Uterine artery embolization for the treatment of uterine leiomyomata midterm results

Tolerance, Hospital Stay, and Recovery after Uterine Artery Embolization for Fibroids: The Ontario Uterine Fibroid Embolization Trial

PURPOSE

Uterine artery embolization (UAE) is gaining popularity as an alternative to hysterectomy for the treatment of fibroids. Although minimally invasive treatments such as UAE offer the potential of fewer complications, shorter hospital stay, and quicker recovery than surgery, there have been few published data on tolerance and recovery in patients undergoing UAE.

MATERIALS AND METHODS

This was a multicenter prospective single-arm clinical treatment trial involving the practices of 11 interventional radiologists in eight Ontario university-affiliated and community hospitals. Between November 1998 and November 2000, 555 women underwent UAE for symptomatic uterine fibroids. Follow-up included ultrasound examinations and telephone interviews. UAE was performed under conscious sedation. Polyvinyl alcohol particles (355-500 micro m) were the primary embolic agent, and the procedural endpoint involved stasis in the uterine arteries. Pain protocols included antiinflammatory medications and narcotics and a planned overnight hospital admission. Tolerance and recovery were measured by patient-reported pain intensity (10-point numeric rating and five-point descriptor scale), hospital length of stay (LOS), and time until return to work.

RESULTS

Intraprocedural pain was reported by 30% of patients and postprocedural pain was reported by 92% of patients (mean pain rating +/- SD, 7.0 +/- 2.47). The mean hospital LOS was 1.3 nights. Postprocedural pain was the most common indication for an LOS greater than 1 night (18%) or 2 nights (5%). Return visits to the hospital (10%) and readmissions (3%) were primarily for pain. The overall postprocedural complication rate was 8.0% (95% CI: 5.9%-10.6%). Of the 44 complications, 32 (73%) were pain-related. The mean recovery time after UAE was 13.1 days (median, 10.0 d).

CONCLUSION

The majority of patients had a 1-night LOS after UAE and recovered within 2 weeks. Postprocedural pain varied considerably and was the major indication for extended hospital stay and recovery.

[State and development of uterine myoma embolization in Germany]

BACKGROUND

To evaluate the current situation and implementation of embolization of uterine leiomyomas into the treatment concept in women with symptomatic uterine leiomyomas in Germany.

MATERIAL AND METHODS

A questionnaire addressing the clinical background of uterine myomas, recommended treatment concepts, preclinical evaluation, technical approach and complications was sent to 164 departments of gynecology and radiology in Germany.

RESULTS

33 radiological departments and 19 gynecological departments submitted a completed questionnaire. Only 7 departments of radiology reported to have own experience with embolization of uterine leiomyomas, while only 2 departments of gynecology considered embolization as an alternative treatment option in patients with symptomatic leiomyomas. 18/33 radiological departments offer this treatment option but get no patient referrals. Agreement was found concerning the indications for treatment, preclinical evaluation by ultrasound and MRI, preferable location of treatable fibroids, technical approach and pain management.

CONCLUSION

The embolization of uterine leiomyomas in patients with symptomatic myomas is regardless of the well documented high efficacy and low complication rate not yet an established treatment option in Germany. Interventional radiologists and gynecologists have to evaluate the indications for the embolization of uterine leiomyomas together before the procedure is advised to the patient, because it seems mandatory to add this procedure to the standard armamentarium of treatment options in uterine myomas.

[Technique and methods in uterine leiomyoma embolization]

OBJECTIVE

Uterine leiomyomas are the most common benign tumors of the female urogenital tract. Beside the classic surgical treatment options the minimal-invasive embolization therapy of the leiomyomas increasingly gains importance world-wide. Technique, complications, and results of uterine leiomyoma embolization will be presented.

METHODS

After careful evaluation of indications for embolization the procedure is mostly performed under conscious sedation. A single-sided femoral access route together with cross-over technique generally allows for a flow-directed embolization via both uterine arteries. After embolizing the vessels supplying the tumor, the uterine arteries should be still patent.

RESULTS

The success rate of embolization of uterine leiomyomas ranges between 85 and 100%, whereas a reduction in size of the tumors in 42 to 83% and a relief of symptoms in up to 96% can be achieved. The total complication rate is about 10% with mainly "minor complications". Worldwide only three deaths following embolization of uterine leiomyomas were reported.

CONCLUSION

The high technical and clinical success rate together with a low complication rate make the embolization of uterine leiomyomas a minimally-invasive alternative to the classic treatment. As long term results are not available indication to embolization of uterine leiomyomas must be carefully established in consensus with gynecologists.

Ovarian Artery Embolization Supplementing Uterine Embolization for Leiomyomata

Uterine artery embolization for leiomyomata may fail due to additional blood supply from the ovarian arteries. The potential role of supplemental ovarian artery embolization is unknown. The authors present here the results for their first six patients who were treated with ovarian artery embolization.

Uterine artery embolization for the treatment of symptomatic myomas in Brazilian women

CONTEXT

Uterine myomas are benign tumors that mostly occur in women of reproductive age at a frequency ranging from 20 to 25%. The symptoms are increased menstrual flow, pain and compressive signs. New treatments have been proposed and uterine artery embolization is one of them.

