Cryosurgery for uterine myomas

Uterine myomas are the commonest pelvic tumours found in at least 20% of the females over thirty years of age. The incidence rises further with age until the time of menopause. There is a spectrum of presentations but a large proportion (1/4) are asymptomatic. The commonest symptoms are excessive uterine bleeding, pelvic pressure and pain, recurrent pregnancy losses and occasionally infertility. The chance of one of these tumors turning into cancer is less than 0.01%.
Uterine myomas may be located on the outer surface of the uterus, with the walls or on the inside surface, and are found in three major areas of the uterus: within the uterine cavity, within the wall of the uterus and on the surface of the organ.  When these benign muscular tumors are found with the uterine cavity they are referred to as submucous myomas. They typically cause very heavy periods.
The most common location of myomas is within the wall of the uterus referred to as intramural myomas. They can cause heavy periods as well because they can interfere with normal contraction of the uterine muscles that is important is stopping menstrual flow.
The last major location is just beneath the lining that covers the uterus or serosa called subserosal fibroids. These tumors seldom cause heavy bleeding but when they became large they can cause pressure on the other pelvis organs such as the urinary bladder etc.
Overview of treatment

For many women, traditional treatment methods of hysterectomy and myomectomy are not choice options for treating fibroids due to various drawbacks. Hysterectomy offers a definitive cure for myomas but causes infertility, onset of menopause, and oftentimes, genital prolapse and urinary incontinence. Myomectomy is often not a long-term solution - within 1-10 years, one quarter to a half of women who undergo the procedure will have evidence of fibroid recurrence and up to 10% will need retreatment .
Recently there is an increasing trend for minimal access surgery (MAS) for treatment of uterine myomas. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy for subserosa and intramural myomas. It is associated with faster postoperative recovery and potentially less postoperative adhesions. Other alternatives are laparoscopic assisted myomectomy, laparoscopic ultraminilaparotomic embolised myomectomy, laparoscopically assisted transvaginal myomectomy, myolysis.
Uterine artery embolization (UAE) is gaining popularity but it has lower successful rate for targeted or focal fibroid disease. In addition UAE causes significant pain that may prolong the 1-2 week recovery time.
Cryosurgery, which is performed through laparoscopic or percutaneous routes, may offer another option for uterine fibroids. Several feasibility studies have been carried out using this approach to treat subserosal and intramural myomas, each yielding promising results.
Indication of cryosurgery for uterine myomas
The criteria used to select patients for the cryomyolysis procedure are similar to those used for laparoscopic myomectomy,and should be only considered in postreproductive-aged women who have no interest in getting pregnant,as disruption of uterine wall integrity caused by myolysis increases the risk of uterine rupture during pregnancy.
Procedure of cryosurgery for uterine myomas
Percutaneous cryomyolysis
Patients are treated by percutaneous cryomyolysis under guidance of ultrasound(trans-abdominal or transvaginal),CT or MRI. The skin of the abdomen and pelvis are prepared and draped in normal sterile fashion. One percent lidocaine with epinephrine was used as local anesthesia and to reduce bleeding from the cutaneous puncture sites. A small (2 mm) incision was made through with a 2- or 3-cm cryoprobe that had been inserted previously into a protective access sheath. The cryoprobe was inserted percutaneously (Fig. 3) and advanced into the substance of the targeted fibroid tumor (Fig. 4).
In general,two or three 5-mm cryoprobes are placed depending on the location of the fibroids, the number of probe is determined by the myoma size and the size of the iceball created, and a probe approximately 5 mm in diameter is created from the serosa of the uterus into the myoma to the proximity of the primary blood supply of the myoma.
When each probe was optimally positioned, the cryosystem was activated (Fig. 5). Cryoablation continued until a black ice ball consumed the entire visualized targeted fibroid tumor (Figs. 6, 7, and 8). Two freezes are typically performed: one deep within the myoma and one more superficial. The duration of freezing depends on the progression of the ice front monitored by transvaginal ultrasound.
Laparoscopic cryomyolysis
The laparoscopic procedure is performed according to routine guiding. One or more cryoprobes are inserted into targeted fibroid tumor through laparocope. Then two freezing- thaw cycles are performed.

