Vol 93, No 8 (2022)
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Transcervical intrauterine radiofrequency ablation of fibroids in high-risk patients with bleeding disorder

Elvin Piriyev1, Ralf Bends2, Sven Schiermeier3, Thomas Romer2
Pubmed: 35894488
Ginekol Pol 2022;93(8):614-619.

Abstract

Objectives: To show the advantages of transcervical radiofrequency ablation (TRFA) in high-risk patients with bleeding disorder.

Material and methods: It is a retrospective analysis. The study included only patients with known pre-existing conditions (obesity, cardiac and neurological disease, coagulation disorder, anaemia) or post-surgical conditions who were treated with the Sonata® System for fibroid-related bleeding complaints at Academic Hospital Cologne Weyertal between January 2015 and March 2021. These patients were classified as high-risk patients. The fibroids were mostly determined due transvaginal sonography. Thirty patients were included, and 43 fibroids were determined.

Results: Therapy with the Sonata® system could be performed without complications in all cases. In our analysis, improvement of fibroid-related symptoms was observed in 89% of cases.

Conclusions: The Sonata® System is on the one hand minimally invasive, uncomplicated and fast and on the other hand a successful method of fibroid therapy, which is particularly suitable for high-risk patients with various pre-existing conditions, for whom a minimally invasive, bloodless and short surgical procedure has great advantages.

ORIGINAL PAPER / GINECOLOGY

Ginekologia Polska

2022, vol. 93, no. 8, 614–619

Copyright © 2022 PTGiP

ISSN 0017–0011, e-ISSN 2543–6767

DOI 10.5603/GP.a2022.0042

Transcervical intrauterine radiofrequency ablation of fibroids in high-risk patients with bleeding disorder

Elvin Piriyev1Ralf Bends2Sven Schiermeier3Thomas Romer2
1Department of Obstetrics and Gynecology, University Witten-Herdecke, Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Germany
2Department of Obstetrics and Gynecology Academic Hospital Cologne Weyertal University of Cologne, Germany
3Department of Obstetrics and Gynecology, University Witten-Herdecke, Marien-Hospital, Witten Marienplatz, Witten, Germany
ABSTRACT
Objectives: To show the advantages of transcervical radiofrequency ablation (TRFA) in high-risk patients with bleeding disorder.
Material and methods: It is a retrospective analysis. The study included only patients with known pre-existing conditions (obesity, cardiac and neurological disease, coagulation disorder, anaemia) or post-surgical conditions who were treated with the Sonata® System for fibroid-related bleeding complaints at Academic Hospital Cologne Weyertal between January 2015 and March 2021. These patients were classified as high-risk patients. The fibroids were mostly determined due transvaginal sonography. Thirty patients were included, and 43 fibroids were determined.
Results: Therapy with the Sonata® system could be performed without complications in all cases. In our analysis, improvement of fibroid-related symptoms was observed in 89% of cases.
Conclusions: The Sonata® System is on the one hand minimally invasive, uncomplicated and fast and on the other hand a successful method of fibroid therapy, which is particularly suitable for high-risk patients with various pre-existing conditions, for whom a minimally invasive, bloodless and short surgical procedure has great advantages.
Key words: Sonata®; fibroid; ablation; high risk patients; bleeding disorder; uterus
Ginekologia Polska 2022; 93, 8: 614–619

Corresponding author:

Elvin Piriyev, Department of Obstetrics and Gynecology, University Witten-Herdecke, Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Germany

e-mail: piriyev.elvins@gmail.com

Received: 3.01.2022 Accepted: 24.04.2022 Early publication date: 3.06.2022

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

INTRODUCTION

The estimated prevalence of uterine fibroids ranging from 4.5% to 68.6% [1]. The prevalence is age-dependent [2]. Figures in the literature vary widely, from 217 to 3745 cases per 100 000 women-years [1]. The prevalence in Germany is 48.6% in women aged 3055 years, with the highest prevalence of 65.2% in the group with patients aged 4650 years [2]. Fibroids cause different symptoms, and hypermenorrhoea is the main symptom with the prevalence of 4054%. The next common symptoms are dysmenorrhea and lower abdominal pain [3, 4]. In 48% cases, fibroids are the cause of severe hypermenorrhoea with anaemia [5]. Even nowadays the most common therapy for symptomatic fibroids is a hysterectomy. The main indication for a hysterectomy is still fibroid [6–9].

