Uterine artery embolization for the treatment of uterine leiomyomata midterm results

Long-Term Outcome of Uterine Artery Embolization of Leiomyomata

OBJECTIVE

To determine the long-term outcome from uterine artery embolization for leiomyomata.

METHODS

In a prospective study, 200 consecutive patients treated with uterine embolization were each followed for 5 years. Outcome, including symptom status compared with baseline, reinterventions, menstrual status, and satisfaction were recorded. Summary statistics were used to report baseline characteristics and outcome at each interval. Predictors of subsequent interventions, failure, and satisfaction with treatment were analyzed using logistic regression and Cox proportional hazards models. Failure was defined as subsequent hysterectomy, definitive myomectomy, repeat embolization, or failure of symptom improvement at the patient's final follow-up interval.

RESULTS

Of the 200 patients initially treated, 5-year follow-up was completed in 182 (91%), with 18 patients missing. At 5 years after treatment, 73% had continued symptom control, whereas 36 (20%) had failed or recurred. There had been 25 hysterectomies (13.7%), 8 myomectomies (4.4%), and 3 repeat embolizations (1.6%). Long-term failure was more likely in those not improved at 1 year (relative risk [RR] 5.73; 95% confidence interval [CI] 2.32-14.12, P < .001) and in those with baseline leiomyoma volumes greater than the median (RR 2.18; 95% CI 1.05-4.51, P = .036). After adjustment, patients in the first tertile of leiomyoma volume reduction (< or = 30.5%) were 3 times more likely to be dissatisfied with outcome compared with women in the third tertile (> or = 56.3% volume reduction) (RR 3.23; 95% CI 1 07-9.81, P = .037).

CONCLUSION

Uterine embolization provides durable symptom relief for most patients, with a 25% chance of failure of symptom control or recurrence over the course of a 5-year follow-up.

LEVEL OF EVIDENCE

II-3.

Successful spontaneous pregnancy following surgical removal of a post uterine artery embolized necrotic fibroid capsule: a case report

Uterine artery embolization has been shown to be an effective treatment in controlling symptomatic uterine fibroids. Reports suggest that significant complications associated with the procedure are rare. However, data pertaining to preservation of fertility after embolization are scarce, and some authors do not advocate this procedure for women considering future pregnancy. We present a case of a post-embolization uterine cavity abnormality which was repaired surgically, followed by successful pregnancy outcome.

Imaging Manifestations of Complications Associated with Uterine Artery Embolization

Uterine artery embolization (UAE) is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. A growing body of literature documents symptomatic improvement in the majority of women who undergo UAE. Although UAE is usually safe and effective, there are a number of known complications associated with the procedure. Major complications include fibroid passage, infectious disease (endometritis, pelvic inflammatory disease-tubo-ovarian abscess, pyomyoma), deep venous thrombosis, pulmonary embolism, inadvertent embolization of a malignant leiomyosarcoma, ovarian dysfunction, fibroid regrowth, uterine necrosis, and even death. Minor complications include hematoma, urinary tract infection, retention of urine, transient pain, and vessel or nerve injury at the puncture site. As UAE takes its place in the treatment arsenal for women with symptomatic fibroids, radiologists need to be familiar with UAE-associated complications, which may require further treatment and may even be life threatening in some cases. Knowledge of these complications and their imaging features should lead to prompt diagnosis and appropriate treatment.

Uterine Artery Embolization for Leiomyomas: Pre- and Postprocedural Evaluation with US

Transabdominal and transvaginal ultrasonography (US) are commonly used to assess the uterus and pelvis prior to and following uterine artery embolization (UAE) for symptomatic leiomyomas (fibroids). Preprocedural US may help identify relative contraindications for UAE, whereas postprocedural US can help determine the quality and quantity of fibroid involution and help identify any complications associated with the procedure. The consulting radiologist should be familiar with certain typical postprocedural US findings, which might otherwise be improperly interpreted, leading to unnecessary intervention. Magnetic resonance (MR) imaging or computed tomography will frequently provide the most accurate information in UAE patients with certain pathologic conditions, and early study results suggest that MR imaging may be helpful in predicting treatment response. Nevertheless, US is a readily available first-line imaging modality and a well-accepted method for both pre- and postprocedural evaluation of patients who undergo UAE. A proper understanding of the US findings in this patient population allows objective determination of treatment response and detection of most of the commonly recognized complications that are associated with UAE.

Pregnancy Following Uterine Artery Embolization with Polyvinyl Alcohol Particles for Patients with Uterine Fibroid or Adenomyosis

PURPOSE

To determine whether uterine fibroid embolization (UFE) with polyvinyl alcohol (PVA) particles affects fertility in women desiring future pregnancy.

METHODS

Of 288 patients managed with UFE with PVA particles for uterine myoma or adenomyosis between 1998 and 2001, 94 patients were enrolled in this study. The age range of participants was 20-40 years. The data were collected through review of medical records and telephone interviews. Mean duration of follow-up duration was 35 months (range 22-60 months). Patients using contraception and single women were excluded, and the chance of infertility caused by possible spousal infertility or other factors was disregarded. Contrast-enhanced magnetic resonance imaging was performed in all patients before and after UFE, and the size of PVA particles used was 255-700 mum.

RESULTS

Among 94 patients who underwent UFE with PVA, 74 were on contraceptives, 6 had been single until the point of interview, and 8 were lost to follow-up. Of the remaining 6 patients who desired future pregnancy, 5 (83%) succeeded in becoming pregnant (1 patient became pregnant twice). Of a total of 8 pregnancies, 6 were planned pregnancies and 2 occurred after contraception failed. Five deliveries were vaginal, and 2 were by elective cesarean. Artificial abortion was performed in 1 case of unplanned pregnancy. There was 1 case of premature rupture of membrane (PROM) followed by preterm labor and delivery of an infant who was small-for-gestational-age. After UFE, mean volume reduction rates of the uterus and fibroid were 36.6% (range 0 to 62.6%) and 69.3% (range 36.3% to 93.3%), respectively.