OBJECTIVE

To evaluate the effects of treatment by embolization of the uterine artery, in women with symptomatic myomas. Uterine and dominant myoma volumes and the major symptoms were evaluated before treatment and 12 weeks later.

TYPE OF STUDY

Open clinical trial.

SETTING

A tertiary-care women's hospital.

PARTICIPANTS

The study was conducted on 32 women with symptomatic single or multiple myomas of the uterine body, seen at the outpatient unit from May 2000 to September 2001.

MAIN MEASUREMENTS

The patients were submitted to gynecological examination and abdominal and endovaginal pelvic ultrasonography, and the examinations were repeated 12 weeks after the first procedure. Uterine artery embolization using PVA (polyvinyl alcohol) particles of 355-700 was performed by catheterization of the right femoral artery in 30 women and by bilateral catheterization in two.

RESULTS

Before embolization, the mean uterine volume of the 32 women was 455 cm and the mean volume of the dominant myoma was 150 cm . Twelve weeks after embolization, the mean uterine volume was 256 cm and the mean volume of the dominant myoma was 91 cm , with p < 0.01 in both cases. Twelve weeks after the treatment, all the women answered a questionnaire, which showed that 71% had improvement in menstrual regularity, 90% decreased menstrual volume and 81% shortened menstrual duration. The most frequent immediate post-procedure symptoms, established as complications, were pain (100%) and fatigue (34%). One woman had myoma degeneration and was submitted to myomectomy.

CONCLUSION

The significant reduction in uterine and dominant myoma volume confirms the validity of the treatment of symptomatic myomas by the technique of uterine artery embolization in Brazilian women. There was significant reduction in menstrual flow and duration, as well as better cycle regularity in the women studied. The few adverse effects observed in the sample studied mainly involved pain immediately after embolization.

Adenomyosis: MRI of the uterus treated with uterine artery embolization

OBJECTIVE

The purpose of this study was to determine the MRI features seen after uterine artery embolization and to evaluate the clinical response in patients with adenomyosis.

MATERIALS AND METHODS

Thirty women with adenomyosis underwent uterine artery embolization and follow-up MRI for 1 year. Of the 30, 27 patients were diagnosed with uterine fibroids and adenomyosis on the basis of MRI before uterine artery embolization. In six of the 27 patients, the dominant disease was adenomyosis. Three of the 30 patients had adenomyosis alone. The distribution, thickness, and enhancement of adenomyosis were analyzed in each patient. Patients completed a symptom questionnaire.

RESULTS

After uterine artery embolization, the junctional zone-myometrial ratio did not change significantly. There were regions of devascularization of adenomyosis on contrast-enhanced images in 12 patients, all with a junctional zone thickness before uterine artery embolization of more than 20 mm (mean thickness, 39.2 mm). Eleven of the 12 patients had focal or asymmetric distribution patterns of adenomyosis. All three patients with pure adenomyosis and all six patients with dominant adenomyosis reported an improvement in symptoms.

CONCLUSION

In patients treated with uterine artery embolization, MRI shows changes in areas of adenomyosis with a decrease in junctional zone vascularity in patients with thickening of the junctional zone greater than 20 mm. Devascularization may be related to the distribution of adenomyosis. The presence of adenomyosis should not be used as a contraindication to uterine artery embolization because most patients show clinical improvement after undergoing this procedure.

Comparison of Pain After Uterine Artery Embolization Using Tris-Acryl Gelatin Microspheres Versus Polyvinyl Alcohol Particles

When compared in a uterine artery embolization (UAE) animal model, Embospheres (ES) (Biosphere Medical, Rockland, MA) were found to induce less uterine ischemia than polyvinyl alcohol (PVA) particles. Given this finding, we aimed to test the hypothesis that ES is associated with less pain after UAE than PVA in human patients. We performed retrospective analysis on data from 72 consecutive UAE patients, collected from a prospectively acquired database. Patient-controlled analgesia (PCA) pump-delivered morphine sulfate (MS) dosages were compared between patients who received ES versus PVA. Subjective pain scores (SPS) were also compared between the two groups. Secondary outcome measures, including embolic volume and clinical outcome data, were also collected. Linear regression and t-test statistical analyses were performed. Null hypotheses were rejected at the p < 0.05 level. Mean follow-up period in the PVA population was 178 days (range 28-426), versus 96 days (range 24-197) in the ES population. The mean MS doses used by ES and PVA patients were 37.2 (s.d. 23.5) versus 47.1 (s.d. 26.8), respectively. This difference was not significant (p > 0.15). Utilizing a standard 0-10 pain scale, the mean peak SPS for the ES and PVA groups were 5.58 (s.d. 2.77) and 5.07 (s.d. 2.99), respectively. The difference was not significant. The mean amount of embolic material used in each ES and PVA patient was 4.86 cc (s.d. 3.01) and 3.52 cc (s.d. 1.63), respectively. The difference revealed a strong trend toward statistical significance (p = 0.05). There was one treatment failure in each group of patients. Within both patient samples, no significant correlation was found when comparing the volume of embolic used and subsequent MS dose. Despite a strong trend toward a significantly higher volume of ES used per patient, there is no subjective or objective difference in pain after UAE with ES when compared to PVA.