The classification of fibroids is according to FIGO classification, which serves as basis [10]. The classification of fibroids is very important for prognosis and therapy recommendation. Therefore localization, size and number of fibroids should be well understood [2].

In the therapy, low effective medicament therapy, invasive and drastic therapy such as a removal of uterus are mostly used. To fill the gap between these methods, transcervical radiofrequency ablation (TRF) was developed. This method is safe and effective [11–14]. A meta-analysis of 32 studies with more than 1200 patients treated with TRF ablation showed a statistically significant and clinically relevant reduction in fibroid-related symptoms and improvement in quality of life, with low reintervention rates [11]. The benefit of TRF is that it is minimally invasive without incision, and the treatment of a broad type of fibroids is possible, especially such fibroids, which cannot be treated with a surgical hysteroscopy (FIGO 3, 4, 5, 6, and 25) [8].

Transcervical radiofrequency ablation has FDA (U.S. Food and Drug Administration) approval for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding. The system also has a CE mark (“Conformité Européenne” French for “European Conformity”) in the European Union [14–16].

Transcervical radiofrequency ablation is performed by a gynaecologist. The instrument has a small ultrasound probe which is to insert intrauterine [17]. Before the ablation the fibroid is determined sonographically. Usually, a general anaesthesia is required for TFA. The diameter of the device is 8.3 mm. The penetration depth is less than 12 cm. The fibroid is represented due graphical navigation. After graphical visualize of fibroid the ablation is carried out. In this phase a safety zone guaranteed no thermal injury in the surrounding organs (for example bladder, bowel). It is important especially for transmural fibroids that are also located near the bladder and bowels. The procedure allows for optimization of the ablated volume in the targeted fibroid. The puncture of serosa is not necessary. The measurements are registered graphically. The ablation time is 17 min depending on the fibroid size (the smallest size of fibroid is 2.0 × 1.3 cm). The temperature of the electrode is about 105°C. A thermal coagulation necrosis is not caused by TFA. This method does not cause a postablation syndrome either. A good knowledge of vaginal ultrasonography and confidence in all other endoscopic fibroid therapy are required, because they can be used at the same time in combination with TRF as needed. Hospital stay time is 12 days [17, 18].

This technique could be of importance in the treatment of fibroids in high-risk patients (e.g., obesity, cardiac disease, coagulopathy, multiple previous surgeries), as it offers the most minimally invasive and effective approach, with short surgical time. Therefore, this study was conducted to analyse the results of the Sonata® System in high-risk patients.

MATERIAL AND METHODS

Transcervical radiofrequency ablation has been performed in our department since 2011. The retrospective study included only patients with known pre-existing conditions (obesity, cardiac and neurological disease, coagulation disorder, anaemia) or post-surgical conditions who were treated with the Sonata® System for fibroid-related bleeding complaints at Academic Hospital Cologne Weyertal between January 2015 and March 2021. These patients were classified as high-risk patients. Diagnosis was mostly performed by transvaginal sonography. Thirty patients were included, and 43 fibroids were determined.

Therapy with the Sonata® System was carried out complications free in all cases. During the operations, the device could be inserted without any difficulty. First, the ablation zone and the safety zone were adjusted and then the fibroid was fixed with the central spike (“introducer”). After checking the safety zone, the electrodes were inserted. After checking the safety zone again, the fibroids were ablated with a temperature of 105°C. All patients without any complications.

RESULTS

The age of the patients ranged from 34 to 54 years (Fig. 1). All patients had abnormal uterine bleeding mostly hypermenorrhoea and two patients still had the desire to become pregnant.

224655.png
Figure 1. Overview of patients depending on age group

A total of 43 fibroids were detected in 30 patients. Nineteen patients had one fibroid, 10 patients had two fibroids, and one patient had four fibroids.

The fibroids were classified according to FIGO classification. Figure 2 shows the number of fibroids based on FIGO classification. The majority of fibroids were classified as of FIGO 25 fibroids 62.8% (27 fibroids) and the minority consisted of FIGO 4 fibroids 2.3% (one fibroid).

224686.png
Figure 2. Number of fibroids related to FIGO classification

F-fibroid

For better visualization, the fibroids were divided into six groups depending on their size. Figure 3 shows this division.

224779.png
Figure 3. Myoma number related to myoma size

Table 1 shows the risks/pre-existing conditions of the patients. Twenty-two patients had one and eight patients had two risk factors/pre-existing conditions.