Clinical results

Percutaneous cryomyolysis
Several feasibility studies have been carried out using the percutaneous cryomyolysis approach to treat subserosal and intramural myomas, each yielding promising results.
The initial series of patients were treated by Yale researchers in the mid 1990s.19 Later, there are some reported case series that describe magnetic resonance-guided percutaneous ablation of uterine fibroid tumors.[7,8] In this technique, 66 women were treated with multiple bare KTP laser fibers placed directly into the center of the fibroid tumor. After 1 year, the uterine fibroid tumor shrinkage was 41%. Furthermore, the menorrhagia outcomes questionnaire showed improvement in the quality of their life.
Cowan and colleagues reported on a series of patients treated using an MRI-guided technique. Overall, nine patients were available for subsequent follow-up after MRI cryoablation and the mean volume reduction in all fibroid tumors that were treated was 65.0% ± 7.0%.
.20 Others have modified the original cryomyolysis technique to include a directed approach involving an ice ball that is targeted to the primary blood supply of the myoma, as well as the bulk of the myoma with the aid of U/S/Doppler guidance.21 This "directed cryomyolysis" caused symptoms to resolve completely and rapidly in 15 out of 20 patients; it also produced marked improvement in four of the remaining five patients. Average reduction of myoma volumes at 6 months was 57%, a result similar to that seen after uterine artery embolization (UAE). But in contrast to UAE, cryomyolysis was not linked with pain during recovery.
20. Cowan BD, Sewell PE, Howard JC, et al. Interventional magnetic resonance imaging cryotherapy of uterine fibroid tumors: preliminary observation. Am J Obstet Gynecol. 2002;186:1183-1187.
21. Zupi E, Piredda A, Marconi D, et al Directed laparoscopic cryomyolysis: a possible alternative to myomectomy and/or hysterectomy for symptomatic leiomyomas. Am J Obstet Gynecol. 2004;190;639-643.

Bryan et al showed that results are distinct from those of another case series that involved laparoscopically directed cryoablation of uterine fibroid tumors. They observed remarkable reduction in the size of uterine fibroid tumors in a short interval of time after MRI-guiding cryoablation, whereas Zreik et al[9] observed only a 10% to 12% reduction with laparoscopically directed therapies in 14 women. They postulate that MRI may provide a superior image of the treatment, whereas laparoscopically directed therapy may have provided ambiguous information regarding the extent of treatment.

[7]Law P, Gedroyc WMW, Regan L. Magnetic resonance-guided percutaneous laser ablation of uterine fibroids. Lancet 1999;354:2049-2050
[8]Hindley JT, Law PA, Hickey M, et al. Clinical outcomes following percutaneous magnetic resonance image guided laser ablation of symptomatic uterine fibroids. Hum Reprod 2002;17:2737-2741.
laparoscopic cryomyolysis
Zupi et al evaluated the long-term effectiveness of laparoscopic cryomyolysis as a minimally invasive technique for the treatment of symptomatic uterine myomas in menstruating women. Twenty patients with symptomatic uterine myomas were treated with directed cryomyolysis. All had reported abnormal bleeding and/or pelvic pain/pressure and/or urinary frequency. Myoma diameters varied from 4 to 10 cm. Patients were evaluated 1, 3, 6, 9, and 12 months after surgery. Power color Doppler ultrasound was performed preoperatively and postoperatively to demonstrate the effectiveness of the technique in reducing or eliminating the primary blood supply to the myomas, as well documenting regression of the myomas. All patients reported a high rate of satisfaction with the treatment including absence of symptoms 12 months after surgery, with no bleeding and no myoma-related symptoms, comparable with patients who underwent hysterectomy. Mean shrinkage of myoma volume increased until 9 months after surgery (59.5% +/- 13.2%), reaching a steady mean-volume reduction of approximately 60% (61.9% +/- 11.9%) 12 months after surgery. It is suggested that directed laparoscopic cryomyolysis appears to be an effective and safe technique for providing rapid symptom relief and at least 12 months' effectiveness in the treatment of symptomatic uterine leiomyomas.
Zupi E, Marconi D, Sbracia M, Exacoustos C, Piredda A, Sorrenti G, Townsend D.
Directed laparoscopic cryomyolysis for symptomatic leiomyomata: one-year follow up. J Minim Invasive Gynecol. 2005 Jul-Aug;12(4):343-6.

Discussion
Current results suggest that the minimally invasive intervention may offer a realistic alternative to surgery for women with symptomatic uterine fibroid tumors. This therapy produces little pain, and dramatic results can be achieved with minimal intervention. Percutaneous or laparoscopic cryotherapy for uterine fibroid tumors is amenable for this most common disease in women.
Cryoablation as a simple, safe, and effective way to treat uterine myomas. The procedure involves freezing the tumors under direct guidance of real-time ultrasound or laparoscopy. In contrast to other approaches to ablation, cryoablation can usually be accomplished without cervical dilation and with little or no anesthesia.
Another appealing aspect of this procedure is its flexibility. Clinicians have more choice during the placement of the freezing probe, and more control over the duration of freezing. And it's this flexibility that makes cryoablation a viable option for a broad range of situations, including submucous myomas and irregular uterine cavities. While neither form of cryotherapy can completely replace more traditional treatments, they may serve the needs of carefully selected patients.
Conclusion
There is an increasing trend for minimal access surgery for treatment of uterine myomas. Percutaneous or Laparoscopic cryomyolysis has provided minimal invasive alternative to laparotomy for subserosa and intramural myomas. It is associated with faster postoperative recovery and potentially less postoperative complications.
References
Bryan D. Cowan, M.D. Myomectomy and MRI-Directed Cryotherapy Semin Reprod Med2004 22(2):143-8,.

