Uterine artery embolization versus surgery for symptomatic uterine fibroids: a randomized controlled trial and a meta-analysis of the literature

Conservative Treatment of Uterine Myomas: A Network Meta-analysis Of Randomized Controlled Studies

OBJECTIVE

To comparatively evaluate the effectiveness of uterine artery embolization (UAE), high-intensity focused ultrasound (HIFU), radiofrequency ablation treatment (RFT), and laparoscopic/laparotomic surgery in the conservative treatment of uterine fibroids.

DATA SOURCES

The research was performed via electronic databases PubMed, Embase, and Cochrane Library, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.

METHODS OF STUDY SELECTION

The network included 10 randomized trials between 2000 and 2024 and 1002 randomized subjects.

TABULATION, INTEGRATIONS, AND RESULTS

The network meta-analysis was conducted with subroutine netmeta on R. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. The surface under the cumulative ranking curve (SUCRA) was computed by Bayesian network meta-analysis. Incidences of reintervention per 100 person/year of follow-up were 4.13 (range, 0-19.4), 16.1 (6.2-32.8), 14.3 (0-15.1), and 6 (4.3-6.7) for myomectomy, UAE, HIFU, and RFT, respectively. The incidence rate ratios compared with myomectomy were 2.45 (95% confidence interval [CI], 1.38-4.37), 5.23 (95% CI, 1.59-17.3), and 4.59 (95% CI, 0.77-27.3; p = .09) for UAE, HIFU, and RFT, respectively. RTF had the highest (SUCRA, 1.25% and 3%) whereas myomectomy had the lowest risk of reintervention (SUCRA, 98% and 95%) or hysterectomy during follow-up (median, 12 months; range, 3-24). The risk of major complications was significantly lower after UAE (odds ratio, 0.38; 95% CI, 0.17-0.85) than myomectomy. The procedure with the lowest likelihood of major complications was HIFU (SUCRA, 81.5%). Finally, in the evaluation of QoL at follow-up visits, there were no differences between the treatments studied, although the model was highly heterogeneous and inconsistent.

CONCLUSION

In the analysis of randomized trials, surgical myomectomy carried the least risk of reintervention and subsequent hysterectomy during a relatively short follow-up period. HIFU was the method with the lowest risk of major complications.

Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids

This review compares the efficacy of Uterine Artery Embolization (UAE) and Myomectomy (MYO) in managing symptomatic Uterine Fibroids (UFs) in women who do not want hysterectomy. A meta-analysis was performed on all available studies that evaluated the relative benefits and harms of MYO and UEA for the management of patients suffering from UFs. Outcomes evaluated reintervention, UFs scores for quality of life (QOL) and symptom severity, and other complications. To determine mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs), a random or fixed-effects model was utilized. A meta-analysis of 13 studies (9 observational and 4 randomized controlled trials) was conducted. The results indicated that UAE had a higher reintervention rate (OR 1.84; 95% CI 1.62-2.10; P < 0.01; I2 = 39%), hysterectomy rate (OR 4.04; 95% CI 3.45-4.72; P < 0.01; I2 = 59%), and symptom-severity score (OR - 4.02; 95% CI 0.82, 7.22; P = 0.01; I2 = 0%) compared to MYO at a four-year follow-up. However, UAE was associated with a lower rate of early complications (OR 0.44; 95% CI 0.20-0.95; P = 0.04; I2 = 25%), and readmission rate (OR 1.16; 95% CI 1.01-1.33; P = 0.04; I2 = 0%) compared to MYO. Furthermore, both procedures had comparable improvement in pregnancy rates and abnormal uterine bleeding. In conclusion, UAE and MYO are effective in treating symptomatic UFs but they have different outcomes. The decision on which procedure to choose should be made based on individual preferences and the physician's expertise.

Uterine artery embolization vs myomectomy for the management of women with uterine leiomyomas: a systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate whether uterine artery embolization offers a better quality of life than myomectomy in premenopausal women diagnosed with leiomyomas of the uterus.

DATA SOURCES

A literature search was performed using the electronic databases of PubMed and Cochrane Central Register of Controlled Trials from inception to January 2023.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials comparing uterine artery embolization with myomectomy in women of premenopausal age suffering from uterine leiomyomas were considered.

