O&G · Gynaecological health — benign gynaecology
Uterine fibroids: surgical and radiological management — myomectomy, UAE, HIFU, morcellation
Also known as Myomectomy · Uterine artery embolisation · Morcellation · MRgFUS · HIFU for fibroids
Exam-exhaustive FRANZCOG fellowship reference on the surgical and radiological management of uterine fibroids: the FIGO-type-to-procedure mapping (hysteroscopic myomectomy for FIGO 0-2, laparoscopic or open myomectomy for 3-7, hysterectomy when the family is complete), uterine artery embolisation detail (RANZCOG C-Gyn 23, REST and EMMY re-intervention rates), HIFU / MR-guided focused ultrasound and radiofrequency ablation, and the power-morcellation controversy and occult-leiomyosarcoma risk (RANZCOG C-Gyn 33 / AGES, in-bag containment). Assessment and medical management live in the uterine-fibroids topic. RANZCOG-primary, globally tagged to MRCOG, ABOG, FRCSC and MRCPI.
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Red flags
- Never morcellate a fibroid when malignancy is suspected — there is no reliable pre-operative test for leiomyosarcoma
- A rapidly growing fibroid in a postmenopausal woman is sarcoma until proven otherwise — plan en-bloc removal, not morcellation
- Uterine rupture after myomectomy in a future pregnancy is a real risk — counsel on it and on mode of delivery
- UAE has a high re-intervention rate — counsel that about a third of women having UAE will need a hysterectomy within ten years
- UAE, HIFU and radiofrequency ablation in women desiring fertility belong in trial settings, not routine care (RANZCOG C-Gyn 27)
- Pre-operative anaemia correction (iron, short-course medical therapy) before myomectomy or hysterectomy reduces transfusion and complications
A registrar presents a 38-year-old, family incomplete, with a 16-week uterus and a FIGO 1 submucosal fibroid plus three large intramural masses — she wants fertility preserved and the bleeding stopped. The decision is not whether to operate, but which route for which fibroid, in what order, and with what counselling about her next pregnancy. This topic carries the operative and radiological options; the assessment, imaging and medical ladder are in the uterine-fibroids topic.[1][2]
The operative principle — match the route to the FIGO type
The single most tested skill in fibroid surgery is the FIGO-type-to-procedure mapping. Before you choose a route you must have mapped every fibroid on TVUS and (for complex cases) MRI to its FIGO type, because the type dictates whether a resectoscope, a laparoscope or a laparotomy is the right instrument.[1][2]
| FIGO type | First-line surgical route |
|---|---|
| 0, 1, 2 (and selected 3) | Hysteroscopic myomectomy — cavity access, fertility-sparing |
| 3, 4, 5, 6, 7 | Laparoscopic or open (abdominal) myomectomy — route by size, number, skill, ureter proximity |
| 8 (cervical, broad-ligament, parasitic) | Usually laparotomy with careful ureteric identification |
| Any type, family complete | Hysterectomy — definitive cure |
References12ShowHide
- [1]American College of Obstetricians and Gynecologists (ACOG) Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228 Obstet Gynecol, 2021.PMID 34011888
- [2]Bajaj S, Gopal N, Clingan MJ, Bhatt S. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas Abdom Radiol (NY), 2022.PMID 34581926
- [3]Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids N Engl J Med, 2007.PMID 17251532
- [4]Gupta JK, Sinha A, Lumsden MA, Hickey M, et al. Uterine artery embolization for symptomatic uterine fibroids Cochrane Database Syst Rev, 2014.PMID 25541260
- [5]de Bruijn AM, Ankum WM, Reekers JA, Birnie E, van der Kooij SM, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial Am J Obstet Gynecol, 2016.PMID 27393268
- [6]Metwally M, Raybould G, Cheong YC, Horne AW. Surgical treatment of fibroids for subfertility Cochrane Database Syst Rev, 2020.PMID 31995657
- [7]Pritts EA, Parker WH, Brown J, Olive DL. Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review J Minim Invasive Gynecol, 2015.PMID 25193444
- [8]Lum DA, Sokol ER, Berek JS, Schulkin J, Chen L, et al. Impact of the 2014 Food and Drug Administration Warnings Against Power Morcellation J Minim Invasive Gynecol, 2016.PMID 26827905
- [9]Zullo F, Venturella R, Raffone A, Saccone G. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy Cochrane Database Syst Rev, 2020.PMID 32374421
- [10]Puri K, Famuyide AO, Erwin PJ, Stewart EA, Laughlin-Tommaso SK. Submucosal fibroids and the relation to heavy menstrual bleeding and anemia Am J Obstet Gynecol, 2014.PMID 24080304
- [11]Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review BJOG, 2017.PMID 28296146
- [12]Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future Hum Reprod Update, 2016.PMID 27466209