Uterine artery embolization for the treatment of uterine leiomyomata midterm results

Preoperative MRI Classification May Not Predict Symptom Relief after Uterine Artery Embolization in Patients with Adenomyosis

OBJECTIVE

To investigate the association between magnetic resonance imaging (MRI) classification and symptom relief after uterine artery embolization (UAE) in patients with adenomyosis.

METHODS

Totally, 73 patients with symptomatic adenomyosis who underwent UAE were retrospectively analyzed. Preoperative MRI classification was defined as: type I, high signal on both T2-weighted images (T2WI) and T1-weighted images (T1WI); type III, high signal only on T2WI, and type II, high signal on neither T1WI nor T2WI. Dysmenorrhea was measured with the visual-analog scales and the degree of menorrhagia was measured according to the number of sanitary pads used in one menstrual cycle. Dysmenorrhea and menorrhagia were measured before UAE and 12 months after UAE.

RESULTS

The number of the type I, II, III cases was 23, 37, and 13, respectively. The baseline characteristics of the three groups exhibited no significant difference. The alleviation rates of dysmenorrhea among type I, II, III cases were 73.9%, 89.2%, and 84.6%, respectively (P=0.455). The alleviation rates of menorrhagia for type I, II, III were 69.6%, 78.4%, and 92.3%, respectively (P=0.714).

CONCLUSION

Pre-procedure MRI classification and symptom relief after UAE exhibited no significant association. UAE has a favorable mid-term control on dysmenorrhea and menorrhagia among patients with adenomyosis. Preoperative MRI classification might not indicate symptom relief. More research is needed before changing clinical practice.

Uterine Artery Embolization of Uterine Leiomyomas: Predictive MRI Features of Volumetric Response

OBJECTIVE. The purpose of this article was to evaluate MRI features of uterine leiomyomas that predict volumetric response after uterine artery embolization (UAE). MATERIALS AND METHODS. This retrospective study included 75 patients with 212 uterine leiomyomas who were successfully treated between August 2013 and December 2018. To predict uterine volumetric response, age, number of lesions, and baseline uterine volume were assessed. To predict leiomyoma volumetric response, a multivariate regression analysis was performed to evaluate six predictive factors: location, baseline leiomyoma volume, signal intensity on T1-weighted and T2-weighted MRI, heterogeneity of signal intensity on T2-weighted MRI, and vascularity on subtraction imaging (SI). A five-variable predictive ROC model was developed to evaluate the diagnostic accuracy of the signal intensity ratio on T2-weighted MRI, enhancement ratio, heterogeneity ratio on T2-weighted MRI, location, and baseline leiomyoma volume in predicting at least 40% leiomyoma volumetric response. RESULTS. Age, number of leiomyomas, and baseline uterine volume were not predictive of uterine volumetric response. A submucosal location was the best predictive factor of leiomyoma volumetric response, and it showed 32.2% more leiomyoma volumetric response compared with a nonsubmucosal location (p < .001). Hyperintensity on T2-weighted MRI was the second best predictive factor of leiomyoma volumetric response, and it showed 16.9% more volumetric response compared with hypointense leiomyomas (p = .013). A small baseline leiomyoma volume (< 58 cm³) was associated with 10.2% more leiomyoma volumetric response compared with larger leiomyomas (p = .01). Leiomyomas that were hyperintense on SI showed 7.9% more leiomyoma volumetric response compared with those that were hypointense (p = .014). The five-variable ROC model showed high diagnostic accuracy with an AUC of 0.85, sensitivity of 82%, and specificity of 71%. CONCLUSION. A submucosal location, hyperintensity on T2-weighted MRI, small baseline leiomyoma volume (< 58 cm³), and hyperintense leiomyoma on subtraction imaging are the main independent favorable predictors of leiomyoma volumetric response after UAE. An accurate predictive ROC model was developed that may help in selecting patients suitable for UAE. Quantitative assessment of heterogeneity on T2-weighted MRI showed promising results as a predictor of volumetric response, and further research in this area using texture analysis and radiomics is suggested.

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.