CONCLUSION

Although the absolute number of cases was small, UFE with PVA particles ultimately did not affect fertility in the women who underwent the procedure.

Uterine fibroid embolization can still be improved: observations on post-procedure magnetic resonance imaging

PURPOSE

To evaluate the efficacy and completeness of uterine fibroid embolization (UFE) measured by changes in volume and signal intensity at magnetic resonance imaging (MRI), and to compare with clinical outcome.

MATERIAL AND METHODS

40 women with symptomatic uterine fibroids underwent bilateral uterine artery embolization. At MRI studies, including post-contrast sequences before and repeatedly after treatment, the uterus and dominant fibroids were evaluated for volume, location, and contrast enhancement. Prior to treatment, all myomas showed significant contrast enhancement. The mean uterine volume was 929 ml. Clinical examinations with emphasis on menorrhagia, pelvic pain, and urinary dysfunction were performed before and 6 and 12 months after treatment.

RESULTS

UFE was bilaterally successful in 38 patients. After UFE, MRI showed no enhancement of myomas in 30 patients. In 8 patients, post-procedural MRI revealed partially remaining vascularization of fibroids despite angiographically complete embolization of the uterine arteries. On average, uterine volume decreased by 46.2% at 12 months. There was significant improvement of symptoms in the majority of patients, but slightly less improvement in patients with partially remaining vascularization of myomas.

CONCLUSION

UFE causes significant volume reduction of myomas and clinical improvement. MRI can reveal remaining vascularization in myomas despite angiographically complete embolization of uterine arteries.

Primary Failure of Uterine Artery Embolization: Use of Magnetic Resonance Imaging to Select Patients for Repeated Embolization

The purpose of this study was to determine if contrast material-enhanced magnetic resonance (MR) imaging could be used to stratify patients who have undergone failed primary uterine artery embolization (UAE) for repeated embolization. One hundred one consecutive patients who underwent UAE at a single center were followed prospectively and assessed for the presence of persistent contrast enhancement of leiomyomas on follow-up MR imaging. Among 11 of the 111 patients with primary clinical failure (10%), MR imaging showed persistent enhancement in eight. Of the eight cases of failure with continued tumor enhancement on MR imaging, six were treated with repeated embolization. All six patients showed complete symptomatic relief at 12-month follow-up. In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE.

Alternative medical and surgical options to hysterectomy

The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.

Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status

Uterine artery embolization (UAE) is increasingly being used as an alternative treatment to hysterectomy for symptomatic fibroids. Symptoms of pelvic pressure, urinary frequency and menorrhagia are controlled in 73-98% of patients who undergo UAE. At the 1-year follow-up, the uterus may shrink by up to 55% but re-growth of fibroid may however occur. The rate of major complications and amenorrhoea following this procedure is low, ranging in most series from 1 to 3.5% and 1 to 7%, respectively. Nevertheless, the rate of amenorrhoea in women over 45 seems to be higher. In order to completely block the arterial supply to the fibroid, UAE is typically performed in both uterine arteries. Different embolic agents are used such as polyvinyl alcohol, gelfoam and more recently gelatine tris-acryl microspheres. After UAE, perfusion of the uterus is maintained. Uterine function is therefore conserved and although women who become pregnant after UAE seem to be at risk for malpresentation, pre-term birth, cesarean delivery and postpartum hemorrhage, successful pregnancies after UAE have been reported in some series. A major technical problem with UAE remains the possible presence of fibroid blood supply from other sources, such as the ovarian arteries or other pelvic branches, which can lead to failure of the procedure. In conclusion, although randomized trials are still underway, UAE appears a good option for those patients who whish to conserve their fertility or when surgery is contra-indicated. However, to evaluate the long-term effects of UAE longer follow up is required.

Predictive factors for fibroids recurrence after uterine artery embolisation

OBJECTIVES

To assess clinical failure and symptom recurrence after uterine artery embolisation (UAE) and to define predictive factors.

DESIGN

Prospective study of a case series.

SETTING

Gynaecology and radiology departments of a French University Hospital.

POPULATION

Eighty-five women who underwent embolisation for the treatment of uterine fibroids.

METHOD

Vascular access was obtained via the right common femoral artery. Free-flow embolisation was performed using 150-250 mum polyvinyl alcohol particles and an absorbable particle sponge.

MAIN OUTCOME MEASURES

Clinical failure was defined as persistence of symptoms at three months of follow up and recurrence as return of symptoms. The main outcome measure was the need for further treatment after UAE.

RESULTS

Results are available for 81 patients. Median follow up was 30 months. There were 15 clinical failures and recurrences requiring further treatment (eight hysterectomies, five hysteroscopic resections for submucous fibroids, one second embolisation and one woman refusing further treatment). Recurrence-free survival rate at 30 months (no clinical failure, no recurrence) was 82.8% (95% CI 73.7-91.8%). Multivariate analysis identified two predictive factors: dominant fibroid size on ultrasound imaging (each 1 cm increase: HR = 1.68, 95% CI 1.10-2.69) and number of fibroids (each additional fibroid: HR = 1.34, 95% CI 1.08-1.66).

CONCLUSIONS

Symptom recurrence rate 30 months after fibroid embolisation was 17.2%. Fibroid size and number were predictive factors for recurrence. As most recurrences occurred after two years, we recommend that patients be monitored clinically and that imaging be for more than two years after UAE.

Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies

OBJECTIVES

To evaluate the outcome of pregnancies after uterine artery embolisation for uterine fibroids.

DESIGN

Retrospective analysis of pregnancy subsequent to uterine artery embolisation by one interventional radiologist.

SETTING

A UK District General Hospital.

