Grand Rounds

What Uterine-Sparing Treatment for Fibroids Has the Best Outcomes?

BACKGROUND:

Interventions to remove fibroids but retain the uterus include
- Uterine artery embolization (UAE)
- Radiofrequency ablation (RFA)
- (Laparoscopic) ligation and cryoablation
- High-intensity focused ultrasound (HIFU)
Sandberg et al. (Fertility and Sterility, 2018) compared the efficacy of uterine-sparing treatment options for fibroids

Systematic review and meta-analysis
Participants: Women with uterine fibroids undergoing a uterine-sparing intervention
Primary outcomes
- Reintervention risk after uterine-sparing treatment for fibroids after 12, 36, and 60 months
- Quality of life outcomes, based on validated questionnaires (scale 0 to 100)
  - Severity Symptom Score (SSS): Score decreases with improvement
  - Health-Related Quality of Life questionnaire (HRQL): Score increases with improvement
- The first group of procedures used an abdominal approach
  - Myomectomy (abdominal, laparoscopic and robotic combined)
  - Uterine artery embolization (UAE)
  - Artery ligation
  - High-intensity focused ultrasound (HIFU)
  - Laparoscopic radiofrequency ablation (RFA)
  - Cryoablation
- The second group of procedures used a hysteroscopic approach, used for intracavitary fibroids
  - Hysteroscopic myomectomy
  - Hysteroscopic RFA

The analyses included 85 articles, totaling 17,789 women
87% of women had abdominal approach and 12.2% had a hysteroscopic approach
Reintervention risk after 12 months
- Varied from 0.3% (laparoscopic RFA, 95% CI 0–1.6%) up to 15% (cryoablation, 1 study)
Reintervention risk after 36 months
- Varied from 1.2% (myomectomy, 95% CI 0–5.2%, 4 studies) to 34.7% (HIFU, 95% CI 27.3%–42.4%, 4 studies)
Reintervention risk after 60 months was
- Myomectomy: 12.2% (95% CI 5.2%–21.2%)
- UAE: 14.4% (95% CI 9.8%–19.6%)
- HIFU: 53.9% (95% CI 47.2%–60.4%)
- 7% (95% CI 4.8%–9.5%) for hysteroscopic myomectomy
No studies were available at 60 months for artery ligation, laparoscopic RFA, and cryoablation
Quality of life improved after treatment for all options
The HIFU procedure had the least favorable outcomes
Subanalysis for hysterectomy as reintervention
- At 36 months, hysterectomy reintervention varied from 0.6% (myomectomy) to 8.1% (laparoscopic RFA)
- at 60 months, hysterectomy reintervention was as follows
  - Myomectomy: 7%
  - UAE: 9.4%
  - HIFU 22.2%

Reintervention was greatest for HIFU to treat fibroids
The authors point out that
- Population selection may be an issue in the HIFU studies
- Although HIFU is FDA approved since 2004 and morbidity is low, more study may be warranted, especially long-term outcomes
- Hysterectomy reintervention following UAE was <10%
- Available evidence did not allow for adjustments based on infertility as an indication for treatment

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