Management of symptomatic fibroids: conservative surgical treatment modalities other than abdominal or laparoscopic myomectomy

Approximately 50% of women of reproductive age have fibroids, and at least 50% of these women have significant symptoms. However, until 15 years ago, the only surgical options available were hysterectomy and myomectomy, and as yet there are no proven effective long-term medical therapies. Fortunately, the past decade has witnessed the emergence of highly sophisticated diagnostic and therapeutic technologies for fibroids. Magnetic resonance imaging and high-resolution ultrasound are non-invasive, high-quality diagnostic procedures. The new treatment modalities include: laparoscopic and vaginal myomectomy; uterine artery embolization (UAE); magnetic-resonance-guided focused ultrasound surgery (MRgFUS); hysteroscopic resection where the fibroids are submucous; myolysis by heat, cold coagulation and laser; laparoscopic uterine artery occlusion; and temporary transvaginal uterine artery occlusion. It is, however, abundantly clear that there is no panacea that suits every woman, nor are all treatment types universally available to all women, even in the developed world. Laparoscopic surgery requires skills that are not common place, and there are limitations on the size and number of fibroids that can be treated by this modality. Much the same applies to vaginal myomectomy. UAE is now widely used in the USA and Western Europe, and has been recommended by the National Institute for Clincial Excellence (NICE) in the UK as an alternative therapy to hysterectomy. However, UAE is still under evaluation in terms of comparison with myomectomy. UAE has a range of complications including premature ovarian failure, chronic vaginal discharge and pelvic sepsis, and may have limited efficacy when the fibroids are large. Although there are a number of reports of successful pregnancy following UAE, the experience is limited and research is required in this area . MRgFUS was approved by the US Food and Drug Administration in 2004, while NICE recommended that the procedure should be used in an audit and research setting. Preliminary data following laparoscopic uterine artery occlusion suggest that outcomes are similar to those with UAE, but these data are derived from studies involving relatively small numbers. Temporary uterine artery occlusion is also promising, but has yet to be evaluated robustly. Thus there is no room for complacency; research involving the available treatment modalities is urgently needed, while innovations in search of newer and more effective therapies must continue. This chapter will review surgical treatment modalities other than hysterectomy and abdominal or laparoscopic myomectomy.