Table 1. Overview of risks in relation to number of patients

Number of patients

Risk groups

Risk subgroup

Number of patients

4

Coagulation disorder

Thrombosis

2

Immune thrombocytopenia

1

AT III Deficiency

1

7

Obesity

BMI 3035 kg/m² (Iº)

1

BMI 3540 kg/m² (IIº)

3

BMI > 40 kg/m² (IIIº)

3

9

Previous operations

1 × midline laparotomy

4

1 × LSK, 1 × midline laparotomy

1

2 × midline laparotomy

2

4 × midline laparotomy

1

4 × LSK

1

6

Anaemia (Hb)

89 g/dL

1

78 g/dL

3

67 g/dL

2

2

Neurological diseases

Apoplexy cerebral vessel

1

Brain pacemaker by strong depression

1

2

Cardiac diseases

Hypertension

1

AVNRT

1

8

Large fibroid with a request for organ-preserving therapy

2 × 6 cm

1

78 cm

4

912 cm

3

AT III antithrombin III; AVNRT atrioventricular nodal reentrant tachycardia; BMI body mass index; LSK laparoscopy

Three patients had third-degree-obesity: with a BMI of 45 kg/m² in two patients and 56 kg/m² in one patient. Seven patients had a large transmural fibroid of7 cm, one patient had two fibroids of 6 cm and all these patients had strongly desired an organ-preserving minimally invasive approach. Laparoscopic fibroid removal in this case would be associated with a high risk of bleeding and a laparotomy.

Intraoperative results

The shortest ablation time of a fibroid was 1 minute 13 seconds and the longest was 25 minutes 6 seconds. Table 2 shows the ablation time of a fibroid in relation to the number of fibroids.

Table 2. Ablation time in relation to the number of fibroids

Ablation time

Number of fibroids

15 minutes

26

> 510 minutes

8

> 1015 minutes

3

> 1520 minutes

4

> 2025 minutes

2

The ablation time and the number of ablation steps vary depending on the fibroid size. As it can be seen in Table 3, both ablation time and ablation steps increase with fibroid size.

Table 3. Ablation time and number of ablation steps in relation to fibroid size

Fibroid size

Fibroid number

Ablation step

Ablation time [min]

1.52 cm

4

1 step

1:132:06

> 24 cm

18

12 fibroids — 1 step

1:305:00

6 fibroids — 2 steps

3:134:06*

> 46 cm

11

6 fibroids — 1 step

3:005:42

4 fibroids — 2 steps

5:487:24*

1 fibroid — 3 steps

10:06

> 68 cm

6

3 fibroids — 2 steps

6:0012:12*

3 fibroids — 3 steps

15:1817:00*

> 810 cm

3

2 fibroids — 3 steps

1 fibroid — 4 steps

13:3218:50*

22:12*

>1012 cm

1

4 steps

25:06*

*Total time of all ablation steps

Postoperative results

Twenty-six patients came to follow-up (Fig. 4). Twenty-three of 26 patients reported subjective improvement in symptoms, with 21 patients reporting marked improvement and two patients reporting a mild improvement. Three patients had no improvement and in one of them a hysterectomy by laparotomy was performed during follow-up. In this case the respective uterus showed four FIGO 25 fibroids, three of which were approximately 5 cm. The patient had already undergone two surgeries by transverse laparotomy, so the hysterectomy was also performed by laparotomy in the presence of adhesions. Therefore, an improvement of the complaints was 89%.

224614.png
Figure 4. Postoperative results in the follow up group in percentages

Special cases

Two patients with severe hypermenorrhoea still had a desire to become pregnant, of which one patient had a current desire and one had a potential desire. In both cases, significant improvement of hypermenorrhoea was observed.

The patient with the current fertility desire had a FIGO 25 fibroid of 7 cm. Prior to presentation at our department, a laparoscopy was performed in another hospital. A hysterectomy was recommended to the patient, due to the size of the fibroid. In our department, the ablation of the fibroid was performed using the Sonata® System. Two ablation steps were performed, 7 minutes and 5 minutes 12 seconds. After 15 months, the patient had a vaginal delivery in our department without any complications.

The second patient with a potential desire to become pregnant had the condition after midline laparotomy with the removal of 1700 g of fibroids. She had a FIGO 2 fibroid of 2.7 × 2 × 2 cm, which was90% intramural. Transcervical radiofrequency ablation was performed with two ablation steps, 1 min. 42 seconds and 2 minutes. Transvaginal ultrasound after three months showed a significant regression to 1.7 × 1.5 × 1.4 cm. Moreover, the position of the fibroid shifted from FIGO 2 to FIGO 4 with sufficient distance from the endometrium, which is highly relevant for fertility.