POPULATION

Twenty-nine pregnancies in 671 women who had undergone uterine artery embolisation.

METHODS

Cases were identified by screening questionnaire and from the study database. Detailed information was collected by questionnaires, direct conversations with women and, when necessary, from hospital records.

MAIN OUTCOME MEASURES

Pregnancy outcome, complications and neonatal outcomes.

RESULTS

Of 26 completed pregnancies, detailed information was available for 24 and limited information for 2. Seven (27%) ended in miscarriage, there were two terminations and one ectopic pregnancy. Of 16 deliveries after 24 weeks, first and second trimester bleeding occurred in 40% and 33%, respectively, 4 (25%) had preterm deliveries and the caesarean section rate was 88%. Two (13%) women developed proteinuric hypertension and two others had preterm spontaneous rupture of the membranes. Fourteen of 16 cases were delivered by caesarean section. The rate of primary postpartum haemorrhage was 3/15 (20%). The mean birthweight of term babies was 3.39 kg (SD 0.64) and none required admission to neonatal intensive care. There was one (6.7%) case of fetal growth restriction.

CONCLUSION

Although this study is relatively small, there is an increase in delivery by caesarean section. There does not appear to be any other major excess obstetric associated risk when the demographics of the population in question is considered.

Midterm Results of Uterine Artery Embolization for Symptomatic Adenomyosis: Initial Experience

PURPOSE

To prospectively evaluate the midterm results of uterine artery embolization for symptomatic adenomyosis.

MATERIALS AND METHODS

The study protocol was approved by the institutional review board, and all participants gave written informed consent. Eighteen women (mean age, 44.3 years) with symptomatic adenomyosis were treated with bilateral embolization of the uterine arteries. The diagnosis of diffuse adenomyosis was based on heterogeneous abnormal myometrial echogenicity with myometrial cysts at ultrasonography (US) or on enlarged junctional zone and myometrial cysts at magnetic resonance (MR) imaging. Focal adenomyosis was diagnosed if there was a circumscribed nodular lesion mimicking intramural fibroid. All patients with associated uterine fibroids were excluded. Embolization was offered as an alternative to hysterectomy in all women. Clinical evaluation was made at regular intervals to assess patient outcome. Follow-up US or MR imaging was performed 6 months after embolization to assess uterine volume reduction.

RESULTS

Bilateral uterine artery embolization was achieved in all but one woman by using polyvinyl alcohol particles or trisacryl microspheres. All women resumed normal menstruation after the procedure. After 6 months, 15 (94%) of 16 women reported improvement in menorrhagia. Follow-up images at 6 months depicted a slight decrease (mean, 15%) in uterine volume in 17 (94%) of 18 women. After 1 year, 11 (73%) of 15 women had improvement in menorrhagia, and eight (53%) of 15, complete resolution. After 2 years, five (56%) of nine women had complete resolution of menorrhagia. Eight (44%) of 18 women required additional treatment during follow-up for failure or recurrence; five women (28%) underwent hysterectomy.

CONCLUSION

Even if short-term results of uterine artery embolization to treat adenomyosis appear encouraging, midterm results are disappointing, with only 55% of treated patients showing clinical improvement after 2 years.

Uterine restoration after repeated sloughing of fibroids or vaginal expulsion following uterine artery embolization

The aim of our study is to present our experience with uterine restoration after repeated sloughing of uterine fibroids or transvaginal expulsion following uterine artery embolization (UAE) and to determine its safety and outcome. One hundred and twenty-four women (mean age, 40.3 years; age range, 29-52 years) with symptomatic uterine fibroids were included in this retrospective study. We performed arterial embolization with poly(vinyl alcohol) particles (250-710 microm). Clinical symptoms and follow-up information for each patient were obtained through medical records. At an average of 3.5 months (range, 1-8 months) after embolization, magnetic resonance imaging examinations with T1- and T2-weighted and gadolinium-enhanced T1-weighted images were obtained for all patients. The mean follow-up duration was 120 days (90-240 days). Eight (6.5%) patients experienced uterine restoration after repeated sloughing of uterine fibroids or spontaneous transvaginal expulsion. The locations of the leiomyomas were submucosal (n=5), intramural (n=2) and transmural (n=1). The maximum diameter of the fibroids ranged from 3.5 to 18.0 cm, with a mean of 8.4 cm. The time interval from embolization to the uterine restoration was 7-150 days (mean 70.5 days). The clinical symptoms before and during vaginal sloughing or expulsion were lower abdominal pain (n=4), vaginal discharges (n=3), infection of necrotic myomas (n=2) and cramping abdominal pain (n=1). Gentle abdominal compression (n=1) and hysteroscopic assistance (n=1) were required to remove the whole fibroid. No other clinical sequelae, either early or delayed, were documented. Magnetic resonance images revealed the disappearance of leiomyomas, intracavitary rupture resulting in transformation of intramural or transmural myomas into submucosal myomas and localized uterine wall defects. Although the small size of this study precludes a strict conclusion, there appear to be few serious complications directly related to vaginal expulsion. Vaginal expulsion or fibroid sloughing is a possible course following UAE that is manageable, and the patients should be informed about this possibility.

Uterine Artery Embolization for Pedunculated Subserosal Fibroids

OBJECTIVE

The objective of our study was to assess the outcomes of uterine artery embolization as a treatment for pedunculated subserosal fibroids, which we defined as those in which the diameter of the stalk was 50% narrower than the diameter of the fibroid.

MATERIALS AND METHODS

During a 72-month period, 196 consecutive women underwent embolization for treatment of symptomatic uterine fibroids that were confirmed on baseline sagittal and axial MR images. We identified those women with pedunculated subserosal fibroids treated with embolization and retrospectively assessed complications and out-comes of embolization using a serial questionnaire and MRI.