METHODS

The primary outcome was quality of life. The secondary outcomes were reintervention rate and timing, successful pregnancy, stillbirth and miscarriage, cesarean delivery on delivery, and perioperative morbidity. Moreover, time-to-event and standard pairwise meta-analyses were performed, as appropriate. The certainty of the evidence was assessed in line with the Grading of Recommendations, Assessment, Development, and Evaluations methodology.

RESULTS

A total of 6 randomized controlled trials met our inclusion criteria. The meta-analysis suggested little to no difference in terms of quality of life between uterine artery embolization and myomectomy (standard mean difference, 0.05; 95% confidence interval, -0.38 to 0.48; I2=92%; very low certainty of evidence). Sensitivity analysis, including randomized controlled trials, which included solely myomectomy procedures in the control arm, demonstrated better quality of life for women treated with myomectomy (standard mean difference, -0.32; 95% confidence interval, -0.49 to -0.15; I2=15%). Concerning reintervention, myomectomy was likely associated with a decreased risk of future reintervention (risk ratio, 0.32; 95% confidence interval, 0.15-0.69; I2=60%; low certainty of evidence) and a more prolonged time interval since a potential reintervention because of recurrence than uterine artery embolization (hazard ratio, 0.41; 95% confidence interval, 0.22-0.77; I2=77%; low certainty of evidence). No difference was found between the 2 interventions concerning severe perioperative adverse events (relative risk, 4.13; 95% confidence interval, 0.44-39.20; I2=0%; low certainty of evidence).

CONCLUSION

Uterine artery embolization is likely associated with increased reintervention rates and less time to reintervention compared with myomectomy in premenopausal women diagnosed with uterine leiomyomas. Evidence suggests no difference between the 2 interventions regarding perioperative morbidity. Uterine artery embolization may exert no effect on quality of life and successful pregnancy; however, the evidence is very uncertain.

Value of interventional radiology and their contributions to modern medical systems

Interventional radiology (IR) is a unique specialty that incorporates a diverse set of skills ranging from imaging, procedures, consultation, and patient management. Understanding how IR generates value to the healthcare system is important to review from various perspectives. IR specialists need to understand how to meet demands from various stakeholders to expand their practice improving patient care. Thus, this review discusses the domains of value contributed to medical systems and outlines the parameters of success. IR benefits five distinct parties: patients, practitioners, payers, employers, and innovators. Value to patients and providers is delivered through a wide set of diagnostic and therapeutic interventions. Payers and hospital systems financially benefit from the reduced cost in medical management secondary to fast patient recovery, outpatient procedures, fewer complications, and the prestige of offering diverse expertise for complex patients. Lastly, IR is a field of rapid innovation implementing new procedural technology and techniques. Overall, IR must actively advocate for further growth and influence in the medical field as their value continues to expand in multiple domains. Despite being a nascent specialty, IR has become indispensable to modern medical practice.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Therapeutic options for the management of abnormal uterine bleeding

Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.

Nononcologic Embolization

The scope of conditions managed by embolization, which was initially used for the treatment of hemorrhage and vascular malformations, is constantly expanding. Apart from oncologic indications, embolization is used to treat a wide range of benign pathology, including uterine fibroids and benign prostatic hyperplasia. While various particulate embolic agents are successfully used for benign embolization, there is growing evidence that unique properties of these may result in different outcomes. This article reviews available evidence comparing various particles used for uterine fibroid embolization and prostate artery embolization. In addition, we provide an overview of periprocedural pharmacology and protocols facilitating same-day discharge for these interventions.

Current Strategies for Prevention of Infection After Uterine Artery Embolisation

Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.

Evidence-Based Management of Uterine Fibroids With Botanical Drugs-A Review

Uterine fibroids (UFs) are a common benign gynecological tumor that affect the majority of women over their lifetime. Several pharmacological agents are available to reduce the size of fibroids and ameliorate the symptoms of UF. However, these drugs are expensive and are usually associated with profound side effects. Thus, botanical drugs are gaining attention in this era due to their cost effectiveness with a comparable and more potent therapeutic efficacy while demonstrating lesser adverse effects. The objective of this review is to summarize the available information on the mechanism of various botanical drugs and polyherbal formulations with anti-uterine fibroid activity. A systematic search was performed on botanical drugs with anti-uterine fibroid activity using several search engines, which include PubMed, Google Scholar, and Science Direct. Based on the literatures identified, a total of five botanical drugs and three polyherbal formulations were included and discussed in this review, which yields useful information regarding the mechanism of different botanical drugs and polyherbal formulations in exerting anti-uterine fibroid activity for its potential use as an alternative treatment choice for uterine fibroids.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT

BACKGROUND

Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options.