Endovascular treatment of uterine myomatosis: a systematic review

Uterine Artery Embolization (UAE) is a noninvasive alternative to open surgery for treatment of uterine myomatosis. This study aims to analyze the efficacy and safety of UAE in these cases. A systematic review was carried out of studies available on the Medline (via PubMed) and the LILACS and PEDro (via the Biblioteca Virtual em Saúde) databases. The searches found 817 studies, 7 of which were selected according to the eligibility criteria (analytical, longitudinal, retrospective, or prospective studies), with a total of 367 patients studied. The variables analyzed and the characteristics of the studies included were collated and input to a database. Rates of volume reduction of the uterus and the dominant myoma were 44.1% and 56.3%, respectively. Mean rate of complete infarction of the dominant myoma was 88.6% (82-100%). The mean number of complications observed was 15±8.6 cases, most of which were classified as minor, and no deaths were recorded. The mean number of re-interventions in absolute values was 12.2±15.5 cases. Therefore, in the literature analyzed, uterine artery embolization is an effective procedure with a low rate of complications for treatment of uterine leiomyomatosis.

Shearwave elastographic evaluation of uterine leiomyomas after uterine artery embolization: preliminary results

Background/aim

We aimed to investigate the role of Shearwave Elastography (SWE) in the evaluation of response to uterine artery embolization (UAE) in patients with uterine leiomyomas.

Materials and methods

SWE images of the dominant uterin leiomyomas were obtained before and 1.5 months after performing UAE in 33 women suffering from symptoms due to leiomyomas (menometrorrhagia, bulk related symptoms, pelvic pain). Leiomyomas were also evaluated by 2 observers for location and longest diameter in axial plane. Interobserver agreement in the quantitative SWE analysis was calculated using intraclass correlation coefficients.

Results

Thirty-three women (mean age, 39.7 years; range, 31–48 years) were examined with SWE 1.5 months after UAE. After treatment, 3 patients (9.1%) had fever, 1 patient had nausea and 29 patients (87.9%) had no complications. The post UAE stiffness measurements of leiomyomas (mean SWE ± SD = 13.34 ± 3.9kPa) were significantly lower than the pre UAE measurements (mean SWE ± SD = 17.16 ± 4.8kPa) (P < 0.001). There was excellent agreement between the 2 blinded observers in SWE measurements.

Conclusion

SWE values of leiomyomas after UAE significantly decreased. SWE, with its high reproducibility, could become a useful tool in the follow up of uterin leiomyomas after UAE.

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

BACKGROUND

Evidence supporting uterine artery embolisation (UAE) for giant fibroids (≥ 10 cm and/or uterine volume ≥ 700 CC) remains sparse. We performed a systemic review and meta-analysis of UAE outcomes for symptomatic giant versus non-giant fibroids.

METHODS

The literature was systematically reviewed. Research studies of UAE as an adjunct to surgery, and those not using peri-operative MRI were excluded. Primary outcomes were fibroid size and uterine volume reduction, procedure time, length of hospital stay, reinterventions, patient symptom improvement/satisfaction and complications.

RESULTS

We identified four observational studies (839 patients; giant = 163, non-giant = 676). Both groups demonstrated reduction in fibroid size and uterine volume after UAE, with equivocal difference in uterine volume reduction (Mean difference (MD) - 0.3 95% confidence interval (CI) - 3.8 to 3.1, p = 0.86) and greater reduction in non-giant dominant fibroid size (MD - 5.9 95% CI - 10.3 to - 1.5, p < 0.01). Giant fibroids were associated with 5.6 min longer mean operative time (MD 5.6 min 95% CI 2.6-8.6, p < 0.01) and 4.8 h longer mean hospital stay (MD 4.8 h 95% CI 1.1-8.6, p = 0.01). Patient symptoms/satisfaction outcomes were summarised, but too heterogeneous for meta-analysis. Major complication and reintervention rates were low, with a statistically higher rate of major complications (Odds ratio (OR) 4.7 95% CI 1.5-14.6, p < 0.01) and reinterventions (OR 3.6 95% CI 1.7-7.5, p < 0.01) in giant fibroids.

CONCLUSIONS

Current evidence shows UAE is a safe and effective option to treat giant fibroids. However, the limited available data indicate a relatively higher risk of complications and reinterventions when compared with non-giant fibroids. Patients should be selected, counselled and managed accordingly.

LEVEL OF EVIDENCE

Level III, Systematic review of retrospective cohort studies.

Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature

Females with symptomatic leiomyomas (fibroids) wishing to maintain fertility are faced with difficult treatment choices. These include uterine fibroid embolization (UFE), myomectomy, hormonal therapy, MRI high intensity focused ultrasound, and myolysis. This review focuses on UFE, one of the most commonly accepted minimally invasive procedural choices among patients with symptomatic fibroids wishing to retain the option of becoming pregnant in the future, and makes comparisons to myomectomy which has historically been the surgical choice for fertility-preserving fibroid treatment. Pubmed and Google Scholar searches using keywords such as: uterine artery embolization, uterine fibroid embolization, pregnancy, complications, infertility were performed between Jan 1, 2019 and May 10, 2019. Publications were chosen based on their inclusion of information pertaining to fertility or pregnancy after UFE without being limited to single case reports.Randomized controlled trials comparing myomectomy and UFE are limited due to study size and confounding variables, but through registry data and familiarity with referring clinicians, UFE has gained wide acceptance. Healthy pregnancies following UFE have been sporadically reported but the actual fertility rate after UFE remains uncertain. Conversely, low birth weight, miscarriage and prematurity have been associated with UFE. Despite inherent risks of possible fertility issues after UFE, the procedure remains an option for females with clinically symptomatic fibroids who desire pregnancy. However, additional research regarding rates of conception and obstetrical risks of infertility following UFE is necessary.

Uterine anteversion after uterine fibroid embolization

Uterine fibroid embolization has been proven effective in treating symptomatic uterine fibroids for appropriately selected patients as an alternative option to surgical approaches. The most common adult uterine position is anteverted followed by a retroverted uterus which can be found in roughly 15%-20% of normal adult females. The positioning of the uterus can change from anteversion to retroversion due to the filling of bladder or during pregnancy; however, changing from retroverted to anteverted position without prior pregnancy or endometriosis is rather uncommon. Here, we describe a case of uterine orientation change from retroversion to anteversion presenting 6 months after uterine fibroid embolization.

Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial

Background

Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking.

Objective

With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis.

Methods

This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)–confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE.

Results

Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started.

Conclusions

This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients’ wellbeing and quality of life.

Trial Registration

Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)

Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center

OBJECTIVE

To evaluate effectiveness and safety of UFE as alternative to surgery, in treatment of uterine fibromatosis.

METHODS/MATERIALS

255 patients (aged 26-55) with symptomatic UF, indication for surgery, followed in our center (2000-2014), single or multiple fibroids, pain and/or functional/compressive disorders, underwent embolization: injection of PVA particles (150-900 μm) from distal portion of uterine arteries (ascending section). Primary end-point: flow-stop distally to injection site, disappearance of lesion design, preservation of flow in main trunk of UA. Secondary end-point: control of pain and functional/compressive disorders during follow-up (2-7 years).

RESULTS

Procedure was performed bilaterally in 250 patients (98%). Mean duration: 47 min (average fluoroscopy: 10:50 min). Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h). Follow-up at 2 years: resolution of menstrual disorders in 78% of patients and improvement in 14%; pain disappeared in 66%; significant improvement of menstrual flow and HCT/HB levels, decrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. Recurrence in 18 patients.

CONCLUSIONS

UFE represents an excellent alternative to surgical treatment: it is safe, tolerable and effective both in short and long term, with evident advantages in economic and social terms.

The management of peri- and postprocedural pain in interventional radiology: a narrative review

Interventional radiology encompasses a wide range of procedures and the degree of associated pain depends predominantly on the procedure being undertaken. Procedures may be painful during but not after the procedure, relatively painless during but painful after the procedure, or relatively painless during and after the procedure. However, there is a lack of good quality publications in interventional radiology that specifically address the subject of peri- and postprocedural pain management. Nevertheless, a variety of more or less complex protocols exist for intraprocedural sedation and for peri- and postprocedural analgesia. While weight-based protocols for procedural sedation have demonstrable benefit, protocols for postprocedural pain relief after major procedures have not been sufficiently rigorously evaluated.

Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis

The effect of uterine artery embolization (UAE) on symptomatic adenomyosis was evaluated in a systematic review and meta-analysis. Four groups were evaluated: short-term (< 12 months) pure adenomyosis, short-term adenomyosis with fibroids (combined adenomyosis), long-term (> 12 months) pure adenomyosis, and long-term combined adenomyosis. Improvement of symptoms occurred in 83.1% (872/1,049) of patients. Reported symptom reduction was 4.8% greater in the short-term combined group (P = .169) and 11.4% greater in the long-term combined group (P = .003). Uterine volume was reduced in all patients at 3 months. The effects of UAE on symptom improvement and uterine volume reduction in patients with adenomyosis are encouraging.