RESULTS

Of the 196 women, 12 (age range, 34-48 years; mean age, 42.3 years) had one or more pedunculated subserosal fibroids. Fifteen pedunculated subserosal fibroids were identified on baseline MR images in the 12 patients. The mean tumor diameter was 8.3 cm (range, 4.0-15.5 cm; 95% confidence interval [CI], 6.7-9.9 cm). The mean stalk diameter was 3.1 cm (range, 2.0-5.5 cm; 95% CI, 2.5-3.7 cm). The follow-up period ranged from 5 to 51 months (mean, 18.1 months). No serious complications such as separation of the tumors from the uterus, torsion of the tumors, or infection occurred after embolization. Enhanced MR images obtained 1 week after embolization showed that complete devascularization of the tumors had been achieved in 73% (11/15) of the tumors. The rates of mean tumor volume reduction were 41% (range, 12-73%) 4 months and 53% (range, 31-85%) 1 year after embolization. The mean stalk diameter was 3.2 cm (range, 1.7-5.4 cm; 95% CI, 2.5-3.9 cm) 4 months and 2.9 cm (range, 1.1-4.2 cm; 95% CI, 1.8-3.9 cm) 1 year after embolization. No significant difference in stalk diameters was noted 4 months (p=0.617) or 1 year (p=0.963) after embolization compared with the diameters before the treatment. The rates of mean uterus volume reduction were 35% (range, 15-47%) 4 months and 47% (range, 35-60%) 1 year after embolization. Marked or moderate improvement in bulk-related symptoms was achieved in 100% (10/10) of the women at 4-month follow-up, 100% (5/5) at 1-year follow-up, and 100% (2/2) at 2-year follow-up.

CONCLUSION

We found no serious complications after embolization for pedunculated subserosal fibroids with stalk diameters of 2 cm or larger. Successful outcomes can be obtained in such tumors.

Comparison of particle penetration with non-spherical polyvinyl alcohol versus trisacryl gelatin microspheres in women undergoing premyomectomy uterine artery embolization

AIM

The purpose of this study was to compare the depth of vascular penetration of non-spherical polyvinyl alcohol (PVA) versus trisacryl gelatin microspheres (MS) in women undergoing uterine artery embolization (UAE) immediately before transabdominal myomectomy.

MATERIALS AND METHODS

A total of 17 patients who had been referred for embolization before myomectomy underwent bilateral uterine artery embolization using either 355-500 microm PVA (group A) or 700-900 microm MS (group B). The depth of penetration of the particles was assessed by identifying their presence and location in the resected specimen.

RESULTS

Of the 17 women enrolled in this study, 10 were in group A and 6 in group B. One woman underwent embolization using both types of particle and was excluded from the analysis. Embolic particles were significantly (p = 0.048) more frequently located within the fibroid (4/6, 67%) in Group B than Group A (1/10, 10%). Particles were also identified in the perifibroid tissues in 4/6 (67%) in Group B and 4/10 (40%) in Group A, with no statistical difference. There were no procedural complications.

CONCLUSION

MS particles (700-900 microm) penetrate significantly deeper into leiomyomata compared with non-spherical PVA (355-500 microm). MS may therefore confer advantages in UAE, as they may more specifically target the fibroid, allowing an earlier end-point to embolization and minimizing ischaemic damage to normal myometrium and ovaries.

Risk of Intrauterine Infectious Complications after Uterine Artery Embolization

PURPOSE

To identify risk factors for the development of intrauterine infection following uterine artery embolization.

MATERIALS AND METHODS

A retrospective review of uterine artery embolizations (UAE) performed for the treatment of symptomatic fibroids from January 2000 to July 2003 was conducted. With logistic regression and the Fisher exact test, multiple variables were analyzed as predictors for intrauterine infectious complications requiring medical and/or surgical therapy, including the use of preprocedural antibiotics, embolic agent used, quantity of embolic material, location of fibroids (submucosal, nonsubmucosal), and size and location of the dominant fibroid.

RESULTS

A total of 414 UAE procedures were performed in 410 patients with a technical success rate of 99%. Average age of the patient cohort was 42.8 years (SD, 5.8 years). One hundred forty-eight patients (36.1%) had submucosal fibroids or fibroids projecting submucosally, 262 patients (63.9%) had nonsubmucosal fibroids. Intrauterine infectious complications requiring intravenous antibiotic therapy and/or surgery occurred in five patients (1.2%). A total of five infectious complications requiring therapy occurred in the submucosal group (3.4%) and none in the nonsubmucosal group. Patients within the submucosal group were more likely to develop intrauterine infectious complications than patients with nonsubmucosal fibroids based on univariate analysis (P = .006) but with logistic regression, the association was not significant (P = .079). No significant difference with embolic agent, quantity of embolic particles, use of preprocedure antibiotics, or size of or location of the dominant fibroid was found.

CONCLUSION

No specific risk factor for intrauterine infection following UAE was identified in this study. Infection after UAE is rare and appears to be a sporadic occurrence. Nevertheless, close surveillance is warranted in all women following UAE given the potential morbidity of this complication.

Uterine Fibroid Embolization (UFE)

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

FEMIC (Fibromes Embolis�s aux MICrosph�res calibr�es): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study

PURPOSE

A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids.

METHODS

Technical recommendations included embolization using large microspheres (>500 microm) with no secondary embolization agent. Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months.

RESULTS

Eighty-five women complaining of fibroid-related symptoms entered the study. In seven women, a secondary embolization agent was used in addition to microspheres. Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively). Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid. Eight women were treated by hysterectomy because of treatment failure. In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids.

CONCLUSION

Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications. Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction. Confidence in the end-point recommended here may require the experience of several cases.

Evaluation of the effect of uterine artery embolisation on menstrual blood loss and uterine volume

OBJECTIVE

To evaluate the effect of uterine artery embolisation (UAE) on menstrual blood loss (MBL) and uterine volume in women with symptomatic uterine fibroids.

