Abstract
Objective
To evaluate the effectiveness of multi-bipolar radiofrequency ablation compared to standard laparoscopic myomectomy in treating uterine fibroids, focusing on women’s quality of life.
Design
Retrospective observational cohort study.
Setting
La Conception Hospital, APHM—Marseille, France.
Patients
50 women with symptomatic fibroids treated between December 2021 and December 2023.
Intervention
Laparoscopic radiofrequency ablation or conventional laparoscopic myomectomy.
Measurements and main results
After excluding patients who did not complete the preoperative quality-of-life questionnaire, 34 underwent myomectomy and 16 radiofrequency ablation. At 3 months, no significant differences were observed in HRQOL improvement (9.2 ± 34.3 vs 24.2 ± 28.2, p = 0.14), SSS (− 27.5 ± 31.5 vs − 23.3 ± 33, p = 0.66), or FSFI (0.9 ± 14.7 vs − 1.5 ± 10.8, p = 0.40). The 6-month outcomes also showed no significant difference. Baseline fibroid-specific quality of life was significantly and negatively associated with improvement (p < 0.05).
Conclusion
Both procedures improved quality of life and reduced fibroid-related symptoms at 3 and 6 months, with no significant difference. Myolysis showed fewer peri- and postoperative complications, suggesting a better safety profile and potential as a conservative treatment option.
Trial registration
The ethics committee of Aix Marseille University approved this study on April 18, 2024, under the reference number 2024-04-18-08.
Keywords: Laparoscopic, Radiofrequency, Myomectomy, Quality of life
Precis
| Myolysis improve quality of life as well as a reduction in fibroid-related symptoms at 3 and 6 months postoperatively, with no significant difference between myomectomy and myolysis. |
Introduction
Uterine fibroids affect between 10.7 and 35.7% of reproductive-age women, contingent upon their ethnic background [1]. Approximately 30% of women present with symptoms, such as menometrorrhagia, dysmenorrhea, dyspareunia, infertility, chronic pelvic pain, and urinary or digestive associated symptoms [2].
Given the frequency and severity of symptoms associated with fibroids, as well as the significant impact on quality of life, surgical intervention is often considered [3]. A multidisciplinary approach is crucial for optimizing the timing of surgical interventions. Myomectomy is currently the reference conservative surgical option for women seeking to preserve fertility [4, 5]. Myomectomy carries a high risk of hemorrhage, potential obstetric complications, and postoperative adhesions [6–8].
Uterine fibroid ablation using radiofrequency, introduced in 2002 by Lee BB et al. causes necrosis of the fibroids through the application of radiofrequency applicators [9, 10]. Chudnoff et al. further standardized the laparoscopic procedure approach guided by ultrasound [11, 12]. Emerging data on fertility preservation and obstetric outcomes suggest that radiofrequency fibroid ablation could represent a promising alternative to current treatments for women who wish to retain their fertility [13, 14]. Radiofrequency myolysis may offer a conservative option for uterine fibroids and other myometrial disorders, such as adenomyosis, in cases of chronic pelvic pain refractory to medical therapy, where existing surgical treatments are limited.
The main goal of this study was to assess the effectiveness of multi-bipolar radiofrequency ablation for treating uterine fibroids, comparing its impact on women’s quality of life to that of the standard laparoscopic myomectomy.
Materials and methods
We conducted a retrospective cohort study at La Conception Hospital, Marseille, France, between December 2021 and December 2023. The ethics committee of Aix Marseille University approved this study on April 18, 2024, under the reference number 2024-04-18-08.
Women with at least one symptomatic fibroid presenting with symptoms, such as dysmenorrhea, dyspareunia, chronic pelvic pain, pelvic heaviness, lower back pain, abnormal bleeding, compression syndromes, or infertility, were considered for laparoscopic treatment. Preoperative MRI was conducted for all patients to reduce the risk of undiagnosed myometrial malignancy [15]. Treatment options were reviewed during monthly multidisciplinary meetings. During a preoperative consultation after informed consent, patients chose between the two laparoscopic treatments based on personal preference.
Inclusion criteria were women over 18 years old, affiliated with the French healthcare system, presenting with an indication for laparoscopic treatment of at least one fibroid ranging from 30 to 80 mm in diameter, classified as FIGO types 2–6, and who provided non-opposition for the use of their health data.
The exclusion criteria were women who opposed the use of their health data, those who did not complete the preoperative quality-of-life questionnaire, or cases where radiofrequency myolysis was combined with myomectomy.
