Impact of ultrasound-guided high-intensity focused ultrasound for the treatment of uterine fibroids on ovarian reserve and quality of life: a single-center prospective cohort study.

BACKGROUND: We aimed to evaluate changes in ovarian reserve and quality of life in women treated with ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids. METHODS: In this single-center prospective study, a total of 69 patients with uterine fibroids treated with USgHIFU from October 2018 to November 2021 were enrolled. Fibroid volume, anti-Müllerian hormone (AMH) levels, uterine fibroid symptom scores, and uterine fibroid symptoms and quality of life (UFS-QOL) questionnaire scores before and 1, 3, and 6 months after USgHIFU treatment were analyzed. Correlations between AMH levels and age, fibroid type, and fibroid location were assessed. RESULTS: Data from 54 of the 69 patients included in the present study were analyzed. The UFS-QOL scores at baseline and at 1 month and 6 months after USgHIFU treatment were 70 (50.75-87.50), 57 (44.75-80.00), and 52 (40.75-69.00) points, respectively (p < 0.001). The rate of fibroid volume reduction increased significantly at the 3-month follow-up compared with the 1-month follow-up (p < 0.001), and no significant change was observed between the 3-month and 6-month follow-ups (p > 0.99). The median AMH levels before and at 1, 3 and 6 months after treatment were 1.22 (0.16-3.28) ng/ml, 1.12 (0.18-2.52) ng/ml, 1.15 (0.19-2.08) ng/ml and 1.18 (0.36-2.43) ng/ml, respectively (p = 0.2). Multivariate linear regression analyses revealed that age was independently associated with AMH levels. CONCLUSIONS: USgHIFU treatment for uterine fibroids can significantly improve quality of life with minimal adverse effects on ovarian function.

Long-term re-intervention after USgHIFU and prediction of NPVR in different ages of patients with uterine fibroids.

OBJECTIVE: Long-term re-intervention after ultrasound-guided high intensity focused ultrasound (USgHIFU) ablation was reported, and the prediction of non-perfusion volume ratio (NPVR) in differently aged patients with uterine fibroids (UFs) was explored. MATERIALS AND METHODS: Patients with UFs who underwent USgHIFU ablation from January 2012 to December 2019 were enrolled and divided into < 40-year-old and ≥ 40-year-old groups. Cox regression was used to analyze the influencing factors of re-intervention rate, and receiver operating characteristic (ROC) curve was used to analyze the correlation between NPVR and re-intervention rate. RESULTS: A total of 2141 patients were enrolled, and 1558 patients were successfully followed up. The 10-year cumulative re-intervention rate was 21.9%, and the < 40-year-old group had a significantly higher rate than the ≥ 40-year-old group (30.8% vs. 19.1%, p < 0.001). NPVR was an independent risk factor in both two groups. When the NPVR reached 80.5% in the < 40-year-old group and 75.5% in the ≥ 40-year-old group, the risk of long-term re-intervention was satisfactory. CONCLUSION: The long-term outcome of USgHIFU is promising. The re-intervention rate is related to NPVR in differently aged patients. Young patients need a high NPVR to reduce re-intervention risk.

Ultrasound Monitoring of Simultaneous high-intensity focused ultrasound (HIFU) therapy using minimum-peak-sidelobe coded excitation.

Bipolar sequences can be readily transmitted by ultrasound (US) pulser hardware with the full driving voltage to boost the echo magnitude in B-mode monitoring of HIFU treatment. In this study, a novel single-transmit bipolar sequence with minimum-peak-sidelobe (MPS) level is developed not only to restore the image quality of US monitoring but also remove acoustic interference from simultaneous HIFU transmission. The proposed MPS code is designed with an equal number of positive and negative bits and the bit duration should be an integer multiple of the period of the HIFU waveform. In addition, different permutations of code sequence are searched in order to obtain the optimal encoding. The received imaging echo is firstly decoded by matched filtering to cancel HIFU interference and to enhance the echo magnitude of US monitoring. Then, Wiener filtering is applied as the second-stage pulse compression to improve the final image quality. Simulations and phantom experiments are performed to compare the single-transmit MPS decoding with conventional two-transmit methods such as pulse-inversion subtraction (PIS) and Golay decoding for their performance in simultaneous US monitoring of HIFU treatment. Results show that the MPS decoding effectively removes HIFU interference even in the presence of tissue motion. The image quality of PIS and Golay decoding, on the other hand, is compromised by the uncancelled HIFU components due to tissue motion. Simultaneous US monitoring of tissue ablation using the proposed MPS decoding has also demonstrated to be feasible in ex-vivo experiments. Compared to the notch filtering that also allows single-transmit HIFU elimination, the MPS decoding is preferrable because it does not suffer from the tradeoff between residual HIFU and speckle deterioration in US monitoring images.