DESIGN

Prospective observational study.

SETTING

West of Scotland gynaecology and radiology departments.

POPULATION

Fifty women (mean age 43 years) with symptomatic fibroids undergoing UAE between January 1999 and June 2003.

METHODS

Women collected sanitary protection from one menses pre-embolisation and at regular intervals thereafter. This allowed objective measurement of MBL using the alkaline haematin technique. Uterine volume was calculated using magnetic resonance imaging (MRI) before and six months following embolisation. Interventional radiologists performed bilateral UAE. The Wilcoxon's signed rank test was used for statistical analysis of data.

MAIN OUTCOME MEASURES

Post-embolisation MBL and uterine volume changes.

RESULTS

Median pretreatment MBL was 162 mL (mean 234, range 9-1339). The median MBL decreased to 60 mL at 3 months (n= 34, range 0-767, P < 0.001), 70 mL at 6-9 months (n= 34, range 0-1283, P < 0.001), 37 mL at 12-24 months (n= 25, range 0-265, P < 0.001), 18 mL at 24-36 months (n= 17, range 0-205, P < 0.001) and 41 mL at 36-48 months (n= 6, range 0-66, P < 0.05). The median reduction in uterine volume was 40% (n= 46, 95% CI 33.0-49.7, P < 0.001).

CONCLUSIONS

UAE causes a statistically significant reduction in objectively measured MBL. UAE is also associated with a statistically significant reduction in uterine volume at six months. There was no relationship between the changes in uterine volume and MBL.

Outcome of uterine embolization and hysterectomy for leiomyomas: results of a multicenter study

OBJECTIVE

The purpose of this study was to estimate the outcomes of uterine embolization and hysterectomy for uterine leiomyomas. Study design This was a multicenter prospective study of patients who were treated with embolization (n=102 patients) and hysterectomy (n=50 patients) for leiomyomas. Changes in symptoms, complications, and quality of life were measured. The data analysis included linear and logistic regression, the Student t and paired t test, Fisher's exact test, and chi-squared test.

RESULTS

For patients who underwent embolization, there were marked reductions in blood loss scores (P <.001) and menorrhagia questionnaire scores (P <.001) compared with baseline. At 12 months, a larger proportion of the patients who had undergone hysterectomy experienced improved pelvic pain (P=.021). Both groups had marked improvement in other symptoms and quality of life scores, with no difference between groups. Complications were more frequent in patients who underwent hysterectomy (50% vs 27.5%; P=.01).

CONCLUSION

Both procedures substantially improved symptoms for most patients, with an advantage for hysterectomy at 12 months for pelvic pain. Serious complications were infrequent in both groups.

Patient satisfaction and disease specific quality of life after uterine artery embolization

OBJECTIVES

This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after uterine artery embolization (UAE) and to consider the impact of these changes on satisfaction with the procedure.

STUDY DESIGN

A validated, fibroid specific, symptom, and HRQOL questionnaire was mailed to 80 women who had undergone UAE from 1998 through 2002. Pre- and postprocedure symptom severity and HRQOL scores were obtained. The primary outcome measure was change in fibroid symptoms and HRQOL after UAE. Secondary outcomes included objective measures of patient satisfaction, and the decrease in uterine volume after UAE.

RESULTS

Questionnaires were completed by 64 women (80.0%) at a mean of 32.1 months from UAE (range: 57.5-6 months). After UAE, mean uterine volume decreased by 26.3% (95% CI 19.6-33.0), and 17 of 79 women (21.5%) underwent an additional procedure after a mean of 18.6 months. Symptom severity scores decreased by a mean of 35.2% (95% CI 29.3-41.1) and HRQOL scores increased by a mean of 35.7% (95% CI 28.9-42.4). Satisfaction with UAE was correlated with the change in symptom severity and HRQL scores (P <.0001 and P=.0004, respectively) and the decrease in uterine volume after UAE (P=.0196).

CONCLUSION

Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL, associated with high levels of satisfaction with the procedure, even when subsequent therapies are pursued.

Uterine artery embolization for adenomyosis without fibroids

AIM

To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for symptomatic adenomyosis in patients without uterine fibroids.

MATERIALS AND METHODS

Uterine artery embolization using polyvinyl alcohol particles sized 250-710 mm was performed in 43 patients (mean; 40.3 years, range; 31-52 years) with dysmenorrhoea, menorrhagia, or bulk-related symptoms (pelvic heaviness, urinary frequency) due to adenomyosis without fibroids. All patients underwent pre-procedural and 3.5 months (range 1-8 months) follow-up magnetic resonance imaging (MRI) with contrast enhancement. Clinical symptoms were also assessed at the time of MRI before and after embolization.

RESULTS

Significant improvement of dysmenorrhoea (95.2%) and menorrhagia (95.0%) was reported in most patients. Contrast-enhanced MRI revealed non-enhancing areas suggesting coagulation necrosis of adenomyosis in 31 patients (72.1%), decreased size without necrosis in 11 patients (25.6%), and no change in one patient (2.3%). The mean volume reduction of the uteri after uterine artery embolization was 32.5% (from 321.7+/-142.9 to 216.7+/-130.1 cm(3)).

CONCLUSION

Transcatheter uterine artery embolization is an effective therapy for the treatment of symptomatic pure adenomyosis, and may be a valuable alternative to hysterectomy.

Persistent vaginal discharge after uterine artery embolization for fibroid tumors: cause of the condition, magnetic resonance imaging appearance, and surgical treatment

OBJECTIVE

The purpose of this study was to establish the cause of and treatment for chronic vaginal discharge after uterine artery embolization.

STUDY DESIGN

This was a retrospective review of the diagnosis and treatment of the procedure at 3 months.

RESULTS

In 94% of patients, the condition either completely resolved or diminished to a nonproblematic level.

