top of page

BackTable / OBGYN / Article

Surgical Management of Fibroids: Myomectomy vs Radiofrequency Ablation

Author Melissa Malena covers Surgical Management of Fibroids: Myomectomy vs Radiofrequency Ablation on BackTable OBGYN

Melissa Malena • Jun 17, 2024 • 34 hits

Surgical fibroid management consists of a diverse range of techniques, from laparoscopic myomectomy to radiofrequency ablation. Differentiating between these techniques in order to match the patient’s goals can be a challenging task for both the patient and the provider. Dr. Sarah Rassier, Director of the Fibroid Clinic at Mayo Clinic, and expert OBGYN Dr. Mark Hoffman share their insights on the surgical management of fibroids, and the role of different treatment options.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• Patient-centered decision-making for fibroids aims to educate the patient and help them make their own treatment decisions based on their personal goals, such as recovery time, fertility, and uterine retention.

• MRI, with the use of vaginal gel, is the recommended imaging modality for possible myomectomy candidates.

• 3D mental modeling and procedural visualization are helpful techniques for surgeons to employ before the first incision is made.

• Radiofrequency ablation treatments, such as Acessa or Sonata, can be used to treat fibroids when a myomectomy procedure would be high-risk or otherwise challenging.

Surgical Management of Fibroids: Myomectomy vs Radiofrequency Ablation

Table of Contents

(1) Patient-Centered Decision-Making in Fibroid Treatment

(2) The Myomectomy Workup: Imaging, Physical Exam & Surgical Models

(3) Fibroid Radiofrequency Ablation: An Alternative to Myomectomy

Patient-Centered Decision-Making in Fibroid Treatment

Myomectomy has previously been posed as a “no-brainer” treatment option for patients with symptomatic fibroids who desire uterine conservation. However, Dr. Rassier has shifted that narrative within her practice, implementing a patient-centered decision-making approach. It is key to work with the patient to determine their priorities and goals relating to fertility, recovery time, and likelihood of recurrence.

Surgical fibroid treatment options range from full hysterectomy to uterine-sparing procedures, such as myomectomy. Patient-led decision-making acts to empower patients and increase outcome satisfaction as it focuses on each patient’s particular goals.

[Dr. Mark Hoffman]
We've talked a little bit about how you manage fibroids. Tell us about the patients who decide on myomectomy or for whom you recommend myomectomy.

[Dr. Sarah Rassier]
I think this is one area where my practice has really evolved over time. I think when we're in medical training, we have this paternalistic way of counseling patients like, "Okay, here's the procedure you need." For most of us, myomectomy was sort of the no-brainer procedure for people that had symptomatic fibroids who wanted uterine conservation.


[Dr. Sarah Rassier]
I feel like I have shifted into more of a patient-centered decision-making where we really try to share the decision making and you go through all the pros and cons because there really are so many options now that it can be overwhelming. I think patients sometimes still try to push me in terms of like, "Well, what would you do if it were you?"

I tend to reply with anecdotes where it's sort of like, "Well, if you're the kind of person who really prioritizes recovery time, getting back to work, getting back to working out, maybe you want one of these non-invasive or interventional shrinking procedures. If you really want to do something that's more aggressive, definitive, lower risk of recurrence, then here's where we're thinking," and try to counsel people that way. I've also noticed lately that even if fertility is not a priority, a lot of patients are really interested in uterine conservation. Even when we're in the mid to late 40s, perimenopausal timeframe, I'm seeing a lot more myomectomy patients in that group too.

[Dr. Mark Hoffman]
It's funny you say that. A lot of my practice has shifted that way too, whether it's sterilization and things like that, or before it was like, "Oh," the counseling we would get from some of our senior attendings is like, "Well, they're too young," or whatever. Listen, I trust adults to make decisions for themselves. I trust that when we provide them with, to the best of our ability, the counseling that could help them make that decision, that when they make a decision, we feel like we have to trust our patients.

I think that when it comes to fibroid management, it's like a buffet. "Here's what we got. Here's what can be expected for this particular treatment or that treatment." I think that's what's allowed our program to be successful as patients get choices. I noticed that in fellowship when they had an alternative to hysterectomy that ended up being probably their busiest hysterectomy clinic because patients felt like, "Well, at least you gave me a choice. Ultimately, I decided on the hysterectomy, but I wasn't told hysterectomy was my only option. I realized what the options were."

[Dr. Sarah Rassier]
Exactly.

