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Introduction: Fibroids are the most common benign uterine tumors. Transcervical radiofrequency ablation with the Sonata® System offers a minimally invasive, incisionfree, organ-preserving therapy, with intraoperative visualization of fibroids using intrauterine ultrasound guidance. To demonstrate the effectiveness of transcervical radiofrequency ablation of fibroids that are 5 cm or larger using the Sonata® System, this retrospective analysis was collected., Method: 151 patients have been treated with this method in our department up to the time of this analysis. Only patients with at least one fibroid of ≥5 cm and with bleeding symptoms, who were treated with the Sonata® System were included in this retrospective study. A total of 50 patients were included in the study and 57 fibroids were treated., Results: A total of 57 fibroids were detected and treated, however FIGO 1 and 2 fibroids (in total three fibroids were excluded). The smallest fibroid was 4 cm and the largest fibroid was 12 cm. A single ablation was performed in 18 cases, two ablation steps in 16 cases, three ablation steps in 13 cases, and more than three ablation steps in three cases. Depending on ablation steps, the shortest ablation time was 3 min 15 s and the longest ablation time was 25 min 6 s, with an average time of 9 min 12 s. 86% of patients reported an improvement of symptoms Conclusion: Thus, the Sonata® System is a simple, minimally invasive, rapid and successful method that shows significant improvement of symptoms even in large myomas from ≥5 cm., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: Currently, no reliable data are available concerning the type and frequency of symptoms in premenopausal women with uterine myomas., Methods: 2296 women were examined by means of vaginal ultrasound for the presence of myomas in seven gynaecological outpatient departments in Germany. From this population, 1314 premenopausal women between the ages of 30 and 55 years were evaluated to determine the type and frequency of myoma-related symptoms and their relationship to anamnestic factors, and the number, size, and location of the myomas. Standardised questionnaires were used to record the symptoms., Results: Prevalence: In almost every second premenopausal woman (n = 639; 48.6%), uterine myomas were diagnosed. The frequency of myomas increased continuously with age and was highest in women between 46 and 50 years (65.2%). Age itself was found to be the main risk factor for the presence of myomas (p < 0.001)., Symptoms: 54.3% (n = 347) of the women suffered from myoma-related symptoms. The four main symptoms were identified as: Heavy menstrual bleeding (40.7%), dysmenorrhoea (28.2%), lower abdominal pain (14.9%), and intermenstrual bleeding (14.1%). In the majority of cases, the symptoms occurred simultaneously. Determinants for symptoms: Symptoms did not follow a clear age-related trend, whilst the number and size of the myomas did determine the presence of symptoms. The main influencing factor for the presence of intermenstrual bleeding was the location of the myomas., Conclusions: The high prevalence of uterine myomas highlights the importance of the diagnosis uterine myomas in standard gynaecological practice: The presence of only one myoma caused symptoms in 46.5% and small myomas of up to 2 cm in diameter resulted in symptoms in 39.5%.

Background: Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures., Methods: Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews., Results: Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators., Conclusion: Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.

A mobile, subserous, pedunculated myoma was located on the anterior surface of the uterus in a 45-year-old woman. Bipolar coagulation was performed on the pedicle, and the myoma was dissected with an electrical morcellator and removed through the umbilicus. This technique required placement of one 5- to 12-mm cannula in the umbilicus and two 2-mm miniports at the pubic hairline. This technique is easy to perform, and the patient benefits from minimal postoperative pain and excellent cosmetic results.

From February 1992 to December 1995 hysteroscopical myoma resections were performed in 70 patients suffering from recurrent bleeding disorders. In 24 cases of single myoma these were submucous with their largest portion located in the uterine wall. In all cases a pretreatment was performed with 2-3 injections of GnRH-analogues. The indication for resection must be proved critical in submucous myoma with their largest portion in the uterine wall, because a higher rate of complications is described. A simultaneous sonographical or laparoscopical control is necessary. In 2 cases of large myomas second resections were performed. The hysteroscopical resection of submucous myoma with their largest position in the uterine wall is a procedure for a surgeon with much experience in the field of operative hysteroscopy. In a follow up of 5 to 52 months a normal menstruation was reached in all patients. No intra- or postoperative complications were seen, no hysterectomy had to be performed until now. The resection of submucous myoma with their largest portion in the uterine wall is a surgery without a higher complication rate when carried out by an experienced surgeon.

