Treatment Options for Uterine Fibroids Using Microwave and Radiofrequency

A 30-year-old infertility patient had a type 2–5 posterior wall myoma measuring 9.5 cm × 6.9 cm × 8.3 cm. Due to the large size of the intramural fibroid, hysteroscopic resection was not feasible, and she refused laparoscopic surgery. Therefore, we performed PMWA. Nine months later, she continued to experience heavy bleeding. Another MRI scan [ Figure 4 ] showed the fibroid protruding into the uterine cavity, now classified as a type 1 myoma. The size had decreased to 70 mm × 69 mm × 62 mm. Given the submucosal nature of the fibroid, hysteroscopic resection became possible, and the myoma was subsequently removed through this method. This case demonstrates the use of PMWA combined with TCRM in treating a patient with multiple myomas. The intramural fibroid was transformed into a submucosal fibroid following microwave ablation

Minimally invasive and noninvasive thermal ablation techniques MWA, with a median conception time of 18 months (1–60 frequency ablation (RFA), and MWA have significantly advanced the treatment landscape for symptomatic uterine fibroids. These modalities utilize heat-induced coagulative necrosis to reduce fibroid volume and relieve associated symptoms. However, they differ notably in their underlying mechanisms, clinical efficacy, technical complexity, and patient experience. A comparative study by Meng et al . demonstrated that while both HIFU and RFA are effective in treating uterine fibroids, RFA achieves significantly higher complete ablation rates overall (90% vs. 58%).[ 31 ] RFA was especially more effective in treating larger and hypervascular fibroids, whereas HIFU showed comparable efficacy only in small (<4 cm) or hypovascular fibroids. In addition, HIFU, being noninvasive, had fewer minor complications and did not require postoperative antibiotics, though it involved a much longer treatment duration. In contrast, RFA, though minimally invasive and requiring sedation provided more consistent and efficient ablation across fibroid types. A retrospective study by Zhao et al . demonstrated that both PMWA and ultrasound-guided HIFU are safe and effective treatments for symptomatic uterine fibroids,[ 7 ] showing similar outcomes in SSS reduction, ablation rate, and fibroid regression after 6 months. However, PMWA was associated with a significantly shorter treatment time (median 46.2 min vs. 92.5 min for HIFU), making it a more time-efficient option. Both modalities had comparable rates of minor adverse events, and no serious complications were reported in either group. While PMWA required hospitalization and intravenous anesthesia, it showed broader applicability, particularly for larger and hypervascular fibroids. In contrast, HIFU, being noninvasive, offered better patient comfort and avoided the need for general anesthesia, although it had higher equipment requirements and longer treatment duration. Zhao’s report offers valuable insights into the comparative effectiveness and safety profiles of minimally invasive techniques for managing uterine fibroids with MWA or HIFU.[ 7 ] The findings underscore the importance of tailoring treatment approaches to individual patient needs and clinical scenarios. While both MWA and HIFU demonstrate efficacy in alleviating fibroid-related symptoms and inducing fibroid shrinkage, nuanced differences emerge upon closer examination. For instance, MWA may exhibit advantages in terms of shorter procedural durations (median 46.2 min vs. 92.5 min for HIFU) and potentially lower associated costs compared to HIFU. Both modalities had comparable rates of minor adverse events, and no serious complications were reported in either group. While PMWA required hospitalization and intravenous anesthesia, it showed broader applicability, particularly for larger and hypervascular fibroids. In contrast, HIFU, being noninvasive, offered better patient comfort and avoided the need for general anesthesia, although it had higher equipment requirements and longer treatment duration. All three techniques offer uterus-preserving, minimally invasive alternatives to surgery [ Table 1 ]. MWA stands out for its procedural speed, efficiency, and versatility. RFA is ideal for reliable ablation of moderate-to-large fibroids. HIFU remains attractive for patients prioritizing noninvasiveness and comfort, despite its technical and anatomical limitations. Treatment selection should be personalized based on fibroid characteristics, patient preferences, and resource availability. Summary: High-intensity focused ultrasound versus radiofrequency ablation versus microwave ablation MRI: Magnetic resonance imaging, RFA: Radiofrequency ablation, HIFU: High-intensity focused ultrasound, MWA: Microwave ablation, MRFUS: MRI-guided focused ultrasound surgery, AEs: Adverse events

