Uterine Artery Embolisation for Women with Giant Versus Non-giant Uterine Fibroids: A Systematic Review and Meta-analysis

A Rare Case of Giant Uterine Leiomyomata: A Difficult Diagnosis Accompanied by Surgical Difficulties

Leiomyomas, also known as fibroids, are a group of benign smooth muscle tumors commonly present in premenopausal women. Giant uterine leiomyomas are rare. It is described as giant when it weighs 11.4 kg. This report concerns a 45-year-old, asymptomatic woman of reproductive age who presented for her first gynecological consultation at the clinic of Trikala General Hospital, Greece, for a routine smear and gynecological examination. A large, painless abdominal mass was palpated during the clinical exam, reaching the level of the xiphoid process. Imaging confirmed the clinical diagnosis of a myomatous uterus, and surgical intervention via laparotomy was decided. Intraoperatively, a giant uterine leiomyoma was identified, leading to an abdominal total hysterectomy with bilateral salpingectomy and oophorectomy. A histological examination confirmed the diagnosis. After a five-day hospitalization with an uneventful postoperative recovery, the patient was discharged. This rare case emphasizes the uncommon presentation of a giant uterine leiomyoma in an asymptomatic reproductive-age patient, highlighting the diagnostic and surgical challenges associated with managing such cases.

Postoperative symptom changes following uterine artery embolization for uterine fibroid based on FIGO classification

BACKGROUND

Classifying uterine fibroid using the International Federation of Gynecology and Obstetrics (FIGO) classification system assists treatment decision-making and planning. This study aimed to study whether different fibroid locations influence clinical outcomes following uterine artery embolization (UAE).

METHODS

This is a retrospective cohort study of patients who underwent UAE for symptomatic uterine fibroid between December 2016 and January 2023 at our hospital. Changes in mean fibroid volume were compared based on MR images. Menstrual pain, excessive flow symptoms, and treatment satisfaction before UAE and 6 months after UAE were compared.

RESULTS

A total of 149 premenopausal patients (mean age 45.7 ± 2.7 years) were included for analysis (FIGO 2/3, n = 57; FIGO 4-7, n = 92). Baseline menstrual pain, fibroid, and uterine volume before UAE were comparable between the two FIGO groups (p > 0.05). The menstrual flow index was higher for the FIGO 2/3 group (mean ± SD [min-max]: 9.4 ± 1.4 [4-10] vs 8.0 ± 2.3 [0-10], p < 0.001). Six months after UAE, the improvements in menstrual flow index (mean ± SD]: -3.7 ± 2.6 vs -2.6 ± 2.2, p = 0.035), fibroid volume (mean ± SD: -54.7 ± 21.7% vs -39.8 ± 16.2%, p < 0.001), and uterine volume (mean ± SD: -38.2 ± 16.3% vs -31.1 ± 11.6%, p = 0.008) in the FIGO 2/3 group were significantly higher than the FIGO 4-7 group. Both groups had comparable improvements in menstrual pain index (-2.1 ± 2.6 vs -1.8 ± 2.5, p = 0.008) and 88% of the patients were satisfied or very satisfied overall.

CONCLUSION

UAE treatment satisfaction was high for patients with fibroids at different FIGO stages. UAE treatment outcomes were better for patients with fibroids affecting the endometrium (FIGO 2/3).

LEVEL OF EVIDENCE

3B, Retrospective observational study.

Impact of superior hypogastric nerve block during uterine fibroid embolisation on pain scores, opioid requirements, and same-day discharge: a case-control study

AIM

To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge.

MATERIALS AND METHODS

Prospectively enrolled case-control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0-10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t-test or Mann-Whitney U-test. A p-value of <0.05 defined significance.

RESULTS

Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p=0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p<0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p=0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p=0.020). No SHNB-related adverse events occurred.

CONCLUSION

SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain.

Update on Endovascular Therapy for Fibroids and Adenomyosis

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus

Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.

Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?

BACKGROUND

Uterine artery embolisation is well established as a treatment for symptomatic fibroids, however, there remain some uncertainties. We have carried out a focused literature review on three particularly challenging aspects - post-procedure fertility, symptomatic adenomyosis and large volume fibroids and uteri, to enable operators to utilise evidence-based guidance in patient selection, consent, and management.