OBJECTIVES

We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids.

DESIGN

A multicentre, open, randomised trial with a parallel economic evaluation.

SETTING

Twenty-nine UK hospitals.

PARTICIPANTS

Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation.

INTERVENTIONS

Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance.

MAIN OUTCOME MEASURES

The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective).

RESULTS

A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years.

LIMITATIONS

There were a substantial number of women who were not recruited because of their preference for a particular treatment option.

CONCLUSIONS

Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy.

TRIAL REGISTRATION

This trial is registered as ISRCTN70772394.

FUNDING

This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.

Choice of primary and secondary outcomes in randomised controlled trials evaluating treatment for uterine fibroids: a systematic review

BACKGROUND

Core outcome sets aim to reduce research heterogeneity and standardise reporting, allowing meaningful comparisons between studies.

OBJECTIVES

To report on outcomes used in randomised controlled trials (RCTs) investigating uterine fibroid treatments, towards the development of a core outcome set for fibroid research.

SELECTION STRATEGY

Database search of MEDLINE, PubMed, EMBASE and CINAHL (inception to July 2021) for all English-language RCTs involving surgical or radiological fibroid treatments.

DATA COLLECTION AND ANALYSIS

A total of 1885 texts were screened for eligibility by two reviewers independently according to PRISMA methodology. JADAD and Management of Otitis Media with Effusion in Cleft Palate (MOMENT) scores were used to assess methodological and outcome reporting quality of studies, respectively. Outcomes were mapped to nine domains. Non-parametric tests for correlation and to compare group medians were undertaken.

MAIN RESULTS

There were 23 primary outcomes (23 outcome measures) and 173 secondary outcomes (95 outcome measures) reported in 60 RCTs (5699 participants). The domains with highest frequency of primary outcomes reported were bleeding and quality of life (QoL). The most frequent primary outcomes were postoperative pain, QoL and menstrual bleeding. No primary outcomes were mapped to fertility domains. Median MOMENT outcome score was 5 (interquartile range 3). There was correlation between MOMENT outcome score and JADAD scores (r = 0.491, P = 0.0001), publishing journal impact factor (r = 0.419, P = 0.008) and publication year (r = 0.332, P = 0.01).

CONCLUSION

There is substantial variation in the outcomes reported in fibroid RCTs. There is a need for a core outcome set for fibroid research, to allow improved understanding regarding the effects of different treatments.

Nonenhanced MRI-based radiomics model for preoperative prediction of nonperfused volume ratio for high-intensity focused ultrasound ablation of uterine leiomyomas

OBJECTIVES

To develop and assess nonenhanced MRI-based radiomics model for the preoperative prediction of nonperfused volume (NPV) ratio of uterine leiomyomas after high-intensity focused ultrasound (HIFU) treatment.

METHODS

Two hundred and five patients with uterine leiomyomas treated by HIFU were enrolled and allocated to training (N =164) and testing cohorts (N = 41). Pyradiomics was used to extract radiomics features from T2-weighted images and apparent diffusion coefficient (ADC) map generated from diffusion-weighted imaging (DWI). The clinico-radiological model, radiomics model, and radiomics-clinical model which combined the selected radiomics features and clinical parameters were used to predict technical outcomes determined by NPV ratios where three classification groups were created (NPV ratio ≤ 50%, 50-80% or ≥ 80%). The receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration and decision curve analyses were performed to illustrate the prediction performance and clinical usefulness of model in the training and testing cohorts.

RESULTS

The multi-parametric MRI-based radiomics model outperformed T2-weighted imaging (T2WI)-based radiomics model, which achieved an average AUC of 0.769 (95% confidence interval [CI], 0.701-0.842), and showed satisfactory prediction performance for NPV ratio classification. The radiomics-clinical model demonstrated best prediction performance for HIFU treatment outcome, with an average AUC of 0.802 (95% CI, 0.796-0.850) and an accuracy of 0.762 (95% CI, 0.698-0.815) in the testing cohort, compared to the clinico-radiological and radiomics models. The decision curve also indicated favorable clinical usefulness of the radiomics-clinical model.

