Current Obstetrics and Gynecology Reports

, Volume 7, Issue 2, pp 106–115 | Cite as

New Horizons in Fibroid Management

  • Rohan Chodankar
  • Jennifer Allison
Uterine Fibroids (N Narvekar, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Uterine Fibroids


Purpose of Review

Review of the latest advances in the treatment of uterine fibroids. Addressing conservative management, medical therapy, interventional radiological procedures (non-surgical alternatives or non-excisional procedures) and conservative or radical endoscopic or open surgery (myomectomy, hysterectomy).

Recent Findings

Newer medical therapy relied on the use of selective progesterone receptor modulators (SPRMs) (Esmya/UPA) for management of heavy menstrual bleeding (HMB) associated with fibroids. However, the drug is currently under investigation for a link with hepatic damage associated with its use. Other SPRMs currently showing promise include vilaprisan and telapristone. New medical therapy also includes oral small molecule GnRH antagonists such as Relugolix, Elagolix and Lizagolix which are undergoing phase 2 and 3 trials and have shown promise. The new NICE guidance on HMB also suggests limited effectiveness of pharmacological methods in fibroids > 3 cm and therefore referral to an expert with possible consideration of surgery as a first-line treatment. Non-excisional procedures include the use of uterine artery embolisation which is currently being compared to myomectomy and its effect on the quality of life in the FEMME study. With regard to excisional therapies, controversy still surrounds the use of laparoscopic power morcellators (LMPs). A white paper has been issued by the US FDA in December 2017 on the matter, and a PneumoLiner still remains the only containment device approved by the US FDA for use with LMPs. With advancing surgical expertise and use the bipolar sealing devices, TLHs are increasingly being performed for larger uteri (> 12 weeks or > 280 g). Hysteroscopic retrieval systems (HRTs) are found to be increasingly used successfully for type 2 submucous myomas as one-step procedures.


Many treatments are available for fibroids that can help women reach the age of menopause prior to embarking on radical surgery. It seems sensible to start with conservative (medical) measures; however, for women with large fibroids, often non-excisional or surgical solution is needed. Which technique is chosen will depend upon local expertise as well as patient preference, especially the need for uterine/fertility preservation, following a detailed discussion regarding risks and benefits.


Fibroids Heavy menstrual bleeding SPRMs Myomectomy 


Compliance with Ethical Standards

Conflict of Interest

Rohan Chodankar and Jennifer Allison declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


