Office Hysteroscopic Treatment of Uterine Fibroids

Advances in endoscopic and therapeutic hysteroscopic technology have made the removal of submucosal fibroids possible in the outpatient setting. Removal of submucosal fibroids can be particularly challenging in the outpatients due to intramural components of some submucosal fibroids and the hard consistency of fibroids which makes specimen retrieval rather difficult through the endocervical canal. Fibroids which are <2 cm and completely intracavitary are easier to remove in the outpatients. Specimen retrieval can be addressed either by slicing the fibroid using bipolar electrodes, by using a hysteroscopic morcellator or leaving the fibroid in the uterine cavity after enucleation to be expelled with uterine contractions. Patient acceptability appears to be high in a small number of retrospective case series published in the literature. Further reports and data from prospective trials would be beneficial in improving our understanding of this procedure which appears to be performed by a relatively small number of centres.     

腹腔镜下子宫动脉阻断术治疗子宫肌瘤的研究进展

近年来,随着妇科微创技术的不断发展,腹腔镜下子宫动脉阻断术逐渐被应用于治疗子宫肌瘤。国内外文献报道,用该术式治疗子宫肌瘤可达到满意的临床疗效,术后能明显缓解月经异常症状,缩小子宫体积,有效降低子宫肌瘤的复发率。另外,该技术治疗子宫肌瘤的机制尚不完全明确,目前认为可能与子宫的血供特点、子宫肌瘤与平滑肌组织的凝血-纤溶激活系统差异有关。现对近年来该技术的临床应用情况以及相关机制研究进行综述。     

Endoscopic Treatment and Power Morcellation of Uterine Fibroids

Although a variety of pharmacological and radiological treatment options are available, surgery in the form of myomectomy or hysterectomy provides a quick and effective relief of many symptoms, albeit with attendant surgical risks. In this article, we discuss endoscopic surgical treatments, their relative benefits, and their risks, including risk of morcellation. Patient selection and preoperative preparation for various surgical approaches is discussed. Overall, the evidence base for surgical treatments, including endoscopic, is weak, and, therefore, a pragmatic approach is outlined.     

子宫平滑肌肉瘤系统治疗

子宫平滑肌肉瘤（uterine leiomyosarcoma,uLMS）是一种罕见的子宫间质肿瘤,其发病率低,是一种高度恶性肿瘤,即使是早期治疗,仍具有较高的复发率和转移风险。该疾病的术前诊断较困难,不如宫颈癌和子宫内膜癌有很好的诊断手段,术中存在治疗不足或治疗方式不恰当的情况,因此该疾病的预后较差。目前手术治疗仍是该疾病的主要治疗方案,术后的辅助治疗方案有很多,如辅助放疗、辅助化疗、靶向治疗、联合治疗或者进行随访观察,由于发病率低、研究的数量少以及疾病进展较快,迄今仍没有一个统一的标准治疗方案,且辅助治疗的效果不理想,临床获益较少。综述uLMS系统治疗的相关知识,尤其是在辅助治疗、转移病灶中以及意外中发现该疾病的治疗,为临床治疗提供参考性意见。     

射频消融治疗子宫肌瘤的临床应用

随着近年来医疗水平的提高及妇科常规体检的普及,子宫肌瘤发病率居高不下。目前子宫肌瘤的治疗有多种方法,其中射频消融是一种临床显著有效的微创治疗手段。其通过破坏肌瘤组织缩小肌瘤体积,同时不伤害其他组织及器官,作为一种简便、安全、有效的治疗方式正逐渐受到临床医生的认可。现从原理、适应证及禁忌证、术中麻醉及手术方法、并发症及其处理、疗效评价、术后病理变化及实用性等方面对射频消融治疗子宫肌瘤作一简要概述。     

GnRH-a在子宫肌瘤治疗中的应用分析

子宫肌瘤是临床上最常见的女性生殖系统良性肿瘤,可引起异常子宫出血、压迫症状、腹痛和不孕等,目前药物治疗效果有限,主要以手术治疗为主。促性腺激素释放激素激动剂（GnRH-a）从高位抑制下丘脑-垂体-性腺轴,减少患者血液中雌、孕激素,缩小子宫肌瘤体积,改善贫血及盆腔压迫症状。与口服药物相比,GnRH-a使用方便,患者依从性好,治疗效果确切。子宫肌瘤体积缩小,使腹腔镜手术及保留子宫的难度下降,术后恢复快。对于绝经过渡期、伴有严重合并症而无法耐受手术的患者,GnRH-a的应用还能使其避免或暂缓手术,控制合并症不进展。停用GnRH-a 2周内垂体促性腺激素分泌可恢复,6～8周后可重建正常月经周期。     

Medical Management of Uterine Fibroids

Uterine leiomyomas are the most common benign tumors of the uterus. Though benign, they can affect the quality of life for many women. Compared with the standard surgical treatments, medical therapy is attractive and avoids possible surgery-related complications. No medical therapy currently exists that can induce rapid regression of the myoma and symptoms with minimal side effects without affecting fertility. This review evaluates medical treatments that are currently available for the treatment of uterine fibroids.     

