COMMENTARY

Fibroids: Which Uterine-Sparing Approach Is Best?

 Peter Kovacs, MD, PhD

Disclosures

August 29, 2018

Uterine Fibroids

Fibroids are benign uterine tumors of smooth-muscle origin. Solitary or multiple, uterine fibroids can be asymptomatic or associated with symptoms, which depend on fibroid size and location. Fibroids that remain mostly in the myometrium or grow toward the outside are usually associated with bulk-related symptoms (eg, pelvic pressure, heaviness, or discomfort; abdominal bloating). Those that grow toward the uterine cavity are mainly detected when evaluation is done for bleeding anomalies.[1]

Medical, radiologic, and surgical treatments are used in the management of uterine fibroids.[2,3,4] Surgical treatments are either definitive and involve the removal of the entire uterus, or are uterine-sparing and involve the removal of the myomas only. Uterine-sparing procedures are considered primarily for women who wish to maintain fertility.

Radiologic interventions, such as uterine artery embolization (UAE), radiofrequency ablation (RFA), cryoablation, and high-intensity focused ultrasound (HIFU), may be attractive because they are noninvasive or minimally invasive. Conservative treatment approaches are associated with recurrence risk, but we lack data on the relative risks associated with different uterine-sparing approaches.

Management Approach and Reintervention Risk

A recent systematic review and meta-analysis[5] compared the reintervention risk for recurrence and quality-of-life outcomes with the various uterine-sparing approaches. Sandberg and colleagues[5] analyzed data from 85 randomized controlled trials or cohort studies.

Outcomes included reintervention risk and/or quality of life using abdominal (myomectomy, UAE, HIFU, laparoscopic artery ligation, laparoscopic RFA, or cryoablation) or hysteroscopic (myomectomy, hysteroscopic RFA) uterine-sparing treatments for fibroids. The analysis included 17,789 women who underwent a total of 15,348 abdominal and 1912 hysteroscopic procedures.

The reintervention risk at 12 months was lowest with abdominal RFA (0.3%) and highest with HIFU (11.1%). The risk was 1.1% with abdominal RFA, 6.6% with hysteroscopic myomectomy, and 3.6% with UAE. At 60 months, rates of reintervention were calculated for abdominal myomectomy (12.2%), UAE (14.4%), HIFU (53.9%), and hysteroscopic myomectomy (7%).

At 12 months, 0.8% of women who had been managed initially with a uterine-sparing procedure subsequently were required to undergo hysterectomy. The hysterectomy rate was 1.1% after hysteroscopic myomectomy. By 60 months, the hysterectomy rate was 7% in the abdominal myomectomy group, 9.8% in the UAE group, and 22.2% in the HIFU group.

Symptom severity significantly improved in all treatment groups (by an average of 35%-37%). The improvement was lowest in the HIFU group (24.5%). Health-related quality of life improved by 36% on average. The smallest improvement (24.6%) was with HIFU.

This review found that the reintervention risk after most uterine-sparing procedures for fibroids (even after 5 years of follow-up) was relatively low, and both symptom severity and quality of life improved. Reintervention risk was significantly higher after HIFU, which was associated with the least improvement in symptom severity or quality of life.

Viewpoint

The definitive treatment for fibroids involves the removal of the uterus. Hysterectomy can be accomplished through the abdominal (open surgery versus laparoscopy) or vaginal route. Women who wish to maintain their fertility, however, should be managed with a uterine-sparing approach. We have the most experience with the surgical methods, but they are also the most invasive and associated with the most risks.

The main limitation of the systematic review is the possibility that patient characteristics influenced treatment decisions. Women at the highest risk for reintervention may be more likely to managed initially with a noninvasive technique. Regardless of this limitation, this is still the largest and most complete meta-analysis comparing reintervention risk and quality-of-life outcomes with the different uterine-sparing treatments for uterine fibroids. Clinicians may use these findings when counseling women on treatment options.

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