CONCLUSION

The persistent discharge in these patients was due to a superficial cavity within the infarcted fibroid tumor that was communicating with the endometrial cavity through a hole in the endometrium. This situation is indicated by a specific appearance on TII sagittal magnetic resonance images. Hysteroscopic resection of the necrotic fibroid tumor cavity was usually curative.

Quantified short-term outcome of uterine artery embolization with gelatin sponge particles and lipiodol for symptomatic myoma

OBJECTIVE

To investigate and quantify clinical outcomes and spectral Doppler analyses of uterine arteries in patients with myoma undergoing uterine artery embolization (UAE) with gelatin sponge particles and lipiodol.

DESIGN

Prospective observational study.

SETTING

Tertiary medical center.

PATIENT(S)

Forty premenopausal women with symptomatic myoma.

INTERVENTION(S)

Uterine artery embolization with gelatin sponge particles and lipiodol.

MAIN OUTCOMES MEASURE(S)

Hemoglobin, hematocrit, CA-125, pictorial blood loss assessment, visual analogue pain scale, questionnaire for symptoms, tumor volume, and spectral Doppler analyses of uterine arteries.

RESULT(S)

The mean follow-up period was 8.1 months (range, 6-12). Menstrual flow improved in 29 of 35 patients (83%) and decreased significantly by 78.4%. Menstrual pain improved in 27 of 35 patients (77%) and decreased significantly by 70%. Hematocrit and CA-125 improved significantly. The mean percentage reductions of uterine and myomal volumes were 40.2% and 54.9%, respectively. The mean peak systolic velocity of the uterine arteries decreased by 52%. The major complication rate was 2.56%. There was no correlation between tumor volume reduction and clinical outcome.

CONCLUSION(S)

Uterine artery embolization with gelatin sponge particles and lipiodol had satisfactory short-term outcomes, comparable to those associated with polyvinyl alcohol particles. Quantified and semiquantified measurements provided objective assessment of clinical outcomes. Serum CA-125 might play a role in clinical follow-up. Reduction of tumor volume is not predictive of UAE efficacy.

Retained calcified fibroid fragments after uterine artery embolization for fibroids

OBJECTIVE

To document a case of retained calcified fibroid fragments after uterine artery embolization (UAE) for fibroids.

DESIGN

Case report.

SETTING

Teaching district general hospital.

PATIENT(S)

A woman with past history of UAE for fibroids.

INTERVENTION(S)

Bilateral UAE.

MAIN OUTCOME MEASURE(S)

Retained calcified fibroid fragments.

RESULT(S)

Retained calcified fibroid fragments can occur after UAE.

CONCLUSION(S)

Retained calcified fibroid fragments can occur after UAE and may be associated with infertility and menstrual disorders. Measures to detect this complication in women with these problems who have undergone UAE are appropriate.

Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years

OBJECTIVE

To evaluate the impact of uterine artery embolization (UAE) for fibroids on ovarian reserve in women younger than 40 years.

DESIGN

Prospective study.

SETTING

University-based reproductive endocrinology unit.

PATIENT(S)

Twenty regularly cycling women aged 33-39 years undergoing UAE for fibroids. All had cycle day 3 FSH levels <10 mIU/mL.

INTERVENTION(S)

Measurements of serum FSH and E2 levels and of the total ovarian volume and antral follicle number by transvaginal ultrasonography on day 3 of the menstrual cycle preceding UAE and on day 3 of the cycles occurring in months 3, 6, and 12 after UAE.

MAIN OUTCOME MEASURE(S)

Preprocedural and postprocedural hormone levels, ovarian volumes, and antral follicle numbers.

RESULT(S)

There were no significant changes from baseline in the mean day 3 FSH and E2 levels, ovarian volume measurements, and antral follicle numbers measured at 3, 6, and 12 months after UAE.

CONCLUSION(S)

Although this study might be not sensitive enough to conclude that UAE for fibroids does not interfere with a woman's ovarian status, these data indicate that in this series of reproductive-aged women UAE did not have short- or mid-term effects on ovarian reserve as assessed by hormonal and sonographic parameters.

Postprocedure pain management of interventional radiology patients

Postprocedure pain management of patients after interventional procedures has to take into account residual drug actions from pre- and intraprocedure medications. A variety of sedatives, narcotics, local anesthetics, nonopioid analgesics, and nonsteroidal antiinflammatory agents can be adjusted to the patient's needs and risk factors. The article addresses the safe use of these agents in addition to reflections on assessment and the cognitive elements of the pain experience.

Uterine artery embolization: state of the art

Since the first report in 1995, there has been rapid expansion of uterine artery embolization as a therapy for symptomatic uterine fibroids. The published literature and clinical experience show that this procedure is safe and effective. This article discusses the history of the procedure, current issues in procedure technique, and the state of the literature regarding outcomes of embolization. Current and future research topics also are discussed.

Pyosalpinx Developing from a Preexisting Hydrosalpinx after Uterine Artery Embolization

The authors describe a case of the development of a pyosalpinx from a preexisting hydrosalpinx after uterine artery embolization (UAE) for leiomyomata. The hydrosalpinx preexisted the UAE procedure and did not cause the patient any symptoms or signs of infection. UAE was performed with standard technique and was technically as well as initially clinically successful. However, the patient presented 8 weeks post-UAE with a pyosalpinx and superinfection of the previously simple fluid collection, requiring treatment with hysterectomy and oophorectomy. A mechanism for the occurrence of this superinfection is proposed, and potential strategies to avoid this serious complication in the future are discussed.

Uterine fibroid tumors: long-term MR imaging outcome after embolization

PURPOSE

To assess and report the long-term magnetic resonance (MR) imaging outcomes of fibroid tumors treated with uterine artery embolization (UAE).