Symptom-Free Interval After Triptorelin Treatment of Uterine Fibroids: Long-Term Results

An increasing number of publications document regression of fibroids under treatment with gonadotropin releasing hormone (GnRH) agonists. However, recurrence after stopping treatment regularly counterbalances its benefit.

We now report on 28 patients with intramural myomas, treated with triptorelin for 4-6 months and followed for 42-56 months. During or shortly after treatment, six patients entered menopause. In this group, a volume reduction of 71% was achieved and no surgery was needed thereafter.

In 22 premenopausal women, a 64% decrease of uterine volumes was obtained at the end of treatment; the long-term reductive effect was 31%. When compared with initial values, a significant decrease was observed at the end of treatment (p=0.0001) and of follow-up (p < 0.0005).

In 13 (of 22) premenopausal patients, surgery was needed after triptorelin treatment for permanent control of fibroids. The remaining nine patients were free of symptoms after 42-56 months, having uteri in situ. These two groups differ significantly in pretreatment uterine volume (p < 0.001) and in reduction rate after therapy (p < 0.01), both parameters beinghigherin patients who finally needed surgery.

In conclusion, triptorelin treatment is definitely beneficial in perimenopausal women and in nearly half of premenopausal women, in whom hysterectomy can be prevented. In the other half, surgery is necessary, despite significant volume reduction. These results need to be corroborated on larger groups of patients. More research is needed to explain different responses to treatment in premenopausal patients.     

Early Severe Haemorrhage Complicating GnRH Analogue Treatment of Submucous Uterine Fibroids

EDITORIAL COMMENT; This case was accepted for publication because of the warning it carries of treatment of women with large submucous uterine fibroids by gonadotropin releasing hormone analogues. We draw readers' attention to the discussion of the cases reported by Friedman (1) where haemorrhage from submucous fibromyomas was apparently successfully managed by hysteroscopy, laparotomy and myomectomy. Mullerian mixed cell sarcomas can also present with a large polypoid mass protruding through the cervix; this condition should be considered when performing uterus-preserving surgery in such women.
Summary: We present 1 case of early severe uterine haemorrhage as a result of GnRH analogue therapy for a submucous fibromyoma resulting in hysterectomy, to alert others of this potentially serious complication.     

高强度聚焦超声治疗子宫肌瘤的研究进展

子宫肌瘤可导致异常子宫出血、尿频或便秘、不孕等症状,影响患者的身心健康。高强度聚焦超声（high-intensity focused ultrasound,HIFU）是通过聚焦体外低能量超声波促使靶组织发生坏死的一项技术,可显著缩小子宫肌瘤的体积,进而改善患者的临床相关症状,已成为子宫肌瘤治疗的一种重要方法。HIFU治疗子宫肌瘤具有无创、可保留子宫结构完整性的优势,可安全地用于有生育要求的子宫肌瘤患者并能缩短其治疗后的避孕时间。但HIFU治疗子宫肌瘤后远期的再干预率较高,还可能增加早产和胎儿生长受限等妊娠并发症的发生率。HIFU治疗前对于子宫肉瘤等恶性疾病的排除问题也尚无完好的解决办法。对近年来HIFU治疗子宫肌瘤的相关研究进行综述,为临床上子宫肌瘤的治疗提供参考。     

Treatment Choices in a National Cohort of Canadian Women With Symptomatic Uterine Fibroids

ObjectivesTo describe treatment choices made at the time of enrollment in CAPTURE, a Canadian patient registry for women with symptomatic uterine fibroids (UFs), and to define demographic and clinical characteristics that independently predict these choices.MethodsWomen arranging appointments for UF care were eligible to enrol. At the time of the enrollment visit, women's self-reported treatment histories were noted, along with their clinical characteristics. Tretment options were discussed and chosen during that visit. Patients could choose medical and/or surgical treatment, or they could opt for no active treatment (i.e., “watchful waiting”); treatment decisions were not binding.ResultsThe most common medication proposed and chosen was ulipristal acetate (UPA), and the most common procedure was myomectomy. These treatments were also the most commonly identified in patients’ histories. Medication alone and medication in combination with surgery were the most common treatment approaches chosen (46% and 26%, respectively). Surgery alone and watchful waiting were chosen by 14% and 13% of patients, respectively. Significant predictors of active treatment included patient pregnancy plans, overall symptom severity, and prior treatment history (medical and surgical). Other parameters, including patient age and history of specific UF symptoms, appear to influence the choice of medical therapies (UPA, gonadotropin-releasing hormone agonists, or other options) and procedures (myomectomy or hysterectomy).ConclusionsThis real-world study documents the patient factors associated with the treatment decisions of women seeking care for symptomatic UFs in contemporary Canadian gynaecology practice. Subsequent analyses will follow the outcomes of these treatments over two years in this population.     