Monitoring Leiomyoma Response to Uterine Artery Embolization Using Diffusion and Perfusion Indices from Diffusion-Weighted Imaging

Purpose

To investigate the potential of diffusion and perfusion indices (ADC and perfusion fraction f) from DWI at 3.0 T in monitoring treatment response to uterine artery embolization (UAE) at 6-month follow-up.

Methods

Twelve female patients with uterine fibroids who underwent 3.0-T pelvic DWI before and 6 months after UAE were included. ADC and perfusion fraction f were calculated from DWI. The Wilcoxon signed-rank test and Spearman rank correlation test were used for statistics.

Results

Seventeen fibroids were studied. The median ADCs showed a significant increase from 1.20 × 10⁻³ mm²/s (range, 0.86–1.66 × 10⁻³ mm²/s) at baseline to 1.56 × 10⁻³ mm²/s (range, 1.00–1.86 × 10⁻³ mm²/s) at 6-month follow-up (P = 0.0003). Conversely, the median perfusion fraction f was significantly decreased after UAE (P = 0.0001), with a median pre-UAE value of 14.2% (range, 6.7%–17.6%) and a median post-UAE value of 9.2% (range, 3.2%–14.6%). Significant correlations were found between fibroid volume reduction rate and percentage changes in ADC and perfusion fraction f at 6-month follow-up relative to baseline, with ρ values of −0.50 (P = 0.04) and 0.55 (P = 0.02), respectively.

Conclusion

ADC and perfusion fraction f obtained from DWI at 3.0 T may help to evaluate treatment response to UAE.

First Versus Second Uterine Artery Embolization for Symptomatic Leiomyoma

OBJECTIVE

The purpose of this study was to compare the outcomes of second uterine artery embolization (UAE) with those of first UAE for symptomatic uterine leiomyoma.

MATERIALS AND METHODS

In this single-institution retrospective study, between December 1997 and May 2016 first UAE was performed on 423 consecutively registered patients and second UAE on 11 consecutively registered patients to treat leiomyoma. The primary endpoint was infarction of all tumor tissue as seen at postprocedural contrast-enhanced MRI. The secondary endpoints were angiographic findings, embolization, MRI, and clinical outcomes 1 year after UAE. The outcomes were compared between the two groups. Multivariable linear regression analysis was performed to assess independent correlations with tumor infarction.

RESULTS

Most of the baseline demographic features and technical outcomes in the two groups were similar. In the second UAE group, all but one uterine artery was reopened. More collateral vessels were observed at the second UAE (1.1/patient versus 0.23/patient, p = 0.043). Contrast-enhanced MRI after UAE revealed that the tumor infarction rate was significantly lower in the second UAE group (69.8 ± 33.9% vs 96.8 ± 9.0%, p = 0.025). The difference remained significant after adjustments for possible confounders (p < 0.001). Whether UAE was a first or a second procedure was significantly associated with tumor infarction rate (p < 0.001). The uterine volume reduction rate 1 year after UAE was significantly lower in the second UAE group (33.4 ± 18.1% versus 46.9 ± 16.6%, p = 0.008). No other 1-year outcomes were significantly different between the groups.

CONCLUSION

Second UAE was effective but inferior to first UAE in that it resulted in less tumor infarction at contrast-enhanced MRI and had a lower uterine volume reduction rate.

Uterine-Sparing Laparoscopic Pelvic Plexus Ablation, Uterine Artery Occlusion, and Partial Adenomyomectomy for Adenomyosis

STUDY OBJECTIVE

To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis.

DESIGN

A prospective controlled study (Canadian Task Force classification II-1).

SETTING

A teaching hospital.

PATIENTS

A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy.

INTERVENTIONS

Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy.

MEASUREMENTS AND MAIN RESULTS

After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group.

CONCLUSION

Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea.

Prise en charge des fibromes utérins en présence d'une infertilité autrement inexpliquée

OBJECTIF

Formuler des recommandations quant à la façon optimale d'assurer la prise en charge des fibromes dans le contexte de l'infertilité. Les options habituelles et novatrices de prise en charge des fibromes seront analysées en mettant l'accent sur leur applicabilité chez les femmes qui souhaitent obtenir une grossesse.