[Dr. Mark Hoffman]
"I decided on it myself," which is a very different place for anyone to be about their own care. To be able to offer them everything, go, "Okay, this is what I want." When I started the program with radiology, people thought I was nuts. Why would you give away a hysterectomy? I'm like, "That uterus doesn't belong to me, first of all. If you're worried about that, maybe we're in a different business here."

Of course, what happens is you build the program, patients come to see you, and some of them ultimately decide on surgery, whether it's myomectomy or all these options we're talking about. Then they tell their friends, "Oh, they have everything there." I think it becomes a great way to build a practice. It's been interesting. I think that transition of giving patients options and educating them as opposed to like, "Here's what you need." It still happens out there for sure. I do think that's a really nice patient-centered approach. I would expect nothing less from Mayo.

[Dr. Sarah Rassier]
Yes. I always say if we're doing a really good job, we're going to eventually put ourselves out of business because the goal should be to get things that are less invasive and potentially non-surgical. One of my biggest soapboxes is that hysterectomy should not be the knee-jerk reaction for anyone that's done with childbearing or not interested in fertility because there are a lot more consequences that we're learning about for potentially comorbidities that occur over time, even if you keep your ovaries in. I'm a big believer in offering, when appropriate, uterine-sparing procedures.

Listen to the Full Podcast

Laparoscopic Myomectomy: Tips & Tricks with Dr. Sarah Cohen Rassier on the BackTable OBGYN Podcast)
Ep 41 Laparoscopic Myomectomy: Tips & Tricks with Dr. Sarah Cohen Rassier
00:00 / 01:04

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

BackTable CMEfy button

Stay Up To Date

Follow:

Subscribe:

Sign Up:

The Myomectomy Workup: Imaging, Physical Exam & Surgical Models

Dr. Rassier’s myomectomy workup relies heavily on MRI to help determine treatment options and candidacy for myomectomy, ablation, embolization, or focused ultrasound. Dr. Rassier’s practice uses vaginal gel which helps with the visualization of delineation, especially in cervical and lower uterine segment fibroids. In addition to MRI, the width, mobility, and fundal height of the uterus should be noted through a physical exam.

Information from imaging and the physical exam can then be used to create a 3D mental model of the procedure. Dr. Hoffman emphasizes the importance of thorough pre-procedural mental visualization and planning for smooth and successful procedures.

[Dr. Mark Hoffman]
For myomectomy, it sounds like, again, providing patients options, whether it's patients who want uterine preservation for pregnancy or whether it's because they just don't want a hysterectomy. Then what about your workup? When they come to see you in clinic, they have fibers, they want surgical treatment, how do you evaluate patients? What's your clinic workup?

[Dr. Sarah Rassier]
I think we're pretty spoiled in terms of working with our MR radiology team here. We have a really excellent GYN radiology group. We do get a lot of MRIs. We try to be thoughtful about not overordering it on everybody. I will say, unless it's a really simple-looking myomectomy, I typically will get some MRI imaging for people just for surgical planning. Oftentimes, especially if they're considering various options, that's helpful to tell them if they're a good candidate for embolization or focused ultrasound or things like that.

I usually have an MRI with some pretty awesome imaging. We use vaginal gel, which is really helpful too. I feel like that's not something I see in a lot of outside facilities, but that really helps with delineation, especially cervical or lower uterine segment fibroids. That helps me with counseling too about the route of surgery. Also for me just planning out, what am I thinking? Do I want to try to shrink this uterus ahead of time? Where will my ports be? Will I need to do a mini-laparotomy? What will the positioning look like?

I'm pretty heavy on the imaging in addition to the exam too, feeling the width and mobility of the uterus as well as just the overall fundal height. Everyone's torso is a little different. How much room do they have between the fundus and the costal margin? Is it realistic to do a purely scope case or what are we trying to think outside the box here? Things like that.

[Dr. Mark Hoffman]
I have a very similar approach, MRI, and we're lucky to be where we are, I think because you have done some 3D modeling and printing and those kinds of things. I remember, and anyone who wants to learn about fibroids just needs to look up Dr. Rassier or Dr. Cohen. There's a lot of her work published.

[Dr. Sarah Rassier]
Yes.

