Ultrasound-Guided Transcervical Ablation of Uterine Leiomyomas

The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties

Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.

Transcervical Fibroid Ablation (TFA): Update on Pregnancy Outcomes

Background/Objectives: Transcervical fibroid ablation (TFA) is an incisionless method to treat symptomatic uterine fibroids. While safety regarding future pregnancy remains to be established, TFA does not preclude the possibility of pregnancy, and a previous 36-patient case series of post-TFA pregnancies reported normal outcomes. That prior series did not include postmarket cases in the United States, as the Sonata® System was initially cleared and used in Europe. This is a substantive update of known pregnancies with the Sonata System since June 2011, and includes pregnancies in Europe, Mexico, and the US. Methods: TFA was carried out under both clinical trial and postmarket use to treat symptomatic uterine fibroids. All post-TFA pregnancies reported by physicians with their patient's consent were included. Results: 89 pregnancies and 55 deliveries have occurred among 72 women treated with the Sonata System. This includes 8 women who conceived more than once after TFA. Completed pregnancies (n = 62 women) include 19 vaginal deliveries, 35 Cesarean sections, 5 therapeutic abortions, 1 ectopic pregnancy, and 1 delivery by an unknown route. Ten pregnancies are ongoing. Mean birthweight was 3276.7 ± 587.3 g. Ten women experienced 18 first-trimester spontaneous abortions (SAbs), with 10 of the 18 SAbs (55.6%) occurring between two patients with a history of recurrent abortion. The SAb rate was 22.8%, inclusive of these two patients, and 10.1% if they were excluded as outliers. There were no instances of uterine rupture, placenta accreta spectrum, or stillbirth. Conclusions: This case series, the largest to date for any hyperthermic ablation modality, suggests that TFA with the Sonata System could be a feasible, safe treatment option regarding eventual pregnancy in women with symptomatic uterine fibroids.

[Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroid: A retrospective study]

OBJECTIVE

To assess clinical and radiological efficacy and safety of laparoscopic ultrasound-guided radiofrequency ablation of uterine leiomyomas.

MATERIAL AND METHODS

Thirty-three patients with symptomatic uterine leiomyomas FIGO type 2 to 7, have undergone a laparoscopic ultrasound-guided radiofrequency ablation at Croix Rousse University Hospital Center (Hospices civils de Lyon) and at Saint-Vincent de Paul Hospital in Lille, between June 2020 and December 2022. The characteristics of each myoma and the symptoms were assessed with pelvic MRI and with Higham score, SSS and HRQL scores preoperatively and at 6 months.

RESULTS

A total of 54 fibroids have been treated in 33 patients. We observed a significant decrease of the volume 6 months after the surgery, on average 21mL (55.97 vs. 74.37mL, 95% CI [7.13-34.88], P=0.001). The maximum diameter of each fibroid was also significantly reduced on average 11.78mm (41.89 vs. 52.06, 95% CI [8.83-14.73], P<0.05). We noticed a significant decrease of the NRS for dysmenorrhea on average 2.79 points (2.1 vs. 4.89, 95% CI [1.14-4.42], P<0.05). There was also a trend to improvement of menorrhagia, assess by Higham score. Indeed, 70.8% of the patients had menorrhagia. Menorrhagia was improved of 108,3 points with an average Higham score before surgery of 197.3 versus 87.9 after surgery (95% CI [47.9-168.8], P=0.001). Concerning UFS-QOL score: the symptom severity score (SSS) decreased on average 33 points, testifying of symptom improvement (27.04 vs. 60.89, 95% CI [22.92-43.39], P<0.001) and the HRQL score increased on average 20 points testifying quality of life improvement (65.57 vs. 42.7, 95% CI [15.83-37.85]. P<0.001). No severe adverse event has been reported.

CONCLUSION

In this first French study about radiofrequency ablation. We confirm its efficiency for improvement of symptoms and quality of life but other study is mandatory to confirm the safety of this procedure in particular in patients with a wish to conceive.

The impact of fibroid treatments on quality of life and mental health: a systematic review

Fibroids significantly impact the quality of life (QOL) and mental health of affected women. However, there are limited comparative data on QOL measures after medical, surgical, and radiologic interventions in women with fibroids. This study aimed to assess the current literature evaluating the impact of fibroids on QOL measures using several validated questionnaires for radiologic, medical, or surgical interventions or a combination of interventions before and after treatment. PubMed, PsycINFO, ClinicalTrials.gov, Embase, and Cochrane Library were searched from January 1990 to October 2023 to evaluate the available evidence, and the risk of bias was assessed using Cochrane RoB 2.0 or the Newcastle-Ottawa Scale. The review criteria included randomized controlled trials (RCTs) and observational cohort studies that included premenopausal women with symptomatic uterine fibroids, confirmed by imaging, who underwent an intervention to target fibroid disease. Only reports using validated questionnaires with a numerical baseline (pretreatment) and posttreatment scores were included. The exclusion criteria included perimenopausal or postmenopausal patients, conditions in addition to uterine fibroids that share similar symptoms, or studies that did not focus on QOL assessment. Abstracts were screened, and full texts were reviewed to determine whether studies met the inclusion criteria. A total of 67 studies were included after final review: 18 RCTs and 49 observational studies. All interventions were associated with a significant improvement in uterine fibroid-specific QOL measures, mental health metrics, and a reduction in symptom severity scores after treatment. These data reveal a substantial impact of uterine fibroids on the QOL and mental health of women with fibroids and indicate the metrics that can be used to compare the effectiveness of fibroid treatment options.