CONCLUSIONS

Nonenhanced MRI-based radiomics has potential in the preoperative prediction of NPV ratio for HIFU ablation of uterine leiomyomas.

Uterine artery embolization, surgery and high intensity focused ultrasound in the treatment of uterine fibroids: a network meta-analysis

Background

To systematic review the safety and effectiveness between uterine artery embolization (UAE), surgery and high intensity focused ultrasound (HIFU) in the treatment of uterine fibroids.

Methods

The PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang Data, and CNKI were electronically searched to collect relevant studies on comparing the safety and effectiveness of UAE, surgery and HIFU in the treatment of uterine fibroids from January 2000 to August 2019. After two reviewers independently screened the literature, extracted the data and evaluated the risk of bias of included studies, network meta-analysis was performed by ADDIS 1.16.8 and Stata 14 software.

Results

A total of 11 studies (22 articles) involving 3,646 patients were included. Compared with surgery, UAE and HIFU patients had higher quality of life (1-year follow-up) improvement, and UAE was higher than HIFU. Network meta-analysis show that patients treated with HIFU had the lowest incidence of major complications within 1 year, followed by UAE, and the highest surgery. Patients treated with HIFU and UAE have shorter hospital stays and quicker recovery time than surgery. The rate of further intervention after surgery treatment might be lower than that of UAE and HIFU.

Conclusions

UAE has the highest quality of life improvement (1-year follow-up) for uterine fibroids. HIFU and UAE are safer with shorter hospital stays and quicker recovery time compared with surgery. However, both UAE and HIFU have the risks of re-treatment. However, limited by the number and quality of included studies, the above conclusions need to be verified through more high-quality studies.

Initial experience with HydroPearl microspheres for uterine artery embolization for the treatment of symptomatic uterine fibroids

Background

Uterine Artery Embolization (UAE) is a minimally invasive procedure used to treat symptomatic uterine fibroids. The HydroPearl Microsphere (Terumo Interventional Systems) is an embolic agent approved for UAE and other embolization procedures. The purpose of this article is to describe our initial experience with HydroPearl for UAE in patients with symptomatic uterine fibroids. Twenty-one patients who underwent UAE using HydroPearl Microspheres at a single institution from May 1, 2018 to December 31, 2019 were included in the study. The electronic medical record (EMR) was reviewed for documentation of short- and long-term complications, as well as improvements in menorrhagia and bulk-type symptoms. We also describe unique attributes of the HydroPearl Microsphere that should be considered when utilizing this embolization particle for UAE.

Results

Of the 21 patients, 18 had a 3-month or later post-procedure follow-up documented in the EMR and were included in the analysis. The average time between the UAE procedure and the most recent clinical note was 145 days. Sixteen patients reported symptoms of menorrhagia and 13 reported bulk symptoms prior to the UAE procedure. On follow-up, 13/16 patients (81%) and 12/13 patients (92%) experienced improvement in menorrhagia and bulk symptoms, respectively. The only recorded complication was amenorrhea in 4 patients (22%) who had an average age of 51 years.

Conclusions

Several characteristics of HydroPearl Microsphere may prove helpful when considering these embolic particles for use in UAE. Our initial experience with this embolic agent suggest that the reatment response for menorrhagia and bulk symptoms are largely similar to success rates reported in the literature for other embolic agents. Larger studies are needed to evaluate the safety and efficacy of this embolic particle for this indication.

Uterine Artery Embolization Compared with High-intensity Focused Ultrasound Ablation for the Treatment of Symptomatic Uterine Myomas: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare the clinical effects of uterine artery embolization (UAE) with those of high-intensity focused ultrasound (HIFU) ablation for the treatment of symptomatic uterine myomas.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, and ClinicalTrials.gov for studies from January 2000 to August 2020. Related articles and relevant references of the included studies were also searched.

METHODS OF STUDY SELECTION

Two researchers independently performed the data selection. We included comparative studies that compared the clinical outcomes of UAE with those of HIFU ablation in women with myomas.

