Spotlight On: Fibroids

This month, we cast a spotlight on articles, SurgeryU videos, and Journal of Minimally Invasive Gynecology (JMIG) article recommendations from the AAGL Fibroids (SIG) led by Chair Arleen H. Song, MD, MPH.

Access to SurgeryU and JMIG are two of the many benefits included in AAGL membership. The SurgeryU library features high-definition surgical videos by experts from around the world. JMIG presents cutting-edge, peer-reviewed research, clinical opinions, and case report articles by the brightest minds in gynecologic surgery.

SurgeryU video and JMIG article recommendations by our SIGs are accessible by AAGL members only. For full access to SurgeryU, JMIG, CME programming, and member-only discounts on meetings, join AAGL today!

SIG Recommended SurgeryU Video #1: 
Surgical Management of 60 Intramural and Submucosal Fibroids
By Yael Yagur, Orla Donohoe, Mohammed Almogren, Jessica Robertson, Sarah Choi, David Rosen, Danny Chou.

This is a demonstration of a robot-assisted laparoscopic approach to a significant number of multiple intramural and intracavitary uterine fibroids. 

Click Image to View Video

SIG Recommended SurgeryU Video #2:
Characterizing Fibroids and Other Atypical Uterine Masses on MRI 
By Mian S, Kwon CS, Oliger K, Sullender RT, Abu-Alnadi N, Carey ET

This is a video-based educational intervention providing detailed instruction on MRI interpretation of uterine fibroids and various forms of degeneration. This video includes annotated imaging examples, contrast-enhanced patterns and differentiation strategies for distinguishing fibroids from adenomyosis and leiomyosarcoma.

   
Dr. Jeffrey J. Woo serves as the Editor-in-Chief of AAGL’s SurgeryU, is a minimally invasive gynecological surgeon, and Associate Professor of Obstetrics and Gynecology at Eastern Virginia Medical School.

JMIG Article Recommendation #1:

Incidence of Intrauterine Adhesions After Myomectomy and Association With Intraoperative Entry of the Endometrial Cavity
Ghatti S, Towers G, Pike M, Hazen M, Robinson J, Ramanathan A.

This retrospective cohort study evaluated the incidence of intrauterine adhesions (IUA) after myomectomy among 422 patients who underwent abdominal, laparoscopic, combined laparoscopic–hysteroscopic, or robotic myomectomy by a single MIGS fellowship-trained surgeon. At 3 months postoperatively, office hysteroscopy was performed in 282 patients and identified IUA in 17.4% of cases, with higher rates observed after abdominal myomectomy and when the endometrial cavity was entered during surgery.

JMIG Article Recommendation #2:

Stepwise REsectoscopic DIscoid SHaping (REDISH) Followed by Ultrasound-guided Forceps Traction for Safe and Effective One-step Removal of Large and Deep Submucous Myomas
Ettore Cicinelli, MD, PhD, Pierpaolo Nicoli, MD, Bart Paul De Bree MD, Antonella Vimercati, MD, Alessandro Favilli, MD, PhD, Amerigo Vitagliano, MD, PhD

This paper describes a new hysteroscopic procedure called REsectoscopic DIscoid SHaping (REDISH) which combines discoid shaping and ultrasound-guided forceps traction of submucous myomas, as an alternative to the cold loop technique. In a cohort of large and deep FIGO type 0 to 3 myomas, REDISH showed a favorable safety profile, shorter operative times, and anatomical results comparable to the cold loop technique.

JMIG Articles Recommendations By:
Connie Cheng, MD
Phillip Connell, MD

Dr. Cheng is a Fellow in Complex Benign Gynecology and practices at North Shore University Hospital, Northwell Health in Manhasset, New York.

Dr. Connell is a Fellow in Complex Benign Gynecology and practices at North Shore University Hospital, Northwell Health in Manhasset, New York.

When Fibroids Are Not Fibroids: Recurrent Giant Myometrial Cyst Managed With Fertility-Sparing Robotic Surgery and Subsequent Pregnancy

Myometrial cysts are rare benign uterine lesions that often present a significant diagnostic challenge. The differential diagnosis includes adenomyotic cysts, cystic degeneration of leiomyomas, congenital cysts, mesothelial cysts, accessory uterus, and, rarely, malignancy. Because these lesions are uncommon and may mimic more familiar gynecologic pathology, diagnosis and management can be particularly challenging in young patients desiring fertility preservation.

We present the case of a 24-year-old woman from Ghana with a history of ultrasound-guided drainage of a pelvic cyst who initially presented with amenorrhea and a large pelvic mass. She underwent laparoscopic drainage elsewhere, where approximately 1.5 liters of clear fluid were removed. Cytology was benign. One month later, she developed recurrent abdominal distention and symptoms related to rapid cyst reaccumulation. Concern was raised for a Müllerian anomaly or hematometra, and she was referred to our Minimally Invasive Gynecologic Surgery service.

Physical examination demonstrated a massively enlarged uterus approximating a 32-week gestation (See Image 1). MRI revealed a uterus extending to the xiphoid process with marked compression of surrounding structures. Two large multiloculated cystic lesions occupied the posterior myometrium and contained enhancing solid components, while both ovaries appeared normal (See Images 2A and 2B).

Image 1. Preoperative abdominal examination demonstrating massive uterine enlargement equivalent to approximately a 32-week gestation.

Image 2A. Preoperative MRI (coronal view) demonstrating a giant multiloculated myometrial cyst extending to the upper abdomen.

Image 2B. Preoperative MRI (axial or sagittal view) demonstrating posterior myometrial cystic lesions with enhancing solid components and marked compression of surrounding structures.