E. faecalis Sepsis and Asherman's Syndrome as Complications of Sonata System Transcervical Fibroid Ablation

The Sonata System is a minimally invasive, ultrasound-guided transcervical fibroid ablation procedure for the management of symptomatic uterine fibroids. Since its approval by the US Food and Drug Administration in 2018, this procedure has demonstrated an excellent safety profile and postprocedure satisfaction rate. We present the case of a patient treated with Sonata, who subsequently developed bacterial sepsis and Asherman's syndrome-serious complications with long-term sequelae and implications for fertility. A nulligravid woman in her 40s presented in the outpatient setting with dysmenorrhea and bulk symptoms, with imaging showing an enlarged myomatous uterus compressing the urinary bladder. She desired minimally invasive, fertility-preserving management and underwent the Sonata procedure at an outside hospital. On postoperative day 3, she was admitted to our institution with abdominal pain, fever, tachycardia, and Enterococcus faecalis bacteremia. Despite 6 days of culture-directed antibiotic therapy, the patient remained septic with worsening symptoms and imaging findings and with persistent bacteremia. On hospital day 7, the patient underwent laparoscopic myomectomy and excision of hemorrhagic, infected myometrium. She recovered appropriately after surgery and was discharged home on hospital day 11 to continue 2 weeks of intravenous antibiotics. Nine months after myomectomy, the patient was diagnosed as having Asherman's syndrome. She subsequently had an early pregnancy loss with retained products of conception, requiring hysteroscopic lysis of adhesions and dilation and curettage. Ultimately, careful patient selection is critical for the optimal application of the Sonata procedure. Limiting the extent of fibroid necrosis after treatment is a reasonable goal to minimize the risk of secondary bacterial infection and adhesiogenesis as procedural sequelae.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Updates on the Surgical Approach to Fibroids: The Importance of Radiofrequency Ablation

Uterine fibroids are the most common benign neoplasm of the female pelvis and have a lifetime prevalence exceeding 80% among African American women and approaching 70% among Caucasian women. Approximately 50% of women with fibroids experience symptoms which can range from heavy menstrual bleeding and bulk-related symptoms such as pelvic pressure with bladder and bowel dysfunction to reproductive dysfunction (e.g., infertility or obstetric complications) and pain. The choice of treatment is primarily guided by the type of symptoms in the individual patient and whether they prefer to retain fertility. While hysterectomy provides definitive resolution of fibroid symptoms and remains the most common treatment option, this procedure is invasive with a long recovery window. Radiofrequency ablation (RFA) is now emerging as a uterine preserving and minimally invasive therapy for symptomatic fibroids. Since its introduction, growing evidence for safety and efficacy of RFA has been generated with low rates of complications. This review will discuss RFA for the management of symptomatic uterine fibroids with a special focus on technical approaches, short- and long-term outcomes including fertility outcomes.

Radiofrequency Ablation of Leiomyomas

Radiofrequency ablation (RFA) of leiomyomas represents a significant advancement in the treatment of this common uterine condition. In the appropriately selected patient, both laparoscopic and transcervical options provide effective treatment for bleeding and bulk symptoms in a uterine-sparing manner. Compared with other minimally invasive leiomyoma treatment options, RFA procedures have comparable or favorable safety profiles, recovery timelines, and reintervention rates. Data on future fertility and pregnancy are limited, although early reports are promising.

Transcervical radiofrequency ablation of focal adenomyosis: pilot results

Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. There are two main types of adenomyosis: diffuse and focal. Previously, adenomyosis was diagnosed only upon histopathological examination after hysterectomy and/or adenomyomectomy. However, the development of imagining techniques such as transvaginal ultrasound and magnetic resonance imaging enables the diagnosis of adenomyosis (diffuse and focal) without any surgical intervention. When medical therapy is contraindicated or ineffective, or if patients have a fertility desire, a surgical treatment may be necessary.Methods: In this study, a total of 13 patients with 16 areas of focal adenomyosis were treated. All patients provided their informed consent to undergo transcervical adenomyosis ablation treatment with the Sonata System, aware that the safety and effectiveness of transcervical radiofrequency (RF) ablation for the treatment of adenomyosis has not been established. Follow-up was performed six months after Sonata treatment.Results: The positive results relating to the improvement of symptoms and reduction of adenomyosis lesion size were observed in our study.Conclusion: Transcervical RF ablation with the Sonata System may be a promising therapeutic alternative method to conventional procedures such as hysterectomy for the treatment of focal adenomyosis, disease which has limited therapeutic approach, and may enable a minimally invasive, uterine preserving option.

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.

Radiofrequency ablation methods for uterine sparing fibroid treatment

PURPOSE OF REVIEW

This article provides a clinical review of radiofrequency ablation (RFA) for the treatment of uterine leiomyomas.

RECENT FINDINGS

RFA is an effective and durable treatment for fibroids with sustained improvements in fibroid volume, bleeding, and patient reported outcomes with low reintervention rates. Although fertility data is limited, it is overall positive and may represent a uterine conserving and fertility preserving treatment modality.

SUMMARY

RFA is a safe and effective uterine preserving treatment option for symptomatic leiomyomas.

