Surgical Techniques
Tips and techniques for robot-assisted laparoscopic myomectomy
With robotic assistance, a surgeon can reduce blood loss, shorten hospitalization, and ease laparoscopic suturing and knot-tying—but myomectomy is...
RFVTA technique, step by step
1. Begin with a standard 5-mm laparoscopic infraumbilical port for the camera and video laparoscope (See VIDEO).
2. Place a 12-mm port in the midline, suprapubically at the level of the uterus, for insertion of the laparoscopic ultrasound probe. Now it is possible to map the uterus and plan an approach to destroy the fibroids.
3. Once you have determined your approach, insert the handpiece containing the radiofrequency needle through the abdominal wall under laparoscopic visualization.
4. Place the needle into the targeted fibroid using both laparoscopic and ultrasound guidance. Depending on the size of the fibroid, the needle array can be deployed to the maximum diameter necessary to effect destruction.
5. Engage the radiofrequency generator (FIGURE 1), utilizing the timing function for optimal destruction of the fibroid, based on the appropriate algorithm. The fibroid then will be ablated and destroyed without damage to the surrounding healthy myometrium.
The Acessa radiofrequency generator and accessories are designed to deliver monopolar radiofrequency energy to tissue through the handheld electrical probe. The procedure is monitored by real-time feedback to and from the generator via each of the thermocouples at the tips of the seven-needle array (FIGURE 1). In addition, laparoscopic ultrasound-guided visualization permits monitoring of needle placement within the fibroid capsule (FIGURES 2A and 2B) and confirmation of hemostasis upon removal of the probe tip (FIGURE 2C).
RFVTA treats a wide range of fibroids
The Acessa System is used to treat fibroids of any location and type, with the exception of pedunculated or Type 0 myomas, in which case laparoscopic or hysteroscopic myomectomy is recommended. Calcified fibroids pose no challenges. A single radiofrequency needle generally is used to treat multiple fibroids, with ablation zones ranging in diameter from 1.0 to 6.7 cm. Large, irregularly shaped fibroids may require multiple ablation zones during the same procedure.
Final steps
6. Once the treatment is complete, as confirmed by informatics transmitted by the generator, retract the needle array, set the generator to coagulation mode to coagulate the needle track during withdrawal of the probe, and confirm hemostasis (FIGURE 2C).
7. After completion of all fibroid destruction, remove the disposable radiofrequency probe and close the laparoscopic and ultrasound port sites using standard procedures.
The patient can be discharged the same day and generally is able to return to normal activities within 3 to 5 days.
Postoperative analgesia usually consists solely of nonsteroidal anti-inflammatory agents.
A look at outcomes data
Garza and colleagues published the first feasibility report in 2011.24 They described the results of laparoscopic, ultrasound-guided RFVTA for the treatment of symptomatic uterine fibroids in Mexico using an Acessa predecessor. The 31 women enrolled in the study desired uterine preservation. Of these participants, 19 had completed 12 months of follow-up by the time the report was submitted for publication. Their responses to the UFS-QOL questionnaire indicated that their symptoms had decreased significantly in severity from baseline to 12 months, and their quality-of-life scores also improved significantly (P <.001). Mean uterine volume also declined significantly.
Robles and colleagues set out to confirm these findings using the investigational Halt Ablation System. They conducted a prospective, single-center, open-label clinical trial in Guatemala.25 They found dramatic improvement in symptom severity and health-related quality of life from baseline to 12 months. Mean uterine volume also decreased by 23.6% during this period. In addition, the severity and duration of menses declined.
Acessa is currently not approved for women seeking future childbearing. However, several successful pregnancies have been reported following the procedure.24,26–28 Theoretically, because it causes less damage to and disruption of healthy myometrium, Acessa may prove to be preferable to myomectomy. Head-to-head studies to evaluate this premise are ongoing.
Latest findings confirm widespread improvement of symptoms
The most recent and detailed reports of safety and efficacy of laparoscopic, ultrasound-guided RFVTA at 12 and 24 months were published by teams led by Chudnoff26 and Guido27 earlier this year. These investigations involved 135 women who reported moderate to severe heavy menstrual bleeding (160 mL–500 mL by alkaline hematin analysis). Clinically significant reduction in menstrual blood loss was achieved in 67.7% of participants at 12 months of follow-up.29
Related article: Tips and techniques for robot-assisted laparoscopic myomectomy Arnold P. Advincula, MD, and Bich-Van Tran, MD (August 2013)
Galen and colleagues performed a retrospective analysis of these same patients, demonstrating that RFVTA of intramural fibroids without submucosal components leads to a clinically and statistically significant reduction in menstrual blood loss.30
Patients generally began these trials with high symptom-severity scores and low health-related quality of life, yet all achieved significant improvement over time, as their UFS-QOL scores indicate (TABLE). The majority of patients (96%) were treated on an outpatient basis. As measured by contrast-enhanced magnetic resonance imaging, total mean uterine volume decreased by 24.3% at 12 months, and total mean fibroid volume decreased by 45.1% during the same interval. Ninety-four percent of the women reported that the treatment was effective in eliminating their symptoms at 12 months, and 98% said they would recommend the procedure to a friend having the same health problems.