OPTIONS

La prise en charge des fibromes chez les femmes qui souhaitent obtenir une grossesse met d'abord en jeu la documentation de la présence des fibromes en question et la détermination de la probabilité que ces derniers affectent le potentiel génésique. Dans un tel contexte, la prise en charge des fibromes s'effectue principalement de façon chirurgicale; toutefois, il faut s'assurer au préalable de mettre en balance les avantages factuels de l'approche chirurgicale en matière d'amélioration des issues cliniques et les risques propres à une telle approche.

ISSUES

L'amélioration des taux et des issues de grossesse que permet la prise en charge des fibromes chez les femmes aux prises avec l'infertilité constitue l'issue principale sur laquelle nous nous sommes attardés. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed, CINAHL et Cochrane Systematic Reviews en novembre 2013 au moyen d'un vocabulaire contrôlé (p. ex. « leiomyoma », « infertility », « uterine artery embolization », « fertilization in vitro ») et de mots clés (p. ex. « fibroid », « myomectomy ») appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais et français. Aucune restriction n'a été appliquée en matière de date. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en novembre 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau). AVANTAGES, DéSAVANTAGES ET COûTS: Les présentes recommandations devraient permettre la prise en charge adéquate des femmes qui présentent des fibromes et qui sont aux prises avec l'infertilité, et ce, par la maximisation de leurs chances de grossesse grâce à la minimisation des risques mis en cause par la tenue de myomectomies inutiles. L'atténuation des complications et l'élimination des interventions inutiles devraient également mener à une baisse des coûts pour le système de santé. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

The effects of uterine artery embolization on ovarian reserve

OBJECTIVE

To evaluate the effects of UAE for symptomatic uterine fibroids on ovarian reserve based on AMH.

STUDY DESIGN

This was a retrospective study conducted between March 2011 and October 2014. All women underwent UAE. At baseline and at the 3-month and 12-month follow-up visits, serum anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels were assessed, and ovarian volume and antral follicle count (AFC) were evaluated in each patient.

RESULTS

There were no statistically significant differences in serum E2, LH, or FSH levels or in ovarian volume 3 or 12 months after UAE (P=0.8194, P=0.3976, P=0.4766, and P=0.6822, respectively). However, AMH and AFC were significantly different 3 and 12 months after the procedure (P=0.00, P=0.029 and P=0.00, P=0.00, respectively). AMH levels remained low after 12 months of follow-up compared to the expected AMH levels. A statistically significant recovery of serum AMH at 12 months compared to at 3 months in those <40 years of age (P=0.00), but not in those ≥40 years (P=0.837).

CONCLUSIONS

Ovarian reserve appears to be affected by UAE in premenopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Uterine Artery Embolization for Symptomatic Myomata

Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.

Uncommon Complication of Uterine Artery Embolization: Expulsion of Infarcted Myoma and Uterine Sepsis

Uterine leiomyomas are the most common benign tumors in young females and leading cause of hysterectomy. Uterine artery embolization is a safe option for women who wish to retain their uterus. Several complications have been reported including expulsion and sepsis. MRI is a useful pretreatment tool to predict results and outcomes. We report a case of a 44-year-old female with a history of uterine fibroids with the largest one being intracavitary. Patient underwent uterine artery embolization that was complicated by endomyometritis that failed antibiotics, leading to sepsis and hysterectomy.

Uterine artery embolisation for uterine fibroids: Our experience at a tertiary care service hospital

BACKGROUND

Uterine artery embolisation (UAE) has evolved as a minimally invasive and effective alternative, treatment modality for women with symptomatic fibroids. We discuss our initial experience of UAE in the management of symptomatic fibroids.

METHODS

Twenty five symptomatic patients of uterine fibroids were treated with UAE by selectively cannulating and injecting poly vinyl alcohol particles into the uterine arteries. Post treatment follow up was done at 2 and 6 months respectively.

RESULTS

Pre-treatment, the sizes of fibroids were between 3.9 and 10.9 cm (mean 7.4) on ultrasonography. Of the total 25 patients, 49 uterine arteries were embolised with a technical success rate of 98%. Menorrhagia persisted in 7 patients, dysmenorrhea in 4 patients and pressure symptoms in 2 patients respectively in follow up study of six months which corresponds to a reduction in symptoms by 68% for menorrhagia, 71% for dysmenorhoea and 75% for those with pressure symptoms respectively. At 2 months follow-up post embolisation, the mean diameter of the fibroid was 4.03 cm (range 2-5.2 cm) and at 6 months 3.2 cm (range 1.3-4.1 cm), corresponding to size reduction of 45.5% and 57%, respectively. Follow up with ultrasonography at 2 and 6 months period showed successful fibroid reduction in 24 patients with corresponding reduction in the symptomatology. One patient remained symptomatic with increase in fibroid size and had to undergo hysterectomy.