  1. 1.
    Laughlin SK, Stewart EA. Uterine leiomyomas: individualizing the approach to a heterogeneous condition. Obstet Gynecol. 2011;117(2 Pt 1):396–403.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Laughlin-Tommaso SK, Jacoby VL, Myers ER. Disparities in fibroid incidence, prognosis, and management. Obstet Gynecol Clin N Am. 2017;44(1):81–94.CrossRefGoogle Scholar
  3. 3.
    Marsh EE, Ekpo GE, Cardozo ER, Brocks M, Dune T, Cohen LS. Racial differences in fibroid prevalence and ultrasound findings in asymptomatic young women (18-30 years old): a pilot study. Fertil Steril. 2013;99(7):1951–7.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Tamaya T, Fujimoto J, Okada H. Comparison of cellular levels of steroid receptors in uterine leiomyoma and myometrium. Acta Obstet Gynecol Scand. 1985;64(4):307–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Dockeray CJ, Sheppard BL, Daly L, Bonnar J. The fibrinolytic enzyme system in normal menstruation and excessive uterine bleeding and the effect of tranexamic acid. Eur J Obstet Gynecol Reprod Biol. 1987;24(4):309–18.CrossRefPubMedGoogle Scholar
  6. 6.
    Matteson KA, Rahn DD, Wheeler TL. Non-surgical management of heavy menstrual bleeding: a systematic review and practice guidelines. Obstet Gynecol. 2013;121(3):632–43.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lethaby A, Augood C, Duckitt K, Farquhar C. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2007;4Google Scholar
  8. 8.
    Pérez-López FR, Ornat L, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, et al. EMAS position statement: management of uterine fibroids. Maturitas. 2014;79(1):106–16.CrossRefPubMedGoogle Scholar
  9. 9.
    Peitsidis P, Koukoulomati A. Tranexamic acid for the management of uterine fibroid tumors: a systematic review of the current evidence. World J Clin Cases: WJCC. 2014;2(12):893–8.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Sayed GH, Zakherah MS, El-Nashar SA, Shaaban MM. A randomized clinical trial of a levonorgestrel-releasing intrauterine system and a low-dose combined oral contraceptive for fibroid-related menorrhagia. Int J Gynecol Obstet. 2011;112(2):126–30.CrossRefGoogle Scholar
  11. 11.
    Jiang W, Shen Q, Chen M, Wang Y, Zhou Q, Zhu X, et al. Levonorgestrel-releasing intrauterine system use in premenopausal women with symptomatic uterine leiomyoma: a systematic review. Steroids. 2014;86:69–78.CrossRefPubMedGoogle Scholar
  12. 12.
    NICE. Heavy menstrual bleeding: assessment and management: National Institute for Health & Care Excellence; 2018 [Available from:
  13. 13.
    Harmon Q, Baird D. Use of depot medroxyprogesterone acetate and prevalent leiomyoma in young African American women. Hum Reprod. 2015;30(6):1499–504.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Lumbiganon P, Rugpao S, Phandhu-fung S, Laopaiboon M, Vudhikamraksa N, Werawatakul Y. Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: a multicentre case-control study. Br J Obstet Gynaecol. 1996;103(9):909–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Campo S, Garcea N. Laparoscopic myomectomy in premenopausal women with and without preoperative treatment using gonadotrophin-releasing hormone analogues. Hum Reprod. 1999;14(1):44–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Lethaby A, Vollenhoven B, Sowter MC. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Libr. 2001;Google Scholar
  17. 17.
    Sowter MC, Lethaby A, Singla AA. Pre-operative endometrial thinning agents before endometrial destruction for heavy menstrual bleeding. Cochrane Libr. 2014;Google Scholar
  18. 18.
    Lethaby AE, Vollenhoven BJ. An evidence-based approach to hormonal therapies for premenopausal women with fibroids. Best Pract Res Clin Obstet Gynaecol. 2008;22(2):307–31.CrossRefPubMedGoogle Scholar
  19. 19.
    Moroni RM, Martins WP, Ferriani RA, Vieira CS, Nastri CO, Candido Dos Reis F, et al. Add-back therapy with GnRH analogues for uterine fibroids. Cochrane Database Syst Rev. 2013;12Google Scholar
  20. 20.
    Gurates B, Parmaksiz C, Kilic G, Celik H, Kumru S, Simsek M. Treatment of symptomatic uterine leiomyoma with letrozole. Reprod BioMed Online. 2008;17(4):569–74.CrossRefPubMedGoogle Scholar
