For uterine-sparing fibroid treatment, consider laparoscopic ultrasound-guided radiofrequency ablation

CASE: WOMAN WITH HEAVY BLEEDING HOPES TO AVOID HYSTERECTOMY
L.W. is a 44-year-old woman (G2P2) with a 2-year history of menorrhagia and severe dysmenorrhea but no intermenstrual spotting or bleeding. She reports that she has tried to control her symptoms using hormonal methods, without success.

Examination reveals that she has an irregular, nontender uterus 8 weeks in size. Transvaginal ultrasonography shows two deep, prominent, intramural fibroids. The first is 2 cm by 3 cm in size in the left lateral uterus, adjacent to the endometrial stripe. The second fibroid is 3 cm by 4 cm in the fundal region. Sonohysterography reveals no intracavitary fibroids, although the left lateral myoma has distorted the endometrial cavity.

The patient is seeking removal of her fibroids but would like to preserve her uterus, if at all possible.

What options would you offer her?

Uterine fibroids are common in premenopausal women, affecting 70% to 80% of the population, especially women of African descent.¹ Although the majority of women with fibroids are asymptomatic, approximately 30% report pelvic pressure, dyspareunia, dysmenorrhea, or abnormal uterine bleeding.²

Our patients are increasingly aware of uterine-sparing treatments for symptomatic fibroids.^3,4 Women seek conservative procedures to avoid the risks and extended recovery times commonly associated with major surgery. Current laparoscopic techniques for removal of uterine fibroids can be complex and require advanced surgical skills. Deep intramural fibroids may not always be visible or readily accessible, making laparoscopic removal a more invasive and challenging approach for many gynecologic surgeons.

A significant recent advancement in minimally invasive gynecologic treatment of fibroids is the Acessa System (Halt Medical, Brentwood, California). This laparoscopic system involves the outpatient use of ultrasound-guided radiofrequency volumetric thermal ablation, or RFVTA.

In this article, I outline the development of this option and step you through its technique. I also review the outcomes data that have been published to date.

How the procedure evolved
In the 1980s, Donnez and Nisolle developed a method of laparoscopic Nd:YAG laser treatment of uterine fibroids, commonly referred to as myolysis.⁵ Later, Goldfarb developed a laparoscopic bipolar needle technique that coagulated and occluded blood vessels at the periphery of the fibroid.⁶ However, myolysis led to the formation of significant adhesions to the small bowel or omentum, or both, and was abandoned by the surgical community.

Other fibroid treatments have been developed, such as laparoscopic myomectomy, uterine artery ligation, uterine artery embolization (alone or as adjuvant treatment), and high-intensity focused ultrasound. Although these procedures have made a significant contribution to the minimally invasive treatment of fibroids, the need for reintervention can be substantial, as high as 29% at 1 to 10 years of follow-up in some reports.^7–17

Related article: Ins and outs of straight-stick myomectomy James Robinson, MD, MD, and Gaby Moawad, MD (September 2012)

Radiofrequency needle ablation has been used successfully in the treatment and destruction of liver and kidney tumors for years. Lee envisioned use of the technology to treat uterine fibroids. He developed a technique using a retractable multiarray radiofrequency needle (Starburst XL, RITA Medical Systems, Fremont, California) that is inserted directly into the fibroid. In 2002, he reported the first use of intraperitoneal ultrasound for needle guidance in the laparoscopic ablation of 197 myomas in 52 symptomatic women who had declined hysterectomy and myomectomy.¹⁸ He found that a significant proportion of women experienced resolution of their symptoms, including heavy menstrual bleeding, dysmenorrhea, dyspareunia, and pelvic pressure, by 3 months, with continued improvement at 12 months.

Because he was unhappy with aspects of the RITA needle that prevented accurate and consistent ablation of fibroids, he developed other devices that would lead to RFVTA and the Acessa System. This system allows the gynecologic surgeon to target and treat deep intramural fibroids that may not be readily visible via conventional laparoscopy.

Between the time of Lee’s first report and his subsequent refinement of the device and procedure, several international fibroid radiofrequency ablation procedures emerged, including those of Bergamini, Milic, Ghezzi, and Carrafiello.^19–22 These investigators published results in small cohorts and described significant improvement in patient-reported Uterine Fibroid Symptom and Quality-of-Life (UFS-QOL) scores as well as a reduction in myoma volume.²³ Their studies provided evidence that RFA is a safe and effective uterine-sparing treatment of symptomatic ­uterine fibroids for selected patients.

Related article: Update on Minimally Invasive Surgery Amy Garcia, MD (April 2011)

How it works
RFVTA uses laparoscopy and laparoscopic ultrasound to guide placement of a needle electrode with a deployable array. Earlier international studies of radiofrequency ablation^18–22 and ongoing studies of RFVTA^23–26 have demonstrated the procedure’s therapeutic potential. Acessa was recently cleared (November 2012) by the US Food and Drug Administration (FDA).