Novel therapeutic techniques for the treatment of benign gynaecological diseases

Over the last two decades, remarkable progress has been made in treating patients with benign gynaecological diseases using minimally invasive or non-invasive treatment techniques. The progress is related not only to novel modalities, but also to innovative unconventional procedures. The main focus in developing new minimally invasive and non-invasive therapeutic techniques lies in minimising harm to patients. As a non-invasive treatment, high-intensity focused ultrasound (HIFU) (or focused ultrasound surgery, FUS) has been used widely to treat patients with uterine fibroids and adenomyosis in routine gynaecological practice in China. Evidence from clinical practice and clinical studies has shown its efficacy and safety, offering the advantages of non-invasiveness and short recovery time. In this special issue, different groups from around the world have reported new studies with ongoing results. There have been many clinical studies of HIFU treatment for uterine fibroids, but none from Africa. In this issue, a group from South Africa has reported their preliminary results of HIFU treatment for uterine fibroids in African women. Their results indicate that multiple uterine fibroids seemed to be more frequently seen in South African women than in other races from other countries. However, most of these fibroids are hypointense on T2-weighted magnetic resonance imaging (T2WI) and are easy to treat with HIFU. Another study discovered that a group from China performed either HIFU or laparoscopic myomectomy in patients with symptomatic uterine fibroids. The short-term follow-up results hinted at equal efficacy. In comparison with laparoscopic myomectomy, patients treated with HIFU had a lower complication rate and shorter hospital stays. Pregnancy outcomes after HIFU treatment are always a major concern. Zou et al. reported on the largest number of subjects so far with uterine fibroids treated with HIFU who wished to conceive. Their results suggested that HIFU treatment is able to reduce the preparation period for pregnancy and to improve the fertility of patients with a history of infertility and abnormal pregnancy, without additional obstetric risks. Previous studies have indicated that HIFU is a new and promising treatment option for patients with adenomyosis. Guo et al. showed that the combination of a gonadotrophin-releasing hormone agonist (GnRH-a) and HIFU ablation could achieve better outcomes than HIFU alone. Multimodality treatment could therefore play an important role in the management of adenomyosis. In this issue, a group from Korea investigating ovarian function in patients with uterine fibroids or adenomyosis after HIFU treatment reported that there was no change after HIFU treatment. Liu et al. compared the cost-effectiveness of ultrasound-guided HIFU and hysterectomy for adenomyosis and found that HIFU is significantly cheaper. Enhancing the ablation achieved with HIFU using microbubble contrast agents is another hot topic. Cheng et al. first performed an experimental study on rabbits and found that SonoVue, a microbubble contrast agent, could enhance ablation in HIFU treatment, and that the optimal time to begin HIFU sonication appears to be 1 minute after the administration of SonoVue. Later, a clinical study suggested that SonoVue could be used safely to enhance the ablation effects of HIFU treatment for uterine fibroids. HIFU is used to treat not only uterine fibroids and adenomyosis, but also other diseases. Wu et al. reported the short- and long-term results of focused ultrasound therapy for non-neoplastic epithelial disorders of the vulva. Two groups from China present their results on patients with abdominal wall endometriosis (AWE) treated with HIFU here. Luo et al. treated 32 patients; their follow-up results showed that the average volume of AWE lesions 6 months after HIFU was significantly decreased. The pain scores at 6 months were also significantly reduced. In another study, 23 patients were treated with HIFU and 28 patients with surgery. The results suggested that both HIFU and surgery are safe and effective in treating patients with AWE. Compared with surgery, HIFU treatment for AWE has the advantages of requiring shorter hospital stays, no blood loss, no new scars, and lower pain scores. Ye et al. reviewed 25 patients diagnosed with placenta accreta who underwent HIFU followed by hysteroscopic resection retrospectively. Their results suggested that HIFU treatment before hysteroscopic resection could help reduce the risk of bleeding during the procedure. Recently, Yan et al. successfully treated a case of uterine arteriovenous malformation using HIFU. These studies have opened new doors for exploring novel treatment strategies for these benign gynaecological diseases. A paper that describes a new way of treating patients with pelvic organ prolapse is included. A laparoscopic extraperitoneal uterine suspension was performed using a suture line instead of a mesh. The results showed that laparoscopic extraperitoneal uterine suspension with a suture line is easier to perform and is associated with fewer mesh-related complications. A paper that compares the effects of dexmedetomidine-remifentanil with the traditional analgesia and sedation regimen midazolam-remifentanil during HIFU treatment of uterine fibroids is also included. In addition, the question of whether exercise after HIFU treatment can improve the absorption of uterine fibroids and the relief of dysmenorrhea of adenomyosis is discussed. These novel therapeutic techniques have shown promising results. However, for these new treatment strategies to be adopted, their safety, efficacy, cost-effectiveness and fertility outcome must be evaluated further using large randomised control trials.