Long-term outcomes of ultrasound guided high intensity focused ultrasound ablation for patients with uterine fibroids classified by T2WI: a multicenter retrospective study.

OBJECTIVE: To evaluate the long-term outcomes of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation of uterine fibroids classified by T2-weighted magnetic resonance imaging (T2WI-MRI). MATERIALS AND METHODS: The data of 1427 premenopausal women with symptomatic uterine fibroids who underwent USgHIFU at four teaching hospitals in China were analyzed retrospectively. The uterine fibroids were classified based on their T2WI-MRI signal intensities relative to that of skeletal muscle, myometrium and endometrium as: hypointense, isointense, heterogeneous hyperintense fibroids (HHF), slightly HHF (sHHF) and markedly HHF (mHHF), respectively. The rates of symptom relief and reintervention post-USgHIFU ablation were compared between the classified groups. RESULTS: A total of 1303 patients were followed up for 44 (40, 49) months. The symptom relief rate of the hypointense and isointense fibroids was 83.3% and 79.5%, respectively, which were significantly higher (p < .05) compared to that of HHF, sHHF and mHHF (58.3%, 44.2% and 60.4%), respectively. sHHF had the lowest symptom relief rate (p < .05). The cumulative reintervention rate for hypointense, isointense, HHF, sHHF and mHHF types were 8.8%, 10.8%, 21.4%, 39.9% and 19.8%, respectively. The reintervention rate of hypointense/isointense fibroids was significantly lower than that of HHF/mHHF/sHHF (p < .01), while sHHF had the highest re-intervention rate (p < .01). Thus, reintervention rate is inversely correlated to the rate of symptom relief. CONCLUSIONS: USgHIFU ablation is effective for hypointense, isointense, HHF and mHHF with acceptable long-term follow-up outcomes. However, sHHF is associated with a higher reintervention rate.

Reproductive and Obstetric Outcomes after UAE, HIFU, and TFA of Uterine Fibroids: Systematic Review and Meta-Analysis.

Novel treatment options for uterine fibroids, such as uterine artery embolization (UAE), ultrasound-guided and magnetic resonance-guided high-intensity focused ultrasound (USgHIFU and MRgHIFU), and transcervical radiofrequency ablation (TFA) methods, are widely used in clinical practice. This systematic review and meta-analysis (CRD42022297312) aims to assess and compare reproductive and obstetric outcomes in women who underwent these minimally invasive approaches for uterine fibroids. The search was performed in PubMed, Google Scholar, ScienceDirect, Cochrane Library, Scopus, Web of Science and Embase. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Cochrane guidelines. The articles were selected to meet the following eligibility criteria: (1) research article, (2) human subject research, and (3) the study of pregnancy outcomes after the treatment of uterine fibroids by either one of three methods-UAE, HIFU, and TFA. The analysis of 25 eligible original articles shows a similar rate of live births for UAE, USgHIFU, MRgHIFU, and TFA (70.8%, 73.5%, 70%, and 75%, respectively). The number of pregnancies varied considerably among these studies, as well as the mean age of pregnant women. However, the results of pregnancy outcomes for TFA are insufficient to draw firm conclusions, since only 24 women became pregnant in these studies, resulting in three live births. The miscarriage rate was highest in the UAE group (19.2%). USgHIFU was associated with a higher rate of placental abnormalities compared to UAE (2.8% vs. 1.6%). The pooled estimate of pregnancies was 17.31% to 44.52% after UAE, 18.69% to 78.53% after HIFU, and 2.09% to 7.63% after TFA. The available evidence confirmed that these minimally invasive uterine-sparing treatment options for uterine fibroids are a good approach for patients wishing to preserve their fertility, with comparable reproductive and obstetric outcomes among the different techniques.

Comparison of ultrasound-guided high-intensity focused ultrasound ablation and hysteroscopic myomectomy for submucosal fibroids: a retrospective study.

