Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis

OBJECTIVE

To summarize the evidence on short-, mid-, and long-term results up to 5 years of uterine artery embolization in comparison to surgery.

STUDY DESIGN

We searched the CENTRAL, MEDLINE and EMBASE databases for randomized clinical trials comparing uterine artery embolization with hysterectomy/myomectomy in premenopausal women with heavy menstrual bleeding caused by symptomatic uterine fibroids, written from September 1995 to November 2010. Two reviewers independently assessed methodologic quality and extracted data from included trials.

RESULTS

Four randomized controlled trials with a total of 515 patients were included. On the short-term, uterine artery embolization showed fewer blood loss, shorter hospital stay, and quicker resumption of work. Mid- and long-term results showed comparable health-related quality of life results and a higher reintervention rate in the uterine artery embolization group, whereas both groups were equally satisfied.

CONCLUSION

Uterine artery embolization has short-term advantages over surgery. On the mid- and long-term the benefits were similar, except for a higher reintervention rate after uterine artery embolization.

Implementation of uterine artery embolisation for symptomatic uterine fibroids: an inventory

The validity of uterine artery embolisation (UAE ) as an alternative treatment for hysterectomy to treat symptomatic uterine fibroids has been well established. Despite its favourable outcomes, UAE is still only marginally applied in the Netherlands. The aim of this inventory is to identify factors which either restrict or facilitate the implementation of UAE. Gynaecologists and interventional-radiologists in three hospitals in Amsterdam were interviewed by means of questionnaires. One of these hospitals had ample experience in UAE for uterine fibroids, one hospital had just started providing this treatment, and one hospital did not perform UAE. Also patients with symptomatic fibroids who were scheduled for either UAE or hysterectomy were interviewed about the counselling for UAE. The following obstacles in the implementation of UAE were found: lack of knowledge about UAE , absence of a multidisciplinary protocol, and above all, the absence of UAE as one of the treatment options in the Dutch national guideline on the management of menorrhagia. 75% of all patients claimed to be well informed about UAE by their gynaecologist. Our recommendations for the implementation of UAE are: 1) adding UAE to the Dutch guideline for the management of menorrhagia with clearly defined indications and contraindications; 2) educating gynaecologists about UAE; 3) composing a patient information leaflet and a website, and 4) arranging a protocol in a multidisciplinary team.

[Uterine artery embolisation in the treatment of uterine fibroids: outcomes of randomised trials]

In the past so years, uterine artery embolisation has gained popularity in the treatment of uterine fibroids compared with traditional surgical interventions. This was based on promising results from a few non-randomised studies, which reported success rates of 95 to 98%. Were these rates accurate? Two recent randomised studies (the Dutch EMMY trial and the Scottish REST trial) showed that, in patients with symptomatic uterine fibroids, the time to recovery and return to work was significantly shorter after embolisation than after surgery (hysterectomy or myomectomy). However, embolisation was insufficiently effective in approximately 20% of patients, who required further treatment. Despite this, quality of life after one and two years in both treatment arms were identical. Embolisation, therefore, may be a valid treatment alternative in patients with symptomatic fibroids who are candidates for hysterectomy.

Sexuality and body image after uterine artery embolization and hysterectomy in the treatment of uterine fibroids: a randomized comparison