Laparoscopic myomectomy protocol
A prophylactic dose of 2 g Cefazolin was systematically administered to prevent pelvic infections in accordance with the current guidelines.
The fibroid capsulotomy was performed using monopolar scissors or a coagulation-section device, followed by enucleation through divergent traction, adhering to an avascular dissection layout. Hemostasis was progressively achieved with bipolar forceps if necessary. The myomectomy cavity was then closed with interrupted or continuous sutures, using absorbable braided or monofilament sutures with unidirectional barbs. For deeply embedded fibroids, the hysterorrhaphy was conducted in one or two deep muscular layers, followed by a systematically applied seromuscular layer. The excised tissue was morcellated under direct visualization within a protective surgical bag, ensuring safe extraction through a 15 mm trocar while preventing tissue dissemination into the peritoneal cavity.
Laparoscopic multi-bipolar myolysis protocol
This study followed the radiofrequency technique described by Chudnoff et al. involving fibroid puncture under dual guidance by laparoscopy and transvaginal ultrasound [11]. No current recommendations existed for routine antibiotic prophylaxis, and none was administered. A 30° laparoscope was used for better visualization of the uterine posterior wall. The specific equipment included the CelonLab Power generator (maximum power: 250 W, frequency: 460 kHz) and CelonAcqua flow III peristaltic pump, allowing simultaneous use of multiple bipolar applicators. Between one and five 1.8 mm-diameter applicators were inserted transcutaneously into the fibroid under direct visual control. The power needed was adjusted based on fibroid size, as recommended by the manufacturer. Applicators were inserted more than a third of the way between the midline and the sagittal plane through the anterior superior iliac spine to avoid injury to the epigastric arteries. A second operator performed real-time transvaginal ultrasound monitoring during applicator insertion, ensuring safety relative to the uterine cavity. Before starting the myolysis, the applicator positions were checked to avoid perforation (Fig. 1). Myolysis was monitored through visual whitening of the serosa during laparoscopy and increased echogenicity on ultrasound. Applicators were withdrawn with bipolar coagulation of the insertion paths. In cases of failure, hemostasis was achieved by repeating the withdrawal process or using a bipolar forceps. For multiple fibroids treatment, the same applicators were reused [16]. Main indications were patients with intramural or subserosal fibroids (FIGO types 3, 4, or 5) measuring 4–5 cm [10].
Fig. 1.
Perforation of the posterior wall of the uterus. Using the 30° optic, the operator needs to check that the applicators do not perforate the posterior wall of the uterus before starting myolysis
Post-operative monitoring
Following the planned surgeries, women were monitored in postoperative consultations at 3 and 6 months. Two groups were established to compare the effectiveness of laparoscopic myomectomy and myolysis. Data collected included demographic and clinical characteristics, fibroid size, number, and location pre- and post-surgery, total operative time, duration of myolysis, number of applicators used, electrode size, and total energy delivered during myolysis, when applicable.
To assess the effectiveness of surgical management, the Uterine Fibroid Symptom and Quality of Life Questionnaire (UFS-QOL) [17], Female Sexual Function Index (FSFI) [18], and EuroQOL-5 Dimensions (EQ-5D) Visual Analog Scale (VAS) were used. These questionnaires which are routinely used in the department to evaluate clinical outcomes were recorded either during preoperative consultation or upon hospital admission, and then at 3 and 6 months postoperatively during gynecological follow-ups or MRI evaluations. Perioperative complications were recorded, while postoperative complications within 3 months after surgery were categorized according to the Clavien–Dindo classification system.
Outcome measures
The primary outcome measure was the difference in fibroid-specific quality-of-life score (HRQOL of the UFS-QOL questionnaire) from baseline to 3 months post-treatment.
The secondary outcome measures where:
The difference from baseline to 6 months in HRQOL score
The difference from baseline to 3 and 6 months in SSS
The difference from baseline to 3 and 6 months in the VAS of the EQ-5D
The difference from baseline to 3 and 6 months in FSFI score
Recording of perioperative and postoperative complications.
Statistical analysis
Data analysis was performed using the R statistical software (R Foundation for Statistical Computing, Vienna, Austria). To address missing data and minimize the loss of statistical power, multiple imputation was conducted using the “mice” package, generating several complete datasets by repeatedly imputing missing values.