OBJECTIVE: To compare the safety, reintervention and pregnancy outcomes between ultrasound-guided high intensity focused ultrasound (USgHIFU) and hysteroscopic myomectomy (HM) for submucosal fibroids. MATERIALS AND METHODS: A total of 215 patients with a solitary submucosal fibroid treated by USgHIFU or HM at the third Xiangya Hospital were retrospectively reviewed. Among them, 58 treated with USgHIFU, 157 treated with HM. RESULTS: A significant difference was observed in size, location and type of the fibroids, effective rate, and cumulative reintervention rate between the two groups (p < .05). The size of the fibroids was 57.9 ± 1.9 mm in the USgHIFU group, while it was 32.6 ± 1.2 mm in the HM group. The number of the fibroids at horn or fundus/uterine cavity was 16/42 in the USgHIFU group, while it was 21/136 in the HM group. The number of type I/II/2-5 was 16/17/25 in the USgHIFU group, while it was 133/24/0 in the HM group. In the USgHIFU group, the effective rate was 100% and the cumulative reintervention rate at 50 (17-97) months was 19.0%, while in the HM group, it was 94.3% and 7.6%, respectively. During the follow-up period, the pregnancy rate was 22.4% (13/58) and the reintervention rate due to invalid and recurrence was 15.5% (9/58) in the USgHIFU group, while they were 18.5% (29/157) and 7.0% (11/157) in the HM group. No significant difference was observed between the two groups (p > .05). Furthermore, the reintervention rate was positively correlated with age, treatment methods and parity and fertility requirements. No other significant difference was observed between the two groups. CONCLUSIONS: Both USgHIFU and HM are safe and effective in treating submucosal fibroids. Compared with the HM group, the USgHIFU group had lower postoperative complications, but higher reintervention rate, with similar recurrence rate, pregnancy rate and reintervention rate due to invalid and recurrence. Reintervention was related to age, treatment methods, parity and fertility requirements.

Ultrasound-guided high intensity focused ultrasound ablation for uterine fibroids: long-term outcomes and factors affecting local recurrence.

OBJECTIVE: To assess the long-term outcomes and the factors affecting local recurrence of uterine fibroids after ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation. MATERIALS AND METHODS: 629 patients with a solitary uterine fibroid smaller than 10 cm in diameter treated with USgHIFU at our institutes between January 2011 and December 2016 were retrospectively analyzed. The patients were requested to take pre-HIFU and one day post-HIFU MRI. The patients were asked to return to the hospital every 3 months until January 2020, for imaging evaluation and to check on improvement in symptoms. RESULTS: Five hundred and thirty-six patients completed follow-up according to our protocol. The median follow-up time was 69 (interquartile range: 48 to 89) months. Among them, local recurrence was detected in 110 patients. 18 (16.4%) patients required additional treatment between 12 and 24 months after USgHIFU treatment, 59 (53.6%) patients required additional treatment 24 months after USgHIFU. Therefore, in total, 77 patients required additional treatment, of which 32 received USgHIFU and 45 underwent myomectomy. The median non-perfused volume (NPV) ratio in patients with recurrence was 73%, compared to 89% among patients without recurrence. Multivariate analysis showed that NPV ratio, maximum fibroid diameter and fibroid enhancement type were the independent factors affecting the recurrence of fibroids after USgHIFU treatment. CONCLUSIONS: Achievement of NPV ratio higher than 70% has led to acceptable re-intervention rate during the follow-up period after USgHIFU. NPV ratio, maximum fibroid diameter, and fibroid enhancement type were the independent factors affecting the recurrence of fibroids after USgHIFU treatment.

The safety and ablation efficacy of ultrasound-guided high-intensity focused ultrasound ablation for desmoid tumors.