Embolização uterina para tratamento de mioma sintomático: experiência inicial revisão da literatura

OBJETIVO: Apresentar os resultados da experiência clínica inicial de 100 casos de mulheres portadoras de miomatose sintomática que foram submetidas a embolização das artérias uterinas como forma de tratamento principal. Apresenta-se, também, extensa revisão bibliográfica sobre o tema, para determinar as indicações e contra-indicações, bem como as eventuais complicações do método. MATERIAL E MÉTODO: Cem pacientes com miomatose sintomática foram submetidas a embolização das artérias uterinas como única forma de tratamento. O principal sintoma que indicou a intervenção foi o aumento do fluxo menstrual em 79 pacientes e dor associada à miomatose em 21. O diagnóstico de miomatose foi realizado por meio de ultra-sonografia em 75 pacientes, e pela associação de ultra-sonografia e ressonância magnética em 25 pacientes. O volume uterino médio avaliado por esses métodos de imagem resultou em 487 cm³. Os procedimentos foram realizados em duas instituições hospitalares: uma pública, onde foram atendidas 56 pacientes dependentes do Sistema Único da Saúde (SUS), e outra particular, onde foram atendidas 46 pacientes com plano de assistência médica. Setenta e seis pacientes foram avaliadas clinicamente após 12 semanas da realização da embolização uterina. RESULTADOS: O procedimento foi completado com sucesso em 97% dos casos, utilizando-se técnica convencional. O acompanhamento e a avaliação clínica após 12 semanas evidenciou que houve melhora dos sintomas em mais de 90% das pacientes. Verificou-se, ainda, redução de volume uterino de 52%. Não foram observadas complicações técnicas ou clínicas relevantes. CONCLUSÃO: A técnica de embolização uterina para tratamento da miomatose sintomática é um método simples, eficiente e seguro.

Abdominal myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine leiomyomas

OBJECTIVE

The purpose of this study was to compare treatment efficacy and complications of abdominal myomectomy with those of uterine fibroid embolization in women with symptomatic uterine fibroids.

MATERIALS AND METHODS

We analyzed the outcomes of 111 consecutive patients who underwent abdominal myomectomy (n = 44) or fibroid embolization (n = 67) over a 30-month period. The mean ages of the two groups were 37.7 years (range, 28-48 years) and 44.2 years (range, 31-56 years), respectively. A questionnaire and review of medical records assessed all procedure-related complications and changes in symptoms. Length of hospital stay, time until resumption of daily activities, and pain medication requirements after the procedure were also analyzed.

RESULTS

Follow-up times for the myomectomy and embolization groups were 14.6 and 14.3 months, respectively. The respective observed success rates in abdominal myomectomy and uterine fibroid embolization patients were 64% versus 92% for menorrhagia (p < 0.05), 54% versus 74% for pain (not significant), and 91% versus 76% for mass effect (p < 0.05). The complication rates were 25% (abdominal myomectomy) and 11% (uterine fibroid embolization) (p < 0.05). The respective secondary end points for the two procedures were 2.9 versus 0 days mean hospital stay, 8.7 versus 5.1 days of narcotics use, and 36 versus 8 days until resumption of normal activities. These differences were all statistically significant.

CONCLUSION

Uterine fibroid embolization is a less invasive and safer treatment option in women with symptomatic leiomyomas than myomectomy. Menorrhagia may be better controlled with embolization, and myomectomy may be a better option in patients with mass effect. Both procedures were equally effective in controlling pain.

Fatal sepsis after uterine artery embolization with microspheres

A case report of fatal sepsis after uterine artery embolization (UAE) with microspheres is presented. At autopsy, microspheres were found not only in arteries in the leiomyomata and myometrium but also in the parametria and the vagina, leading to a necrotic vaginal wall and uterine cervix. At present, polyvinyl alcohol particles are usually used in UAE. Recently, study results of the use of microspheres in embolization procedures have become available. The rationale for the choice of a specific embolization particle and the clinical implications of possible sepsis after UAE are discussed.

Uterine arterial embolization for the treatment of diffuse leiomyomatosis

Diffuse leiomyomatosis of the uterus is an extremely rare condition and presents as a diffuse involvement of the myometrium by numerous leiomyomata. Despite patients being in only the third or fourth decades of life, all previously reported patients with this condition have undergone hysterectomy because myomectomy is impossible for this condition. Uterine arterial embolization (UAE) successfully reduced the uterine volume of diffuse leiomyomatosis without major complications in the case presented herein, and the symptoms improved remarkably. Enhanced magnetic resonance imaging after intravenous injection of gadolinium demonstrated global infarction of the vast majority of nodules.

Technical results and effects of operator experience on uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial

PURPOSE

To document the technical results and spectrum of practice of uterine artery embolization (UAE) for fibroids in the health care setting in Canada. The effects of interventional radiologist's (IR's) experience with UAE on procedure and fluoroscopy time were also investigated.