  21. 21.
    Shozu M, Murakami K, Segawa T, Kasai T, Inoue M. Successful treatment of a symptomatic uterine leiomyoma in a perimenopausal woman with a nonsteroidal aromatase inhibitor. Fertil Steril. 2003;79(3):628–31.CrossRefPubMedGoogle Scholar
  22. 22.
    Deng L, Wu T, Chen XY, Xie L, Yang J. Selective estrogen receptor modulators (SERMs) for uterine leiomyomas. Cochrane Libr 2012.Google Scholar
  23. 23.
    Halder S, Goodwin S, Al-Hendy A. Vitamin D exhibits antiestrogenic effects in human uterine leiomyoma cells. Fertil Steril. 2010;94(4):S219–S20.CrossRefGoogle Scholar
  24. 24.
    Donnez J, Donnez O, Matule D, Ahrendt H-J, Hudecek R, Zatik J, et al. Long-term medical management of uterine fibroids with ulipristal acetate. Fertil Steril. 2016;105(1):165–73. e4.CrossRefPubMedGoogle Scholar
  25. 25.
    Donnez J, Tomaszewski J, Vazquez F, Bouchard P, Lemieszczuk B, Baro F, et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med. 2012;366(5):421–32.CrossRefPubMedGoogle Scholar
  26. 26.
    Chwalisz K, Larsen L, Mattia-Goldberg C, Edmonds A, Elger W, Winkel CA. A randomized, controlled trial of asoprisnil, a novel selective progesterone receptor modulator, in women with uterine leiomyomata. Fertil Steril. 2007;87(6):1399–412.CrossRefPubMedGoogle Scholar
  27. 27.
    Wilkens J, Chwalisz K, Han C, Walker J, Cameron IT, Ingamells S, et al. Effects of the selective progesterone receptor modulator asoprisnil on uterine artery blood flow, ovarian activity, and clinical symptoms in patients with uterine leiomyomata scheduled for hysterectomy. J Clin Endocrinol Metab. 2008;93(12):4664–71.CrossRefPubMedGoogle Scholar
  28. 28.
    Luo X, Yin P, Coon VJ, Cheng YH, Wiehle RD, Bulun SE. The selective progesterone receptor modulator CDB4124 inhibits proliferation and induces apoptosis in uterine leiomyoma cells. Fertil Steril. 2010;93(8):2668–73.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Bradley L, Ren X, Groettrup-Wolfers E, Petersdorf K, Seitz C. Results of the asteroid (assess safety and efficacy of vilaprisan in patients with uterine fibroids) 1 study: a phase 2, placebo-controlled dose finding study. Fertil Steril. 2016;106((3):e95-e6.Google Scholar
  30. 30.
    Hoshiai H, Seki Y, Kusumoto T, Kudou K, Komura E, Tanimoto M. Phase 2 study of relugolix vs placebo in heavy menstrual bleeding associated with uterine fibroids [17H]. Obstet Gynecol. 2017;129:86S.CrossRefGoogle Scholar
  31. 31.
    Archer DF, Stewart EA, Jain RI, Feldman RA, Lukes AS, North JD, et al. Elagolix for the management of heavy menstrual bleeding associated with uterine fibroids: results from a phase 2a proof-of-concept study. Fertil steril. 2017;108(1):152–60. e4.CrossRefPubMedGoogle Scholar
  32. 32.
    Stewart E, Owens C, Duan WR, Gao J, Chwalisz K, Simon JA. Elagolix alone and with add-back decreases heavy menstrual bleeding in women with uterine fibroids [21H]. Obstet Gynecol. 2017;129:87S.CrossRefGoogle Scholar
  33. 33.
    Ravina J, Aymard A, Ciraru-Vigneron N, Clerissi J, Merland J. Uterine fibroids embolization: results about 454 cases. Gynecologie, Obstetrique & Fertilite. 2003;31(7–8):597–605.CrossRefGoogle Scholar
  34. 34.
    Silberzweig JE, Powell DK, Matsumoto AH, Spies JB. Management of uterine fibroids: a focus on uterine-sparing interventional techniques. Radiology. 2016;280(3):675–92.CrossRefPubMedGoogle Scholar
  35. 35.
    Smeets AJ, Nijenhuis RJ, van Rooij WJ, Weimar EA, Boekkooi PF, Lampmann LE, et al. Uterine artery embolization in patients with a large fibroid burden: long-term clinical and MR follow-up. Cardiovasc Intervent Radiol. 2010;33(5):943–8.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    van Overhagen H, Reekers JA. Uterine artery embolization for symptomatic leiomyomata. Cardiovasc Intervent Radiol. 2015;38(3):536–42.CrossRefPubMedGoogle Scholar
  37. 37.
    Stokes LS, Wallace MJ, Godwin RB, Kundu S, Cardella JF, Society of Interventional Radiology Standards of Practice C. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv Radiol. 2010;21(8):1153–63.CrossRefPubMedGoogle Scholar
  38. 38.