OBJECTIVE: To evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for desmoid tumors (DTs). METHOD: A total of 111 patients with histologically proven DTs were included and treated by USgHIFU ablation. Adverse events were continuously evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 until 3 months after treatment. The incidence of non-perfused areas within the treated tumors, non-perfused volume rate (NPVR) and tumor volume reduction were evaluated using contrast-enhanced MRI before and one week and 3 months after the procedure. RESULTS: The enrolled patients (32 male, 79 female, mean age 29.5 ± 1.0 years) with 145 DTs (118 extra-abdominal, 16 abdominal wall, 11 intra-abdominal; median maximum diameter: 9.6 cm, range: 3-34.5 cm) underwent 188 sessions of HIFU ablation, and the mean number of ablations was 1.7 (range, 1-7) per patient. In majority of cases (143/145 cases, 98.6%), no serious adverse events were observed. There was no significant difference in the incidence of adverse events between patients who received a single treatment and those who received multiple treatments. Non-perfused area was observed within every treated tumor, and the median NPVR was 84.9% (range, 1.9-100%). The tumor volume reduction rate was 36.1 ± 4.2% at 3 months after treatment. CONCLUSION: USgHIFU ablation, as a noninvasive and easily repeatable local treatment, is a promising treatment for DTs.

Long-term follow-up outcome and reintervention analysis of ultrasound-guided high intensity focused ultrasound treatment for uterine fibroids.

OBJECTIVE: To investigate the long-term reintervention of ultrasound-guided high intensity focused ultrasound (USgHIFU) treatment for uterine fibroids and analyze the factors affecting reintervention rate after USgHIFU. MATERIALS AND METHODS: Three hundred and eight-one patients with uterine fibroids treated by USgHIFU at the third Xiangya Hospital of Central South University from April 2012 to December 2014 were retrospectively reviewed. The factors that affect the reintervention rate were analyzed. RESULTS: The mean follow-up time was 70.0 ± 9.0 months. During the follow-up period, 86.4% (329/381) of the patients reported symptomatic relief and the fibroids shrank after USgHIFU treatment. Seventy-nine patients received reintervention included myomectomy, a second session of HIFU, and hysterectomy. The overall reintervention rate was 20.7% (79/381). The reasons for reintervention included symptomatic recurrence in 50 (50/79, 63.3%) patients, psychological factors in 14 (14/79, 17.7%) patients, fertility requirement in three (3/79, 3.8%) patients, suspected uterine sarcoma in two (2/79, 2.5%) patients and others in 10 (10/79, 12.7%) patients. The reintervention rate has significant correlation with some factors including age, size, type and the signal intensity on T2 weighted image (T2WI) of the uterine fibroids. CONCLUSION: USgHIFU for uterine fibroids is effective due to low reintervention rate in a long-term follow-up.

The impact of ultrasound-guided high-intensity focused ultrasound for uterine fibroids on ovarian reserve.

Objective: To evaluate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids on ovarian reserve in women of reproductive age.Materials and methods: From September 2015 to September 2017, 84 patients with uterine fibroids in reproductive age were enrolled from Chongqing Haifu Hospital, Three Gorges Central Hospital of Chongqing and Aegisroen obstetric gynecology Clinic of Seoul, Korea. Blood was collected before HIFU treatment and 6 months after USgHIFU treatment. The enzyme-linked immune analysis was used for assay of circulating anti-Mullerian hormone (AMH).Results: All the 84 patients were successfully treated with USgHIFU and 67 patients completed the follow-up. The median age of the 67 patients was 38 years at the time of treatment. The median AMH value before and 6 months after treatment was 1.26 ng/mL and 1.27 ng/mL, respectively. Patients who completed AMH measurements 6 months after treatment were further classified into three groups based on age, including younger than 35 years, 36 to 40 years, and older than 40 years. The median AMH values before treatment were 3.04 ng/mL, 1.73 ng/mL and 0.87 ng/mL, and the corresponding values 6 months after treatment were 3.24, 1.44 and 0.75, respectively. A significant difference in AMH level was observed in the group of patients at the age between 36 and 40 years (p < 0.05), but no significant difference in AMH levels was observed in the other two groups (p > 0.05).Conclusion: Based on our results, we conclude that USgHIFU has no influence on ovarian reserve.

A comparison of ultrasound-guided high intensity focused ultrasound for the treatment of uterine fibroids in patients with an anteverted uterus and a retroverted uterus.