Durable Improvement in Generic and Fibroid-Specific Quality of Life in Women Treated with Transcervical Fibroid Ablation with the Sonata System After Three Years

Objective:

To determine quality-adjusted life years (QALYs) over 3 years after transcervical fibroid ablation (TFA) with the Sonata System.

Methods:

The SONATA trial was a prospective multicenter interventional trial that assessed the safety and efficacy of TFA for treatment of women with symptomatic uterine fibroids. Change in generic health status was assessed with the EuroQol 5-Dimension questionnaire (0–1 scale). Fibroid-specific quality of life (QOL) was measured on a 0 to 100 scale with the health-related quality of life subscale of the Uterine Fibroid Symptom and Quality-of-Life (UFS-QOL). The number of QALYs gained relative to baseline and cumulative QALYs were calculated using the area under the curve at each follow-up visit over 3 years.

Results:

Among 147 women receiving TFA, fibroid-specific QOL increased from 40 ± 21 at baseline to 84 ± 19 at 1 year and 83 ± 23 at 3 years (p < 0.001). Generic QOL increased from 0.72 ± 0.21 at baseline to 0.89 ± 0.12 at 1 year and 0.88 ± 0.16 at 3 years (p < 0.001). Over 3 years, TFA resulted in 1.24 ± 0.64 QALYs gained when using fibroid-specific health utility scores and 0.49 ± 0.61 QALYs gained when using generic health utility scores. Cumulative QALYs experienced at 3 years as a percentage of perfect health were 82% with fibroid-specific scores and 88% with generic health scores.

Conclusions:

Women treated by TFA with the Sonata System for symptomatic uterine fibroids reported durable improvements in generic and fibroid-specific QOL, as well as clinically meaningful increases in QALYs over 3 years. Clinical Trials.gov ID: NCT02228174. (J GYNECOL SURG 38:143)

The significance of transcervical ultrasound-guided radiofrequency ablation in the treatment of symptomatic fibroids: results of an expert consensus from German-speaking countries

Uterine fibroids are one of the most common diseases in female patients, lead mainly to bleeding disorders and lower abdominal pain, and reduce the chance of having children. In recent years we have seen a trend towards more and more pharmacotherapies and minimally invasive organ-preserving treatments. One novel and innovative procedure for an organ-preserving treatment of symptomatic uterine fibroids is the transcervical ultrasound-guided radiofrequency ablation (TRFA). TRFA has been used in Germany since 2013 and later found use in other German-speaking countries as well. There have now been more than 1200 TRFA treatments performed in Germany, Austria, and Switzerland. Experts from these three countries came together for a consensus meeting to analyze the significance of the procedure in the overall concept of the treatment of symptomatic uterine fibroids.

Radiofrequency Ablation of Uterine Fibroids and Pregnancy Outcomes: An Updated Review of the Literature

OBJECTIVE

To provide a systematic review of pregnancy outcomes after radiofrequency ablation of uterine fibroids.

DATA SOURCES

A literature search was conducted using PubMed, Cochrane Library, Scopus, Web of Science, and EMBASE, from database inception until October 2021.

METHODS OF STUDY SELECTION

Two reviewers conducted independent literature searches. Studies that met criteria based on title and abstract underwent full text review. Publications were included if they reported pregnancies and obstetric outcomes after laparoscopic or transcervical radiofrequency ablation (RFA) of fibroids.

TABULATION, INTEGRATION, AND RESULTS

405 publications were initially identified and screened, 39 underwent full text review, and 10 publications were ultimately included. There were 50 pregnancies reported among 923 RFA patients: 40 pregnancies after 559 laparoscopic RFAs and 10 pregnancies after 364 transcervical RFAs. The number of patients from these studies actively trying to conceive after RFA is unknown. Among the RFA patients who conceived, the average age at ablation was 37 years old (range 27 to 46 years). The majority of patients had between 1 and 3 fibroids ablated, and fibroid size ranged from less than 2 centimeters to 12.5 centimeters. There were 6 spontaneous abortions (12%) and 44 full-term pregnancies (88%), of which 24 were vaginal deliveries and 20 were cesarean deliveries. There were only 2 complications among 44 deliveries: 1 placenta previa that underwent an uncomplicated cesarean delivery and 1 delayed postpartum hemorrhage with expulsion of a degenerated myoma, with no long-term sequelae. There were no cases of uterine rupture, uterine window, or invasive placentation, and no fetal complications. The spontaneous abortion rate was comparable to the general obstetric population.

CONCLUSION

Almost all pregnancies after radiofrequency ablation of fibroids were full-term deliveries with no maternal or neonatal complications. These findings add to the literature that radiofrequency fibroid ablation may offer a safe and effective alternative to existing treatments for women who desire future fertility.

Transcervical radiofrequency ablation of fibroids that are 5 cm or larger in women with abnormal uterine bleeding

INTRODUCTION

Fibroids are the most common benign uterine tumors. Transcervical radiofrequency ablation with the Sonata® System offers a minimally invasive, incisionfree, organ-preserving therapy, with intraoperative visualization of fibroids using intrauterine ultrasound guidance. To demonstrate the effectiveness of transcervical radiofrequency ablation of fibroids that are 5 cm or larger using the Sonata® System, this retrospective analysis was collected.

METHOD

151 patients have been treated with this method in our department up to the time of this analysis. Only patients with at least one fibroid of ≥5 cm and with bleeding symptoms, who were treated with the Sonata® System were included in this retrospective study. A total of 50 patients were included in the study and 57 fibroids were treated.