    So O, Canada Go. SOGC clinical practice guidelines. Uterine fibroid embolization (UFE). Number 150, October 2004. Int J Gynaecol Obstet: Off Organ Int Fed Gynaecol Obstet. 2005;89(3):305.CrossRefGoogle Scholar
  39. 39.
    de Bruijn AM, Ankum WM, Reekers JA, Birnie E, van der Kooij SM, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016;215(6):745. e1-. e12.Google Scholar
  40. 40.
    Kirby JM, Burrows D, Haider E, Maizlin Z, Midia M. Utility of MRI before and after uterine fibroid embolization: why to do it and what to look for. Cardiovasc Intervent Radiol. 2011;34(4):705–16.CrossRefPubMedGoogle Scholar
  41. 41.
    de Blok S, de Vries C, Prinssen HM, Blaauwgeers HL, Jorna-Meijer LB. Fatal sepsis after uterine artery embolization with microspheres. J Vasc Interv Radiol. 2003;14(6):779–83.CrossRefPubMedGoogle Scholar
  42. 42.
    Tulandi T. Uterine fibroids: embolization and other treatments: Cambridge University Press; 2003.Google Scholar
  43. 43.
    Goldberg J. Pregnancy after uterine artery embolization for leiomyomata: the Ontario Multicenter Trial. Obstet Gynecol. 2005;106(1):195–6. author reply 6CrossRefPubMedGoogle Scholar
  44. 44.
    Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008;31(1):73–85.CrossRefPubMedGoogle Scholar
  45. 45.
    Mohan PP, Hamblin MH, Vogelzang RL. Uterine artery embolization and its effect on fertility. J Vasc Interv Radiol. 2013;24(7):925–30.CrossRefPubMedGoogle Scholar
  46. 46.
    McPherson K, Manyonda I, Lumsden M-A, Belli A-M, Moss J, Wu O, et al. A randomised trial of treating fibroids with either embolisation or myomectomy to measure the effect on quality of life among women wishing to avoid hysterectomy (the FEMME study): study protocol for a randomised controlled trial. Trials. 2014;15(1):468.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Hesley GK, Gorny KR, Henrichsen TL, Woodrum DA, Brown DL. A clinical review of focused ultrasound ablation with magnetic resonance guidance: an option for treating uterine fibroids. Ultrasound Q. 2008;24(2):131–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Behera MA, Leong M, Johnson L, Brown H. Eligibility and accessibility of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of uterine leiomyomas. Fertil Steril. 2010;94(5):1864–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Chen J, Li Y, Wang Z, McCulloch P, Hu L, Chen W, et al. Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration study. BJOG. 2018;125(3):354–64.CrossRefPubMedGoogle Scholar
  50. 50.
    Froling V, Kroncke TJ, Schreiter NF, Scheurig-Muenkler C, Collettini F, Hamm B, et al. Technical eligibility for treatment of magnetic resonance-guided focused ultrasound surgery. Cardiovasc Intervent Radiol. 2014;37(2):445–50.CrossRefPubMedGoogle Scholar
  51. 51.
    Gorny KR, Woodrum DA, Brown DL, Henrichsen TL, Weaver AL, Amrami KK, et al. Magnetic resonance-guided focused ultrasound of uterine leiomyomas: review of a 12-month outcome of 130 clinical patients. J Vasc Interv Radiol. 2011;22(6):857–64.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Stewart EA, Rabinovici J, Tempany CM, Inbar Y, Regan L, Gostout B, et al. Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids. Fertil Steril. 2006;85(1):22–9.CrossRefPubMedGoogle Scholar
  53. 53.
    Patel A, Malik M, Britten J, Cox J, Catherino WH. Alternative therapies in management of leiomyomas. Fertil Steril. 2014;102(3):649–55.CrossRefPubMedGoogle Scholar
  54. 54.
    Rabinovici J, David M, Fukunishi H, Morita Y, Gostout BS, Stewart EA, et al. Pregnancy outcome after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertil Steril. 2010;93(1):199–209.CrossRefPubMedGoogle Scholar
  55. 55.
    Hahn M, Brucker S, Kraemer D, Wallwiener M, Taran FA, Wallwiener CW, et al. Radiofrequency volumetric thermal ablation of fibroids and laparoscopic myomectomy: long-term follow-up from a randomized trial. Geburtshilfe Frauenheilkd. 2015;75(5):442–9.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Bongers M, Brolmann H, Gupta J, Garza-Leal JG, Toub D. Transcervical, intrauterine ultrasound-guided radiofrequency ablation of uterine fibroids with the VizAblate(R) system: three- and six-month endpoint results from the FAST-EU study. Gynecol Surg. 2015;12(1):61–70.CrossRefPubMedGoogle Scholar