RFA is based on the application of a high-frequency electrical current (400 kHz) that produces heat (>65C) inside the fibroid, achieving coagulative necrosis of the tissue. The size and shape of the ablation volume are determined by the temperature reached, the length of time at that temperature, and the shape of the electrode (i.e., single electrode, multiple electrodes in an array, curved or straight electrodes). According to the location of uterine fibroids, the application of RFA could be done through transvaginal or transabdominal approaches. In general, fibroids of 1.5 cm in diameter do not require deployment of the electrode array to ablate the myoma periphery. Irregular myomas and those with diameters 4 cm and greater often require multiple overlapping ablations in order to ensure adequate ablation of the myoma periphery.[ 26 ] In a systematic review by Bradley et al. , a comprehensive synthesis of prospective studies investigating the clinical performance of RFA for treating uterine fibroids was presented.[ 27 ] By aggregating data from multiple studies, the researchers provide a robust assessment of RFA’s efficacy, safety, and patient-reported outcomes. The findings corroborate previous evidence suggesting RFA as a promising minimally invasive treatment option for uterine fibroids, demonstrating notable improvements in symptom severity and reduction of fibroid volume. On average, fibroid volume decreased by 66% at 12 months posttreatment, with a progressive reduction observed as early as 3 months (47%) and continuing beyond 1 year (71%). Symptom Severity Scores (SSS) improved markedly, showing an average reduction of 42 points at 12 months, while Health-related quality of life (QoL) scores improved by 39 points, both with high statistical significance ( P < 0.001). Importantly, the meta-analysis underscores RFA’s favorable safety profile, characterized by low rates of procedural complications and adverse events. Such findings are instrumental in bolstering confidence among clinicians regarding the utility of RFA in their therapeutic armamentarium for managing uterine fibroid. Furthermore, the study highlights the importance of ongoing research efforts to refine procedural techniques, optimize patient selection criteria, and enhance long-term treatment outcomes. By fostering a deeper understanding of RFA’s clinical utility and limitations, this study paves the way for continued advancements in minimally invasive fibroid therapies, ultimately benefiting patients through improved treatment options and outcomes.

The overall efficacy of HIFU, MWA, and RF in treating uterine leiomyoma is advantageous.[ 32 ] Safety is a primary concern with new technology. All three thermal ablation techniques – HIFU, MWA, and RFA – demonstrate favorable safety profiles, with low rates of serious complications and generally mild, self-limited adverse events. Common complications of microwave and RFA therapy include bleeding, organ injury, skin burn, pain, watery discharge, and infection. Nerve injury is rarely seen during microwave and RFA but can occur during HIFU and MRFUS.[ 33 34 ] Bleeding [ Figure 6 ], and infection are unique to microwave and RFA. In most cases, bleeding does not require further intervention. However, since necrotic tissue is more prone to infection, when vaginal procedures such as hysteroscopic resection and endometrial ablation are combined, the incidence of infection is higher compared to HIFU and MRFUS. Antibiotics are recommended as a regular practice after ablation therapy. If a patient exhibits a high temperature or odorous vaginal discharge with or without abdominal pain, a bacterial culture is needed, and sensitive antibiotics are recommended. Dilated and curettage may be necessary in some cases, and sometimes, a hysterectomy is required. Laparoscopic view of active bleeding seen after microwave ablation