[Dr. Mark Hoffman]
There's a ton out there that you've done, which is amazing work. For me, it's that 3D model and it's looking at all three axes back and forth and back and forth. I've got one here. Here's where the uterine arteries are. Here's where IP is. I think this is where the tube is. It looks rotated to me based on where the cavity is. I'm going to have to make my hysterectomy in this direction. Which fibroids can I get out through which incision? Try to have as much of a plan before you make an incision. Yes, I think a lot of it is that 3D mapping in my mind of how we approach it.

[Dr. Sarah Rassier]
Yes, I totally agree. I think that's something that comes with experience. I find that that's something that the trainees tend to have a little bit harder time with in the beginning until they do more and more of these cases is seeing things in a three-dimensional field, especially if you're a straight stick surgeon where you are working with 2D vision usually.

I sometimes, I think, liken it to sports psychology, how you're running through the game in your head before you actually get on the field. I definitely do that, especially with my challenging cases of running through the steps, how am I going to prepare, and doing most of the planning before you even make an incision.

[Dr. Mark Hoffman]
I've had that exact same conversation with my trainees. It's that visualizing the win kind of thing, like, how am I going to actually achieve this goal? Seeing it in my mind first, it makes it so much easier. Oftentimes when you get in there and actually see the uterus, I don't know if you ever get this feeling, but today we had a case, I had a plan for it. You get in there and you go, "All right, we're done. Okay, big fiber, then put your cul-de-sac, the case is over." I know all the steps, it's any worries of what might be when you see it, you go, "Okay, I can boop, boop, boop, see my views and we're done."

[Dr. Sarah Rassier]
Exactly.

Fibroid Radiofrequency Ablation: An Alternative to Myomectomy

Fibroids can be treated in a variety of manners, ranging from complex surgical removal to targeted radiofrequency ablation. Dr. Rassier implements all such avenues in her practice. When utilizing radiofrequency modalities, she prefers the transcervical Sonata over Acessa, as it provides consistent results while minimizing patient recovery time.

There is debate on the usefulness of radiofrequency ablation techniques, as both radiofrequency and myomectomy techniques require anesthesia and laparoscopic incisions, but only myomectomy removes the fibroid. However, Dr. Rassier recommends radiofrequency treatments for challenging myomectomy cases. Radiofrequency techniques offer a less invasive procedure than myomectomies, a shorter recovery time, and a lowered risk of blood loss, all without myometrial disruption.

[Dr. Mark Hoffman]
With your program, obviously, myomectomies, and that's why you're here, hysterectomies, are you guys using any other treatment options, any other procedural treatment options for fibroids?

[Dr. Sarah Rassier]
Yes. I don't want to be too much of an advertisement for our program with this, but we're really proud to offer every possible treatment option. That's one thing that I felt really strongly about was offering all the possible things, whether it's medical interventions for shrinking fibroids with our radiology colleagues or the radiofrequency treatments, as well as complex surgical options.

[Dr. Mark Hoffman]
Yes. We're just getting Sonata here. Are you guys using Sonata, Acessa, or both?

[Dr. Sarah Rassier]
Yes. We use both. Initially, I think when I was coming on to using radiofrequency, I had a harder time picturing where Acessa or a laparoscopic approach would fit into my practice. I thought, well, if you're going to go through general anesthesia and have some incisions for laparoscopy, why don't you just take the fibroid out, especially if you're comfortable with myomectomies and suturing?

I find that there are some patients who really want a less invasive procedure, something that's quicker, with a quicker recovery time of probably a week or two, less risk of blood loss or transfusion, or just shorter surgeries in general. I think there are some select patients who really do gravitate towards laparoscopic radiofrequency. For me, the Sonata or the transcervical radiofrequency is really amazing. I feel like that just gives you such an opportunity for great results with a very low recovery time.

[Dr. Mark Hoffman]
It seems like a game-changer. We're just going to be starting that pretty soon. I think those of us who operate on and manage patients with fibroids, those fibroids were like, "They're there, I can see them. You're having some bleeding, probably pretty well medically managed for now." They come back in two or three years and now they're six or seven centimeters or they've got three or four or five of them. It's like, "Man, we could have zapped this thing when it was little and kept it small with no myometrial disruption."

I know the pregnancy data is there. It's limited, but it's pretty good. I don't think of myomectomies as being a traumatic uterine muscle either. I'm very, very curious about the pregnancy data with RF ablation of fibroids too. I think it's going to be very interesting.

[Dr. Sarah Rassier]
Yes. I think that's really where the future is going for us. I sort of suspect that down the road in 50 years or however long, people will think like, "Oh, my gosh, that was so barbaric what they used to do," with the major procedures that we're doing for myomectomies. Especially if we could identify fibroids when they're smaller, even asymptomatic fibroids and potentially stun them and stall them in place, so they don't keep growing, yes. I think that would be amazing.