  57. 57.
    Brucker SY, Hahn M, Kraemer D, Taran FA, Isaacson KB, Kramer B. Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy. Int J Gynaecol Obstet. 2014;125(3):261–5.CrossRefPubMedGoogle Scholar
  58. 58.
    Jones S, O'Donovan P, Toub D. Radiofrequency ablation for treatment of symptomatic uterine fibroids. Obstet Gynecol Int. 2012;2012:194839.CrossRefPubMedGoogle Scholar
  59. 59.
    Berman JM, Guido RS, Garza Leal JG, Pemueller RR, Whaley FS, Chudnoff SG, et al. Three-year outcome of the Halt trial: a prospective analysis of radiofrequency volumetric thermal ablation of myomas. J Minim Invasive Gynecol. 2014;21(5):767–74.CrossRefPubMedGoogle Scholar
  60. 60.
    Berman JM, Bolnick JM, Pemueller RR, Garza Leal JG. Reproductive outcomes in women following radiofrequency volumetric thermal ablation of symptomatic fibroids. A retrospective case series analysis. J Reprod Med. 2015;60(5–6):194–8.PubMedGoogle Scholar
  61. 61.
    Keltz J, Levie M, Chudnoff S. Pregnancy outcomes after direct uterine myoma thermal ablation: review of the literature. J Minim Invasive Gynecol. 2017;24(4):538–45.CrossRefPubMedGoogle Scholar
  62. 62.
    Hald K, Langebrekke A, Kløw NE, Noreng HJ, Berge AB, Istre O. Laparoscopic occlusion of uterine vessels for the treatment of symptomatic fibroids: initial experience and comparison to uterine artery embolization. Am J Obstet Gynecol. 2004;190(1):37–43.CrossRefPubMedGoogle Scholar
  63. 63.
    Lichtinger M, Hallson L, Calvo P, Adeboyejo G. Laparoscopic uterine artery occlusion for symptomatic leiomyomas. J Am Assoc Gynecol Laparosc. 2002;9(2):191–8.CrossRefPubMedGoogle Scholar
  64. 64.
    Hald K, Noreng HJ, Istre O, Klow NE. Uterine artery embolization versus laparoscopic occlusion of uterine arteries for leiomyomas: long-term results of a randomized comparative trial. J Vasc Interv Radiol. 2009;20(10):1303–10. quiz 11CrossRefPubMedGoogle Scholar
  65. 65.
    Dickner SK, Cooper JM, Diaz D. A nonincisional, Doppler-guided transvaginal approach to uterine artery identification and control of uterine perfusion. J Am Assoc Gynecol Laparoscopists. 2004;11(1):55–8.CrossRefGoogle Scholar
  66. 66.
    Vilos GA, Vilos EC, Abu-Rafea B, Hollett-Caines J, Romano W. Transvaginal Doppler-guided uterine artery occlusion for the treatment of symptomatic fibroids: summary results from two pilot studies. J Obstet Gynaecol Can. 2010;32(2):149–54.CrossRefPubMedGoogle Scholar
  67. 67.
    Hald K, Kløw N-E, Qvigstad E, Istre O. Treatment of uterine myomas with transvaginal uterine artery occlusion: possibilities and limitations. J Minim Invasive Gynecol. 2008;15(5):631–5.CrossRefPubMedGoogle Scholar
  68. 68.
    Vilos GA, Hollett-Caines J, Burbank F. Uterine artery occlusion: what is the evidence? Clin Obstet Gynecol. 2006;49(4):798–810.CrossRefPubMedGoogle Scholar
  69. 69.
    Szydlowska I, Starczewski A. Laparoscopic coagulation of uterine myomas with the use of a unipolar electrode. Surg Laparosc Endosc Percutaneous Tech. 2007;17(2):99–103.CrossRefGoogle Scholar
  70. 70.
    Vilos G, Daly L, Tse B. Pregnancy outcome after laparoscopic electromyolysis. J Am Assoc Gynecol Laparoscopists. 1998;5(3):289–92.CrossRefGoogle Scholar
  71. 71.
    Exacoustos C, Zupi E, Marconi D, Romanini M, Szabolcs B, Piredda A, et al. Ultrasound-assisted laparoscopic cryomyolysis: two-and three-dimensional findings before, during and after treatment. Ultrasound Obstet Gynecol. 2005;25(4):393–400.CrossRefPubMedGoogle Scholar
  72. 72.
    Zupi E, Piredda A, Marconi D, Townsend D, Exacoustos C, Arduini D, et al. Directed laparoscopic cryomyolysis: a possible alternative to myomectomy and/or hysterectomy for symptomatic leiomyomas. Am J Obstet Gynecol. 2004;190(3):639–43.CrossRefPubMedGoogle Scholar
  73. 73.
    Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;10:CD004638.Google Scholar
  74. 74.