Radiofrequency Ablation of Uterine Fibroids: a Review

Laparoscopic, ultrasound-guided radiofrequency ablation (RFA) is a new, FDA-cleared uterine sparing, outpatient procedure for uterine fibroids. The procedure utilizes recent technological advancements in instrumentation and imaging, allowing surgeons to treat numerous fibroids of varying size and location in a minimally invasive fashion. Early and mid-term data from multi-center clinical trials have demonstrated safety and efficacy, with resolution or improvement of symptoms and significant volume reduction. Re-intervention rates for fibroid symptoms have been low. The procedure is well tolerated with a typically uneventful and rapid recovery requiring NSAIDs only for postoperative pain. While post RFA pregnancy data are limited, the results are promising.     

超声引导下射频消融治疗子宫肌瘤的研究进展

子宫肌瘤又称平滑肌瘤或肌瘤,是女性生殖器官最常见的良性肿瘤,由平滑肌和结缔组织组成,常见于30～50岁妇女,发病率约20%。子宫肌瘤的治疗包括保守治疗及手术治疗,其中射频消融（RFA）是一种微创治疗手段,目前已应用于多种疾病,在治疗妇科良性疾病方面的价值也得到了充分的认可。理想的RFA是运用热能以微创的方式、不损伤邻近正常组织的前提下,使靶组织遭受到彻底的破坏。现从作用机制、超声造影技术的临床应用、疗效评价、对生育功能的影响、安全性和有效性、影响因素等方面对RFA治疗子宫肌瘤进行简要概述。     

Ultrasound-Guided Percutaneous Microwave Ablation for Submucosal Uterine Fibroids

Study ObjectiveTo prospectively evaluate the efficiency and safety of ultrasound-guided percutaneous microwave ablation (PMWA) in treating symptomatic submucosal uterine myomas.DesignSelf-controlled study (Canadian Task Force classification II-1).SettingSingle center.PatientsTwenty-two premenopausal women with 22 symptomatic submucosal uterine myomas.InterventionAll patients underwent ultrasound-guided PMWA.Measurements and Main ResultsPMWA was performed in 22 premenopausal women with 22 symptomatic submucosal uterine myomas. Mean (SD) patient age was 42 (4.60) years (95% confidence interval [CI], 39.96–44.04). Five symptomatic submucosal uterine myomas were identified as type 0, 7 as type 1, and 10 as type 2. Contrast-enhanced ultrasound and magnetic resonance imaging were performed before and after surgery. Myoma volume, hemoglobin concentration, and scores on the UFS-QOL (Uterine Fibroid Symptom and Quality of Life) questionnaire were recorded before and at 3 and 12 months after ablation. Complications were also recorded. In all patients, therapy was completed with a single ablation. The baseline diameter of the symptomatic submucosal uterine myomas was 4.90 (1.60) cm. Mean myoma volume reduction rate was 81.46% (16.33%) (95% CI, 73.06%–89.86%) at 3 months (p < .001) and reached 90.00% (9.79%) (95% CI, 85.07–95.13) at 12 months (p < .001). At 3 months after ablation, hemoglobin concentration increased from 88.64 (21.87) g/L (95% CI, 78.94–98.34) to 123.21 (15.77) g/L (95% CI, 115.10–131.32) (p < .001), and remained stable at 12 months, with a value of 125.92 (14.90) g/L (95% CI, 117.98–133.86). Scores on the UFS-QOL were comparable, with normal levels observed at 1 year. No major complications were observed. Nine patients were discharged with necrotic masses.ConclusionPMWA seems to be effective and safe for treatment of submucosal myomas.     

子宫肌瘤的非手术治疗

子宫肌瘤是女性生殖器官最常见的良性肿瘤。其治疗包括手术治疗和非手术治疗。介绍了药物治疗,高强度聚焦超声（high intensity focusedultrasound,HIFU）及子宫动脉栓塞（uferine artery embolization,UAE）3种非手术疗法的应用范围及利弊,为子宫肌瘤的非手术治疗方法的选择提供参考。