In this paper the effect of uterine artery embolization (UAE) on sexual functioning and body image is investigated in a randomized comparison to hysterectomy for symptomatic uterine fibroids. The EMbolization versus hysterectoMY (EMMY) trial is a randomized controlled study, conducted at 28 Dutch hospitals. Patients were allocated hysterectomy (n = 89) or UAE (n = 88). Two validated questionnaires (the Sexual Activity Questionnaire [SAQ] and the Body Image Scale [BIS]) were completed by all patients at baseline, 6 weeks, and 6, 12, 18, and 24 months after treatment. Repeated measurements on SAQ scores revealed no differences between the groups. There was a trend toward improved sexual function in both groups at 2 years, although this failed to reach statistical significance except for the dimensions discomfort and habit in the UAE arm. Overall quality of sexual life deteriorated in a minority of cases at all time points, with no significant differences between the groups (at 24 months: UAE, 29.3%, versus hysterectomy, 23.5%; p = 0.32). At 24 months the BIS score had improved in both groups compared to baseline, but the change was only significant in the UAE group (p = 0.009). In conclusion, at 24 months no differences in sexuality and body image were observed between the UAE and the hysterectomy group. On average, both after UAE and hysterectomy sexual functioning and body image scores improved, but significantly so only after UAE.

Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy

BACKGROUND

Ovarian failure as a complication of uterine artery embolization (UAE) for symptomatic uterine fibroids has raised concerns about this new treatment modality.

METHODS

We investigated the occurrence of ovarian reserve reduction in a randomized trial comparing UAE and hysterectomy by measuring follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH). A total of 177 pre-menopausal women with menorrhagia due to uterine fibroids were included (UAE:n=88; hysterectomy:n=89). FSH and AMH were measured at baseline and at several time-points during the 24 months follow-up period. Follow-up AMH levels were also compared to the expected decrease due to ovarian ageing during the observational period.

RESULTS

FSH increased significantly compared to baseline in both groups after 24 months follow-up (within group analysis: UAE:+12.1; P=0.001; hysterectomy:+16.3; P<0.0001). No differences in FSH values between the groups were found (P=0.32). At 24 months after treatment the number of patients with FSH levels>40 IU/l was 14/80 in the UAE group and 17/73 in the hysterectomy group (relative risk=0.75; P=0.37). AMH was measured in 63 patients (UAE: n=30; hysterectomy: n=33). After treatment AMH levels remained significantly decreased during the entire follow-up period only in the UAE group compared to the expected AMH decrease due to ageing. No differences were observed between the groups.

CONCLUSIONS

This study shows that both UAE and hysterectomy affect ovarian reserve. This results in older women becoming menopausal after the intervention. Therefore, the application of UAE in women who still wish to conceive should only be considered after appropriate counselling.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial

OBJECTIVE

The purpose of this study was to compare the 2 years' efficiency of uterine artery embolization (UAE) with hysterectomy in the treatment of menorrhagia caused by uterine fibroids in a randomized controlled trial.

STUDY DESIGN

Twenty-eight Dutch hospitals recruited patients with uterine fibroids and menorrhagia, who were eligible for hysterectomy. Patients were randomized to UAE or hysterectomy. The primary endpoint was if UAE could avoid a subsequent hysterectomy in at least 75% of cases. Secondary endpoints were changes in pain, bulk-related complaints, and uterine and dominant fibroid volume reduction.

RESULTS

One hundred seventy-seven patients were randomized to UAE (n = 88) or hysterectomy (n = 89). Two years after treatment 23.5% of UAE patients had undergone a hysterectomy. There were no significant differences in improvement compared to baseline in pain and bulk-related complaints. Uterine and dominant fibroid volume reduction in UAE patients was 48.2% and 60.5%, respectively.

CONCLUSION

UAE is a valuable alternative treatment for symptomatic uterine fibroids. Nevertheless, when patients seek for certainty on the cessation of bleeding problems, a hysterectomy remains the treatment of choice.

Anti-Müllerian hormone levels in the spontaneous menstrual cycle do not show substantial fluctuation

CONTEXT

Anti-Müllerian hormone (AMH), a quantitative marker for ovarian reserve, has been suggested to be independent of the classical endocrine fluctuations of the menstrual cycle.

OBJECTIVE

The objective of the study was to determine whether AMH levels are constant throughout the menstrual cycle, compared with those of FSH, LH, and estradiol.

DESIGN/PATIENTS

Frequent blood sampling was performed in 44 fertile, regularly cycling, female volunteers during one full menstrual cycle.