    Gobern JM, Rosemeyer CJ, Barter JF, Steren AJ. Comparison of robotic, laparoscopic, and abdominal myomectomy in a community hospital. JSLS. 2013;17(1):116–20.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Chen I, Motan T, Kiddoo D. Gonadotropin-releasing hormone agonist in laparoscopic myomectomy: systematic review and meta-analysis of randomized controlled trials. J Minim Invasive Gynecol. 2011;18(3):303–9.CrossRefPubMedGoogle Scholar
  76. 76.
    Goldman KN, Hirshfeld-Cytron JE, Pavone ME, Thomas AP, Vogelzang RL, Milad MP. Uterine artery embolization immediately preceding laparoscopic myomectomy. Int J Gynaecol Obstet. 2012;116(2):105–8.CrossRefPubMedGoogle Scholar
  77. 77.
    Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Libr. 2014;Google Scholar
  78. 78.
    Shen Q, Chen M, Wang Y, Zhou Q, Tao X, Zhang W, et al. Effects of laparoscopic versus minilaparotomic myomectomy on uterine leiomyoma: a meta-analysis. J Minim Invasive Gynecol. 2015;22(2):177–84.CrossRefPubMedGoogle Scholar
  79. 79.
    Wang T, Tang H, Xie Z, Deng S. Robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids: a meta-analysis. Minim Invasive Ther Allied Technol. 2018:1–16.Google Scholar
  80. 80.
    FDA updated assessment of the use of laparoscopic power morcellators to treat uterine fibroids: US FDA; 2017 [Available from:
  81. 81.
    Parker WH, Kaunitz AM, Pritts EA, Olive DL, Chalas E, Clarke-Pearson DL, et al. US Food and Drug Administration’s guidance regarding morcellation of leiomyomas: well-intentioned, but is it harmful for women? Obstet Gynecol. 2016;127(1):18–22.CrossRefPubMedGoogle Scholar
  82. 82.
    FDA allows marketing of first-of-kind tissue containment system for use with certain laparoscopic power morcellators in select patients [press release]. US FDA2016.Google Scholar
  83. 83.
    Hart R, Molnar BG, Magos A. Long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynaecol. 1999;106(7):700–5.CrossRefPubMedGoogle Scholar
  84. 84.
    Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet. 2011;113(1):3–13.CrossRefGoogle Scholar
  85. 85.
    Hamidouche A, Vincienne M, Thubert T, Trichot C, Demoulin G, Nazac A, et al. Operative hysteroscopy for myoma removal: morcellation versus bipolar loop resection. J Gynecol Obstet Biol Reprod (Paris). 2015;44(7):658–64.CrossRefGoogle Scholar
  86. 86.
    Vitale SG, Sapia F, Rapisarda AMC, Valenti G, Santangelo F, Rossetti D, et al. Hysteroscopic morcellation of submucous myomas: a systematic review. Biomed Res Int. 2017;2017:1–6.CrossRefGoogle Scholar
  87. 87.
    Liang Y, Ren Y, Wan Z, Guo L, Dong J, Chen Y, et al. Clinical evaluation of improved MyoSure hysteroscopic tissue removal system for the resection of type II submucosal myomas. Medicine. 2017;96(50):e9363.CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    Jefferys A, Akande V. Modern management of fibroids. Obstet Gynaecol Reprod Med. 2016;26(5):127–32.CrossRefGoogle Scholar
  89. 89.
    Worldwide AAMIG. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1–3.CrossRefGoogle Scholar
  90. 90.
    Daraï E, Soriano D, Kimata P, Laplace C, Lecuru F. Vaginal hysterectomy for enlarged uteri, with or without laparoscopic assistance: randomized study. Obstet Gynecol. 2001;97(5):712–6.PubMedGoogle Scholar
  91. 91.
    Zeng W, Chen L, Du W, Hu J, Fang X, Zhao X. Laparoscopic hysterectomy of large uteri using three-trocar technique. Int J Clin Exp Med. 2015;8(4):6319–26.PubMedPubMedCentralGoogle Scholar
  92. 92.
    Wu K-Y, Lertvikool S, Huang K-G, Su H, Yen C-F, Lee C-L. Laparoscopic hysterectomies for large uteri. Taiwan J Obstet Gynecol. 2011;50(4):411–4.CrossRefPubMedGoogle Scholar
  93. 93.
    Terzi H, Hasdemir PS, Biler A, Kale A, Sendag F. Evaluation of the surgical outcome and complications of total laparoscopic hysterectomy in patients with enlarged uteruses. Int J Surg. 2016;36:90–5.CrossRefPubMedGoogle Scholar
  94. 94.
    Bonino L, Mabrouk M, Del Piano E, Roviglione G, Deltetto F, Camanni M, et al. Hysterectomy for large sized uteri with benign pathology: total laparoscopic or vaginal hysterectomy using blood vessel sealing systems? Analysis of 514 patients. J Gynecol Surg. 2016;32(6):324–8.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Victoria HospitalScotlandUK
  2. 2.Royal Infirmary of EdinburghScotlandUK

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