TABULATION, INTEGRATION, AND RESULTS

We assessed the study quality using the Cochrane Handbook for Systematic Reviews of Interventions for evaluating the risk of bias. Two independent researchers performed the article selection according to the screening criteria and rated the quality of evidence for each article. We calculated pooled mean difference with 95% confidence interval (CI) for continuous data and relative risk (RR) with 95% CI for dichotomous data. The systematic review registration number is CRD42020199630 on the International Prospective Register of Systematic Reviews. A total of 7 articles (5 trials), involving 4592 women with symptomatic uterine myomas, were included in the meta-analysis. Compared with the HIFU ablation group, the decrease in "uterine fibroid symptom" scores as well as the increase in quality-of-life scores at the time of follow-up were higher in the UAE group, with overall mean difference 19.54 (95% CI, 15.21-23.87; p <.001) and 15.72 (95% CI, 8.30-23.13; p <.001), respectively. The women in the UAE group had a significantly lower reintervention rate (RR 0.25; 95% CI, 0.15-0.42; p <.001). The women undergoing UAE had a significantly lower pregnancy rate than those undergoing HIFU ablation (RR 0.06; 95% CI, 0.01-0.45; p = .006). The difference in the incidence of adverse events between the 2 groups was not statistically significant (p = .53).

CONCLUSION

Compared with HIFU ablation, UAE provided more significant alleviation of symptoms and improvement in quality of life, lower postoperative reintervention rate, and lower pregnancy rate for women with uterine myomas. However, we cannot conclude that HIFU ablation is more favorable for desired pregnancy than UAE because of the confounding factors.

Uterine-Artery Embolization or Myomectomy for Uterine Fibroids

BACKGROUND

Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options.

METHODS

We conducted a multicenter, randomized, open-label trial to evaluate myomectomy, as compared with uterine-artery embolization, in women who had symptomatic uterine fibroids and did not want to undergo hysterectomy. Procedural options included open abdominal, laparoscopic, or hysteroscopic myomectomy. The primary outcome was fibroid-related quality of life, as assessed by the score on the health-related quality-of-life domain of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire (scores range from 0 to 100, with higher scores indicating a better quality of life) at 2 years; adjustment was made for the baseline score.

RESULTS

A total of 254 women, recruited at 29 hospitals in the United Kingdom, were randomly assigned: 127 to the myomectomy group (of whom 105 underwent myomectomy) and 127 to the uterine-artery embolization group (of whom 98 underwent embolization). Data on the primary outcome were available for 206 women (81%). In the intention-to-treat analysis, the mean (±SD) score on the health-related quality-of-life domain of the UFS-QOL questionnaire at 2 years was 84.6±21.5 in the myomectomy group and 80.0±22.0 in the uterine-artery embolization group (mean adjusted difference with complete case analysis, 8.0 points; 95% confidence interval [CI], 1.8 to 14.1; P = 0.01; mean adjusted difference with missing responses imputed, 6.5 points; 95% CI, 1.1 to 11.9). Perioperative and postoperative complications from all initial procedures, irrespective of adherence to the assigned procedure, occurred in 29% of the women in the myomectomy group and in 24% of the women in the uterine-artery embolization group.

CONCLUSIONS

Among women with symptomatic uterine fibroids, those who underwent myomectomy had a better fibroid-related quality of life at 2 years than those who underwent uterine-artery embolization. (Funded by the National Institute for Health Research Health Technology Assessment program; FEMME Current Controlled Trials number, ISRCTN70772394.).

Comparing Perioperative Outcomes of Uterine Artery Embolization and Hysterectomy in Insurer and Demographically Diverse Populations: A Retrospective, Multi-Center Database Study

INTRODUCTION

Past studies comparing perioperative outcomes of hysterectomy (HYST) and uterine artery embolization (UAE) do not control for demographically and insurer diverse populations. This study sought to identify the 30‑day readmission, 15‑day complication, and minimum 1‑year surveillance reintervention rates of diverse, propensity matched patients undergoing UAE or HYST for uterine leiomyoma.

METHODS

Adults from the New York's Statewide Planning and Research Cooperative System (SPARCS) database 2009‑2013 who underwent HYST or UAE for uterine leiomyoma were retrospectively reviewed and 1:1 propensity matched. Univariate analysis compared demographics, complications, readmissions, and reintervention rates. Binary logistic and linear regression models identified independent predictors of outcomes.