MATERIALS AND METHODS

Contrast material-enhanced pelvic MR imaging was performed in 20 patients before UAE, at 3 months after UAE, and then yearly for up to 3 years. Two readers compared the uterine fibroid, dominant (ie, largest) fibroid, and percentage of perfusion measurements from each of these examinations by using intraclass correlations. Seventeen patients underwent contrast-enhanced MR imaging at baseline and 3 months and 3 years after treatment. Among these patients, those with complete infarction were compared with those with incomplete infarction of the dominant fibroid at 3 years to determine extents of infarction, differences in baseline characteristics, degrees of volume reduction of the uterus and fibroid, and extents of symptom change. Comparisons were performed by using t and Pearson chi(2) tests. Differences in proportions, with 95% CIs, were calculated. Each follow-up MR image was also evaluated for the presence of myometrial perfusion defects and new fibroids.

RESULTS

Intraclass correlation coefficients calculated for the two readers (range, 0.974-0.995) and with the MR imaging data (range, 0.966-0.988) were high. Of the 17 patients included in the outcome analysis, the 12 with complete fibroid infarction were more likely not to have enhancing lesions at 3-year follow-up (P =.002) than were those with incomplete infarction. No significant differences in volume or symptom changes between the two groups were detected, but growth of residual perfused portions of the incompletely infarcted fibroids was seen in three patients, two of whom had recurrent symptoms. Four patients developed new fibroids, none of which has caused symptoms. There were no instances of myometrial infarction.

CONCLUSION

Although the small study population prevented the drawing of definitive conclusions, the data suggest that although incomplete fibroid infarction may not affect outcome immediately, regrowth of uninfarcted fibroid tissue may result in symptom recurrence.

Outcome in patients undergoing unilateral uterine artery embolization for symptomatic fibroids

AIMS

To evaluate patients undergoing uterine artery embolization for symptomatic fibroids who, for technical reasons, underwent unilateral rather than bilateral embolization.

PATIENTS

Prospective data were collected on 109 patients undergoing uterine artery embolization for symptomatic fibroids. Of these, six underwent unilateral embolization. They were followed with ultrasound or magnetic resonance imaging (MRI) at 3, 6 and 12 months. Patients' histories were reviewed and patients were asked to evaluate their symptoms at 3, 6 and 12 months on a scoring system, which scored their pre-embolization symptoms as 10.

RESULTS

In one case the patient's symptoms did not change in the first 3 months. This patient underwent a second embolization procedure to occlude the non-embolized uterine artery. In four cases the patients' symptoms had begun to resolve at 3 months and by 12 months the patients no longer required any further treatment. In one case the patient passed a 10 cm fibroid per vagina 2 months post uterine artery embolization. After this the patient had a normal uterus on MRI and no further symptoms.

CONCLUSION

Where planned bilateral uterine artery embolization is not possible for technical reasons and a unilateral embolization only is performed a conservative approach is indicated.

Changing Trends in Gynecologists' Opinions of Uterine Artery Embolization for Fibroids: The Patient's Perspective

This study's purpose was to survey patients' perceptions of gynecologists' opinions of uterine artery embolization (UAE) for fibroids. Twenty-one women who underwent UAE between July 2000 and April 2002 and 21 women who underwent UAE between September 1998 and July 2000 completed questionnaires. Each woman was asked what her gynecologist's initial opinion was toward UAE, what treatment options were offered, who initiated discussion of UAE, and whether she returned to the same gynecologist after UAE. As of 2002, more gynecologists had a favorable opinion of UAE and were offering UAE versus in the year 2000. The majority of patients whose gynecologists initially opposed UAE did not return to the same gynecologists, reflecting a similar trend noted 2 years earlier.

Embolization of uterine fibroids

Since the first description of uterine artery embolization for the treatment of symptomatic fibroids of the uterus in 1994, this minimally invasive procedure has been increasingly performed in many Western countries. The method is characterized by a high technical success rate of about 85%, a highly significant relief of symptoms, and a very low rate of complications that make this method an appealing alternative to classic treatment options of surgical or laparoscopic myomectomy or hysterectomy. These characteristics have made the procedure well accepted by affected women. Nevertheless, indications and potential contraindications have to be evaluated carefully, especially in patients of childbearing age whenever a considerable number of deliveries is reported after uterine fibroid embolization. This article discusses the clinical background, indications and contraindications, angiographic techniques, potential complications and side effects, and the mid-term results known at present.

Medico-economic approach to the management of uterine myomas: a 6-month cost-effectiveness study of pelvic embolization versus vaginal hysterectomy

INTRODUCTION

Uterine artery embolization is a technique that has been recently proposed for the management of uterine myomas an alternative to vaginal hysterectomy. The results provided by the first published studies demonstrate a significant decrease in symptoms in 70-95% of cases. The aim of our study was to compare the cost-effectiveness ratios for pelvic embolization and vaginal hysterectomy looked at from the hospital point of view.

MATERIALS AND METHODS

Two populations of patients were randomly selected from women undergoing pelvic embolization or vaginal hysterectomy. We retrospectively measured the cost at 6 months of the two types of procedure (costs of hospitalization, drugs, and complementary examinations) as well as the success of each of them at 6 months. The cost of the techniques themselves were measured prospectively on the basis of four procedures.

RESULTS

The cost-effectiveness ratios were 2320 Euros per success (mean cost 2134 Euros per effectiveness 92%) for embolization and 2789 Euros per success (mean cost 2789 Euros per effectiveness 100%) for hysterectomy.

DISCUSSION

Pelvic embolization is more cost-effective than vaginal hysterectomy. The integration of the notion of quality of life with the notion of cost should permit a future study to reinforce interest in performing pelvic embolizations in the management of uterine myomas.

Is a Large Fibroid a High-Risk Factor for Uterine Artery Embolization?

OBJECTIVE

The objective of our study was to determine whether tumor size, specifically uterine fibroids of 10 cm or larger, predisposes a patient to an unacceptably high risk at uterine artery embolization.

