Evaluation of Ultrasound-guided Transuterine Vaginal Biopsy Technique in Uterine Fibromatous Disease

Fibroma is the most common uterine smooth muscle tumor. Women are symptomatic in 30% of cases. A large proportion of fibroids are asymptomatic and discovered on imaging. Surgical management is the only recommended first-line treatment option in cases of symptoms. Hysterectomy is the most radical treatment, but for women wishing to preserve their fertility, myomectomy is the most suitable option. This is performed by hysteroscopy, laparoscopy or laparotomy. The main risk of myomectomy is massive intraoperative haemorrhage, requiring blood transfusion or even a haemostasis hysterectomy. There are non-surgical alternatives using embolization and radiofrequency, but these techniques do not provide a definitive diagnosis of fibroids, as they do not involve histological sampling.

The benign uterine fibroma is part of the broader concept of uterine smooth muscle tumors, which also includes myometrial malignancies of varying malignancy (uterine sarcomas, cellular fibromas, STUMP (Uterine smooth muscle tumors of uncertain malignant potential)).

Magnetic resonance imaging (MRI) is the most effective examination for discriminating fibroids from TMM, but its reliability is limited. This leads to inappropriate management in a number of situations. The first is the risk of over-treatment by performing surgery for suspected TMM on MRI in a patient with few or no symptoms and a final histological diagnosis of fibroid. The second is the risk of unsatisfactory, even deleterious, carcinological surgical treatment in a symptomatic patient with a reassuring MRI diagnosis but a final histological diagnosis of TMM. The last situation is the possibility of treating a lesion labelled fibroid on MRI with an alternative technique (embolization, radiofrequency, HIFU) when it is in fact a TMM, thereby delaying appropriate management and worsening the prognosis.

Ultrasound-guided transuterine vaginal biopsy (ETVB) is an innovative and promising minimally invasive technique for preoperative anatomopathological diagnosis. It can be used to obtain a histological diagnosis, thus avoiding the need for surgery and the inappropriate treatment described above Primary objective: To validate an innovative, minimally invasive surgical technique for diagnosing uterine smooth muscle tumors by biopsy.

Secondary objectives Evaluate the complications associated with the technique, as well as its potential adverse effects.

Exploratory objectives: To assess the feasibility of the technique in routine practice.

Primary endpoint: Estimation of the anatomopathological sensitivity of BVTE, with its 95% confidence interval, by comparing it with the reference technique, i.e. anatomopathological diagnosis on surgical specimen, to ensure a low number of false negatives (fibroid diagnosis on BVTE with final diagnosis of TMM).

Secondary endpoints: Estimation of specificity, positive and negative predictive values and likelihood ratios of BVTE, with their confidence intervals, number of intraoperative and postoperative complications according to the Clavien-Dindo classification.

Exploratory criteria if applicable: Evaluation of equipment availability, cost, simplicity of performance as assessed by the operator.