For statistical tests, appropriate methods were chosen based on data characteristics and underlying assumptions. For normally distributed quantitative variables, intergroup comparisons were made using the parametric Student’s t test. When data did not follow a normal distribution, the non-parametric Wilcoxon–Mann–Whitney test was used to compare ranks between two independent groups.
Categorical variables were analyzed using the Chi-square (χ2) test to assess associations between two categorical variables. When the assumptions for the Chi-square test were not met, Fisher’s exact test was applied, which is more accurate for small sample sizes.
A multivariate analysis using multifactorial linear regression models was conducted. Additionally, a propensity score was calculated using logistic regression to estimate the conditional probability (p) of each patient receiving myolysis treatment based on their baseline characteristics. A post hoc analysis was also performed to determine the necessary sample size (NSS) for achieving adequate statistical power of 0.80, with an effect size of 12 points and a significance level (α) of 0.05, based on the literature data [19].
Results
Between December 2021 and December 2023, 72 women received laparoscopic fibroid treatment, with 55 undergoing myomectomy and 17 undergoing myolysis. In the myomectomy group, 5 women were excluded due to refusal to share their data and 16 for missing preoperative quality-of-life responses. In the myolysis group, 1 woman was excluded for missing preoperative quality of life responses. We found 16% missing data for the primary outcome (Fig. 2). These were handled using the multiple imputation method described above, to minimize the loss of statistical power and maximize the use of available data.
Fig. 2.
Flow diagram of women included. Missing data for the primary outcome were handled using a multiple imputation method
The general characteristics and preoperative symptom data of the treated women are presented in Table 1. Baseline characteristics were comparable between the two groups, except for the preoperative score of the HRQOL.
Table 1.
Baseline characteristics of the study population
| Myomectomy n = 34 | Myolysis n = 16 | p value | |
|---|---|---|---|
| Age, years | 35.1 ± 7.5 | 37.5 ± 4.8 | 0.10 |
| Menopause | 1 (2.9) | 0 (0) | 1 |
| BMI, kg/m2 | 25.1 ± 4.1 | 26.2 ± 4.0 | 0.37 |
| Gravidity | 1.8 ± 2 | 1.9 ± 1.8 | 0.10 |
| Parity | 0.4 ± 0.9 | 1 ± 1.3 | 0.26 |
| Medical history | |||
| Myomectomy | 0 (0) | 2 (12.5) | 0.10 |
| Abdominal surgerya | 11 (32.4) | 8 (50) | 0.38 |
| Desire for conception | 26 (76.5) | 10 (62.5) | 0.49 |
| Gynecological symptoms | |||
| Dysmenorrhea | 19 (55.9) | 8 (50.0) | 0.93 |
| Chronic pelvic pain | 17 (50.0) | 9 (56.3) | 0.91 |
| Menorrhagia | 14 (41.2) | 6 (37.5) | 1 |
| Metrorrhagia | 7 (20.6) | 7 (43.8) | 0.17 |
| Dyspareunia | 8 (23.5) | 4 (25.0) | 1 |
| Urinary symptoms | 10 (29.4) | 4 (25.0) | 1 |
| Digestive symptoms | 5 (14.7) | 3 (18.8) | 0.70 |
| Infertility | 15 (44.1) | 5 (31.3) | 0.58 |
| Quality-of-life questionnaires | |||
| UFS-QOL questionnaire | |||
| Initial SSS score | 55.8 ± 20.3 | 51.4 ± 22.6 | 0.51 |
| Initial HRQOL total score | 41.0 ± 18.4 | 57.9 ± 22.5 | 0.02 |
| EQ-5D questionnaire | |||
| Visual analog scale | 53.0 ± 23.0 | 61.9 ± 24.8 | 0.24 |
| FSFI questionnaire | |||
| Initial FSS score | 17.2 ± 10.3 | 20.0 ± 10.4 | 0.44 |
The data are presented as means ± standard deviation (SD) or n (%)
BMI Body Mass Index, SSS Symptom Severity Score; higher transformed scores indicate greater severity or discomfort of symptoms, HRQOL Health-Related Quality of Life; higher transformed scores indicate greater quality of life, FSS full scale score
aAbdominal surgeries include appendectomy, cesarean section, endometriosis resection, salpingectomy, cholecystectomy, and cystectomy
The comparison of postoperative quality of life scores is presented in Table 2. When examining the severity score of symptoms, it appears that, at 3 months, symptoms are less severe in the myolysis group compared to the myomectomy group, though this difference is not statistically significant (23.8 ± 18.1 vs 32.5 ± 23.4, p = 0.18). At 6 months, the trend reverses, with the myomectomy group showing less severe symptoms compared to the myolysis group, again without a statistically significant difference (23 ± 22.2 vs 35.6 ± 21.7, p = 0.08). There were no significant differences between the two procedures in HRQOL, or FSFI at 3 and 6 months postoperatively.