MATERIALS AND METHODS

One hundred fifty-two consecutive women underwent embolization for uterine fibroids. Complications and outcomes were analyzed using questionnaires and serial MRI between women with one or more uterine fibroids of 10 cm or larger diameter (mean, 12.4 cm; range, 10-19 cm) (n = 47, group 1) and women with each uterine fibroid of less than 10 cm diameter (mean, 6.8 cm; range, 2-9.5 cm) (n = 105, group 2).

RESULTS

Thirty complications (19.7%, 30/152), which occurred in 27 women (17.8%, 27/152), were noted. However, 25 of 30 complications were minor, requiring no or nominal therapy. They occurred in 19.1% (9/47) of group 1 and in 15.2% (16/105) of group 2 women (p = 0.637). Major complications requiring major therapy, unplanned increased level of care, or unanticipated prolonged hospitalization (> 48 hr) or including permanent adverse sequelae were noted in 6.4% (3/47) of group 1 and in 1.9% (2/105) of group 2 women (p = 0.172). Of these five women, four underwent surgery because of sloughing fibroids. Permanent adverse sequelae were observed in one woman of group 1, who has had sexual dysfunction after embolization. No deaths occurred in either group. There was no significant difference in most outcomes or in intervals until the complete disappearance of postprocedural pain and full recovery between the two groups.

CONCLUSION

We found no increased risk to patients undergoing uterine artery embolization for fibroids on the basis of tumor size. Successful outcomes can be obtained for such lesions.

Leiomyoma Recurrence after Uterine Artery Embolization

PURPOSE

The purpose of this study was to evaluate the rate of leiomyoma recurrence after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

MATERIALS AND METHODS

A prospective study of UAE of uterine leiomyomas has been ongoing at the authors' hospital since 1997. The recurrence rate was assessed in June 2002. Vascular access was obtained via the right common femoral artery and free-flow embolization was performed with use of 150-250- micro m polyvinyl alcohol particles and an absorbable particle sponge. Follow-up included clinical and ultrasound (US) examinations at 3, 6, and 12 months, and once per year thereafter.

RESULTS

Eighty-five UAE procedures were performed between January 1997 and June 2000. Five patients were lost to follow-up. Median follow-up was 30 months (range, 2-57 months). There were six immediate failures: one technical failure, three cases of concomitant disease (one case of endometrial cancer and two cases of adenomyosis), and two cases of large subserosal leiomyomas. There were eight late failures or recurrences: one case of leiomyoma progression, seven cases of new leiomyomas. Mean time to recurrence was 27.4 months.

CONCLUSIONS

Although UAE is an effective primary treatment for leiomyomas, this study recorded a recurrence rate of 10% at just more than 2 years. Clinical and US examinations are needed before UAE to exclude pedunculated submucosal leiomyomas and cancers, and must be repeated for more than 2 years after UAE to monitor patients' progress. Longer follow-up and more events are needed to define risk factors for recurrence.

Transvaginal sonographic appearance of thrombosed uterine arteries after uterine artery embolization: the "white snake" sign

PURPOSE

The aim of this prospective study was to describe the appearance of thrombosed uterine arteries on transvaginal sonography performed after uterine artery embolization (UAE) and to assess the prognostic value of the "white snake" sign with regard to symptomatic outcome at 12 months.

METHODS

Patients who underwent UAE from January 1, 1999, to July 31, 2000, for the treatment of symptomatic leiomyomas were included in the study. Transvaginal sonography was performed before and at 3, 6, and 12 months after UAE. Patients graded the severity of their symptoms on a scale from 1 to 5, with 1 being the least and 5 the most severe, before and at 12 months after the procedure. The Wilcoxon rank-sum test was used to determine correlations between severity of symptoms and presence of the white snake sign; a p value of less than 0.05 was considered significant.

RESULTS

During the study period, UAE was performed in 19 patients with a mean age of 41 years (range, 32-48 years). UAE was technically successful in all patients. Eighteen patients (95%) reported symptomatic improvement at 12 months: 8 patients (42%) by 4 severity-scale points, 5(26%) by 3 points, and 5 (26%) by 2 points. The 1 patient who did not experience improvement had undergone a hysterectomy at 4 months after the UAE. At the 3-month follow-up, transvaginal sonography demonstrated a tortuous echogenic structure in the adnexa (the white snake sign) in all patients; the finding was still apparent in 10 patients at 6 months but in only 2 patients at 12 months. A direct correlation was found between persistence of the white snake sign and the degree of symptomatic improvement at 6 months (p=0.04) but not at 12 months (p=0.08).

CONCLUSIONS

After UAE, a thrombosed uterine artery appears on transvaginal sonography as an echogenic tortuous structure in the adnexa. Persistence of this white snake sign at 6 months after UAE may suggest a more favorable symptomatic outcome.

Coil Embolization of a Tuboovarian Anastomosis before Uterine Artery Embolization to Prevent Nontarget Particle Embolization of the Ovary

Uterine artery embolization (UAE) is being used more frequently as a primary treatment for uterine leiomyoma. Performing UAE in women who desire future fertility is controversial because of the risks of premature menopause and the undetermined effects on pregnancy. The etiology of ovarian failure after UAE is not yet clearly defined, but one of the leading possibilities is nontarget embolization of the ovaries. In this case report, the authors describe a technique of selective coil embolization of a uterine artery-to-ovarian artery communication before UAE performed specifically to protect the ovary from nontarget embolization.

Ovarian Protection by Occlusion of Uteroovarian Collateral Vessels before Uterine Fibroid Embolization

In an attempt to decrease the incidence of premature ovarian failure, three patients with prominent ovarian collateral vessels from the uterine artery (UA) underwent collateral vessel embolization before uterine fibroid embolization. UA anatomy and collateral pathways are reviewed.