RESULTS

A total of 682 patients were identified, where the number (n) of patients in each cohort was n=341, HYST, and n=341, UAE. Significance levels are shown with p values. No significant differences were identified between HYST and UAE demographics, complication (2.60% HYST vs 2.90% UAE, p=0.816) or readmission rates (3.20% HYST vs 3.80% UAE, p=0.678); 0.30% of UAE patients had a reintervention UAE and 2.90% of UAE patients had reintervention hysterectomy. HYST patients had a significantly longer average length of stay (2.59 days HYST vs 1.63 days UAE, p<0.001). The Deyo-Charlson (Deyo) comorbidity score positively predicted any complication with odds ratio=34.262, 95% confidence interval [4.938, 237.725], and p<0.001, but did not predict readmissions.

CONCLUSION

HYST patients had significantly longer hospital stays. UAE and HYST had comparable readmission and complication rates. The Deyo comorbidity score was a significant predictor of any complication. This study supports the safety and efficacy of UAE when compared to HYST in demographic and insurer diverse populations.

Symptomatic Fibroid Management: Systematic Review of the Literature

Background and Objectives:

Symptomatic uterine fibroids are a societal and healthcare burden with no clear consensus among medical professionals as to which procedural treatment is most appropriate for each symptomatic patient. Our purpose was to determine whether recommendations can be made regarding best practice based on review and analysis of the literature since 2006.

Database:

A systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was performed within PubMed, clinical society websites, and medical device manufacturers' websites. All clinical trials published in English, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered. Each article was screened and selected based on study type, content, relevance, American College of Obstetricians and Gynecologists score, and internal/external validity. Outcomes of interest were patient baseline characteristics, fibroid characteristics, procedural details, complications, and long-term follow-up. Random-effects meta-analyses were used to test the quantitative data. Assessment of 143 full-length articles through January 2016 produced 45 articles for the quantitative analysis. The weighted combined results from hysterectomy trials were compared with those from uterine-preserving fibroid studies (myomectomy, uterine artery embolization, laparoscopic radiofrequency ablation, and magnetic resonance-guided focused ultrasound).

Conclusion:

We explored trends that might guide clinicians when counseling patients who need treatment of symptomatic fibroids. We found that fibroid therapy is trending toward uterine-conserving treatments and outcomes are comparable across those treatments. Since minimally invasive options are increasing, it is important for the clinician to provide the patient with evidence-based therapeutic strategies.

Uterine Artery Embolization and Surgical Methods for the Treatment of Symptomatic Uterine Leiomyomas: A Systemic Review and Meta-analysis Followed by Indirect Treatment Comparison

PURPOSE

There is significant discussion and uncertainty about the optimal management of symptomatic uterine leiomyomas (SULs). Nonsurgical procedures such as uterine artery embolization (UAE) have been developed. The goal of this study was to conduct a meta-analysis and an indirect treatment comparison to examine the comparative efficacy and safety of the surgical procedures to treat SULs compared with UAE.

METHODS

MEDLINE, EMBASE, Lilacs, and the Cochrane Central Register of Controlled Trials databases were searched from inception to February 2016. Ten randomized controlled trials comparing UAE versus hysterectomy, myomectomy, and laparoscopic occlusion of the uterine arteries in patients with SUL published in a peer-reviewed journal were included. Two reviewers independently selected studies, assessed quality, and extracted data. Discrepancies were resolved through consensus.

FINDINGS

Data from 986 patients submitted to UEA (n = 527) or surgery (n = 459) were analyzed. UAE had a lower risk of major complications (risk ratio [RR], 0.45 [95% CI, 0.22-0.95]; P = 0.04)and a higher risk of minor complications (RR, 1.65 [95% CI, 1.32-2.06]; P < 0.00001); UAE had a higher risk of re-intervention up to 2 years (RR, 3.74 [95% CI, 1.76-7.96]; P = 0.0006) and up to 5 years (RR, 5.01 [95% CI, 1.37-18.39]; P = 0.02); UAE had a similar risk of follicle-stimulating hormone levels >40 IU/L after 6 months (RR, 1.76 [95% CI, 0.24-12.95]; P = 0.58)and of recommending the procedure to another patient up to 5 years after treatment (RR, 1.00 [95% CI, 0.87-1.14]; P = 0.94). The indirect comparison between myomectomy and hysterectomy found that the 2 procedures were similar in the studied outcomes.