[Dr. Mark Hoffman]
I think that's going to be the big leap because doing procedures on asymptomatic patients, it's not risk-free, but when I was a resident and I saw a bunch of open myomectomies, one of my attendings used to take a needle without a suture on it, would stick it and do it like these little small fibroids, little pedunculated fibroids and would put the Bovie on it, basically cooking these fibroids when they're real little to prevent them from getting bigger.

In hindsight, that's what we're doing now. To do it transcervically and have no incisions and have it be coagulative necrosis without the pain of ischemic necrosis, I do think that's going to be something that I'm optimistic about. I'm really glad to hear you're having that experience up in Minnesota because to me, there's those you want, do I want to do a myomectomy when I know there's a chance I may do a second one in four or five years? Those are not a great case, the second myomectomy. I'm excited about it. I'm hoping it does what I'm reading that it does.

[Dr. Sarah Rassier]
Yes, definitely. I think I'm finding the place for Acessa or laparoscopic radiofrequency in my practice is tending to be people where their myomectomy would not be easy. It's sort of a complex fibroid, maybe it's a cervical fibroid location or something that's going to be a more challenging case. Not that it's impossible, but when I'm counseling them about the risks and benefits, I'm thinking, "Okay, well, maybe do we want to just get some volume reduction," especially if it's mainly bulk symptoms for them. I think it really does help with that quite a bit.

[Dr. Mark Hoffman]
Interesting. Yes. I guess I think about that when I counsel patients about UFE because I'm really proud of our fibroid program with radiology. They come to our clinic. It's been a really nice program for our patients, very patient-centered. I tell them, we don't need to make them go away. You were fine and asymptomatic up until about whatever, six months, two years ago. This is a time machine. This is going to bring these fibroids back a few years to when they weren't causing you trouble, and hopefully, they won't grow.

If that's our goal and avoiding a major abdominal surgery, then I think that's an important goal. I guess what I'll find out when we're doing the transcervical approach is which ones we cannot address through that approach and where the laparoscopic approach may be a benefit. That's interesting. I've been watching both for a long time, but this is the first one where I was like, "All right, I think we need this." I'll let you know we end up learning from our cases here.

[Dr. Sarah Rassier]
Definitely.

Podcast Contributors

Dr. Sarah Cohen Rassier discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Sarah Cohen Rassier

Dr. Sarah Cohen Rassier is a minimally invasive gynecologic surgeon at Mayo Clinic in Rochester, Minnesota.

Dr. Amy Park discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, December 21). Ep. 41 – Laparoscopic Myomectomy: Tips & Tricks [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

backtable-earn-free-cme.jpg
backtable-plus-vi-cta.jpg

Podcasts

Laparoscopic Myomectomy: Tips & Tricks with Dr. Sarah Cohen Rassier on the BackTable OBGYN Podcast)
Tackling the Big Uterus with Dr. Uchenna Acholonu on the BackTable OBGYN Podcast)
Reevaluating Activity Guidelines After Surgery with Dr. Margaret Mueller and Dr. Kim Kenton on the BackTable OBGYN Podcast)
Sustainable Global Healthcare Missions with Dr. Princess Urbina on the BackTable OBGYN Podcast)
The Natural Orifice Surgery: Vaginal Hysterectomy with Dr. Amy Park on the BackTable OBGYN Podcast)
Advanced Hysteroscopy with Dr. Linda Bradley on the BackTable OBGYN Podcast)

Articles

How to Reduce Blood Loss During Myomectomy

How to Reduce Blood Loss During Myomectomy: Advanced Techniques in Laparoscopic Myomectomy Surgery

Decision Points in Laparoscopic Myomectomy Surgery

Decision Points in Laparoscopic Myomectomy Surgery

Transcervical Fibroid Ablation: Advancements in Uterine Fibroid Treatment

Transcervical Fibroid Ablation: Advancements in Uterine Fibroid Treatment

In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care

In-Office Hysteroscopy Surgery: Tools, Techniques & Post-Op Care

Topics

Get in touch!

We want to hear from you. Let us know if you’re interested in partnering with BackTable as a Podcast guest, a sponsor, or as a member of the BackTable Team.

Select which show(s) you would like to subscribe to:

Thanks! Message sent.

bottom of page