REVIEW

Literature searches were performed of the PubMed/Medline, Google scholar, EMBASE and Cochrane databases. The outcomes of our analysis of studies which recorded fertility rates in women desiring pregnancy following UAE for symptomatic fibroids found an overall mean pregnancy rate of 39.4%, live birth rate of 69.2% and miscarriage rate of 22%. The major confounding factor was patient age with many studies including women over 40 years who already have lower fertility compared to younger cohorts. Miscarriage rates and pregnancy rates in the studies analysed were comparable to the age matched population. Treatment of pure adenomyosis and adenomyosis with co-existing uterine fibroids with UAE has been shown to produce symptomatic improvement with better outcomes in those with combined disease. Although the effectiveness is not as high as it is in pure fibroid disease, UAE provides a viable and safe alternative for patients seeking symptom relief and uterine preservation. Our analysis of studies assessing the outcomes of UAE in patients with large volume uteri and giant fibroids (> 10 cm) demonstrate no significant difference in major complication rates demonstrating that fibroid size should not be a contraindication to UAE.

CONCLUSION

Our findings suggest uterine artery embolisation can be offered to women desiring pregnancy with fertility and miscarriage rates comparable to that of the age-matched general population. It is also an effective therapeutic option for symptomatic adenomyosis as well as for the treatment of large fibroids > 10 cm in diameter. Caution is advised in those with uterine volumes greater than 1000cm³. It is however clear that the quality of evidence needs to be improved on with an emphasis on well-designed randomised controlled trials addressing all three areas and the consistent use of validated quality of life questionnaires for outcome assessment to enable effective comparison of outcomes in different studies.

Can uterine artery embolization be an alternative to plastic and reconstructive uterus operation by minimally invasive surgery?

Introduction: Plastic and reconstructive minimally invasive surgery has been established as gold standard in myomectomy. Therapy failure eventually leads to future surgical interventions or hysterectomy: surgeons and patients should be aware of the risks and benefits. We conducted a systematic review to analyse the evidence on the therapeutic indications and adverse events associated with uterine artery embolization and thereby evaluating if this method could be a valid alternative therapy. Methods: In concordance with PRISMA guidelines, literature research was made in PubMed, Cochrane Library, UpToDate, Amboss and Medline databases. Clinical trials, reviews and case reports published in English between January 2010 and June 2020 were included. Results: 44 articles were included out of 838 papers identified at initial search. Regarding uterine fibroids, three original papers and one Cochrane review reported the benefits of the procedure as an alternative to surgery, even in large and giant fibroids. Furthermore, several studies discussed the use of embolization for postpartum haemorrhage to decrease rates of hysterectomy after other haemostatic methods were exhausted, because of the potential risk of abnormal placentation in a future pregnancy. The procedure can also be successfully used as prophylactic method in different obstetrical procedures. Conclusions: The use of embolization in different uterine pathologies is a minimally invasive procedure as an alternative to surgery, especially in women who desire to preserve their uterus. Its related complications are described and can be avoided by a stringent indication of the procedure. More evidence regarding fertility after UAE, use of the procedure prophylactically in obstetrical haemorrhage or in adenomyosis is needed.

Uterine Myomas: Endovascular Treatment

Uterine fibroids embolization is a safe and effective organ sparing treatment for fibroid-related symptoms based on a broad range of published evidence including randomized-controlled trials. Indication to treatment is usually the presence of symptomatic uterine fibroids. In this review, a systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was conducted, with a special focus on the indication to treatment, technique, procedural outcomes and pain control. All clinical trials published in English language, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered.

Clinical, Imaging and Procedural Risk Factors for Intrauterine Infective Complications After Uterine Fibroid Embolisation: A Retrospective Case Control Study

Introduction

This was a retrospective case–control study at a single tertiary centre investigating all UFE procedures between January 2013 and December 2018 for symptomatic fibroids. The aim was to determine the clinical, imaging and procedural risk factors which impact upon the risk of post-uterine fibroid embolisation (UFE) intrauterine infection. Cases were patients which developed intrauterine infection post-procedure, and controls were the background UFE population without infection.

Methods

Clinical demographics, presenting symptoms, uterine and fibroid characteristics on imaging and procedural variants were analysed. A p value of less than 0.05 was considered statistically significant. The main outcome measures were presence of infection and requirement of emergency hysterectomy.

Results

333 technically successful UFE procedures were performed in 330 patients. Infection occurred after 25 procedures (7.5%). 3 of these patients progressed to overwhelming sepsis and required emergency hysterectomy. Clinical obesity (BMI > 30) (OR 1.53 [1.18–1.99]) and uterine volume > 1000cm3 (2.94 [1.15–7.54]) were found to increase the risk of infection

Conclusions

UFE is generally safe in patients with symptomatic fibroids. Obese patients (BMI > 30) and those with large volume uteri (> 1000cm³) are at slight increased risk of developing infection and require appropriate pre-procedural counselling, as well as careful post-UFE follow-up. BMI and uterine volume may be useful to assess before the procedure to help to determine post-UFE infection risk.

Electronic supplementary material

The online version of this article (10.1007/s00270-020-02622-2) contains supplementary material, which is available to authorised users.