IMPLICATIONS

Compared with surgery, UAE had lower rates of major complications with an increased risk of re-intervention up to 2 and 5 years after the first procedure. UAE compared with surgery had a similar risk of ovarian failure and similar recommendation of the procedure to another patient. However, the number of trials was limited, and there was a high risk of bias in at least 2 domains. None of the trials blinded the participants and personnel or the outcome assessment. PROSPERO identifier: CRD42015026319.

Uterine artery embolization for heavy menstrual bleeding

Uterine artery embolization (UAE) as a treatment option for fibroids was first reported by Ravina in 1995. Although rapidly adopted by enthusiasts, many were skeptical and its introduction varied widely across the globe. It was not until randomized controlled trials and registries were published and national guidance statements issued that UAE was accepted as a safe and proven treatment for fibroids. The technique is now established as one of the treatment options to be discussed with patients as an alternative to surgery for fibroid-associated heavy menstrual bleeding. Research is on-going to evaluate the relative merits of UAE compared with other medical and surgical treatment options for heavy menstrual bleeding, particularly for women wishing to maintain their fertility.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence that is based on case controlled studies and case reports. This is an update of the review previously published in 2012.

OBJECTIVES

To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids.

SEARCH METHODS

We searched sources including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries. The search was last conducted in April 2014. We contacted authors of eligible randomised controlled trials to request unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids. The primary outcomes of the review were patient satisfaction and live birth rate (among women seeking live birth).

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) independently selected studies, assessed quality and extracted data. Evidence quality was assessed using GRADE methods.

MAIN RESULTS

Seven RCTs with 793 women were included in this review. Three trials compared UAE with abdominal hysterectomy, two trials compared UAE with myomectomy, and two trials compared UAE with either type of surgery (53 hysterectomies and 62 myomectomies).With regard to patient satisfaction rates, our findings were consistent with satisfaction rates being up to 41% lower or up to 48% higher with UAE compared to surgery within 24 months of having the procedure (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.59 to 1.48, 6 trials, 640 women, I(2) = 5%, moderate quality evidence). Findings were also inconclusive at five years of follow-up (OR 0.90; 95% CI 0.45 to 1.80, 2 trials, 295 women, I(2) = 0%, moderate quality evidence). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy, but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution (live birth: OR 0.26; 95% CI 0.08 to 0.84; pregnancy: OR 0.29; 95% CI 0.10 to 0.85, 1 study, 66 women).Similarly, for several safety outcomes our findings showed evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups. This applied to intra-procedural complications (OR 0.91; 95% CI 0.42 to 1.97, 4 trials, 452 women, I(2) = 40%, low quality evidence), major complications within one year (OR 0.65; 95% CI 0.33 to 1.26, 5 trials, 611 women, I(2) = 4%, moderate quality evidence) and major complications within five years (OR 0.56; CI 0.27 to 1.18, 2 trials, 268 women). However, the rate of minor complications within one year was higher in the UAE group (OR 1.99; CI 1.41 to 2.81, 6 trials, 735 women, I(2) = 0%, moderate quality evidence) and two trials found a higher minor complication rate in the UAE group at up to five years (OR 2.93; CI 1.73 to 4.93, 2 trials, 268 women).UAE was associated with a higher rate of further surgical interventions (re-interventions within 2 years: OR 3.72; 95% CI 2.28 to 6.04, 6 trials, 732 women, I(2) = 45%, moderate quality evidence; within 5 years: OR 5.79; 95% CI 2.65 to 12.65, 2 trials, 289 women, I(2) = 65%). If we assumed that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE.The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery (OR 0.07; 95% CI 0.01 to 0.52, 2 trials, 277 women, I(2) = 0%). UAE was also associated with a shorter procedural time (two studies), shorter length of hospital stay (seven studies) and faster resumption of usual activities (six studies) in all studies that measured these outcomes; however, most of these data could not be pooled due to heterogeneity between the studies.The quality of the evidence varied, and was very low for live birth, moderate for satisfaction ratings, and moderate for most safety outcomes. The main limitations in the evidence were serious imprecision due to wide confidence intervals, failure to clearly report methods, and lack of blinding for subjective outcomes.