RESULTS

A total of 57 fibroids were detected and treated, however FIGO 1 and 2 fibroids (in total three fibroids were excluded). The smallest fibroid was 4 cm and the largest fibroid was 12 cm. A single ablation was performed in 18 cases, two ablation steps in 16 cases, three ablation steps in 13 cases, and more than three ablation steps in three cases. Depending on ablation steps, the shortest ablation time was 3 min 15 s and the longest ablation time was 25 min 6 s, with an average time of 9 min 12 s. 86% of patients reported an improvement of symptoms Conclusion: Thus, the Sonata® System is a simple, minimally invasive, rapid and successful method that shows significant improvement of symptoms even in large myomas from ≥5 cm.

Pregnancy Outcomes After Transcervical Radiofrequency Ablation of Uterine Fibroids with the Sonata System

Objective:

To describe pregnancy outcomes in women who conceived after undergoing transcervical fibroid ablation (TFA) as treatment for symptomatic uterine fibroids.

Materials and Methods:

TFA was used to treat symptomatic uterine fibroids with radiofrequency energy, both under clinical trial protocol and commercial usage in hospitals in Europe, the United Kingdom, Mexico, and the United States. All women who reported pregnancies to their physicians after undergoing TFA with the Sonata^® System and provided consent for use of their data were included.

Results:

There have been 36 pregnancies representing 20 deliveries among 28 women who were treated with TFA. Five women conceived more than once postablation, and four conceived as a result of assisted reproductive technology (ART). Outcomes include 8 vaginal deliveries, 12 Cesarean sections, 3 therapeutic abortions, and 8 first trimester spontaneous abortions (four occurring in a patient with a history of recurrent pregnancy loss and an immunologic disorder). Five women are currently pregnant, two of whom previously delivered after TFA. There were no 5-minute Apgar scores <7, and all neonates weighed >2500 g. All deliveries occurred at ≥37 weeks except for one delivery at 35 6/7 weeks. There were no uterine ruptures or abnormal placentation and no reports of postpartum hemorrhage or stillbirths. Ablated fibroids included transmural, submucous, and intramural myomata up to 7 cm in diameter.

Conclusions:

Normal pregnancy outcomes at term have occurred after TFA with the Sonata System, including in women with recurrent abortion and in those undergoing ART. There were no instances of low Apgar scores, low birthweight, stillbirth, postpartum hemorrhage, or uterine rupture (FAST-EU, NCT01226290; SONATA, NCT02228174; SAGE, NCT03 118037). (J GYNECOL SURG 38:207)

Transcervical microwave ablation in type 2 uterine fibroids via a hysteroscopic approach: analysis of ablation profiles

Type 2 uterine fibroids are challenging to resect surgically as ≥ 50% volume of myoma lies within the myometrium. A hysteroscopic approach for ablating fibroids is minimally-invasive, but places a considerable burden on the operator to accurately place the ablation applicator within the target. We investigated the sensitivity of transcervical microwave ablation outcome with respect to position of the ablation applicator within 1 - 3 cm type 2 fibroids.Methods:A finite element computer model was developed to simulate 5.8 GHz microwave ablation of fibroids and validated with experiments inex vivotissue. The ablation outcome was evaluated with respect to applicator insertion angles (30°, 45°, 60°) , depth and offset from the fibroid center (±2 mm for 3 cm fibroid and ±1 mm for 1 cm fibroid) with 35 W and 15 W applied power for 3 cm and 1 cm fibroids, respectively. Power deposition was stopped when thermal dose of 40 cumulative equivalent minutes at 43 °C (CEM43) was accrued in adjacent myometrium.Results:Within the range of all evaluated insertion angles, depths and offsets, the ablation coverage was less sensitive to variation in angle as compared to depth and offset, and ranged from 34.9 - 83.6% for 3 cm fibroid in 140 - 400 s and 34.1 - 67.9% for 1 cm fibroid in 30 - 50 s of heating duration. Maximum achievable ablation coverage in both fibroid cases reach ∼ 90% if thermal dose is allowed to exceed 40 CEM43 in myometrium.Conclusion:The study demonstrates the technical feasibility of transcervical microwave ablation for fibroid treatment and the relationship between applicator position within the fibroid and fraction of fibroid that can be ablated while limiting thermal dose in adjacent myometrium.

A Systematic Review of the Treatment of Uterine Myomas Using Transcervical Ultrasound-Guided Radiofrequency Ablation with the Sonata System

OBJECTIVE

To evaluate the treatment success, possible side effects, and safety of radiofrequency ablation with the Sonata System.

DATA SOURCES

An electronic literature search in the PubMed and Medline databases was carried out from inception to August 2020.

METHODS OF STUDY SELECTION

The review was performed in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Keywords such as "Sonata," "transcervical ablation," and "uterine myoma" were used to identify all relevant articles independently by both authors. Full-text articles in English that reported at least 1 of the following outcomes were included in the study: reduction in perfused/total myoma volume, effect of treatment on bleeding intensity and myoma-related symptoms, number of surgical reinterventions, adverse events, return to activities of daily life, effects on surrounding tissue, and safety during pregnancy.