For patients with multiple uterine fibroids, traditional treatment options include: Open myomectomy ± hysteroscopic myomectomy Laparoscopic myomectomy (including single port surgery) ± hysteroscopic myomectomy Vaginal myomectomy ± hysteroscopic myomectomy HIFU or MRFUS Uterine artery embolization Mirena insertion Endometrial ablation. Open myomectomy ± hysteroscopic myomectomy Laparoscopic myomectomy (including single port surgery) ± hysteroscopic myomectomy Vaginal myomectomy ± hysteroscopic myomectomy HIFU or MRFUS Uterine artery embolization Mirena insertion Endometrial ablation. For laparoscopic myomectomy, Ai et al . highlight the technical nuances and potential benefits of combining uterine artery occlusion with myomectomy, such as reducing blood loss and improving surgical outcomes in patients with uterine myomas.[ 12 ] Han provides insights into the effectiveness and safety of the transumbilical single-site laparoscopic approach for myomectomy.[ 13 ] Wada et al . highlight the importance of meticulous surgical techniques to minimize the risk of breaching the uterine cavity during laparoscopic myomectomy, particularly in women desiring future pregnancies.[ 14 ] D’Silva et al . suggest that while laparoscopic myomectomy may offer certain advantages over open myomectomy, such as shorter hospital stays and quicker recovery times, patient-specific factors and surgeon expertise are crucial in determining the most appropriate surgical approach.[ 15 ] Martinez and Domingo mentioned that factors such as the size, type, and location of myomas play a crucial role in predicting the success of laparoscopic myomectomy.[ 16 ] Sleiman et al . concluded that considering these factors during patient selection and preoperative planning can contribute to better surgical outcomes.[ 17 ] Especially in oncologic surgery, these studies have shown that laparoscopic myomectomy requires extremely high surgical skills; otherwise, it is prone to relative risks.[ 18 19 20 21 ] Moreover, to remove intramural fibroids, at least several 5–10 mm skin incisions are needed. Combining hysteroscopic resection of submucosal myoma and ablation therapy is another option for minimizing the technical barriers. HIFU and MRFUS may be considered, as patients can be treated in the outpatient clinic or MRI room.[ 22 ] During the procedure, patients are usually in a supine or prone position, making hysteroscopic resection and general anesthesia impossible. Microwave and RF are usually performed in the operating room under general or regional anesthesia. Patients are placed in the lithotomy position for these procedures. A uterine manipulator is inserted to adjust the uterine position. In this situation, hysteroscopic surgery can be combined with microwave and RF if necessary.[ 23 ] For those with heavy bleeding and no desire for childbirth, endometrial ablation with microwave or RF can also be used. A specialized microwave or RFA probe can be inserted into the uterine cavity through the cervix. With abdominal ultrasound guidance, the probe can be directed to different areas of the uterine cavity. Impedance detection can be utilized during RFA. Hysteroscopic examination is performed during the ablation to ensure the completion of endometrial ablation [ Figure 5 ]. After microwave or RF endometrial ablation, a high success rate is achieved; about half of the patients will have no menstruation, and most of the others will experience reduced menstrual flow.[ 24 25 ] Hysteroscopic view before and after microwave endometrial ablation

Ahmadzade et al . provides valuable insights into the clinical utility of ultrasound-guided PMWA (UPMWA) for the treatment of symptomatic uterine fibroids.[ 28 ] By meticulously assessing patient outcomes and procedural parameters, the researchers offer a comprehensive evaluation of UPMWA’s efficacy and safety profiles in a real-world clinical setting. The findings underscore UPMWA’s effectiveness in achieving significant symptom relief and fibroid volume reduction, thereby improving patients’ QoL. The average fibroid volume was reduced by 70.9% at 12 months posttreatment. Hemoglobin levels improved from 9.96 g/dL before treatment to 12.14 g/dL ( P = 0.002) after 12 months, while SSSs significantly decreased and health-related QoL scores markedly increased (from 61.0 to 95.4, P < 0.001). According to the meta-analysis conducted by Liu et al .,[ 29 ] which included 10 studies and a total of 671 patients. Quantitative analysis revealed a mean fibroid volume reduction rate of 85.3%, demonstrating a substantial treatment effect. This volume reduction was consistently observed across various fibroid types and sizes, suggesting MWA’s versatility. In terms of symptom relief, the Uterine Fibroid Symptom (UFS) scores decreased by an average of 65.9%, while QoL scores improved by 72.0%. These outcomes reflect significant and sustained clinical improvement following treatment. In addition, hemoglobin concentration increased by 30.3%, indicating effective control of fibroid-related bleeding and resolution of anemia. Notably, the low incidence of adverse events and procedural complications further validates UPMWA as a safe and well-tolerated treatment option for uterine fibroids. These outcomes are particularly significant in the context of minimally invasive interventions, where optimizing patient safety and comfort remains paramount. In addition, the study sheds light on potential factors influencing treatment outcomes, such as fibroid characteristics, procedural techniques, and patient demographics. By identifying these variables, clinicians can refine treatment strategies and tailor interventions to individual patient needs, thereby maximizing therapeutic efficacy while minimizing risks. Overall, this study contributes to the growing body of evidence supporting UPMWA as a valuable addition to the armamentarium of minimally invasive therapies for uterine fibroids, offering patients an alternative treatment option with favorable outcomes and safety profiles. One of the key considerations in evaluating UPMWA as a treatment for infertility is its effect on pregnancy rates. Current evidence on the reproductive outcomes following MWA remains limited. One study prospectively assessed pregnancy outcomes in patients who underwent MWA for symptomatic UFS and found promising results.[ 30 ] The study reported a pregnancy rate of 55.56% (45/81) following MWA, with a median conception time of 18 months (1–60 months). Notably, natural conception occurred in 48.15% (39/81) of cases, while 7.41% (6/81) required assisted reproductive technology. These findings suggest that MWA can be an effective option for infertility patients, though its success rates vary based on patient-specific factors such as age and fibroid type.

