparoscopic myomectomy – advantages include shorter recovery time, fewer complications, and less bleeding with same day discharge home. 

  • Providers should consider size, number, and location of fibroids when evaluating a patient’s eligibility for a robotic approach and obtain the proper imaging such as MRI prior to robotic myomectomy 

Abdominal myomectomy – enables the surgeon to have tactile feedback, but it has a higher complication rate and a longer recovery

VNOTES – is a method of laparoscopy through the vagina, which requires no abdominal incision and can be used for myomectomy in patients who want the best cosmetic result

Radiofrequency ablation – performed laparoscopically or vaginally, ablating the fibroid to shrink its size, patients are able to return to wok in 5 days 

Providers and patients should make a decision together about which technique is right for the patient. Factors to consider include efficacy, recovery time, quality of life after the procedure, the procedure’s reintervention rate, and the potential impact on future fertility or pregnancy.

Optimizing patient outcomes in minimally invasive myomectomy

Dr. Seifi advises providers to take steps to set their patients up for success after minimally invasive myomectomy:

  • Preoperative iron infusion can increase hemoglobin levels, improve healing, and reduce reoperation and bleeding risks.
  • Preoperative uterine artery embolization can shrink fibroids before surgery.
  • Temporary ligation of uterine and uterine variant vessels can minimize blood loss during myomectomy.
  • Tranexamic acid (TXA) intraoperatively to control bleeding
  • Vasopressin

The presentation included a video case study covering the use of bulldog clamps to reduce blood loss in a minimally invasive myomectomy. The advantages include easy application and removal, although a 11mm laparoscopic port is required to use bulldog clamps. A posterior approach helps isolate the uterine artery, and double ligation of arteries may also help reduce blood loss.

Radiofrequency ablation (RFA) of fibroids: a promising approach 

New in the last 5 years, RFA has significant advantages for fibroid treatment. The technique uses controlled, monopolar radiofrequency energy, paired with visualization of the area using 3D ultrasound. It can be performed laparoscopically or vaginally. 

RFA is designed to spare healthy tissue and target the fibroid only, and it does not require laparoscopic suturing. It is recommended for type 2 to 6 fibroid and can result in an up to 50% reduction in the fibroid size at one year. It is important to note, however, that RFA should not be offered to patients who want to get pregnant in the future.

Research shows that RFA is associated with improved health-related quality of life. Dr. Seifi presented a meta-analysis of 32 peer-reviewed articles documenting RFA’s results. The average time to normal activities after RFA was just over 5 days. Fibroid volume decreased by 66% after 12 months, on average, and quality of life improved significantly. Reintervention rates were 4.2%, 8.2%, and 11.5% through 3 years. 

Dr. Seifi also reviewed two studies comparing laparoscopic myomectomy with RFA. The first study showed RFA had a shorter surgery time and faster return to work, and after 12 months, equivalent quality of life results. The other study showed quality of life results at 2 years were the same as laparoscopic myomectomy.

There are also treatment options outside OB-GYN, such as uterine artery embolization or MRI-guided focused ultrasound. Dr. Seifi noted that it’s important for different disciplines to collaborate in a multidisciplinary effort. This enables the team to offer the full range of options to patients.

View Dr. Seifi's full grand rounds presentation

 

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