Uterine submucosal leiomyomas: modern diagnosis and miniinvasive surgery

Uterine leiomyomatosis is one of the most common benign pelvic tumors diagnosed in women aged 25-44 years. Clinically, it is manifested by vaginal bleeding, pelvic pain, infertility, digestive and urinary symptoms. The diagnosis of uterine fibroids requires careful clinical and paraclinical evaluation. Based on these data, the therapeutic decision is conducted in most cases. The treatment of uterine leiomyomatosis involves several procedures, such as: total abdominal hystectomy, total vaginal hystectomy, abdominal myomectomy, vaginal, laparoscopic or hysteroscopic myomectomy. Hysteroscopic myomectomy is currently the preferred procedure for submucosal fibroids. It has multiple advantages: shorter recovery time, reduced pain related to movements, shorter duration procedure and fewer risks. The procedure has few contraindications. The most common complication is recurrence. The treatment of choice for prolapsed pedunculated submucous leiomyoma is vaginal myomectomy. As described, the procedure has multiple advantages and generally has a low recurrence rate.

A Study on the Diagnostic Abilities of Ultrasound Scans in Assessing the Uterine Fibroids Against Magnetic Resonance Imaging Findings in the Same Subject Population

Background: This study was designed to evaluate the matching percentage among findings of the ultrasound scans to the magnetic resonance imaging in women with fibroids in Bahrain.Methods: This descriptive, retrospective study was conducted from January 2016 to December 2018 including all the female patients referred from the Gynaecological Department to the Radiological Department in the Bahrain Defense Force Hospital for magnetic resonance imaging and ultrasound scan for fibroid evaluation.The data collected included their age, parity and nationality. The StatsDirect software was used to analyze the fibroids according to the site, size, type and number. Results: The average age of the recruited 205 female patients for the study was 43 years, with 81.5%as Bahraini citizens and a mean parity of 2.3. Ultrasound scan findings matched the Magnetic Resonance Imaging in the posterior fibroid sites in 52.5% of cases, followed by anterior (38.1%) and fundal (21.8%). For fibroid size, Ultrasound scans matched Magnetic Resonance Imaging findings in 83.3% for fibroids between >5 to ≤ 10 cm, in 78.3% for fibroids between >2 to ≤ 5cm, and in 36.8% for fibroids sized ≤ 2 cm. Fibroids more than 10cm in size were in agreement for 33.33% of fibroids. Submucosal fibroids matched in just 29.4% of cases, but for the subserosal fibroids, it was 44.8%. The matching score for more than 4 fibroids was 61.8%, followed by single fibroids (54.8%) and lastly for two fibroids (34.8%).Conclusions: Fibroid site and size had the highest matching rates amongst all the categories.

Potential benefit of GnRH-agonist treatment before uterine artery embolization for large fibroids: MRI prediction of fibroid volume reduction

Background Signal intensity (SI) of predominant fibroid (F1) on T2-weighted (T2W) images is useful for predicting the volume reduction response after gonadotropin-releasing hormone (GnRH)-agonist treatment. Few studies have been published regarding when and how to use GnRH agonist before UAE. Purpose To investigate magnetic resonance imaging (MRI) prediction of volume reduction rate (VRR) of large fibroids after GnRH-agonist treatment before uterine artery embolization (UAE) as well as the efficacy of UAE based on MRI. Material and Methods Data from 30 patients with a large fibroid and MRI results both before and after GnRH-agonist treatment were retrospectively analyzed. Indications for GnRH-agonist treatment are fibroids with a maximum diameter ≥10 cm or pedunculated submucosal fibroids ≥8 cm. GnRH agonist (3.75 mg leuprolide acetate) was administered subcutaneously once per month 2–6 times. SI of F1 on T2W imaging was measured: the SI was referenced to the SI of the rectus abdominis muscle (F/R). Results Mean maximum fibroid diameter was 11.1 ± 1.9 cm (range = 8.0–15.5 cm). Mean number of GnRH-agonist injections before UAE was 2.8 (range = 2–6). For predicting VRR ≥50% and <30%, the optimal cut-off values of F/R were 2.58 (sensitivity 80%, specificity 80%) and 1.69 (sensitivity 100%, specificity 70%), respectively. Of the 30 patients, fibroid infarction was complete in 29 (96.7%). Conclusion SI of F1 on T2W imaging is useful for predicting the volume reduction response after GnRH-agonist treatment. After GnRH-agonist treatment for large fibroids, UAE is effective to achieve complete infarction of fibroids.

Uterine Fibroids and Infertility

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

Fibroids and Infertility

Uterine fibroids (also known as leiomyomas or myomas) are the most common pelvic tumors, affecting more than 70% of women over 70 years of age and although most are asymptomatic, some women may experience symptoms, depending on their location and size, which can alter your quality of life, such as abnormal uterine bleeding, anemia, pelvic pain and pressure, dyspareunia, increased urinary frequency and constipation. Its relationship with infertility has been controversial and, although insignificant for subserous fibroids, it appears that submucosal and intramural fibroids that distort the endometrial cavity can affect embryo implantation and are associated with an increased risk of early pregnancy loss. Its treatment will depend on the patient’s symptoms, size, location, whether it is one or multiple, and whether or not she suffers from infertility. It is clear that submucosal fibroids have a negative impact on fertility and with respect to intramural fibroids it is known that fibroids larger than 4 cm alter the probability of pregnancy, however there are studies that show that even smaller or multiple fibroids could affect pregnancy rates. There are multiple options for the treatment of fibroids; however, patients who are candidates for expectant, medical or surgical management should be individualized, and especially if they are going to be taken to surgery, an excellent mapping of fibroids prior to surgical intervention is recommended. Minimally invasive surgery continues to be the approach of choice, it should be left for the open approach in cases in which Laparoscopy is contraindicated or the patient with multiple myomatosis.

Fibroids and Hysteroscopy: An Overview

Submucosal fibroids account for 10% of total fibroids. They significantly impact quality of life causing abnormal uterine bleeding (AUB), reduction in fertility rates/infertility, obstetrics complications and abdominal pain. They are a major public health concern because of economic cost their monitoring and treatment requires. Hysteroscopic myomectomy is the first line minimally invasive and conservative surgical treatment. Treating a fibroid correctly implies knowing its physiopathology: What is a submucosal fibroids and what is its origin, what is the Pseudocapsule?. Proper diagnosis and standardized classification such as the Wamsteker classification are required. What are the limits to perform a hysteroscopic myomectomy? What devices are currently used? What are the requirements for conducting myomectomy procedures in the outpatient setting?. Different forms of surgical approach. Complications and consequences of a myomectomy. What will we do in the future with the management of small submucosal fibroids in asymptomatic patients with future genetic desires and can we resect type 3 fibroids by hysteroscopy avoiding a higher risk surgery by abdominal route?