AUTHORS' CONCLUSIONS

When we compared patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) our findings are that there is no evidence of a difference between the interventions. Findings at five year follow-up were similarly inconclusive. There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE, but this information was only available from a selected subgroup in one small trial.We found no clear evidence of a difference between UAE and surgery in the risk of major complications, but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. If we assume that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE. This increase in the surgical re-intervention rate may balance out any initial cost advantage of UAE. Thus although UAE is a safe, minimally invasive alternative to surgery, patient selection and counselling are paramount due to the much higher risk of requiring further surgical intervention.

MRI predictors of clinical success in MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids: results from a single centre

OBJECTIVES

To assess the technical and clinical results of MRgFUS treatment and factors affecting clinical treatment success.

MATERIALS AND METHODS

A total of 252 women (mean age, 42.1 ± 6.9 years) with uterine fibroids underwent MRgFUS. All patients underwent MRI before treatment. Results were evaluated with respect to post-treatment nonperfused volume (NPV), symptom severity score (SSS), reintervention rate, pregnancy and safety data.

RESULTS

NPV ratio was significantly higher in fibroids characterized by low signal intensity in contrast-enhanced T1-weighted fat saturated MR images and in fibroids distant from the spine (>3 cm). NPV ratio was lower in fibroids with septations, with subserosal component and in skin-distant fibroids (p < 0.001). NPV ratio was highly correlated with clinical success: NPV of more than 80 % resulted in clinical success in more than 80 % of patients. Reintervention rate was 12.7 % (mean follow-up time, 19.4 ± 8 months; range, 3-38). Expulsion of fibroids (21 %) was significantly correlated with a high clinical success rate. No severe adverse events were reported.

CONCLUSIONS

Adequate patient selection and correct treatment techniques, based on the learning curve of this technology, combined with technical advances of the system, lead to higher clinical success rates with low complications rate, comparable to other uterine-sparing treatment options.

KEY POINTS

• MRgFUS appears to be a valid alternative to other uterus-preserving therapies • Patient selection is a significant factor in achieving high NPV ratios • MRI screening parameters correlate with the amount of fibroid ablation in MRgFUS • NPV results of more than 80 % correlate with higher clinical success rates.

Current evidence on uterine embolization for fibroids

Strong evidence for both safety and effectiveness of uterine fibroid embolization has been generated since the procedure's introduction. This review will focus on the key articles representing the best evidence to summarize the outcomes from uterine embolization. This review will attempt to answer three important questions associated with uterine embolization. First, does uterine embolization relieve symptoms caused by uterine fibroids? Second, how well does the improvement in symptoms and quality of life after uterine embolization compare with standard surgical options for fibroids? Finally, how durable is the improvement in fibroid-related symptoms and quality of life after embolization?

Complications and reinterventions in uterine artery embolization for symptomatic uterine fibroids: a literature review and meta analysis

PURPOSE

To perform a literature review of the spectrum of complications associated with UAE relative to surgery and compare the risk of reintervention as well as minor, major, and overall complications.

MATERIALS AND METHODS

Literature review was conducted in PubMed, MEDLINE, Cochrane, and CINAHL databases, and meta-analysis was performed.

RESULTS

In randomized clinical trials, common complications were discharge and fever (4.00 %), bilateral uterine artery embolization (UAE) failure (4.00 %), and postembolization syndrome (2.86 %). Two trials showed a significantly decreased risk in major complications with UAE, with odds ratios (ORs) of 0.07143 (0.009426-0.5413) and 0.5196 (0.279-0.9678). None of the trials showed a significant difference in OR for minor complications of UAE. None of the trials showed a significant difference in risk for overall complications of UAE. Three trials showed a significantly increased risk for reintervention with UAE with ORs of 10.45 (2.654-41.14), 2.679 (1.289-5.564), and 9.096 (1.269-65.18). In 76 nonrandomized studies, common complications were amenorrhea (4.26 %), pain (3.59 %), and discharge and fever (3.37 %). In 41 case studies, common complications were discharge and fever (n = 22 cases), repeat UAE (n = 6 cases), and fibroid expulsion (n = 5 cases).

CONCLUSION

Overall, UAE has a significantly lower rate of major complications relative to surgery, but it comes at the cost of increased risk of reintervention in the future. Educating patients about the rate and types of complications of UAE versus surgery, as well as the potential for reintervention, should help the patient and clinician come to a reasoned decision.