SETTING

The study was conducted at a university hospital.

MAIN OUTCOME MEASURES

AMH, FSH, LH, and estradiol measurements were allocated to one of seven cycle phases, and a multilevel analysis was performed. Consistent fluctuation patterns were tested by fitting sine patterns to the data. Finally, the frequency in which randomly selected individual samples would remain in one of five preset level categories (quintiles) for each of the variables was studied.

RESULTS

A sine pattern fitted to the AMH data was not statistically significant (P = 0.40). In contrast, sine patterns for FSH, LH, and estradiol were highly significant. Comparing the seven cycle phases, no significant differences could be observed between phase-specific AMH levels (P = 0.06). Repeated selection of AMH samples for each individual showed that in 71.5% of selections, AMH values remained in the same quintile, whereas in 27.9% values fell in an adjacent quintile.

CONCLUSIONS

AMH levels measured through a full menstrual cycle did not show consistent fluctuation patterns in contrast to levels of FSH, LH, and estradiol. Furthermore, random fluctuations were small, indicating that AMH can be relied on as a cycle-independent marker for ovarian reserve.

Uterine Artery Embolization in the Treatment of Symptomatic Uterine Fibroid Tumors (EMMY Trial): Periprocedural Results and Complications

PURPOSE

Uterine artery embolization (UAE) is an emerging treatment for symptomatic uterine fibroid tumors. This study was performed to evaluate the periprocedural results of the UAE procedure and identify risk factors for technical failure, fever after UAE, pain, and other complications.

MATERIALS AND METHODS

As part of a multicenter, randomized trial to compare UAE versus hysterectomy in patients with symptomatic uterine fibroid tumors, 81 patients underwent UAE. Univariate and multivariate analyses were used to identify predictors for technical failure, postprocedural fever, complications as defined by the Society of Interventional Radiology (SIR), and pain scores.

RESULTS

The technical failure rate according to SIR guidelines was 5.3% (95% CI, 2.3%-10.1%). The procedural failure rate was 17.3% (95% CI, 9.8%-27.3%). Bilateral failure occurred in four of 81 patients and unilateral failure occurred in 10 of 81 patients. Technical failure occurred mainly as a result of difficult anatomy (3.7%) or absence of the uterine artery (3.1%). The overall complication rates were 28.4% during the patients' hospital stay and 60.5% for the 6 weeks after discharge. The risk of technical failure was found to increase in the presence of a single fibroid tumor (odds ratio [OR], 6.21; 95% CI, 1.65-23.41; P = .007) and/or a small uterine volume (<500 cm(3); OR, 10.8; 95% CI, 1.25-93.36; P = .03). The amount of embolization material was associated with the onset of fever after UAE (OR, 2.05; 95% CI, 1.09-3.87; P = .027), major complications (OR, 5.68; 95% CI, 2.05-15.75; P = .001), and high pain scores (OR, 1.97; 95% CI, 1.08-3.58; P = .027).

CONCLUSIONS

The procedural failure rate for UAE was higher than those reported by others, mainly as a result of difficult anatomy and absence of a uterine artery in some cases. The risk of procedural failure was increased for patients with single fibroid tumors and/or small uterine volumes. A clear dose-effect response was revealed between the amount of embolization material used and the risk for postprocedural fever, major complications, and severe pain.

Pain and Return to Daily Activities after Uterine Artery Embolization and Hysterectomy in the Treatment of Symptomatic Uterine Fibroids: Results from the Randomized EMMY Trial

PURPOSE

To evaluate the safety and efficacy of uterine artery embolization (UAE) and hysterectomy for symptomatic uterine fibroids by means of a randomized controlled trial. The present paper analyses short-term outcomes, i.e., pain and return to daily activities.

METHODS

Patients were randomized (1:1) to UAE or hysterectomy. Pain was assessed during admission and after discharge, both quantitatively and qualitatively, using a numerical rating scale and questionnaires. Time to return to daily activities was assessed by questionnaire.