DISCUSSION

For the therapy of fibroids there are a wide spectrum of options, from medicament treatment to a removal of uterus [6–9, 11–14]. Several factors must be considered in the therapy of fibroid, as a FIGO type, size, number of fibroids, severity of symptoms, patient’s life stage (fertile, peri- or postmenopausal), health risk factors, medical contraindications as well the patient’s wishes.

In a study, almost a thousand women with symptomatic fibroids were asked about the therapy desire. Almost 80% of respondents did not want an invasive method and the half of respondents wanted avoid a hysterectomy [9]. In the therapy of fibroids is a need for less invasive organ-preserving therapy without incision, that is available for wide spectrums of fibroids [14–16]. For this reason, TRF was developed. This method is effective and safe [11–14]. According to the literature review as well as in our analysis, no specific intraoperative or postoperative complications were found.

In Luke’s et al. [19] study, patient satisfaction with TRF was 94% (99/105) and 88% of patient had an improvement of symptoms. Toub reported an improvement in 90% of cases [14]. In our analysis, an improvement of fibroid-related symptoms was observed in 89% of cases.

The long-term results after TRF are available. The reintervention rate is 11.8% [20]. it is slightly higher than after an abdominal myomectomy (9%) and the same as with laparoscopic myomectomy (11%), but significantly lower compared to other methods (17% after uterine artery embolization, 21% after hysteroscopic fibroid resection) [21].

Bipolar operative hysteroscopy is most suitable for submucosal fibroids [2]. For large (> 3 cm), multiple (n > 3), and type-2 fibroids the hysteroscopy can be difficult. In this case there is a 2050% chance for least one additional resection for complete treatment [2, 22, 23]. Hysteroscopy has a low intraoperative complication rate [24]. Postoperative complications in terms of intrauterine adhesions occur in 10% to 37.5% for the resection of one fibroid and up to 45% for multiple fibroids [2, 25].

Intramural and subserosal fibroids can be removed by laparoscopy and/or laparotomy. In a meta-analysis involving 576 patients, laparoscopic and abdominal removal of fibroids were compared. In the meta-analysis, the advantages of laparoscopy over laparotomy were shown, including faster postoperative recovery of patients, less blood loss and less postoperative pain. Therefore, laparotomy should be performed only in certain cases [2, 26].

Intraoperative complications of laparoscopic fibroid removal arise from inadequate hysterotomy, enucleation, haemostasis, and morcellation. Postoperative complications include hematomas after a hysterotomy, uterine adhesions, abdominal adhesions, and parasitic fibroids [27–29]. In an analysis with the laparoscopic resection of 654 fibroids (average size 5.3 cm), intraoperative complications occurred in 2.6% cases and postoperative complications in 5.7% cases [27]. Another study of 2050 laparoscopic fibroid resections showed an overall complication rate of 11.1% (225/2050) [30]. The increase of complications with laparoscopic myoma enucleation is observed [27, 31]. One possible reason for this is the increasing number of gynaecologists with lack of experience in laparoscopic fibroid removal, laparoscopic suturing, as well as electromechanical morcellation [32].

The complication rate of laparoscopy increases in patients with additional risks. Driessen et al. [33] compared two groups of patients with and without risks. Among all, BMI, number of previous surgeries and uterus size were considered. A total of 2237 laparoscopic hysterectomies were analysed. The complication rate in the group with known risks was significantly higher (10.5% vs 4.8%), blood loss 167.6 mL vs 110.1 mL and operation time 114.3 minutes vs 95.3 minutes [33].

Especially in high-risk patients with fibroids, that more difficult to reach, the therapy should be chosen very carefully. Our study shows that fibroid therapy with the Sonata® System is suitable for FIGO 2 to 5, whereas FIGO 2 to 4 fibroids are rather difficult to reach for the other surgical option. This method can also be used to treat multiple fibroids in a single session. The method is particularly suitable for patients with anaemia, as there is hardly any bleeding with the Sonata® System compared to other surgical measures.

CONCLUSIONS

Therefore, the Sonata® System is on the one hand minimally invasive, uncomplicated and fast and on the other hand a successful method of fibroid therapy, which is particularly suitable for high-risk patients with various pre-existing conditions, for whom a minimally invasive, bloodless and short surgical procedure has great advantages.