TABULATION, INTEGRATION, AND RESULTS

10 studies matching the inclusion criteria were identified and used for further analysis. A reduction in total and perfused myoma volume of 63.2% and 64.5% was achieved. One of the studies showed a 53.8 ± 50.5% (n = 48) reduction in Menstrual Pictogram Score, and another study showed a 51.1 ± 40.9% (n = 142) reduction in Pictorial Blood Loss Assessment Chart at 12 months. 87.2% (n = 190) of the patients reported a clinically meaningful reduction in menstrual blood loss after 12 months. While Symptom Severity Scores dropped by 28.8 ± 19.3, 23.3 ± 23.7, and 23.7 ± 19.4 points at 3, 6, and 12 months, respectively, Health-Related Quality of Life Scores increased to 77.5 ± 22.0, 82.8 ± 19.0, and 83.3 ± 20.5 points. One study had an 8% reintervention rate after 12 months, and another study showed a 0.7% and 5.2% rate after 12 and 24 months. After an average of 64 months after ablation, the reintervention rate was 11.8%. Time to return to activities of daily life was 2.9 ± 2.5 days. No related complications during pregnancy and delivery were reported.

CONCLUSION

Radiofrequency ablation with the Sonata System represents a minimally invasive, organ-preserving treatment option in patients with symptomatic uterine myomas, associated with clinically meaningful improvement of myoma-related symptoms.

Transcervical fibroid ablation with the Sonata™ system for treatment of submucous and large uterine fibroids

Objective

To examine the role and benefits of transcervical fibroid ablation (TFA) in the treatment of submucous and large uterine fibroids.

Methods

A subgroup of patients with submucous or large fibroids were analyzed from two prospective clinical trials (FAST‐EU and SONATA) of sonography‐guided TFA with the Sonata^® system. Key outcomes were changes in menstrual blood loss, symptom severity and health‐related quality of life on the Uterine Fibroid Symptom and Quality‐of‐Life Questionnaire, health‐related quality of life on the EQ‐5D questionnaire, and surgical reinterventions for heavy menstrual bleeding.

Results

Among 197 women (534 treated fibroids), 86% of women with only submucous fibroids and 81% of women with large fibroids (>5 cm) experienced bleeding reduction within 3 months post‐ablation. Overall symptom severity and health‐related quality of life showed sustained, significant improvements over 12 months. Additional fibroid mapping of large fibroids with magnetic resonance imaging in the FAST‐EU trial showed an average volume reduction of 68%. Among women with only submucous fibroids, the rate of surgical reintervention through 1 year of follow up was 3.7% in FAST‐EU and 0.0% in SONATA.

Conclusion

With the Sonata system, TFA is an effective single‐stage treatment option for non‐pedunculated submucous myomata, and larger or deeper uterine fibroids (including fibroid clusters) for which hysteroscopic treatment is not suitable.

ClinicalTrials.gov: FAST‐EU, NCT01226290; SONATA, NCT02228174.

Transcervical fibroid ablation with the Sonata™ system is an effective single‐stage treatment option for non‐pedunculated submucous and large myomata.

Transcervical Radiofrequency Ablation of Uterine Fibroids Global Registry (SAGE): Study Protocol and Preliminary Results

Background

Transcervical fibroid ablation (TFA) is a minimally invasive, effective treatment of symptomatic uterine fibroids that utilizes intrauterine ultrasound for imaging and radiofrequency energy for ablation. Outcomes reported with TFA have been positive, with significant reductions in fibroid volume, improvements in symptom severity and health-related quality of life, and low complication and surgical reintervention rates. The SAGE registry characterizes the long-term (5-year) outcomes of TFA when used to treat symptomatic uterine fibroids in real-world usage.

Methods/Design

SAGE is an ongoing postmarket global registry involving up to 50 sites and up to 500 women who select TFA with the Sonata system for treatment of symptomatic uterine fibroids. Patients are followed for 5 years. Main outcomes include symptom severity score and health-related quality of life subscales of the UFS-QoL, general health status on the EQ-5D, perceived treatment benefit, treatment satisfaction, work and activity patterns, overall patient treatment outcome, adverse events, pregnancy incidence and outcomes, and surgical reinterventions for heavy menstrual bleeding.

Discussion

The SAGE registry represents the largest known study of TFA for uterine fibroids and will generate up to 2500 patient-years of outcome data. Preliminary results from the first 160 treated women suggest broad applicability of TFA to a wide range of fibroid types and sizes and an excellent safety profile, with a device-related adverse event rate of 0.6% and a serious procedure-related adverse event rate of 0.6%. Of the 241 fibroids treated, 10% were submucous, 52% transmural, 28% intramural, and 10% subserous. Ablated fibroid diameters ranged from <1 cm to >10 cm, with 27% of fibroids having maximum diameters >5 cm. The real-world experience from SAGE will strengthen the existing evidence on the durability of TFA in providing meaningful relief from uterine fibroid symptoms and will have important clinical and economic implications for patients, physicians, and healthcare payers.

Trial Registration

https://clinicaltrials.gov, NCT03118037. Registered on 18 April 2017.

A systematic review of the psychosocial impact of fibroids before and after treatment

OBJECTIVE

Despite the high prevalence of uterine fibroids, the psychosocial impact of fibroids has not been evaluated across different quality of life indicators and compared with other chronic conditions. Here, we rigorously analyzed available evidence pertaining to the psychosocial burden of uterine fibroids in premenopausal women and compared validated quality of life and symptom scores before and after treatment.

