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Fibroid2 Fibroid2 Presentation Transcript

  • Rajesh Varma MA PhD MRCOG Consultant Obstetrician and Gynaecologist Guy’s and St.Thomas’ NHS Foundation Trust 1415-1515: Tue 25 th November 2008 Hot Topics in Clinical Practice Postgraduate Centre, Gassiot House, St.Thomas’ Hospital
  • Fibroids
    • Benign, but have 0.2% risk of malignant transformation
    • Occur in 10% of HMB
    • Recurrence risk after myomectomy (10% at 5 years)
    • May undergo degeneration (hyaline, fatty, Red during pregnancy)
    • May become acutely painful ( torsion, haemorrhage, sepsis, degeneration)
  • Wamsteker K et al. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993; 82(5):736-740.
  • Do all women with fibroids need treatment?
    • Asymptomatic
    • Abnormal Uterine Bleeding (AUB)
    • Menorrhagia, anaemia
    • Pelvic pressure effects (renal tract-ureter, bladder)
    • Pelvic Pain
    • Improve fertility (reduce risk of miscarriage)
  • Myomectomy and AUB
    • Removal of the intracavity component of the submucous
    • fibroid improves AUB (70-80% improvement)
    • (Level II evidence)
    Parker WH. Uterine myomas: management. Fertil Steril. 2007 Aug;88(2):255-71. 2007 Jul 20. Varma R et al. Hysteroscopic myomectomy for menorrhagia using Versascope™ bipolar system: efficacy and prognostic factors at a minimum of one year follow up. In Press 2008, EJOG. Paradox : Post operative adhesions may cause pain and infertility
  • Myomectomy and Fertility Klatsky PC et al. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008 Apr;198(4):357-66. ASRM. Myomas and reproductive function. Fertility and Sterility, Volume 90, Issue 5, Supplement 1, November 2008, Pages S125-S130 Pritts EA et al. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2008 Mar 11 Removal of the intracavity component of the submucous fibroid improves fertility (RR 1.72; 95% CI 1.13-2.58) Subserosal fibroids do not affect fertility outcome Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. (Level II evidence)
  • NICE (Jan 2007) HMB
  • MEDICAL THERAPIES FIBROID SIZE AUB FERTILITY NSAIDs No effect fibroid size Decrease 30% No effect COC No data Decrease 20-30% Contraceptive GNRHa * (3m-6m) Decrease 30% Decrease uterine volume by 35% Decrease >80% Contraceptive Progestins LARC LNG-IUS Mirena (uterine cavity<12cm) Decrease 30% Decrease uterine volume by 35% Decrease>60% Breakthrough bleeding systemic side effects Contraceptive
  • GnRHa
    • Side effects
    • Experienced by 95%
    • Hot flushes; vaginal dryness; frontal headaches
    • 10% women stop treatment due to side effects
    • Osteopenia: >6m use
    • Prevented with add-back (tibilone, raloxifene)
    • Suitable women?
    • 3-4 m prior to myomectomy (hysteroscopic, abdominal) or hysterectomy (anaemia, transfusion, avoid midline entry) (concern: recurrence of small myomas & surgical dissection)
    • Late perimenopause as “short-term” treatment (+/- add-back)
  • NEW MEDICAL THERAPIES (UNDER TRIAL) FIBROID SIZE AUB FERTILITY GnRH antagonist Ganirelix (sc daily/6m) Decrease 30-40% Decrease Contraceptive Mifepristone (5mg daily/6m) Decrease 40% Decrease uterine size 40% Decrease (risk of endometrial hyperplasia) Contraceptive SPRM Asoprisnil (10mg daily/6m) Decrease Decrease Contraceptive Aromatase Inhibitors Decrease Decrease Contraceptive
  • Fibroids >3cm size Fertility preserved Contraceptive Fertility is potentially retained
  • Abdominal Myomectomy
    • >80% improvement in AUB
    • Very low conversion rate to hysterectomy
    • Comparable risk to hysterectomy (organ damage, transfusion)
    • Correct pre-operative anaemia (EPO, GnRHa)
    • Tourniquet
    • Transverse uterine incisions (parallel to arcuate vessels)
    • Anti-adhesion : limit number of uterine incisions, anti-adhesion barrier, drainage
    • Re-treatment rates after myomectomy over 5-10 years ( symptom +/-fibroid recurrence ):
    • 10% single myomectomy vs. 25% multiple myomectomy
  • Abdominal Myomectomy
  • Value of adhesion prevention ?