Ethical approval

According to §15 of the professional code of the North Rhine Medical Association, neither advice nor an ethics vote is necessary for a retrospective study.

Conflict of interest

Elvin Piriyev has no conflict of interest. Ralf Bends, Sven Schiermeier and Thomas Römer are consultants for the Sonata System. The authors report no other conflicts of interest in this work.

Funding

This study was not funded.

REFERENCES

  1. Stewart EA, Cookson CL, Gandolfo RA, et al. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017; 124(10): 15011512, doi: 10.1111/1471-0528.14640, indexed in Pubmed: 28296146.
  2. Römer T. Medical treatment of fibroids. De Gruyter. : 2019.
  3. Foth D, Röhl FW, Friedrich C, et al. Symptoms of uterine myomas: data of an epidemiological study in Germany. Arch Gynecol Obstet. 2017; 295(2): 415426, doi: 10.1007/s00404-016-4239-y, indexed in Pubmed: 27873052.
  4. Zimmermann A, Bernuit D, Gerlinger C, et al. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health. 2012; 12: 6, doi: 10.1186/1472-6874-12-6, indexed in Pubmed: 22448610.
  5. Nelson AL, Ritchie JJ. Severe anemia from heavy menstrual bleeding requires heightened attention. Am J Obstet Gynecol. 2015; 213(97): e197.e6, doi: 10.1016/j.ajog.2015.04.023 , indexed in Pubmed: 25935784.
  6. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002; 99(2): 229234, doi: 10.1016/s0029-7844(01)01723-9, indexed in Pubmed: 11814502.
  7. Wise LA, Palmer JR, Stewart EA, et al. Age-specific incidence rates for self-reported uterine leiomyomata in the Black Women’s Health Study. Obstet Gynecol. 2005; 105(3): 563568, doi: 10.1097/01.AOG.0000154161.03418.e3, indexed in Pubmed: 15738025.
  8. Downes E, Sikirica V, Gilabert-Estelles J, et al. The burden of uterine fibroids in five European countries. Eur J Obstet Gynecol Reprod Biol. 2010; 152(1): 96102, doi: 10.1016/j.ejogrb.2010.05.012, indexed in Pubmed: 20598796.
  9. Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol. 2013; 209(4): 319.e1319.e20, doi: 10.1016/j.ajog.2013.07.017, indexed in Pubmed: 23891629.
  10. Munro MG, Critchley HOD, Broder MS, et al. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011; 113(1): 313, doi: 10.1016/j.ijgo.2010.11.011, indexed in Pubmed: 21345435.
  11. Bradley LD, Pasic RP, Miller LE. Clinical Performance of Radiofrequency Ablation for Treatment of Uterine Fibroids: Systematic Review and Meta-Analysis of Prospective Studies. J Laparoendosc Adv Surg Tech A. 2019; 29(12): 15071517, doi: 10.1089/lap.2019.0550, indexed in Pubmed: 31702440.
  12. Iversen H, Dueholm M. Radiofrequency Thermal Ablation for Uterine Myomas: Long-term Clinical Outcomes and Reinterventions. J Minim Invasive Gynecol. 2017; 24(6): 10201028, doi: 10.1016/j.jmig.2017.05.021, indexed in Pubmed: 28662989.
  13. Lin L, Ma H, Wang J, et al. Quality of Life, Adverse Events, and Reintervention Outcomes after Laparoscopic Radiofrequency Ablation for Symptomatic Uterine Fibroids: A Meta-Analysis. J Minim Invasive Gynecol. 2019; 26(3): 409416, doi: 10.1016/j.jmig.2018.09.772, indexed in Pubmed: 30253997.
  14. Toub DB. A New Paradigm for Uterine Fibroid Treatment: Transcervical, Intrauterine Sonography-Guided Radiofrequency Ablation of Uterine Fibroids with the Sonata System. Curr Obstet Gynecol Rep. 2017; 6(1): 6773, doi: 10.1007/s13669-017-0194-2, indexed in Pubmed: 28357157.
  15. Bongers M, Brölmann H, Gupta J, et al. Transcervical, intrauterine ultrasound-guided radiofrequency ablation of uterine fibroids with the VizAblate® System: three- and six-month endpoint results from the FAST-EU study. Gynecol Surg. 2015; 12(1): 6170, doi: 10.1007/s10397-014-0873-1, indexed in Pubmed: 25774122.
