Intermediate-Term Outcomes After Transcervical Radiofrequency Ablation of Uterine Fibroids in Women With Larger Uteri

INTRODUCTION: Uterine fibroids affect 70–80% of women in the United States. Various uterus-sparing treatment options for fibroids exist, including myomectomy, uterine artery embolization, and radiofrequency ablation (RFA). Transcervical RFA is a newer, incisionless modality designed to treat FIGO 1–6 fibroids and has been studied in fibroids up to 7 cm, and uteri up to 14 weeks in size and those less than 1000 g. Current data demonstrate widely variable surgical reintervention rates following transcervical RFA. OBJECTIVE: To describe intermediate-term clinical outcomes of transcervical RFA and identify risk factors for symptom recurrence or reintervention in patients desiring uterus-sparing treatment of fibroids. METHODS: We performed a retrospective analysis of all patients who underwent transcervical RFA between January 2021 and December 2023 at an urban tertiary academic center. The procedure was offered to patients desiring uterus-sparing treatments, including some with fibroid characteristics outside the parameters of prior studies. Patient demographics, fibroid characteristics, operative details, and clinical outcomes were collected. Symptom relief was assessed at 2 weeks, 6 months, and thereafter as clinically indicated. Primary outcomes were symptom recurrence and reintervention rates, including both hormonal and surgical management. RESULTS: A total of 34 patients underwent a transcervical RFA, with a median follow-up of 8 months (IQR 6–15, range of 1–30 months). Mean age was 46 years (SD 5.95), and mean BMI was 27.6 kg/m2 (SD 5.01). Most patients (28/34) were ASA class 2 (82.4%). Preoperative imaging revealed a median uterine volume of 605 g (IQR 430–929, range 227–2284 g), a median fibroid count of 5.5 (IQR 2.25–13, range 1–20), and a mean maximum fibroid diameter of 5.1 cm (SD 1.9, range 2–8.7 cm). The median uterine size on examination was 12 weeks (IQR 10–14.75, range 8–20 weeks). Ablation was performed on a median of 3 fibroids per patient (IQR 2–3.75), with 70.5% (24/34) of patients having additional untreated fibroids. No intraoperative complications were noted. On postoperative day one, 59% of patients (20/34) had no complaints, 6% (2/34) had mild pain, and 35% (12/34) were unable to be reached. At the 2-week postoperative visit, all patients reported symptom improvement. By 6 months, 55.9% (19/34) of patients had durable symptom relief, while 44.1% (15/34) reported symptom recurrence. Over the study period, 58.8% (20/34) experienced symptom recurrence, with abnormal uterine bleeding (AUB) being the most common symptom (70%), followed by pain (20%), and both AUB and pain (10%). Median time to symptom recurrence was 4.5 months (IQR 3.75–6.25). Nine patients (26%) required hormone reintervention, and 7 (20%) underwent surgical reintervention, which included 3 hysterectomies, 3 hysteroscopic myomectomies, and 1 combined hysteroscopic myomectomy with endometrial ablation. Median time to reoperation was 16 months (IQR 7–18.5), with a mean of 13.9 months (SD 8.2). CONCLUSIONS: Transcervical RFA remains a safe and effective uterus-sparing treatment for fibroids, including in women with larger uteri. It routinely provides short-term symptom relief and is well tolerated. Patients with larger uteri may need to be counseled on their relatively higher risk for symptom recurrence and the possibility of needing future interventions.