DATA SOURCES

We searched PubMed, PsycINFO, ClinicalTrials.gov, Embase, and Cochrane Library for publications from January 1990 to January 2020.

STUDY ELIGIBILITY CRITERIA

We considered English-language publications that evaluated the association between uterine fibroids diagnosed by imaging studies in premenopausal women and quality of life by standardized and validated questionnaires at baseline and after treatment. We used a detailed list of terms related to quality of life, questionnaires, and uterine fibroids to conduct the search.

METHODS

Three reviewers screened titles and abstracts and then obtained full-text articles for further analysis. The reviewers assessed risk of bias using established Cochrane and Newcastle-Ottawa Scale guidelines. The quality of life scores of premenopausal women with fibroids were reviewed at baseline and compared with those of published quality of life scores in other disease populations in addition to after fibroid treatment.

RESULTS

A total of 57 studies were included in the review: 18 randomized controlled trials and 39 observational studies. Of note, the 36-Item Short Form Survey and European Quality of Life Five-Dimension Scale questionnaires both indicated a diagnosis of uterine fibroids to have a disability score that was similar to or exceeded (was a greater psychosocial stressor) a diagnosis of heart disease, diabetes mellitus, or breast cancer. Quality of life scores were lower at baseline than after treatment in all instruments measuring these variables in women with uterine fibroids, indicating significantly impaired psychosocial functioning. Uterine fibroids were associated with significant patient-reported health disabilities related to bodily pain, mental health, social functioning, and satisfaction with sex life.

CONCLUSION

A diagnosis of uterine fibroids was a significant psychosocial stressor among women at baseline and relative to other diseases. Validated quality of life instruments indicated therapeutic success and the improvement of both physical and emotional symptoms after treatment.

Three-Year Results of the SONATA Pivotal Trial of Transcervical Fibroid Ablation for Symptomatic Uterine Myomata

Objective: This article reports on 3-year clinical outcomes of the Sonography Guided Transcervical Ablation of Uterine Fibroids (SONATA) pivotal trial of transcervical fibroid ablation (TFA) in women with symptomatic uterine myomata.

Materials and Methods: The SONATA, prospective, controlled, multicenter interventional trial enrolled 147 premenopausal women with symptomatic uterine fibroids who underwent uterus-preserving, sonography-guided TFA with the Sonata^® System (Gynesonics, Inc., Redwood City, CA, USA). Clinical outcomes were assessed over 3 years and included surgical reinterventions, Symptom Severity Score (SSS), and Health-Related Quality of Life (HRQoL) subscales of the Uterine Fibroid Symptom and Quality-of-Life Questionnaire, EuroQol 5-Dimension (EQ-5D) questionnaire, Overall Treatment Effect, treatment satisfaction, physical activity, work impairment, pregnancy outcomes, and adverse events.

Results: The 3-year rates of surgical reintervention for heavy menstrual bleeding calculated by the binomial and Kaplan–Meier methods were 9.2% and 8.2%, respectively. Compared to baseline, mean SSS decreased from 55 ± 19 to 22 ± 21, HRQoL increased from 40 ± 21 to 83 ± 23, and EQ-5D increased from 0.72 ± 0.21 to 0.88 ± 0.16 (all p < 0.001). Treatment benefit on the SSS, HRQoL, and EQ-5Q exceeded the minimal clinically important difference at every follow-up visit over 3 years. At 3 years, 94% of the subjects reported treatment satisfaction, 88% reported reduced fibroid symptoms, work absenteeism due to fibroid symptoms decreased from 2.9% to 1.4%, and impairment due to fibroids decreased from 51% to 12% for work, and 58% to 14% for physical activity (all p < 0.001). No late complications occurred.

Conclusions: Women treated with sonography-guided TFA in the SONATA pivotal trial experienced significant and durable reduction of fibroid-related symptoms, with low surgical reintervention rates over 3 years of follow-up.

Uterine Myomas: Extravascular Treatment

Uterine fibroids are common benign tumors that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality. The main advantages offered by mini invasive techniques are low grade of invasiveness and short times of hospitalization. The most diffuse technique is uterine artery embolization (UAE). Common concerns with UAE include postprocedural pain, postembolization syndrome, and risk of infection. Image-guided thermal ablation techniques like radiofrequency ablation, percutaneous microwave ablation, and imaging-guided high-intensity focused ultrasound were introduced to overcome the side effects related to UAE and surgery. The aim of this review is to briefly analyze the ablative procedures and their role in the management of symptomatic fibroids, and to describe the safety profile and outcomes of these modalities.

Non-extirpative Treatments for Uterine Myomas: Measuring Success

OBJECTIVE

To analyze outcomes of nonextirpative treatments for uterine myomas compared with myomectomy.

DATA SOURCES

A systematic search of the following databases from inception to January 2020 was performed: Ovid Medline, Embase, PubMed, and Cochrane Controlled Register of Trials.

METHODS OF STUDY SELECTION

Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they compared nonextirpative interventions for uterine myomas to myomectomy and reported at least one outcome of interest.