Not only for benign but also for malignant gynecologic lesions, laparoscopy and hysteroscopy are traditional minimally invasive treatments.[ 1 2 3 4 5 6 ] In recent years, the trend of minimally invasive treatment has been increasing rapidly worldwide. Minimally invasive technology has become the focus of uterine fibroid treatment.[ 7 ] Instead of removing the fibroids, ablation therapy uses energy to ablate and shrink them. Ablation therapy using energy is now becoming a trend in the treatment of fibroids and adenomyosis. High-intensity focused ultrasound (HIFU) and magnetic resonance imaging (MRI)-guided focused ultrasound surgery (MRFUS) are traditional ablation treatments. However, microwave and radiofrequency ablation (RFA) are less recognized. Compared with the resection of uterine fibroids by laparoscopy, hysteroscopic resection of myomas results in less pain and faster recovery.[ 8 ] Moreover, ablation therapy results in less pain, less bleeding, and faster recovery.[ 9 ] Thus, microwave and RFA are also called super-microinvasive treatments. Microwave and radiofrequency (RF) are new energy sources for ablation therapy. Like HIFU, microwave and RF can produce energy inside the tumor and cause necrosis. Unlike HIFU, both microwave and RF require the use of a 14-17G antenna inserted into the tumor under ultrasound or MRI image guidance.[ 9 ] Ablation therapy for uterine fibroids and adenomyosis differs from that for lung or liver cancer. In malignancy lesions, ablation must encompass the entire tumor to prevent recurrence after treatment. However, for benign uterine conditions, safety is paramount, with symptom relief being a primary treatment goal.[ 10 11 ] During uterine tumor ablation, protecting the surrounding organs, especially the endometrium, if fertility is desired, is crucial.[ 9 ] Thus, the ablation rate is typically <100% [ Figure 1 ]. The remaining viable part of the fibroids may continue to grow if the patient has not reached menopause after ablation treatment. Magnetic resonance imaging image showing a uterine myoma adjacent to the endometrium Each treatment modality has its own advantages, and the best results may be achieved by complementing their strengths and weaknesses. Here, we present two cases and provide a mini-review.

MWA, HIFU, and UPMWA are emerging as promising alternatives to traditional surgical interventions for uterine fibroids, demonstrating efficacy in alleviating symptoms and inducing fibroid shrinkage. RFA shows notable improvements in symptom severity and fibroid volume reduction, with low rates of procedural complications reported across various prospective studies. UPMWA is particularly promising, with studies consistently demonstrating significant symptom relief, fibroid volume reduction, and favorable safety profiles. However, the importance of treatment approaches lies in tailoring them to individual patient characteristics and preferences. In addition, factors such as fibroid characteristics, procedural expertise, and patient demographics play crucial roles in optimizing treatment outcomes and minimizing risks. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consents for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. X Gong: Conceived and designed the analysis; contributed analysis tools. C Lee: Conceived and designed the analysis. S Liu: Performed the literature search and data analysis; wrote the manuscript. Z Sun: Collected the data and performed the analysis; wrote the manuscript. All authors have read and agreed to the final version of the manuscript. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Prof. Chyi-Long Lee, the Edior-in-Chief at Gynecology and Minimally Invasive Therapy , had no role in the peer review process of or decision to publish this article. All authors declared no conflicts of interest in writing this paper.