  • Hysteroscopic Myomectomy Versapoint ® Resectoscope
  • Hysteroscopic myomectomy Fibroid size Intracavity fibroid 90-100% AUB Decrease >80% Fertility Increase 40-60% Secondary treatment (2yr 10%; 5yr 30%) Complication rate 1-2% Uterine perforation Sepsis; intrauterine adhesions Haemorrhage Hyponatraemic fluid overload Additional treatment May be combined with endometrial resection or ablation-improved effect on AUB
  • Hysteroscopic myomectomy: New developments
    • Use of pre-operative GnRHa 3-4m
    • Improved video instrumentation
    • Bipolar resectoscopes: virtually eliminates risk of hyponatraeimc fluid overload syndrome
    • Outpatient microhysteroscopy and Versapoint®- concept of One Stop See-and-Treat gynaecology clinic
  • 3.5mm diameter disposable outer sheath
  • Video clip Outpatient fibroid resection
  • New Interventional Technologies
    • Treatment in women with fibroid-related symptoms and not desiring future fertility
    • Uterine artery embolization (UAE)
    • Magnetic resonance image-guided transcutaneous focused ultrasound for uterine fibroids (MRgFUS)
    • Magnetic resonance (MR) image-guided percutaneous laser ablation of uterine fibroids
    • Laparoscopic or transvaginal uterine artery occlusion
    • Laparoscopic cryomyolysis
  • Aims: New Interventional Technologies
    • Improvement in AUB, fertility and & QoL
    • Avoid risks of major surgery (e.g. quicker recovery)
    • Safety (lower complication rate)
    • Sustained benefit (low re-treatment rate)
    • Cost-effective
    Insufficient evidence: RCTs with long term data are lacking
  • NICE (Oct 2004) Audit and review clinical outcomes of all patients having UAE . Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org).
    • Both uterine arteries are blocked by Interven. Radiol.
    • Contraindications :active genitourinary infection, genital tract malignancy
    • Relative contraindications: submucous myomas (check hysteroscopy prior to UAE), pedunculated myomas, recent GnRHa, previous UAE, postmenopausal status
    Uterine artery embolisation (UAE)
    • Gupta, JK et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane 2008.
    • G. Tropeano et al.Non-surgical management of uterine fibroids. Hum Reprod Update 2008;14(3): 259 – 274.
    • Agdi et al. Intraabdominal adhesions after uterine artery embolization. AJOG, Volume 199, Issue 5, November 2008, Pages 482.e1-482.e3
    UAE Fibroid size Reduced 30-50% AUB Improved (>80% satisfaction)- sustained over 5yr Fertility Reported case series: obstetric outcome uncertain Secondary treatment 20-30% within 5yr Complication rate 1-2w recovery back to work 10-15% persistent vaginal discharge 5% Post embolization syndrome (pain, fever, nausea, vomiting) 10-15% risk premature ovarian failure (especially>45y) 20% intra-abdominal adhesions <1% uterine necrosis/sepsis; death 1/10,000
  • NICE (Sept 2007) Audit and review clinical outcomes of all patients having MRgFUS. Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org).
  • MRI-guided focused ultrasound (MRgFUS) Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-1719 Woman lying on ExAblate 2000 (InSightec) focused ultrasound system ready to be placed into MRI unit
  • MRgFUS: outline of procedure
    • Clear pathway from the anterior abdominal wall to the fibroid without passing through the bladder or the bowel
    • Shaved anterior abdomen
    • A urinary catheter is inserted
    • Unsuitable for very large uteri (>24w) or fibroids (>10cm)
    • IV analgesia and conscious sedation
    • Maximum treatment time of 3 hr ; recovery 1-2 days
    • Thermal ablation of selected fibroid
    • Real time MR Thermometry (aiming >55 degrees C)
    • Gadolinium-enhanced MRI performed immediately after treatment
  • Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-19 AFTER MRgFUS: Non-Perfused Volume (NPV) ratio calculated from the gadolinium-enhanced MRI performed immediately after treatment BEFORE
    • E. A. Stewart et al. Sustained Relief of Leiomyoma Symptoms by Using Focused Ultrasound Surgery. Obstet. Gynecol., August 1, 2007; 110(2): 279 - 287.
    • Z. M. Lenard et al. Uterine Leiomyomas: MR Imaging-guided Focused Ultrasound Surgery--Imaging Predictors of Success. Radiology, Oct 1, 2008; 249(1): 187 – 194
    • Rabinovici J et al. Pregnancy outcome after magnetic resonance–guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertility &Sterility, In Press, 2008
    MRgFUS Fibroid size 20% at 2yr AUB 60-70% Higher NPV corresponds to greater fibroid size reduction and symptom relief at 12-month Fertility Reported-mainly for single fibroid ablations Secondary treatment ? 30% Complication rate 10% (pain, vaginal discharge)
  • Conclusions
    • Multiple treatment options exist
    • Advances in hysteroscopy
    • New interventional technologies show early promise
    • However,
    • Several unanswered questions
    • Urgent need for further research
    • Need for increased consumer input
  • CONSUMER WEBSITE UNDER DEVELOPMENT