CONCLUSION

Uterine artery embolisation can be considered as an alternative to hysterectomy in appropriately selected symptomatic patients of uterine fibroids.

Potential mechanisms of an antiadenomyosis chinese herbal formula shaoyao-gancao decoction in primary cell culture model

Background. Shaoyao-Gancao Decoction (SGD), a well-known traditional Chinese medicine prescription, has been widely used to treat adenomyosis, dysmenorrhea, abdominal pain, and inflammation in Asia. However, the mechanism underlying the effectiveness of SGD in the treatment of adenomyosis still remains elusive. The present study aimed to investigate the bioactivity of SGD and its underlying molecular mechanisms using cultured human adenomyosis-derived cells. Methods. Human adenomyosis-derived cells were treated with SGD and its major constituents (paeoniflorin and liquiritin) in vitro. Effects of SGD, paeoniflorin, and liquiritin on cell proliferation and apoptosis were examined by MTT assay and flow cytometry analyses. The effects of SGD, paeoniflorin, and liquiritin on the production of PGE₂ and PGF_2α were assayed using ELISA. ER-α and OTR mRNA expression levels were also evaluated by real-time qRT-PCR. Results. SGD, paeoniflorin, and liquiritin inhibited proliferation and induced apoptosis of human adenomyosis-derived cells in a dose-dependent manner. SGD and paeoniflorin significantly reduced the PGE₂ and PGF_2α production. Furthermore, they remarkably decreased the mRNA levels of ER-α and OTR. Conclusions. The results of this study provide possible mechanisms for the bioactivity of SGD for treating adenomyosis and contribute to the ethnopharmacological knowledge about this prescription.

Incidence and risk factors for clinical failure of uterine leiomyoma embolization

OBJECTIVE

To estimate the incidence of clinical failure after uterine leiomyoma embolization and identify possible risk factors.

METHODS

One hundred seventy-six consecutive women undergoing uterine leiomyoma embolization were followed prospectively for a median of 48 months (range 12-84 months) to estimate the occurrence of clinical failure, defined as persistence or recurrence of leiomyoma symptoms, and any subsequent invasive treatment. Cumulative failure and reintervention rates were estimated by survival analysis and log-rank tests according to baseline patient characteristics. Multivariable Cox proportional hazards analysis was performed to adjust for confounders.

RESULTS

Overall, there were 18 failures at a median of 36 months (range 3-84 months). The cumulative failure rate increased steadily over time, 3% at 1 year, 7% at 3 years, 14% at 5 years, and 18% at 7 years. Of the 18 failures, 11 had reintervention, including six hysterectomies, four myomectomies, and one repeat uterine leiomyoma embolization, at a median of 56 months (range 15-84 months). The cumulative reintervention rate was 0 at 1 year, 3% at 3 years, 7% at 5 years, and 15% at 7 years. Women aged 40 years or younger had a higher failure risk (hazard ratio [HR] 5.89, 95% confidence interval [CI] 2.50-20.02, P=.023) compared with older women. A history of previous myomectomy was also associated with an increased failure risk (HR 3.79, 95% CI 2.07-13.23, P=.037).

CONCLUSION

The 7-year cumulative rates of clinical failure and reintervention after uterine leiomyoma embolization were 18% (95% CI 8.2-27.8) and 15% (95% CI 5.2-24.8), respectively. The failure risk was higher for younger patients and for those with a prior myomectomy.

LEVEL OF EVIDENCE

III.

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?

Clinical and periprocedural pain management for uterine artery embolization

Uterine artery embolization has Level A data supporting excellent safety and efficacy in treating symptomatic uterine leiomyomata. However, there is a perception that either postprocedural pain is severe or poorly managed by the physician performing these procedures. This has led some primary care physicians to omit this procedure from the patients' options or to steer patients away from this procedure. A few simple techniques (pruning of the vascular tree and embolizing to 5-10 beat stasis) and fastidious pre-, intra-, and post-procedural management can nearly eliminate significant pain associated with embolization. Specifically, early implementation of long-acting low-dose narcotics, antiemetics and anti-inflammatory medications is critical. Finally, the use of a superior hypogastric nerve block, which takes minutes to perform and carries a very low risk, significantly reduces pain and diminishes the need for narcotics; when this technique was used in a prospective study, all patients were able to be discharged the day of the procedure. In the authors' experience, patients treated in this manner largely recover completely within 5 days and have a far less traumatic experience than patients traditionally treated with only midazolam (Versed) and fentanyl citrate (fentanyl) intraprocedurally, and narcotics and nonsteroidal antiinflammatory drugs postprocedurally.