Table 2.
Comparison of quality-of-life scores at 3 and 6 months postoperative
| A 3 months | A 6 months | |||||
|---|---|---|---|---|---|---|
| Myomectomy n = 34 |
Myolysis n = 16 |
p value | Myomectomy n = 34 |
Myolysis n = 16 |
p value | |
| UFS-QOL questionnaire | ||||||
| SSS | 32.5 ± 23.4 | 23.8 ± 18.1 | 0.18 | 23 ± 22.2 | 35.6 ± 21.7 | 0.08 |
| HRQOL total score | 65.2 ± 28.9 | 67.1 ± 19.2 | 0.82 | 70.4 ± 27.7 | 70.9 ± 17.9 | 0.95 |
| EQ-5D questionnaire | ||||||
| Visual analog scale | 70.4 ± 17.2 | 68.4 ± 11.7 | 0.65 | 69.6 ± 23.9 | 73.4 ± 27.7 | 0.43 |
| FSFI questionnaire | ||||||
| FSS | 15.7 ± 11.1 | 20.9 ± 9.9 | 0.11 | 18.4 ± 11.6 | 23.4 ± 9.7 | 0.16 |
The data are presented as means ± standard deviation (SD)
SSS Symptom Severity Score; higher transformed scores indicate greater severity or discomfort of symptoms, HRQOL Health-Related Quality of Life; higher transformed scores indicate greater quality of life, FSS full scale score
The comparison of changes in quality-of-life scores is presented in Table 3. There was no significant difference between the two procedures in terms of HRQOL improvement at 3 months (9.2 ± 34.3 vs 24.2 ± 28.2, p = 0.14). There was no significant difference between the two procedures in terms of SSS improvement at 3 months (− 27.5 ± 31.5 vs − 23.3 ± 33, p = 0.66). There was no significant difference between the two procedures in terms of FSFI improvement at 3 months (0.9 ± 14.7 vs − 1.5 ± 10.8, p = 0.40). The results regarding the improvement in quality of life at 6 months also demonstrate no significant difference between the two procedures.
Table 3.
Comparison of changes in quality-of-life scores at 3 and 6 months postoperative
| At 3 months | At 6 months | |||||
|---|---|---|---|---|---|---|
| Myomectomy n = 34 Difference from baseline |
Myolysis n = 16 Difference from baseline | P value | Myomectomy n = 34 Difference from baseline | Myolysis n = 16 Difference from baseline | p value | |
| UFS-QOL questionnaire | ||||||
| SSS | − 23.3 ± 33 | − 27.5 ± 31.5 | 0.66 | − 32.8 ± 29.8 | − 15.8 ± 22.6 | 0.03* |
| HRQOL total score | 24.2 ± 28.2 | 9.2 ± 34.3 | 0.14 | 29.4 ± 28.3 | 13.0 ± 29.7 | 0.08 |
| EQ-5D questionnaire | ||||||
| Visual analog scale | 17.4 ± 19.1 | 6.6 ± 24.3 | 0.13 | 16.5 ± 33.1 | 11.6 ± 27.6 | 0.58 |
| FSFI questionnaire | ||||||
| FSS | − 1.5 ± 10.8 | 0.9 ± 14.7 | 0.40 | 1.3 ± 10.9 | 3.4 ± 10 | 0.40 |
The data are presented as means ± standard deviation (SD). The effects of time were adjusted for the following confounding variables: age, gravidity, initial fibroid-specific quality-of-life score, size of the largest fibroid, history of myomectomy, and metrorrhagia
SSS Symptom Severity Score; higher transformed scores indicate greater severity or discomfort of symptoms, HRQOL Health-Related Quality of Life; higher transformed scores indicate greater quality of life, FSS full scale score
p values were calculated to compare the differences in scores over time (*p < 0.05—statistically significant)
The baseline fibroid-specific quality-of-life score was significantly and negatively associated with the change in quality of life (p < 0.05), as indicated by a coefficient of − 0.658, suggesting that a higher initial score correlates with a smaller perceived improvement between M0 and M3 (Table 4). Additionally, other variables showed non-significant coefficients, indicating that they did not substantially contribute to explaining variations in post-treatment quality-of-life differences.