MATERIALS AND METHODS

The study involved a multicenter prospective single-arm clinical treatment trial and included the practices of 11 IRs at eight university-affiliated teaching and community hospitals. Vascular access with percutaneous femoral artery approach was followed by transcatheter delivery of polyvinyl alcohol (PVA) particles into uterine arteries with fluoroscopic guidance. Technical success, complications, procedural time, fluoroscopy time, and effects of operator experience were outcomes analyzed.

RESULTS

Between November 1998 and November 2000, 570 embolization procedures were performed in 555 patients. UAE was bilaterally successful in 97% (95% CI: 95%-98%). Variant anatomy was the most common reason for failure to embolize bilaterally. The procedural complication rate was 5.3% (95% CI: 3.6%-7.4%). Of the 30 events, three involved major complications (one seizure and two allergic reactions) that resulted in additional care or extended hospital stay. Procedure time and fluoroscopy time averaged 61 minutes (95% CI; 58-63 minutes) and 18.9 minutes (95% CI; 18-19.8) and varied significantly among IRs (P <.001; P <.001). The average 27% reduction in procedure time (20 minutes; P <.001) and 24% reduction in fluoroscopy time (5.1 minutes; P <.001) with increasing UAE experience were significant.

CONCLUSIONS

A high level of technical success with few complications was obtained with a variety of operators in diverse practice settings. Increased experience in UAE significantly reduced procedure and fluoroscopy time.

Hysterectomy for complications after uterine artery embolization for leiomyoma: results of a Canadian multicenter clinical trial

STUDY OBJECTIVE

To determine the complication-related hysterectomy rate after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

DESIGN

Prospective, multicenter, nonrandomized, single-arm clinical trial (Canadian Task Force classification II-2).

SETTING

Eight Ontario University-affiliated teaching and community hospitals.

PATIENTS

Five hundred fifty-five women.

INTERVENTION

Polyvinyl alcohol particles were delivered through a catheter into uterine arteries under fluoroscopic guidance.

MEASUREMENTS AND MAIN RESULTS

Prospective follow-up investigations consisted of telephone interviews, ultrasound examinations, and reviews of pathology and surgery reports. Median follow-up was 8.1 months, and all but five patients had complete 3-month follow-up. At 3 months, eight women (1.5%, 95% CI 0.6-2.8) underwent complication-related hysterectomy. Half of the surgeries were performed at institutions other than where UAE had been performed. Indications for hysterectomies were infections (2), postembolization pain (4), vaginal bleeding (1), and prolapsed leiomyoma (1).

CONCLUSIONS

The 3-month complication rate resulting in hysterectomy after UAE in a large cohort of women was low. Hysterectomy after UAE is an important measure of safety and a key outcome measure of this new therapy.

Pathologic features of uteri and leiomyomas following uterine artery embolization for leiomyomas

The objectives of this study were to identify the presence/absence and location of any embolic material and to describe the morphologic appearance of the leiomyoma and adjacent tissues of cases undergoing surgical intervention following uterine artery embolization (UAE) for leiomyomas. A total of 555 women underwent UAE using polyvinyl alcohol particles (PVA) in a multicenter clinical trial. The histopathologic slides from 17 of 18 women who subsequently underwent myomectomy or hysterectomy in the follow-up period (median 8.2 months) were reviewed without knowledge of the indication for surgery or time elapsed since UAE. The presence/absence and distribution of PVA emboli, associated inflammatory response, and necrosis were noted. Necrosis of leiomyoma(s) was classified as hyaline-type, coagulative tumor cell necrosis, and/or acute suppurative necrosis. In all cases PVA emboli were identified within smooth muscle tumors of the uterine body, its periphery, cervix, uterine body, myometrium, and/or the adnexa. A florid foreign body giant cell type of chronic inflammatory reaction was seen within 1 week of UAE and persisted with visible PVA for up to 14 months post-UAE. Typically, post-UAE leiomyomas showed hyaline-type, but rarely coagulative tumor cell necrosis and acute suppurative necrosis could be seen as well. Five of eight cases coming to surgery for complications showed necrotizing endomyometritis with tissue infarction. PVA particles are recognizable in post-UAE specimens. Leiomyoma necrosis is typically of the hyaline type; coagulative tumor cell necrosis was rarely seen. In some cases with complications, uterine and/or cervical necrosis occurred. The applicability of these findings for UAE patients who have been successfully treated and not resected is uncertain.

Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment--a prospective, randomized, and controlled clinical trial

PURPOSE

To evaluate the effectiveness of uterine artery embolization (UAE) in the management of bleeding in patients with uterine fibroids and to compare UAE with hysterectomy, particularly with regard to length of hospital stay and associated complications (ie, safety).