Uterine artery embolization: pre- and post-procedural evaluation using magnetic resonance imaging

Magnetic resonance (MR) imaging has become the preferred method in assessing the uterus and pelvis prior to and following uterine artery embolization (UAE). The multiplanar imaging capabilities, increased spatial and contrast resolution, anatomic detail and assessment of fibroid viability that MR provides over ultrasound allows for accurate pre-treatment planning and post-treatment assessment. The purpose of this article is to demonstrate the use of MR in the selection of patients, anatomic evaluation and procedural planning before UAE, describe the use of MR in evaluating treatment response after UAE and illustrate the use of MR in identifying post-UAE complications. An understanding of these principles is essential in guiding appropriate therapy, determining treatment effectiveness and identifying associated complications before and after UAE.

Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma

OBJECTIVE

Minimally invasive methods are used as alternatives to treat leiomyomas and include uterine artery embolization, which has emerged as a safe, effective method. This study aims to evaluate the magnetic resonance imaging predictors for a reduction in leiomyoma volume in patients undergoing uterine artery embolization.

METHODS

This prospective longitudinal study was performed at a university hospital. We followed 50 symptomatic premenopausal women with uterine leiomyomas who underwent uterine artery embolization. We examined 179 leiomyomas among these patients. Magnetic resonance imaging was performed one month before and six months after uterine artery embolization. Two radiologists who specialized in abdominal imaging independently interpreted the images.

MAIN OUTCOME MEASURES

The magnetic resonance imaging parameters were the uterus and leiomyomas volumes, their localizations, contrast perfusion pattern and node-to-muscle ratio.

RESULTS

Six months after treatment, the average uterine volume reduction was 38.91%, and the leiomyomas were reduced by 55.23%. When the leiomyomas were submucosal and/or had a higher node-to-muscle ratio in the T2 images, the volume reduction was even greater (greater than 50%). Other parameters showed no association.

CONCLUSIONS

We conclude that symptomatic uterine leiomyomas in patients undergoing uterine artery embolization exhibit volume reductions greater than 50% by magnetic resonance imaging when the leiomyomas are submucosal and/or had a high node-to-muscle ratio in the T2 images.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.

Degeneration of leiomyoma in patients referred for uterine fibroid embolization: incidence, imaging features and clinical characteristics

PURPOSE

Imaging features and clinical characteristics of degenerated leiomyoma in patients referred for uterine fibroid embolization (UFE) were analyzed to assess the incidence of degenerated leiomyoma.

MATERIALS AND METHODS

Patients referred for UFE between 2008 and 2009 were retrospectively analyzed (n=276). Patients ranged in age from 27 to 51 years (mean 38.0 years). All patients underwent screening MRI with contrast enhancement. Medical histories and clinical symptoms were evaluated.

RESULTS

Among the 276 patients who underwent MRI, 14 (5.1%) showed degenerated leiomyomas. Symptoms were abdominal pain (n=4, 26.7%), menorrhagia (n=5, 35.7%) and bulk-related symptoms (n=5, 35.7%) and no symptoms (n=5, 35.7%). Of the 14 patients with degenerated leiomyomas, 5 (42.9%) had a history of pregnancy in the past two years. For T1-weighted imaging (T1WI), a high signal intensity (SI) of the leiomyoma was the most common finding (n=9, 64.3%) and a hyperintense rim (n=4, 28.6%) was the second most common. On T2-weighted imaging (T2WI), a low SI of the leiomyoma was found in six patients (42.9%), a high SI in four (28.6%) and a heterogeneous SI in four (28.6%) patients. Conservative management was performed in 11 (78.6%) patients, surgery in 3 (21.4%) and uterine artery embolization in one (7.1%) patient.

CONCLUSION

The incidence of degeneration of leiomyoma in patients referred for UFE was 5.1%. Patients presented with variable clinical symptoms with or without a history of pregnancy. MR imaging showed a high SI on T1WI and various SIs on T2WI without contrast enhancement. An understanding of the degeneration of leiomyomata is essential when considering UFE.