Table 4.
Linear regression model results predicting the change in Health-Related Quality of Life total score (HRQOL) from baseline to 3 months
| Independent variable | Coefficient (estimate) | Standard (SE) | t value | p value | 95% Confidence interval |
|---|---|---|---|---|---|
| Intercept | 51.1694 | 9.5177 | 5.376 | < 0.001* | 32.0 to 70.3 |
| Myolysis | − 3.8994 | 9.0293 | − 0.432 | 0.67 | − 22.1 to 14.3 |
| Initial HRQOL total score | − 0.6577 | 0.2013 | − 3.268 | < 0.001* | − 1.06 to -0.26 |
*p value < 0.05—statistically significant
A propensity score was calculated using logistic regression to evaluate how covariates affected the likelihood of receiving radiofrequency treatment. The results indicated that the effect of the propensity score on the outcome was not statistically significant (estimate = − 73.94, p = 0.28), suggesting that while the propensity score might have had an impact, it was not robust enough to be considered significant in this context.
Safety data
Perioperative and postoperative data for myomectomy and myolysis procedures are presented in Table 5.
Table 5.
Comparison of perioperative and postoperative data
| Myomectomy n = 34 | Myolysis n = 16 | p value | |
|---|---|---|---|
| Perioperative data | |||
| Operative duration, min | 194.4 ± 61.3 | 94.8 ± 40.5 | < 0.001* |
| Blood loss, mL | 504.4 ± 592.7 | 12.5 ± 50 | < 0.001* |
| Transfusion | 11 (32.4) | 0 | 0.01* |
| Intraoperative complicationsa | 4 (11.8) | 0 | 0.29 |
| Post-operative data | |||
| Length of hospital stay, days | 3.3 ± 1.3 | 1.6 ± 0.9 | < 0.001* |
| Rehospitalization | 1 (2.9) | 2 (12.5) | 0.23 |
| Reoperation | 0 | 1 (6.3) | 0.32 |
| Post-operative complicationsb | |||
| Grade I | 0 | 0 | |
| Grade II | 6 (17.6) | 0 | |
| Grade III | 0 | 1 (6.3) | |
| Grade IV | 0 | 1 (6.3) | |
| Grade V | 0 | 0 | |
| Total | 6 (17.6) | 2 (12.5) | 0.03* |
The data are presented as means ± standard deviation (SD) or n (%)
aIntraoperative complications: laparoconversion, anaphylactic shock
bPost-operative complications classified according to the Clavien–Dindo classification
*p value * < 0.05—statistically significant
The myolysis procedure was shorter (94.8 min for myolysis vs 194.4 min for myomectomy, p < 0.001), associated with less blood loss (12.5 ± 50 mL for myolysis vs 504.4 ± 592.7 for myomectomy, p < 0.001) and a significantly shorter average hospital stay (1.6 days for myolysis vs 3.29 days for myomectomy, p < 0.001). The average size of fibroids treated with myolysis was 52 mm. The most common location was the anterior uterine wall (63% of cases) and the fibroids were predominantly intramural or subserosal (FIGO types 4 or 5 in 64% of cases).
In the myomectomy group, five women experienced acute anemia with iron deficiency, necessitating iron infusion before discharge, while one woman was readmitted for an intra-myometrial hematoma. In the myolysis group, a 40-year-old woman presented with pelvic pain and an obstructive syndrome 15 days postoperatively. Imaging showed fibroid necrosis, a large rectal fistula, and stercoral peritonitis, leading to a polymyomectomy and Hartmann procedure [20]. A second woman presented on postoperative day 11 with pain and fever, imaging revealed a 9.5 cm hydro-aeric collection at the site of the treated fibroid. She underwent image-guided drainage, received intravenous tazocin, and was prescribed a 6-month course of penicillin G following the identification of Actinotignum schaalii in the drainage fluid.
Discussion
Fibroids are associated with a lower overall quality of life, affecting both physical and emotional well-being. Abnormally low quality-of-life scores reflects impaired psychosocial functioning. Since myolysis has demonstrated efficacy in reducing the volume of uterine fibroids, as shown in this systematic review [21], early treatment could help limit fibroid growth over time and prevent the onset of symptoms, such as pelvic pain, menorrhagia, and fertility disorders.