MATERIALS AND METHODS

A prospective clinical trial was performed with patients who were randomly assigned to one of two groups: patients who were offered the option of undergoing either UAE or hysterectomy (group 1) and patients who were not informed of the alternative treatment-that is, UAE (group 2). The primary variables that were considered for evaluation of the effectiveness, efficiency, and safety of the two procedures were, respectively, bleeding cessation, total length of hospital stay, and resulting complications. The lengths of hospital stay in the two study arms were compared on an intent-to-treat basis. Owing to crossover between the treatment arms, however, effectiveness and safety were evaluated on the basis of the actual treatment received.

RESULTS

The clinical success rate for the patients who underwent UAE, which was based on the cessation of bleeding, was 86% (31 of 36 patients). The mean hospital stay for group 1 was 4.14 days shorter than that for group 2 (P <.001). Ten (25%) of the 40 patients who underwent UAE experienced minor complications, in contrast to four (20%) of the 20 who underwent hysterectomy and experienced major complications.

CONCLUSION

Compared with hysterectomy, UAE is safe and effective for treatment of bleeding fibroids, necessitates a shorter hospital stay, and results in fewer major complications.

[Prospective clinical and sonographic assessment of uterine artery embolization as the treatment of symptomatic uterine leiomyomata]

OBJECTIVE

To evaluate the effectiveness of the uterine artery embolization as the treatment of symptomatic uterine leiomyomata.

PATIENTS AND METHODS

Eighty-five women with symptoms caused by uterine leiomyomata underwent uterine artery embolization as an alternative to surgery from january 1997 to june 2000. The effectiveness of this method was evaluated by clinical and sonographic examination.

RESULTS

The recession average was of 18.9 months. There were ten failures. We had immediate failures (n = 5) with a case of technical failure, one endometrium cancer, one adenomyosis, one larger subserosal leiomyomata and one parametrial leiomyomata. We had recurrences (n = 5) with the occurrence of new leiomyomatas (1 intramural and 3 submucosal) and an evolution of previous leiomyomata. The average volume reduction was 51% for the uterus and 65% for the main fibroid at one year follow-up. Minor complications occurred in 5%. Permanent amenorrhoea was observed for 3.75% of the women. Using cox model, no predictive factors of embolisation effectiveness were found.

DISCUSSION AND CONCLUSION

In the treatment of symptomatic uterine leiomyoma, uterine artery embolization is an effective alternative to surgery. After one year and half, we had 12.5% of failures.

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVE

To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms.

DESIGN

A pilot study on 26 women affected by uterine single myoma.

SETTING

Tertiary level care in an university hospital.

PATIENT(S)

Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization.

INTERVENTION(S)

Selective uterine artery embolization performed under peridural anesthesia.

MAIN OUTCOME MEASURE(S)

We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure.

RESULT(S)

Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination.

CONCLUSION(S)

Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.

Serious complications of uterine artery embolization for conservative treatment of fibroids

OBJECTIVE

Document major complications following treatment of fibroids by uterine artery embolization (UAE).

DESIGN

Two case reports.

SETTING

University medical center.

PATIENTS

Two women with symptomatic fibroid uteri.

INTERVENTION(S)

Selective bilateral uterine artery embolization.

MAIN OUTCOME MEASURE(S)

Complications attributable to UAE.

RESULT(S)

Two patients experienced significant morbidity requiring hysterectomy due to infection and/or partial bowel obstruction resulting from UAE.

CONCLUSION(S)

Reports of the management of symptoms related to fibroids with UAE infrequently include adverse outcomes and/or complications. The two cases we managed reinforce that UAE is not free of the risk of life-threatening complications that require emergency hysterectomy. Increasing surveillance for complications may help define the selection criteria that decrease the risks of UAE.

The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids

OBJECTIVE

To evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids.

DESIGN

Multicenter, prospective, single-arm clinical treatment trial.

SETTING

Eight Ontario university and community hospitals. Five hundred thirty-eight patients undergoing bilateral UAE.

INTERVENTION(S)

Bilateral UAE performed with polyvinyl alcohol particles sized 355-500 microm.

MAIN OUTCOME MEASURE(S)

Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale).

RESULT(S)

Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%-7%) in women under age 40 to 41% (26%-58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment.

CONCLUSION(S)

UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high.

Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids

PURPOSE

To evaluate the midterm results of limited embolization of the uterine arteries in the management of symptomatic uterine fibroids and to evaluate the efficacy and safety of limited uterine artery embolization (UAE) with use of calibrated tris-acryl gelatin microspheres in the management of symptomatic uterine fibroids.

MATERIALS AND METHODS

Twenty women (mean age, 43 years) with symptomatic uterine fibroids underwent bilateral embolization of the uterine arteries with use of calibrated microspheres. Devascularization of the fibroids was achieved and the main uterine artery was left patent in all women. Embolization was offered as an alternative to surgery in all women who had been treated unsuccessfully with medical therapy.

RESULTS

All procedures were technically successful. Microspheres 700-900 micro m in diameter were used in 14 women (70%). After a mean follow-up duration of 30.2 months (range, 24-48 mo), all women reported improvement in their symptoms, with 85% reporting complete resolution of menorrhagia at the most recent follow-up. One woman with multiple fibroids required a second embolization procedure because of persisting symptoms at 6 months. She is currently symptom-free after 48 months. In two women with submucosal fibroids, expulsion of necrotic fibroids occurred 2 and 7 months after the procedure, respectively. All women resumed normal menstruation after the procedure. One woman had a successful full-term pregnancy after embolization.