Given the patient’s strong desire for future fertility, a fertility-preserving surgical approach was pursued. Surgical planning was complicated by the size of the uterus, which displaced the cervix superiorly and significantly altered pelvic anatomy. Initial abdominal entry was achieved using a Hasson technique. Aspiration of the cyst confirmed straw-colored fluid and excluded hematometra. Following decompression of approximately 2.5 liters of fluid, robotic-assisted excision of the myometrial cyst was performed (See Images 3A–3B).

Image 3A. Intraoperative appearance of the enlarged uterus before cyst decompression.

Image 3B. Robotic aspiration and decompression of approximately 2.5 liters of straw-colored cyst fluid.

The cyst wall was carefully dissected from the surrounding myometrium and excised. To minimize blood loss, vasopressin and tranexamic acid were utilized. The resulting myometrial defect was reconstructed with multilayer closure using barbed suture to restore uterine integrity (See Image 4). Intraoperative hysteroscopy demonstrated a normal endometrial cavity with visualization of both tubal ostia, and chromopertubation confirmed bilateral tubal patency.

Image 4. Multilayer robotic reconstruction of the myometrium following complete cyst excision.

The postoperative course was notable only for transient subcutaneous emphysema, which resolved with conservative management. The patient recovered well and was discharged home.

One year later, she conceived spontaneously. During pregnancy, concern arose for recurrence of the myometrial cyst, and she was co-managed with Maternal-Fetal Medicine due to the history of extensive uterine reconstruction. At 36 weeks and 6 days, she underwent cesarean delivery of a healthy female infant. Intraoperatively, a recurrent 15-cm cornual myometrial cyst and a separate 10-cm fundal fibroid were identified. Given the increased hemorrhagic risk during pregnancy, the cyst was drained for symptom relief, and definitive treatment was deferred until the postpartum period.

This case highlights the diagnostic complexity and recurrence potential of giant myometrial cysts. It also demonstrates that, despite massive uterine distortion and recurrence, fertility-preserving robotic surgery can successfully restore reproductive potential and result in a favorable obstetric outcome. The case underscores the importance of advanced imaging, individualized surgical planning, multidisciplinary care, and long-term follow-up in young patients with rare uterine pathology.

Image 5. Postoperative abdominal examination

About the Author: 
Asha Bhalwal, MD, FACOG

Yesterday’s Controversy, Tomorrow’s Standard: A Technology Update in Fibroid Care

The management of uterine fibroids currently offers a wide range of therapeutic options. Treatment initially relied almost exclusively on hysterectomy. Myomectomy, which is now a standardized procedure, was highly controversial in its early years, with mortality rates approaching 40% during the nineteenth century. The introduction of improved hemostatic techniques, including the Bonney clamp, dramatically changed outcomes and transformed myomectomy into one of the pillars of uterus-preserving surgery. A similar evolution occurred with uterine artery embolization (UAE). Initially questioned because of concerns regarding safety, fertility outcomes, and long-term efficacy, UAE progressively gained acceptance and is now incorporated into modern treatment algorithms for appropriately selected patients. This historical perspective may mirror the transition we are witnessing today with emerging fibroid technologies. One of the most significant advances has been the development of radiofrequency ablation (RFA). Both laparoscopic and transcervical platforms have demonstrated favorable outcomes regarding symptom relief, rapid recovery, and uterine preservation, offering an attractive alternative for selected patients.

Microwave ablation represents another promising energy-based technology. Unlike RFA, microwave energy generates larger ablation zones through a mechanism independent of tissue electrical conductivity, potentially enabling more consistent coagulative necrosis across fibroids of varying composition. Early clinical experience has shown meaningful
reductions in symptom severity and improvements in quality of life following ultrasound guided percutaneous  microwave ablation. Reproductive outcomes and long-term durability require further investigation, but accumulating data support its potential as an additional uterus-preserving option.

Innovation extends beyond energy devices. Advances in imaging — including enhanced ultrasound, MRI-based planning, and image-guided procedures — are improving patient selection and procedural accuracy. Artificial intelligence is beginning to contribute across three areas: automated fibroid segmentation on MRI and ultrasound, which reduces variability in imaging interpretation and supports preoperative planning; prediction of treatment response based on imaging features and clinical parameters; and estimation of recurrence risk following minimally invasive procedures. None of these tools has been validated for routine clinical use, but they point toward a gradual shift from pattern recognition to decision support. The broader concept emerging from these developments is one of a more individualized approach to fibroid care — not built around a single technology, but around the ability to
match the right intervention to the right patient. These innovations do not compete with one another; they expand the options available to both clinician and patient.

History suggests that many disruptive technologies eventually become part of routine clinical practice. The challenge for gynecologic surgeons today is not simply to adopt innovation, but to evaluate it critically and integrate it where the evidence supports doing so. The future of fibroid management will depend on our ability to offer each patient the
full spectrum of available options and engage in shared decision-making that respects their symptoms, reproductive wishes, and personal goals.

References:

1. Jonsdottir G, Beermann M, Lanz E, et al. Ultrasound guided microwave ablation
treatment of uterine fibroids: clinical response and patient acceptability. Acta Obstet
Gynecol Scand. 2025;104(2):350–356. doi:10.1111/aogs.15041

2. Tinelli A, Morciano A, Sparic R, et al. Artificial intelligence and uterine fibroids: a
useful combination for diagnosis and treatment. J Clin Med. 2025;14(10):3454.
doi:10.3390/jcm14103454

About the Author: 
Santiago Artazcoz, MD

Dr. Artazcoz is an obstetrics and gynecology specialist providing comprehensive women’s health care throughout all stages of life with over 19 years of experience.