TABULATION, INTEGRATION, AND RESULTS

Of the 2010 articles identified and reviewed, 125 full text articles were reviewed, and 22 were ultimately included in the analysis. Nonextirpative treatments reviewed included uterine artery embolization (UAE; 16 studies, n = 9555 subjects), focused ultrasound (FUS; 4 studies, n = 1516), laparoscopic radiofrequency ablation (RFA; 3 studies, n = 49). UAE, FUS, and laparoscopic RFA groups were compared with patients undergoing myomectomy (n = 34 872, n = 20 677, n = 47 respectively). In comparison with myomectomy, UAE had similar quality of life scores, symptom severity scores, sexual function scores, ovarian function, and miscarriage rates following intervention. There was lower likelihood of conceiving after UAE and a higher rate of reintervention after UAE compared with myomectomy. FUS had similar postprocedure sexual function scores and reintervention rates compared with myomectomy. Laparoscopic RFA had similar quality of life scores, symptom severity scores, sexual function scores, reintervention rates, and pregnancy rates after the procedure compared with myomectomy.

CONCLUSION

Nonextirpative treatments for uterine myomas have similar outcomes to myomectomy in multiple domains, with most available evidence comparing UAE with myomectomy.

The CHOICES Study: Facility Level Comparative Cost, Resource Utilization, and Outcomes Analysis of Myomectomy Compared to Transcervical Fibroid Ablation

Purpose

The CHOICES study compared short-term resource utilization, facility costs, and perioperative patient outcomes between transcervical fibroid ablation (TFA) with the Sonata® system and myomectomy through a case-matched comparative trial design. This is the first facility-level comparative study conducted for TFA.

Patients and Methods

The study enrolled 88 patients from 4 centers equally divided among the two cohorts. The TFA arm consisted of 44 women who had enrolled in the SONATA Pivotal IDE trial, whereas the myomectomy arm included 44 patients who were identified through retrospective case-matching to the enrolled SONATA patients at the same 4 centers.

Results

TFA had a significantly lower mean operating room duration (90 minutes) and length of stay (5.2 hours) than myomectomy (143 minutes and 45.8 hours, respectively). The average total mean facility costs for TFA procedure ($7,563) were significantly lower than those associated with myomectomy ($11,425; p=0.002). TFA mean facility costs were also compared with other stratifications of myomectomy (inpatient or outpatient and surgical route). TFA facility costs were significantly lower than that associated with inpatient, abdominal, or laparoscopic myomectomy (all p<0.001).

Conclusion

TFA using the Sonata system has a significantly shorter operating room time and length of stay than myomectomy for the treatment of symptomatic uterine fibroids. All procedure, anesthesia, laboratory, pathology, and pharmacy costs were significantly higher for myomectomy as compared to TFA. TFA was also associated with significantly lower facility procedure-related costs compared to myomectomy, including inpatient, abdominal, or laparoscopic myomectomy.

The INSPIRE Comparative Cost Study: 12-Month Health Economic and Clinical Outcomes Associated with Hysterectomy, Myomectomy, and Treatment with the Sonata System

Purpose

The INSPIRE study compared perioperative and 12-month health economic and clinical outcomes associated with hysterectomy, myomectomy, and sonography-guided transcervical fibroid ablation (TFA) using the Sonata^® system.

Patients and Methods

Cost and health care resource utilization (HCRU) data for TFA were obtained from a prospective, multicenter, single-arm clinical trial. Data for hysterectomy and myomectomy arms were derived from the Truven Health MarketScan commercial payer claims database. The Truven data was used to determine health economic outcomes and costs for the hysterectomy and myomectomy arms. For each arm, payer perspective costs were estimated from the available charge and HCRU data.

Results

TFA with Sonata had significantly lower mean length of stay (LOS) of 5 hrs versus hysterectomy (73 hrs) or myomectomy (79 hrs; all p< 0.001). The average payer cost for TFA treatment, including the associated postoperative HCRU was $8,941. This was significantly lower compared to hysterectomy ($24,156) and myomectomy ($22,784; all p< 0.001). In the TFA arm, there were no device- or procedure-related costs associated with complications during the peri- or postoperative time frame. TFA subjects had significantly lower costs associated with complications, prescription medications, and radiology.

Conclusion

Compared to hysterectomy and myomectomy, TFA treatment with the Sonata system was associated with significantly lower index procedure cost, complication cost, and LOS, contributing to a lower total payer cost through 12 months.

Transcervical Radiofrequency Ablation of Symptomatic Uterine Fibroids: 2-Year Results of the SONATA Pivotal Trial

Objective: To report 2-year results of sonography-guided transcervical fibroid ablation (TFA) using the Sonata^® system in women with symptomatic uterine fibroids. Design: This is a prospective multicenter single-arm interventional trial. Methods: Premenopausal women with up to 10 clinically relevant uterine fibroids, each ranging from 1 to 5 cm in diameter, were treated with sonography-guided TFA on an outpatient basis and returned for regular follow-up visits for 2 years. Assessed outcomes included changes in symptom severity, heath-related quality of life, general health status, work and activity limitations, treatment satisfaction, adverse events, surgical reintervention, and occurrence of pregnancy and associated outcomes. Results: Among 147 enrolled women, 125 (85%) returned for follow-up at 2 years. Compared with baseline, symptom severity decreased from 55 ± 19 to 24 ± 18 (p < 0.001), health-related quality of life increased from 40 ± 21 to 83 ± 19 (p < 0.001), and EuroQol 5-Dimension scores increased from 0.72 ± 0.21 to 0.89 ± 0.14 (p < 0.001). Overall treatment satisfaction at 2 years was 94%. The mean percentage of missed work time, overall work impairment, and activity impairment significantly decreased at follow-up. Through 2 years, surgical reintervention for heavy menstrual bleeding was performed in 5.5% of patients. One singleton pregnancy occurred with a normal peripartum outcome. Conclusions: TFA treatment with the Sonata system provides significant clinical improvement through 2 years postablation, with a low incidence of surgical reintervention. Other favorable outcomes included a rapid return to work and substantial improvements in quality of life, symptom severity, work productivity, and activity levels.