In 20 patients, a hysteroscopic resection of myomas because of menometrorrhagia was carried out between February 1992 to July 1993. Solitary myoma was diagnosed before sonographically, hysteroscopically and histologically. 14 patients had been pretreated with GnRH-analogs for 2 or 3 months, whereas in 6 patients the transcervical resection of myomas was carried out immediately after menstruation. In a follow-up period of 3-18 months, an eumenorrhea could be reached in 19 patients. In one patient, a second session for a resection of a small myoma was necessary. There were no intra- or postoperative complications. The resection of myomas is a useful organ-retaining option of treatment in patients with submucous myoma and menometrorrhagia.

By means of laparoscopic supracervical and pelviscopic intrafascial hysterectomy (CISH) new minimally invasive hysterectomy methods for benign indications have been developed where the cervix or a portion of the cervix remain intact. The carcinoma risk is extremely small. Using the example of a large cervical myoma 25 years after a supracervical hysterectomy, the possibility of recurrent myomas is emphasized.

A proliferative leiomyoma, which had possibly been removed only subtotally by hysteroscopic resection, grew postoperatively so that vaginal hysterectomy had to be carried out. The histology of the leiomyoma showed an increased expression of the proliferative marker Ki-67.

In a retrospective study, the value of pretreatment with a gonadotropin-releasing-hormone (GnRH) agonist before hysteroscopic myoma resection was assessed in 31 patients suffering from menorrhagia. No difference in operating time, intra-operative fluid deficit, blood loss and postoperative eumenorrhoea rate was found between pretreated and non-pretreated patients with solitary submucous myomas smaller than 4 cm in diameter. Thus, pretreatment with GnRH agonists before the resection of small solitary submucous myomas has no benefit for the patients.

Ladina Christoffel,1 Thomas Römer,2 Sven Schiermeier3 1Spital Oberengadin, Samedan, Switzerland; 2Evangelisches Klinikum Köln-Weyertal, Köln, Germany; 3Marien-Hospital, Witten, GermanyCorrespondence: Ladina ChristoffelSpital Oberengadin, Via Nouva 3, Samedan, CH-7503, SwitzerlandTel +41 81851 8111Email Christoffel.Ladina@spital.netBackground: Transcervical fibroid ablation (TFA) is a minimally invasive, effective treatment of symptomatic uterine fibroids that utilizes intrauterine ultrasound for imaging and radiofrequency energy for ablation. Outcomes reported with TFA have been positive, with significant reductions in fibroid volume, improvements in symptom severity and health-related quality of life, and low complication and surgical reintervention rates. The SAGE registry characterizes the long-term (5-year) outcomes of TFA when used to treat symptomatic uterine fibroids in real-world usage.Methods/Design: SAGE is an ongoing postmarket global registry involving up to 50 sites and up to 500 women who select TFA with the Sonata system for treatment of symptomatic uterine fibroids. Patients are followed for 5 years. Main outcomes include symptom severity score and health-related quality of life subscales of the UFS-QoL, general health status on the EQ-5D, perceived treatment benefit, treatment satisfaction, work and activity patterns, overall patient treatment outcome, adverse events, pregnancy incidence and outcomes, and surgical reinterventions for heavy menstrual bleeding.Discussion: The SAGE registry represents the largest known study of TFA for uterine fibroids and will generate up to 2500 patient-years of outcome data. Preliminary results from the first 160 treated women suggest broad applicability of TFA to a wide range of fibroid types and sizes and an excellent safety profile, with a device-related adverse event rate of 0.6% and a serious procedure-related adverse event rate of 0.6%. Of the 241 fibroids treated, 10% were submucous, 52% transmural, 28% intramural, and 10% subserous. Ablated fibroid diameters ranged from < 1 cm to > 10 cm, with 27% of fibroids having maximum diameters > 5 cm. The real-world experience from SAGE will strengthen the existing evidence on the durability of TFA in providing meaningful relief from uterine fibroid symptoms and will have important clinical and economic implications for patients, physicians, and healthcare payers.Trial Registration: https://clinicaltrials.gov, NCT03118037. Registered on 18 April 2017.Keywords: leiomyoma, myoma, radiofrequency ablation, SAGE, Sonata, transcervical fibroid ablation, uterine fibroid