As stressed by Stewart (2015), there are areas of uncertainty surrounding
the management of myomas, as only a few randomized
trials have compared different therapies for fibroids. Moreover, data
on their comparative effectiveness in terms of future fertility are lacking.
There are also inadequate data on long-term outcomes in
women who have undergone hysterectomy according to indication
(Stewart, 2015). Prospective data and studies are essential to compare
different options and evaluate long-term outcomes with regard
to QoL, recurrence of symptoms (bleeding, bulk symptoms), fertility
and even complications.
Indeed, in a cohort study of 30 117 Nurse’s Health Study participants
undergoing hysterectomy for benign disease, bilateral oophorectomy
was found to be associated with increased mortality in
patients under 50 years of age who had never used estrogen therapy
(Parker et al., 2013).
While guidelines exist in the literature (ACOG, 2008; ASRM,
2008; Marret et al., 2012; Stewart, 2015), the risks and benefits of
each option should be discussed with the patient. It should also be
stressed that many other factors need to be taken into account,
including the skill of the surgeons involved, as well as the experience
of different centers in the available techniques.
Current management strategies involve mainly surgical interventions,
but the choice of treatment is guided by the patient’s age and
desired to preserve fertility or avoid ‘radical’ surgery such as
hysterectomy (Donnez and Jadoul, 2002; Practice Committee of the
American Society for Reproductive Medicine, 2008; Lumsden et al.,
2015). Other surgical and non-surgical approaches include myomectomy
by hysteroscopy, myomectomy by laparotomy or laparoscopy,
uterine artery embolization (UAE) and other interventions performed
under radiologic or ultrasound guidance (Fig. 4) (Donnez and Jadoul,
2002; Practice Committee of the American Society for Reproductive
Medicine, 2008; Lumsden et al., 2015; Stewart, 2015; Zupi et al.,
2015).
Hysteroscopic myomectomy

Over the last 30 years, advances in instruments and techniques have
promoted hysteroscopic myomectomy to the rank of a standard
minimally invasive surgical procedure for submucous myomas. Small
fibroids (<2 cm) are now routinely removed in an outpatient setting
according to the technique described by Bettocchi (Bettocchi et al.,
2003, 2004; Di Spiezio Sardo et al., 2010; Casadio et al., 2011;
Mazzon et al., 2015; Vilos et al., 2015).
Depending on personal experience and available equipment, the
gynecologist has a choice of several alternative procedures.
The first involves cutting the base of pedunculated fibroids with
either the resectoscopic loop or laser fiber (Stamatellos and Bontis,
2007; Bettocchi et al., 2004; Di Spiezio Sardo et al., 2008; Tan and
Lethaby, 2013). The base of the pedicle is cut and the fibroid is
extracted by forceps or may be left in place.

Laparoscopic myomectomy
Laparoscopic myomectomy is perceived by many gynecological surgeons
to be more difficult, but the advantages are real: less severe
post-operative morbidity, faster recovery with laparoscopic procedures
and no significant difference between reproductive outcomes
after laparoscopic or abdominal myomectomy (by minilaparotomy)
(Donnez et al., 2014a,b; Bhave Chittawar et al., 2014; Segars et al.,
2014). However, there have been reports of uterine rupture after
laparoscopic myomectomy, thus emphasizing the importance of
adequate closure of the myometrial defect (Dubuisson et al., 2000;
Parker et al., 2010; Thomas et al., 2010). In a review of nine trials
including 808 patients (Bhave Chittawar et al., 2014), there was no
evidence of any difference in recurrence risk between laparoscopy
and open myomectomy.

Laparoscopic hysterectomy
Hysterectomy has long been considered standard surgical treatment
for symptomatic intramural and submucous fibroids, particularly for
women not wishing to conceive or those of premenopausal age
(40–50 years). In the US, more than 600 000 hysterectomies are performed
each year (Flynn et al., 2006). In Denmark, the overall hysterectomy
rate was around 180/100 000 women during the period
1977–2011 (Lykke et al., 2013).

Laparoscopic cryomyolysis and thermo-coagulation
Both laparoscopic cryomyolysis and thermo-coagulation have the
same goal: reduction or suppression of the primary blood supply and
induction of myoma shrinkage by causing sclerohyaline degeneration
(by very low or very high temperatures).

Laparoscopic occlusion of the uterine arteries
Laparoscopic occlusion of the uterine arteries appears to have no
specific advantage over vaginal occlusion, as it requires a laparoscopic
approach. Moreover, when compared to UAE, the outcomes were
found to be inferior in terms of myoma size reduction and devascularization
(Hald et al., 2004).