CONCLUSION

Early experience with UAE with use of calibrated tris-acryl gelatin microspheres indicates that it is safe and efficacious in controlling menorrhagia.

The Ontario Uterine Fibroid Embolization Trial. Part 1. Baseline patient characteristics, fibroid burden, and impact on life

OBJECTIVE

To determine baseline characteristics of women undergoing uterine artery embolization (UAE) for symptomatic fibroids.

DESIGN

Multicenter, prospective, single-arm clinical treatment trial.

SETTING

Eight Ontario university and community hospitals.

PATIENT(S)

Five hundred fifty-five women undergoing UAE for fibroids.

INTERVENTION(S)

Baseline questionnaires completed before UAE.

MAIN OUTCOME MEASURE(S)

Questionnaires were analyzed for demographic, medical, and gynecologic histories. Fibroid symptoms, impact of symptoms, previous consultations, and treatments were also analyzed.

RESULT(S)

The Ontario cohort (66% white, 23% black, 11% other races) had an average age of 43. Thirty-one percent were under age 40. Most women were university educated (68%) and working outside the home (85%). Women reported heavy menstrual bleeding (80%), urinary urgency/frequency (73%), pain during intercourse (41%), and work absences (40%). They experienced fibroid-related symptoms for an average of 5 years and consulted with on average of three gynecologists before UAE. High fibroid life-impact scores were reported by 58%. Black women were significantly younger (40.7 vs. 44.0 years), more likely to experience symptoms longer (7 vs. 5 years), and more likely to undergo myomectomy before UAE (24% vs. 9%) than white women.

CONCLUSION(S)

Our study illustrates that large numbers of women with highly symptomatic fibroid disease are averse to surgery despite their burden of suffering and are actively seeking alternatives to hysterectomy.

Estimated costs for uterine artery embolization and abdominal myomectomy for uterine leiomyomata: a comparative study at a single institution

PURPOSE

To determine and compare the costs associated with uterine artery embolization (UAE) and abdominal myomectomy for the treatment of symptomatic leiomyomata.

MATERIALS AND METHODS

Charge information was gathered and analyzed from 23 patients who underwent UAE and 17 who underwent abdominal myomectomy in a single institution. The mean charges for each procedure were calculated from the patients' billing data. Cost-to-charge ratios were applied to the mean charges to estimate costs. The work relative value units (RVUs) for all physician services for each procedure were calculated. These total work RVUs for each intervention were multiplied by the appropriate Medicare conversion factors to estimate a uniform physician fee. These costs were totaled and compared with use of the unpaired t test to estimate the cost difference between UAE and abdominal myomectomy.

RESULTS

The estimated hospital cost for UAE was $3,193, which was significantly lower than the $5,598 estimated for abdominal myomectomy (P <.0001). The discrepancy was caused primarily by increased hospital care and operating room costs for abdominal myomectomy. The total professional costs were significantly higher for UAE ($2,220) than for abdominal myomectomy ($1,611) (P =.002). When all associated costs, including typical imaging costs, were considered, there was a trend toward lower costs for UAE ($6,708) compared to abdominal myomectomy ($7,630) (P =.086).

CONCLUSION

UAE had lower procedure-related costs than abdominal myomectomy despite higher physician costs. When typical imaging costs were included, there was still a trend toward lower costs for UAE.

Review of readmissions due to complications from uterine fibroid embolization

AIM

To determine the frequency, nature and outcome of complications resulting in readmission to hospital following uterine artery embolization (UAE).

MATERIAL AND METHODS

A retrospective review of the medical notes and available imaging of 42 consecutive patients who had undergone elective uterine artery embolization for the treatment of fibroid disease was performed.

RESULTS

The mean age of the patients was 42 years (range 31--54 years) and seven patients (17%) were readmitted to hospital. The median time to readmission was 3 weeks (range 1-29 weeks). All seven patients were admitted with signs and symptoms of infection. In four patients an organism was isolated from high vaginal swabs, and in one patient the midstream urine sample was confirmed as the source of infection. In the other two patients no definite source of infection was identified. All patients were treated with intravenous antibiotics. Six of the seven patients responded to treatment. The remaining patient required hysterectomy for uncontrolled uterine sepsis.

CONCLUSION

Readmission following UAE is common and arises secondary to infection. Infection can occur several months after the procedure.

Cost analysis of myomectomy, hysterectomy, and uterine artery embolization

OBJECTIVE

The purpose of this study was to compare inpatient hospital costs of different treatments of uterine fibroid tumors, including myomectomy, hysterectomy, and uterine artery embolization in a teaching hospital.

STUDY DESIGN

We reviewed the hospital database of 545 women with uterine fibroid tumors who were treated with abdominal myomectomy, total abdominal hysterectomy, vaginal hysterectomy, and uterine artery embolization between April 1997 and October 2001.

