This ‘scalpel-free surgery’ is a novel, non-invasive treatment for the painful condition which is estimated to affect one in four women. The Women’s is the only public hospital in Australia to offer MRgFUS.

The MRgFUS technology uses an MRI scanner to deliver a high-intensity focused ultrasound beam to heat fibroid tissue above 70 degrees, causing coagulative necrosis of the target tissue.

There is no damage to surrounding areas, and the body then reabsorbs and excretes the dead tissue, thus reducing the size of the fibroid and reducing the patient’s symptoms.

The procedure is performed under the guidance of thermally sensitive MRI imaging, giving accurate feedback, in real time, of the location and effectiveness of heat delivery.

The recovery time is rapid – within two days – and MRgFUS is performed as a day procedure in the Pauline Gandel Imaging Centre at the Women’s.

Normally the recovery period for invasive surgery for uterine fibroids is six weeks, but MRgFUS means that a woman can have a same-day procedure and resume normal activities within a few days.

The MRgFUS unit was installed at the Women’s in September 2008, and the next six months were spent recruiting patients for the treatment.

The media attention gained from the official launch of the MRgFUS facility in June 2009 resulted in a flood of enquiries from interested clinicians and patients from Victoria, interstate and overseas.

In collaboration with one of the hospital’s three specialist gynaecology clinics, the first patient was treated on 15 May 2009. Accreditation was achieved in August 2009 and since then the facility has been busy, facilitating an average of at least five procedures each month.

Between June 2009 and January 2011, imaging staff screened 276 patients with routine pelvic MRI to determine their suitability for the treatment. As 130 have been deemed suitable – with 101 treated so far – the suitability rate is 47 per cent.

The remainder were either unsuitable, or considered not optimal because their fibroid size was larger than 10cm or the growths were too close to surrounding tissue or organs.

The recommendation for this group of patients was reassessment with repeat pelvic MRI following three cycles of gonadotrophin releasing hormone (GnRH) against to reduce the size of the fibroid.

The radiology staff at the Pauline Gandel Imaging Centre are now evaluating the first group of treated patients with a follow-up MRI at four months and Quality of Life score (QOL) at six months to asses both fibroid size and symptom improvement.

The hospital is now 18 months into the three year pilot program and the results have been very positive. The mean treated fibroid volume (non perfused volume or NPV) has been 67 per cent and the mean shrinkage in fibroid volume at four months has been 32 per cent.

Symptom improvement has also been significant, with a mean symptom severity score reduction of 50 per cent at 12 months post treatment.

Patient feedback has been extremely encouraging. One patient, who showed a decrease in fibroid size and a dramatic improvement in symptoms, commented in the survey that the treatment had changed her life.

Two of the MRgFUS patients have now delivered healthy, full term babies following uncomplicated pregnancies. The babies were born in December 2010 and January 2011.

One patient was a young married woman who had been warned not to attempt pregnancy due to a large fibroid which, it was feared, could impede fetal development.

After MRgFUS treatment in May 2010 to shrink the fibroid, the patient became pregnant and delivered her first child at the Women’s by Caesarean section on 26 January 2011. This outcome underlines the potential of MRgFUS as a fertility enhancing technique.

None of the MRgFUS patients has had any major adverse outcomes such as burns, bowel perforation or nerve injury.

One patient required temporary pain relief after treatment, and four patients declined MRgFUS treatment due to positional discomfort. Most of these patients had pre-existing rotator cuff shoulder problems.

The MRgFUS procedure requires the patient to lie, face down and immobile on the MRI scanner bed for up to four hours for each treatment. The patient is usually given a mild sedative to maximise comfort during the procedure but they are awake and able to respond to questions from the radiologist and other technicians and clinicians, who attend continuously throughout the entire procedure.

It is an exciting step forward for women’s health care and the Women’s is very proud to be able to provide patients with access to such highly specialised, innovative treatment. The sophisticated technology is world class. The technology was made possible at the Women’s through the generous philanthropic support of the Pauline Gandel Charitable Trust whose $1 million donation, in addition to state government funding, enabled the Women’s to purchase this technology. The facility is also supported by GE Healthcare and InSighTec. More than 6000 women worldwide have been treated with the procedure which is available in countries including the US, Canada, Mexico, Brazil, France, Germany, Spain, UK, Japan, Israel, Singapore, Korea, Hong Kong, Taiwan and Russia.

What is MRgFUS?
Magnetic Resonance Guided Focused Ultrasound (MRgFUS) uses focused ultrasound energy to heat and destroy unwanted tissue in the body. The ultrasound beam is directed (focused) onto the unwanted tissue, passing through skin, muscle, fat and other soft tissues without causing damage.

This is similar to the way in which sunlight focused by a magnifying glass can create sufficient heat a single point.

This treatment takes place while the patient lies in an MRI scanner.

Where is this technology available in Australia?
The Royal Women’s Hospital is the only public hospital in Australia to offer MRgFUS.

How is MRgFUS used at the Women’s?
This treatment is used at the Royal Women’s Hospital to treat symptomatic uterine fibroids.

Why is an MRI used?
During the procedure, real-time MRI images enable the doctor to watch the progress and accuracy of the treatment. These MRI images also show a thermal map of the target area allowing the doctor to monitor that the unwanted tissue has been sufficiently heated and that the surrounding tissue is not harmed.

What does this mean for women?
MRgFUS is a breakthrough technology that offers women with uterine fibroids more treatment options aside from traditional, invasive surgery such as hysterectomy or myomectomy.

MRgFUS reduces the symptoms and severity of uterine fibroids and, therefore, greatly improves the quality of life for patients.

Compared with surgery, MRgFUS offers numerous advantages. It is carried out as a same day procedure, with no overnight hospital stay required. There is also a quick recovery time – with most women returning to normal activities within a few days, rather than the six week recovery time associated with invasive surgery.

After MRgFUS, women will have no incision wound or scar, so there is less risk of infection. Comparison studies have also shown that MRgFUS is associated with fewer adverse events, because the complications associated with anaesthetic and surgery are avoided.

In addition, this technology uses harm-free ultrasound waves, which present no risk to the woman. It does not use radiation.

Who can access MRgFUS?
Women with symptomatic uterine fibroids must be assessed by a gynaecologist to determine the most appropriate treatment option.

Depending on the woman’s circumstances, MRgFUS may be considered appropriate. If so, a screening MRI scan will be performed to check the exact size, location and number of fibroids for treatment to determine that MRgFUS is suitable.

What are uterine fibroids?
They are the most common benign tumors in females. The wall of the uterus is made of a powerful thick muscular wall. Fibroids are balls of muscle and fibre that grow within this wall.

Fibroids are classified according to their location:

• subserosal – on the outer covering of the uterus
  
  
• intramural – within the muscular wall of the uterus – most common
  
  
• submucosal – just underneath the uterine lining – least common
  
  
• pendunculated – connected to the uterus by a stalk
  
  
• uterine cavity

What causes fibroids?
The cause of fibroids remains unknown but female hormones accelerate growth.

Are they common?
It is estimated that between 30-50 per cent of women will have one or more fibroids.

While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation.

Are fibroids dangerous?
Fibroids are not cancerous but they may result in heavy menstrual bleeding which can lead to anaemia.

What are the symptoms fibroids?
There may be no symptoms, but they can cause pain and heavy bleeding. Symptoms are usually related to the fibroids’ size which can become very large until the uterus expands to the size of about a 14 week pregnancy.

Further information about MRgFUS treatment at the Women’s, contact the Gynaecology outpatients clinic on 03 8345 3100.

Dr Andrew Dobrotwir