  16. Chudnoff S, Guido R, Roy K, et al. Ultrasound-Guided Transcervical Ablation of Uterine Leiomyomas. Obstet Gynecol. 2019; 133(1): 1322, doi: 10.1097/AOG.0000000000003032, indexed in Pubmed: 30531573.
  17. Römer T, Bends R, Christoffel L, et al. The significance of transcervical ultrasound-guided radiofrequency ablation in the treatment of symptomatic fibroids: results of an expert consensus from German-speaking countries. Arch Gynecol Obstet. 2022 [Epub ahead of print], doi: 10.1007/s00404-022-06516-1, indexed in Pubmed: 35316395.
  18. Piriyev E, Schiermeier S, Römer T. Combined procedure of the transcervical radiofrequency ablation (TRFA) system and surgical hysteroscopy. Increased risk or safe procedure? Videosurgery and Other Miniinvasive Techniques. 2022, doi: 10.5114/wiitm.2022.113565.
  19. Lukes A, Green MA. Three-Year Results of the SONATA Pivotal Trial of Transcervical Fibroid Ablation for Symptomatic Uterine Myomata. J Gynecol Surg. 2020; 36(5): 228233, doi: 10.1089/gyn.2020.0021, indexed in Pubmed: 33061253.
  20. Garza-Leal JG. Long-Term Clinical Outcomes of Transcervical Radiofrequency Ablation of Uterine Fibroids: The VITALITY Study. J Gynecol Surg. 2019; 35(1): 1923, doi: 10.1089/gyn.2018.0051, indexed in Pubmed: 30713407.
  21. Davis MR, Soliman AM, Castelli-Haley J, et al. Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids. J Womens Health (Larchmt). 2018; 27(10): 12041214, doi: 10.1089/jwh.2017.6752, indexed in Pubmed: 30085898.
  22. Vercellini P, Cortesi I, Oldani S, et al. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia. Hum Reprod. 1997; 12(8): 17681771, doi: 10.1093/humrep/12.8.1768, indexed in Pubmed: 9308809.
  23. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol. 1993; 82(5): 736740, indexed in Pubmed: 8414318.
  24. Römer T. Operative Hysteroscopy: A Practical Guide. 2 Edition. De Gruyter, https://doi.org/10.1515/9783110225006 2011.
  25. Revaux A, Ducarme G, Luton D. [Prevention of intrauterine adhesions after hysteroscopic surgery]. Gynecol Obstet Fertil. 2008; 36(3): 311317, doi: 10.1016/j.gyobfe.2007.11.014, indexed in Pubmed: 18308609.
  26. Jin C, Hu Y, Chen X, et al. Laparoscopic versus open myomectomy a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009; 145: 1421.
  27. Altgassen C, Kuss S, Berger U, et al. Complications in laparoscopic myomectomy. Surg Endosc. 2006; 20(4): 614618, doi: 10.1007/s00464-004-2181-8, indexed in Pubmed: 16508820.
  28. Malzoni M, Rotond M, Perone C, et al. Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results. Eur J Gynaecol Oncol. 2003; 24(1): 7982, indexed in Pubmed: 12691325.
  29. Mettler L, Schollmeyer T, Tinelli A, et al. Complications of uterine fibroids and their management, surgical management of fibroids, laparoscopy and hysteroscopy versus hysterectomy, haemorrhage, adhesions, and complications. Obstet Gynecol Int. 2012; 2012: 791248, doi: 10.1155/2012/791248, indexed in Pubmed: 22619681.
  30. Sizzi O, Rossetti A, Malzoni M, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol. 2007; 14(4): 453462, doi: 10.1016/j.jmig.2007.01.013, indexed in Pubmed: 17630163.
  31. Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invasive Gynecol. 2014; 21(3): 486491, doi: 10.1016/j.jmig.2013.12.003, indexed in Pubmed: 24333632.
  32. Tanos V, Socolov R, Demetriou P, et al. Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues. Facts Views Vis Obgyn. 2016; 8(2): 111118, indexed in Pubmed: 27909568.
  33. Driessen SRC, Sandberg EM, Rodrigues SP, et al. Identification of risk factors in minimally invasive surgery: a prospective multicenter study. Surg Endosc. 2017; 31(6): 24672473, doi: 10.1007/s00464-016-5248-4, indexed in Pubmed: 27800588.