OBJECTIVE: The aim of this study was to compare the treatment outcomes of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids in patients with an anteverted uterus versus a retroverted uterus. MATERIALS AND METHODS: Based on the principles of statistics we enrolled 221patients with an anteverted uterus and 221 with a retroverted uterus. All patients had a solitary uterine fibroid and every fibroid was identified as hypointense on the T2 weighted images (T2WI) on magnetic resonance. The baseline characteristics of the patients, treatment results and adverse events were compared between the two groups. RESULTS: There were no significant differences in baseline characteristics between the two groups. The average non-perfused volume ratio of fibroids was 85.2 ± 18.7% in the group of patients with a retroverted uterus, while it was 87.7 ± 11.8% in patients with an anteverted uterus (P < 0.05). The fibroids in patients with a retroverted uterus were treated using lower sonication power and longer sonication time. During the procedure patients with a retroverted uterus had a higher incidence of sciatic/buttock pain and groin pain, while patients with an anteverted uterus complained of lower abdominal pain or a burning sensation on the skin. Immediately after USgHIFU, the rates of sciatic/buttock pain and skin burn were significantly higher in patients with a retroverted uterus. CONCLUSION: The results of this study indicated that uterine fibroids with hypointensity on T2WI in a retroverted uterus can be safely and effectively treated with USgHIFU. However, the fibroids in an anteverted uterus are easier to treat with USgHIFU.

Ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for the treatment of patients with adenomyosis and prior abdominal surgical scars: A retrospective study.

OBJECTIVE: The aim of this paper was to retrospectively compare the therapeutic efficacy and adverse effects of ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment for adenomyotic patients with or without prior abdominal surgical scars. METHODS: From January 2011 to March 2014, 534 patients with adenomyosis were referred for HIFU treatment. Among them, 118 patients had prior abdominal surgical scars, 416 patients did not have prior abdominal surgical scars. Contrast-enhanced MRI was used to evaluate the treatment outcomes. All the adverse effects were recorded. RESULTS: All patients completed USgHIFU treatment. A fractional ablation of 74.8 ± 27.8% was achieved in the group of patients without abdominal scars; the fractional ablation was 75.6 ± 22.3% in the group of patients with prior abdominal surgical scars. No significant difference in fractional ablation between the two groups was observed (p > 0.05). The rate of skin burn in the group of patients with prior abdominal surgical scars was significantly higher than that in the group without abdominal scars (2.5% vs. 0.2%, p < 0.05), but it is still acceptable. CONCLUSION: The prior abdominal surgical scars have no significant influence on the effectiveness of HIFU treatment for adenomyosis. The risk of skin burn is higher in patients with abdominal scars than without, but the incidence rate is still acceptable.

Ultrasound guided high intensity focused ultrasound (USgHIFU) ablation for uterine fibroids: Do we need the microbubbles?

PURPOSE: The aim of this study was to assess the safety and effectiveness of contrast-enhanced ultrasound (CEUS) on ultrasound guided high intensity focused ultrasound (USgHIFU) ablation of uterine fibroids. METHODS: Thirty-three patients (37 fibroids) were randomly assigned to two groups: group A (17 patients, 20 fibroids) in which CEUS was used before, during and after HIFU treatment, and group B (16 patients, 17 fibroids) in which CEUS was not administered at all. Follow-up including contrast-enhanced magnetic resonance imaging (MRI) and a clinical questionnaire was performed, and technical success, ablation efficacy, volume reduction and complications were assessed. RESULTS: Technical success was 100% in both groups. CEUS revealed residual enhancement in 40% of the patients in group A and the treatment was continued until the completion of ablation. MRI at 1 month after treatment revealed significant difference in the relative fibroid volume reduction rate between the two groups: 16.1% in group A versus 4.8%, in group B (p = 0.01). There was no statistically significant relative volume reduction rate for the results at 3, 6 and 12 months and no significant changes in the quality of life results or the complication rate. CONCLUSIONS: CEUS was safe and effective in enhancing US guidance during HIFU ablation of uterine fibroids. Moreover, the use of CEUS during HIFU sonication increased the ablation efficacy, leading to a more relevant fibroid volume reduction at 1 and 3 months. This gap disappeared after 6 months, when there were no differences between the two groups of patients at MRI. However, in our experience, USgHIFU represented a very effective method for the treatment of uterine fibroids, and the use of CEUS during HIFU procedure reduced the treatment time and treatment repetitions for incomplete fibroid ablation.

Thermal ablative treatment of uterine fibroids.

In addition to surgical methods of treating uterine fibroids, numerous non-invasive treatments have been developed. Many of these involve the use of hyperthermia, the heating of tissue by a variety of methods. These include the use of lasers, radiofrequency, microwave energy and high intensity focused ultrasound, guided by both ultrasound and magnetic resonance imaging. In this review we examine the technology behind these treatment modalities and review the current evidence for their use.