Surgical Management of Fibroids: Myomectomy vs Radiofrequency Ablation

[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.
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[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.

[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.