Clinical Performance of Radiofrequency Ablation for Treatment of Uterine Fibroids: Systematic Review and Meta-Analysis of Prospective Studies

Background: Radiofrequency ablation (RFA) has emerged as a safe and effective treatment option for women with symptomatic uterine fibroids and can be delivered by laparoscopic, transvaginal, or transcervical approaches. The evidence regarding typical patient outcomes with RFA has not previously been examined in a comprehensive fashion. Materials and Methods: We performed a systematic review of prospective studies for treatment of uterine fibroids with RFA. Main outcomes were procedure time, patient recovery metrics, change in fibroid volume, symptom severity score (SSS), health-related quality of life (HRQL), and reinterventions. Data were analyzed with random effects meta-analysis and metaregression. Results: We identified 32 articles of 1283 unique patients (median age: 42 years) treated with laparoscopic RFA (19 articles), transvaginal RFA (8 articles), or transcervical fibroid ablation (5 articles). Mean procedure time was 49 minutes, time to discharge was 8.2 hours, time to normal activities was 5.2 days, and time to return to work was 5.1 days. At 12 months follow-up, fibroid volume decreased by 66%, HRQL increased by 39 points, and SSS decreased by 42 points (all P < .001 versus baseline). The annual cumulative rate of reinterventions due to fibroid-related symptoms was 4.2%, 8.2%, and 11.5% through 3 years. Conclusions: RFA of uterine fibroids significantly reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates.

Term Delivery in an Infertile Patient after Transcervical Radiofrequency Fibroid Ablation and Assisted Reproductive Technology

Background: Transcervical radiofrequency (RF) ablation of uterine fibroids is an incisionless procedure to treat nonpedunculated uterine fibroids, including those that are not amenable to operative hysteroscopy. However, its safety and effectiveness regarding fertility and fecundity have not been established, including among women with infertility. Case: A 38-year-old nullipara with infertility since 2008 and a recent complaint of refractory dysmenorrhea in association with a uterine fibroid underwent transcervical RF ablation with the Sonata^® System (Gynesonics, Redwood City, CA) to treat the symptomatic myoma. Unsuccessful assisted reproduction (intracytoplasmic sperm injection/embryo transfer) as confirmed by negative pregnancy testing had been attempted 1 month preablation, and a second embryo transfer after thawing the previously cryopreserved pronuclei was performed 7 months postablation. Results: RF ablation with the Sonata System resulted in a 68% reduction in fibroid volume noted on sonography 2 months post-treatment along with resolution of the patient's dysmenorrhea. No residual fibroid was noted on sonography 7 months postablation. A second attempt at assisted reproduction produced an uncomplicated pregnancy that resulted in vacuum-assisted vaginal delivery of a liveborn infant at term weighing 3670 g with Apgar scores of 9¹/10⁵/10¹⁰. Pelvic sonography 4 months postpartum an unremarkable uterus, again, with no evidence of a fibroid remnant. Conclusions: This is the first report of a pregnancy and delivery in an infertile couple who underwent transcervical RF ablation of a uterine fibroid followed by assisted reproduction.

12-month outcomes of the US patient cohort in the SONATA pivotal IDE trial of transcervical ablation of uterine fibroids

Objective

The prospective SONATA pivotal Investigational Device Exemption (IDE) trial was performed in the United States (US) and Mexico to examine the safety and effectiveness of transcervical fibroid ablation (TFA) in the treatment of symptomatic uterine fibroids. This is an analysis of 12-month clinical outcomes in the US cohort.

Methods

TFA with the Sonata^® System was performed on women with symptomatic uterine fibroids. The 12-month co-primary endpoints were reduction in menstrual blood loss and freedom from surgical reintervention. Symptom severity, quality of life, patient satisfaction, safety, and reductions in uterine and fibroid volumes were also evaluated.

Results

One hundred twenty-five patients were enrolled and treated in the US. Both co-primary endpoints were achieved in this US-based cohort, as 65.3% of patients reported ≥50% reduction in menstrual bleeding and 99.2% of patients were free from surgical reintervention. Symptom improvement was noted by 97.4% of patients and 98.3% were satisfied. Ninety-five percent of patients reported reduced menstrual bleeding at 12 months, and 86.8% noted >20% reduction. Significant mean improvements at 12 months were realized in both symptom severity and health-related quality of life (33.8 points and 45.8 points, respectively; all P<0.0001). Mean maximal fibroid volume reduction per patient was 63.8%. There was a 0% incidence of device related adverse events. Mean length of stay was 2.5 hrs and 50% of patients returned to normal activity within 1 day.

Conclusion

This analysis of US patients in the SONATA pivotal IDE trial demonstrates results consistent with those in the full cohort. TFA with Sonata significantly reduced fibroid symptoms with a low surgical reintervention rate through 12 months. These results support the efficacy and safety of the Sonata system as a first-line treatment for women affected by symptomatic uterine fibroids.