1. Verispan Physician Drug and Diagnosis Audit, MAT 6/02.
2. Web-based survey, Women's Menstrual Issues Report, March 2004.
3. Ostergard DR, Townsend DE. The treatment of vulvar condyloma acuminata by cryosurgery. A preliminary report. Cryobiology. 1969;5:340-342.
4. Cahan WG, Brockunier A Jr. Cryosurgery of the uterine cavity. Am J Obstet Gynecol. 1967;99:138-153.
5. Droegemueller W, Makowski E, Macsalka R. Destruction of the endometrium by cryosurgery. Am J Obstet Gynecol. 1971;110:467-469.
6. Pittrof R, Majid S, Murray A. Transcervical endometrial cryoablation (ECA) for menorrhagia. Int J Gynaecol Obstet. 1994;47:135-140.
7. Rutherford TJ, Zreik TG, Troiano RN, et al. Endometrial cryoablation, a minimally invasive procedure for abnormal uterine bleeding. J Am Assoc Gynecol Laparosc. 1998;5:23-28.
8. Duleba AJ, Heppard MC, Soderstrom RM, et al. A randomized study comparing endometrial cryoablation and rollerball electroablation for treatment of dysfunctional uterine bleeding. J Am Assoc Gynecol Laparosc. 2003;10:17-26.
9. Levy B, Isaacson K. Office-based cryoablation of the endometrium. ACOG poster, 2003.
10. Townsend DE, Duleba AJ, Wilkes MM. Durability of treatment effects after endometrial cryoablation versus rollerball electroablation for abnormal uterine bleeding: two-year results of a multicenter randomized trial. Am J Obstet Gynecol. 2003;188:699-701.
11. Townsend DE, McCausland V, McCausland A, et al. Post-ablation tubal sterilization syndrome. Obstet Gynecol. 1993;82:422-424.
12. Taskin O, Onoglu A, Inal M, et al. Long-term histopathologic and morphologic changes after thermal endometrial ablation. J Am Assoc Gynecol Laparosc. 2002;9:186-190.
13. McCausland AM, McCausland VM. Depth of endometrial penetration in adenomyosis helps determine outcome of rollerball ablation. Am J Obstet Gynecol. 1996; 174:1786-1794.
14. Turnbull LW, Jumaa A, Bowsley SJ, et al. Magnetic resonance imaging of the uterus after endometrial resection. Br J Obstet Gynaecol. 1997;104:934-938.
15. McCausland AM, McCausland VM. Frequency of symptomatic cornual hematometra and postablation tubal sterilization syndrome after total rollerball endometrial ablation: a 10-year follow-up. Am J Obstet Gynecol. 2002;186:1274-1280
16. Valle RF, Baggish MS. Endometrial carcinoma after endometrial ablation: high-risk factors predicting its occurrence. Am J Obstet Gynecol. 1998;179(3 Pt 1):569-572.
17. Margolis MT, Thoen LD, Boike GM, et al. Asymptomatic endometrial carcinoma after endometrial ablation. Int J Gynaecol Obstet. 1995;51:255-258.
18. Bruno R, Townsend DE. Hysteroscopic Evaluation Following Endometrial Ablation. ACOG 2004.
19. Zreik TG, Rutherford TJ, Palter SF, et al. Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids. J Am Assoc Gynecol Laparosc. 1998;5:33-38.
20. Cowan BD, Sewell PE, Howard JC, et al. Interventional magnetic resonance imaging cryotherapy of uterine fibroid tumors: preliminary observation. Am J Obstet Gynecol. 2002;186:1183-1187.
21. Zupi E, Piredda A, Marconi D, et al Directed laparoscopic cryomyolysis: a possible alternative to myomectomy and/or hysterectomy for symptomatic leiomyomas. Am J Obstet Gynecol. 2004;190;639-643.
22. Vilos GA. Pregnancy outcome after laparoscopic electromyolysis. J Am Assoc Gynecol Laparosc. 1998;5:289-292.
23. Arcangeli S. Gravid uterine rupture after myolysis. Obstet Gynecol. 1997;89:857.

Figure 2. This is a longitudinal section of a uterine fibroid that measures 78 × 53 mm. The uterus is easily seen with the MRI view.( Bryan D. Cowan, M.D. Semin Reprod Med2004 22(2):143-8)

Figure 5. Three probes have been placed. ( Bryan D. Cowan, M.D. Semin Reprod Med2004 22(2):143-8)

Figure 6. This is an AP projection of the uterine fibroid with five cryoprobes that have been activated for ~2 minutes. Each MRI probe is easily seen. ( Bryan D. Cowan, M.D. Semin Reprod Med2004 22(2):143-8)

Figure 7. A transverse section of the uterine fibroid that shows two of the five cryoprobes. They have each been activated for ~3 minutes. ( Bryan D. Cowan, M.D. Semin Reprod Med2004 22(2):143-8)

Figure 8. Entire consumption of the uterine fibroid after ~40 minutes of treatment. ( Bryan D. Cowan, M.D. Semin Reprod Med2004 22(2):143-8)