RESULTS

Seventy-five patients underwent hysterectomy and 81 patients underwent UAE. UAE patients experienced significantly less pain during the first 24 hr after treatment (p = 0.012). Non-white patients had significantly higher pain scores. UAE patients returned significantly sooner to daily activities than hysterectomy patients (for paid work: 28.1 versus 63.4 days; p < 0.001). In conclusion, pain appears to be less after UAE during hospital stay. Return to several daily activities was in favor of UAE in comparison with hysterectomy.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial

OBJECTIVE

This was a randomized controlled trial to evaluate the safety of uterine artery embolization (UAE) compared with hysterectomy.

STUDY DESIGN

Twenty-eight Dutch hospitals recruited 177 patients with symptomatic uterine fibroids and menorrhagia who were eligible for hysterectomy. Patients were randomized to UAE (n = 88) or hysterectomy (n = 89). In this paper we evaluate the peri- and postprocedural complications, length of hospital stay, unscheduled visits, and readmission rates up to 6 weeks' post-intervention. Analysis was by intention to treat.

RESULTS

Bilateral UAE failure occurred in 4 patients (4.9%). Major complications occurred in 4.9% (UAE) and 2.7% (hysterectomy) of cases (P = .68). The minor complication rate from discharge until 6 weeks after was significantly higher in the UAE group than in the hysterectomy group (58.0% vs 40.0%; RR 1.45 [1.04-2.02]; P = .024). UAE patients were more often readmitted (11.1% vs 0%; P = .003). Total length of hospital stay was significantly shorter in UAE patients (mean [SD]: 2.5 [2.7] vs 5.1 [1.3], P < .001).

CONCLUSION

UAE is a procedure similar to hysterectomy with a low major complication rate and with a reduced length of hospital stay. Higher readmission rates after UAE stress the need for careful postprocedural follow-up.

Comparison of Portapres with standard sphygmomanometry in pregnancy

BACKGROUND

Continuous beat-to-beat noninvasive blood pressure (BP) measurement is possible with Portapres. It constructs finger arterial waveforms beat-to-beat. Dedicated software is used to analyze the arterial waveforms. A new technique has been developed to reconstruct brachial intra-arterial pressure that uses return to flow (RTF). This method has been validated against invasive intra-arterial measurements in nonpregnant individuals.

OBJECTIVES

To validate Portapres in normal and preeclamptic pregnant women against standard aneroid sphygmomanometry according to Riva-Rocci-Korotkoff (RRK).

METHODS

In 30 normotensive (10 in each trimester) and 20 preeclamptic women, two trained observers blinded from each other's results took BP measurements with a standard sphygmomanometer. These measurements were compared with sequential same-arm averaged measurements obtained during 30 sec by Portapres, following protocols from the Association for the Advancement of Medical Instrumentation (AAMI, mean accepted difference < or = 5 mmHg, SD < or = 8) and British Hypertension Society (BHS, gradings A down to D).

RESULTS

A total of 150 measurement pairs were analyzed. Cumulative percentages of absolute pressure differences for all women (BHS) and mean pressure differences (SD) for different trimesters and preeclampsia (AAMI) between sphygmomanometry and Portapres were calculated. Overall, mean difference (SD) for systolic BP was 5 (SD 8) and for diastolic BP was -3 (SD 8), although analysis of variance revealed a significant effect for preeclampsia on diastolic differences between the two methods of BP measurement ( p<0.001).

CONCLUSIONS

Portapres with RTF, developed to equal intra-arterial brachial pressure, compares reasonably well to RRK and overall meets the criteria set by the AAMI. According to the BHS, Portapres receives a B-grading for diastolic BP and a C-grading for systolic BP. As Portapres measures BP and calculates cardiac output continuously and noninvasively, it would appear worthwhile to further evaluate this device in pathological pregnancies.