RESULTS

Women who underwent hysterectomies and uterine artery embolization were significantly older than the women who underwent myomectomy. Uterine artery embolization was associated with the shortest hospital stay, although the hospital stay in the vaginal hysterectomy group was shorter than in the abdominal myomectomy and the total abdominal hysterectomy groups. Compared with other groups, the inpatient cost of nursing in the uterine artery embolization group was the lowest. The total inpatient cost of uterine artery embolization ($1,007.44 +/- $60.65 [Canadian dollars]) was significantly lower than the cost of total abdominal hysterectomy ($1,933.37 +/- $47.68 [Canadian dollars]), abdominal myomectomy ($1,781.73 +/- $47.16 [Canadian dollars]), and vaginal hysterectomy ($1,515.39 +/- $66.72 [Canadian dollars]; P <.001). Sixteen of the 85 patients (18.8%) were hospitalized after uterine artery embolization, mainly for abdominal pain.

CONCLUSION

Compared with abdominal myomectomy, abdominal hysterectomy, and vaginal hysterectomy, uterine artery embolization is associated with a lower hospital cost and a shorter hospital stay. Hospitalization after uterine artery embolization is mainly for abdominal pain after the procedure. A better method of pain control to reduce the rate of hospitalization and its cost is needed.

Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up

OBJECTIVE

To evaluate the mid-term efficacy and complications of uterine artery embolisation in women with symptomatic fibroids. To assess reduction in uterine and dominant fibroid volumes using ultrasound and magnetic resonance imaging.

DESIGN

Prospective observational single-centre study.

SETTING

A district general hospital in Surrey and a private hospital in London.

METHODS

Four hundred consecutive women were treated between December 1996 and February 2001. Indications for treatment were menorrhagia, menstrual pain, abdominal swelling or bloating and other pressure effects. Uterine artery embolisation was performed using polyvinyl alcohol particles and platinum coils.

MAIN OUTCOME MEASURES

Imaging was performed before embolisation and at regular intervals thereafter. Clinical evaluation was made at regular intervals after embolisation to assess patient outcome.

RESULTS

Bilateral uterine artery embolisation was achieved in 395 women, while 5 women had a unilateral procedure. With a mean clinical follow up of 16.7 months, menstrual bleeding was improved in 84% of women and menstrual pain was improved in 79%. Using ultrasound, the median uterine and dominant fibroid volumes before embolisation were 608 and 112 cc, respectively, and after embolisation 255 and 19 cc, respectively (P = .0001). Three (1%) infective complications requiring emergency hysterectomy occurred. Twenty-three (6%) patients had clinical failure or recurrence. Of these, nine (2%) had a hysterectomy. Twenty-six (7%) women had permanent amenorrhoea after embolisation including four patients under the age of 45 (2%). Of these, amenorrhea started between 4 and 18 months after embolisation, and only three had elevated follicle stimulating hormone levels when amenorrhea developed. Thirteen (4%) women had chronic vaginal discharge considered as a major irritant. Thirteen pregnancies occurred in 12 patients. Ninety-seven percent of women were pleased with the outcome and would recommend this treatment to others.

CONCLUSIONS

Uterine artery embolisation is associated with a high clinical success rate and good fibroid volume reduction. Infective complications requiring hysterectomy, amenorrhoea under the age of 45 and chronic vaginal discharge may complicate the procedure.

Uterine artery embolisation for the treatment of symptomatic uterine fibroids: short-term results of work in progress

Bilateral uterine artery embolisation (UAE) was used to treat 11 women with symptomatic uterine fibroids. Uterine volume and dominant fibroid volume were assessed quantitatively by ultrasonography both before and at two and six months post procedure. Both uterine arteries were occluded effectively in all of the women, and the procedure was well tolerated, with hospital stays limited to 24-48 hours in all cases. An improvement of symptoms occurred in 10 of the 11 women. There were no significant complications. The mean percentage reductions in uterine volume and dominant fibroid volume at six months following the procedure were 45.32% and 56.34%, respectively. Bilateral uterine artery embolisation for the treatment of uterine fibroids is a minimally invasive technique with very good clinical results. This procedure may be considered as an alternative to hysterectomy, or myomectomy in properly selected cases.

The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids

PURPOSE

To determine if magnetic resonance (MR) imaging significantly alters the diagnostic thinking and treatment plans of interventional radiologists during the evaluation of women for uterine fibroid embolization (UFE) for presumed uterine fibroids.

MATERIALS AND METHODS

At a single institution, interventional radiologists prospectively completed questionnaires (n = 60) before and after MR imaging was performed in their evaluation of women presenting for potential UFE. The questionnaires asked these physicians the probability (0%-100%) of their most likely diagnosis before MR imaging and after receiving the MR imaging information. They were also asked their anticipated and final treatment plans. Diagnostic confidence gains and the proportion of patients with changed initial diagnoses or anticipated management were calculated. The Wilcoxon signed-rank test was used to assess gains in diagnostic confidence.

RESULTS

MR imaging caused a mean gain in diagnostic confidence of 22% (P <.0001). MR imaging changed initial diagnoses in 11 patients (18%). Immediate clinical management changed in 13 patients (22%). UFE was not performed in 11 of 57 women (19%) who were anticipated before MR imaging to receive UFE.

