Uterine fibroids: surgical and radiological management — structured SAQ (15 marks)

(a) FIGO-type-to-procedure mapping and operative principle (4 marks)

One mark per point. [1]

• The overriding operative principle: surgery is goal- and fertility-directed, and the route follows the FIGO type.
• The FIGO type 1 submucosal fibroid is managed first-line by hysteroscopic myomectomy — cavity access, controls bleeding, improves fertility, uterus-sparing.
• The FIGO type 4 intramural fibroids are managed by laparoscopic or open (abdominal) myomectomy if she wishes to conserve the uterus; route by size, number, skill and ureter proximity.
• A woman who has completed her family is offered hysterectomy as the definitive cure; this patient is family-incomplete, so uterus-sparing options apply.[1]

(b) UAE, durability versus surgery, and place in fertility (5 marks)

One mark per point, maximum five. [2][3]

• UAE catheterises the uterine arteries via the common femoral artery and injects embolic particles to ischaemic-infarct the fibroids while collateral supply recovers normal myometrium (RANZCOG C-Gyn 23).
• The REST trial showed similar quality-of-life at one year versus surgery, but a shorter hospital stay (median 1 day versus 5 days) and faster return to work; about 9 per cent needed repeat embolisation or hysterectomy within the first year.[2]
• The EMMY trial 10-year follow-up reported a hysterectomy rate of 28 of 81 (35 per cent) by 10 years — about two-thirds avoided hysterectomy, but the re-intervention rate is substantial.[3]
• Complications include embolisation syndrome, pelvic infection (pyomyoma), expulsion of a necrotic submucosal fibroid, ovarian insufficiency and VTE (about 0.3 per cent).
• Effects on ovarian reserve, fertility and pregnancy are uncertain; RANZCOG does not recommend routine UAE in young patients wishing to conceive (Recommendation 1, consensus-based), and pregnancy after UAE carries higher caesarean, postpartum haemorrhage and miscarriage rates.[3][5]

(c) RANZCOG C-Gyn 33 morcellation framework (4 marks)

One mark per point. [4]

• RANZCOG C-Gyn 33 (Power morcellation at Minimally Invasive Procedures, developed by AGES, current November 2022) requires: (1) the patient is engaged in the discussion of tissue extraction; (2) morcellation only in the absence of a suspicion of malignancy (including atypical endometrial hyperplasia); (3) a trained, skilled, credentialed operator (generally AGES-RANZCOG Level 5 and above).
• Good Practice Note: in procedures using a power morcellator, an in-bag containment system should be used.
• The leiomyosarcoma numbers, verbatim: incidence 0.36 to 1.8 per 100,000 woman-years, and the risk of diagnosing LMS after surgery for a presumed fibroid 0.01 to 0.08 per cent — figures that followed the April 2014 US FDA Safety Communication and the Australian TGA alert.[4]

(d) Counselling for her next pregnancy (2 marks)

One mark per point. [1]

• Counsel explicitly on the risk of uterine rupture in a future pregnancy after myomectomy (higher for deep intramural and laparoscopic routes), and discuss the mode of a future delivery.
• Note also the recurrence rate of fibroids after myomectomy (15-30 per cent at 5 years) so expectations are set.[1]