The design of this study allowed us to collect quality-of-life questionnaire responses during routine care, effectively managing recall bias. Our minimally restrictive inclusion criteria allowed us to study a population that closely matched the target group, specifically women of reproductive age.
Our results demonstrated an improvement in quality of life as well as a reduction in fibroid-related symptoms at 3 months postoperatively, with no significant difference between the two procedures. Therefore, our study did not demonstrate the superiority of myolysis over myomectomy. However this reduction reflects an improvement in the two groups in terms of fibroid-related symptoms, including heavy menstrual bleeding (Item 1 and 2 from SSS), cycle irregularity (Item 3 and 4 from SSS), lower abdominal distension and bloating (Item 5 from SSS), and urinary frequency (Item 6 and 7 from SSS). Consistently across the three different validated questionnaires used, postoperative quality of life was comparable between the two procedures. Additionally, the rate of peri- and postoperative complications was lower with myolysis, suggesting that it has a better safety profile as previously showed in the literature [22].
The higher baseline quality of life in the myolysis group raised concerns about indication bias, which could have influenced the changes in quality of life between the groups. We used a linear regression model with a propensity score to control confounding factors, confirming that individual variables did not introduce significant bias into the results.
The meta-analysis by Go et al. reported similar findings regarding symptom reduction and improvement in quality-of-life following myolysis [19]. Krämer et al. observed a non-significant 11% improvement in quality of life at 24 months for the myolysis group, with a 95% confidence interval ranging from − 1.6 to 23.0 and a p value of 0.08 [23]. The authors suggested that this lack of significant improvement might be due to the myolysis group having a higher baseline quality of life compared to the myomectomy group, with preoperative mean scores of 77.1 and 70.2, respectively. Some studies have reported a greater improvement in quality of life after myolysis, such as the TRUST study, where baseline quality-of-life scores were lower with a mean HRQOL of 39.8 in the myolysis group [24]. Rattray et al. found a significant 44.8% reduction in symptom severity at 3 months (p < 0.01), with the mean score dropping from 61.55 points preoperatively to 34.8 points postoperatively. Hudgens et al. reported a mean reduction of 24.8 points in the UFS-QOL symptom severity score at 12 months (p < 0.01), from a preoperative mean score of 54.3 points [25].
A short postoperative follow-up period was a limitation of our study, as we did not assess the durability of the surgical effects or potential side effects beyond 6 months [26].
The small sample size in our study may have led to an underestimation of the complication rate associated with myolysis. Nevertheless, our complication rate was close to the 10.5% global complication rate reported in Lim’s meta-analysis on myolysis [27]. Two severe postoperative complications were reported within our cohort despite the generally low observed complication rate. This suggests a potentially significant learning curve associated with the technique.
The small sample size limited our analysis and interpretation of the results. A post hoc power analysis showed that to detect a significant difference in quality-of-life improvement at 3 months between the groups, at least 44 subjects in each group would have been needed, based on an effect size of 12 points from literature data [19].
In our cohort, 62% of the women in the myolysis group desired pregnancy before the intervention, and two of them achieved spontaneous pregnancies within the year. Further data on long-term side effects, fertility, and postoperative obstetrical outcomes are needed before expanding the indications.
In conclusion, our myolysis cohort demonstrated an improvement in quality of life as well as a reduction in fibroid-related symptoms at 3 and 6 months postoperatively, with no significant difference between the two procedures. However, our data suggest that myolysis may serve as a useful conservative treatment option for patients with symptomatic fibroids. The rate of peri- and postoperative complications was lower with myolysis, showing a better safety profile. To support these results, a medico-economic study is needed to demonstrate a cost-effectiveness balance in favor of myolysis. Myolysis may also represent a conservative surgical alternative for adenomyosis, a condition for which surgical therapeutic options currently remain limited [28]. It could thus be considered for the treatment of adenomyomas or in patients with pelvic pain refractory to medical therapy in the context of adenomyosis.
Author contributions
Conception and design of study: R.N., B.C., A.A, L.M. Data collection: R.N., L.M. Data analysis and interpretation: R.N., L.M. Responsible surgeon: L.M., A.A Statistical analysis: A.N., L.M. Manuscript preparation: R.N., A.N., L.M. Patient recruitment: A.A., L.M.
Funding
None.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Conflict of interest
The authors declare no competing interests.
Attestation statement
Data regarding any of the subjects in the study have not been previously published.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.