CONCLUSIONS

MR imaging significantly alters the diagnoses and treatment plans of interventional radiologists evaluating women with presumed symptomatic fibroids. MR imaging should be considered in all patients before UFE.

Uterine artery embolization for the treatment of uterine leiomyomata

OBJECTIVES

To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids.

METHODS

Twenty-six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow-up was performed before the procedure, at 3 months, and 1 year after.

RESULTS

All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm(3), after 3 months 255 cm(3) and after 1 year 202 cm(3). The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow-up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients).

CONCLUSIONS

UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Uterine artery embolization treatment of uterine fibroids: effect on ovarian function in younger women

PURPOSE

To evaluate how uterine artery embolization (UAE) treatment for uterine fibroids (UF) affects ovarian function in young Middle Eastern women.

MATERIALS AND METHODS

In this prospective study, 32 patients (mean age, 34 y; range, 26-45 y) underwent UAE treatment of symptomatic fibroids. Serum follicle-stimulating hormone (FSH) levels were measured before and after the embolization treatment. Preprocedural levels were determined on the second day of the menstrual cycle. Postprocedural levels were measured 3 months and 6 months after embolization. A detailed history of menstrual cycles was obtained before and after UAE.

RESULTS

Thirty premenopausal patients had normal menses before UAE. Mean FSH levels before and 3 months after UAE were 6.83 IU/L +/- 1.8 and 6.99 IU/L +/- 1.67, respectively (P =.66). Normal menstruation resumed 2-3 months after the procedure. In two perimenopausal women, who had irregular menses and decreased ovarian reserve, mean FSH levels increased transiently from 22 and 30 IU/L to 40 and 48 IU/L, respectively, 3 months after UAE; they developed transient amenorrhea.

CONCLUSION

In this study, UAE had no clinically relevant adverse effects on normally functioning ovaries and could be used safely in the treatment of symptomatic fibroids in premenopausal women. Larger studies are required for further support of this observation.

Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization

PURPOSE

To prospectively study and classify the anastomoses between the ovarian and uterine arteries in women undergoing uterine fibroid embolization, and to compare the presence of such with procedural failures and premature menopause.

MATERIALS AND METHODS

Angiographic ovarian artery-to-uterine artery anastomoses were studied in 76 consecutive patients undergoing uterine fibroid embolization. Mean patient age was 44.7 years (range, 29-56 years). Clinical follow-up consisted of a standard questionnaire. Procedural failure and complications were compared with the presence of various types of ovarian artery-to-uterine artery connections.

RESULTS

Three types of anastomoses were identified. In type I (33 [21.7%] of 152 arteries), flow from the ovarian artery to the uterus was through anastomoses with the main uterine artery. In type II (six arteries [3.9%]), the ovarian artery supplied the fibroids directly. In type III (10 arteries [6.6%]), the major blood supply to the ovary was from the uterine artery. Seven patients (9%) were considered to have clinical failure, with three of the six women with type II anastomoses being in this group. Three of the five women who experienced menopause after fibroid embolization had bilateral ovarian artery-to-uterine artery anastomoses that were classified as high risk.

CONCLUSION

Delineation of ovarian artery-to-uterine artery anastomosis is of practical relevance in avoiding nontarget ovarian embolization, in identification of those who would be at risk of uterine artery embolization or ovarian failure, and in those in whom the ovarian artery can be embolized safely.

Uterine artery replacement by the round ligament artery: an anatomic variant discovered during uterine artery embolization for leiomyomata

The authors report a case of an unusual anatomic variation encountered during uterine embolization, that of absence of a uterine artery, with replacement by an enlarged round ligament artery. This case highlights the importance of understanding the arterial anatomy of the uterus and its potential variations and their potential impact on the outcome of the procedure.

Laparoscopic uterine artery ligation for treatment of symptomatic adenomyosis

STUDY OBJECTIVE

To investigate the effect of laparoscopic uterine artery ligation on symptomatic adenomyosis.

DESIGN

Prospective pilot study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Twenty women with symptomatic adenomyosis.

INTERVENTION

Laparoscopic ligation of bilateral uterine arteries with hemoclips and electrocoagulation of bilateral uterine ovarian vessels.

MEASUREMENTS AND MAIN RESULTS

Patients underwent sonographic measurement of uterine size, and recorded amount of menstruation and dysmenorrhea preoperatively and postoperatively. Six months postoperatively, mean uterine size had decreased by an amount ranging from 0.4% to 74.0%. Two of nine women achieved remission of the mass effect of an enlarged uterus. Thirteen of 16 patients achieved bleeding control and 5 returned to eumenorrhea or hypomenorrhea. Twelve of 16 patients achieved control of dysmenorrhea and 6 were analgesic free. However, nine women experienced nonmenstrual pain after surgery, three of whom underwent hysterectomy later. Treatment was rated as satisfactory by 15% of patients, but 45% were dissatisfied. Seventeen women would have refused to undergo the procedure if they could make the decision again.

CONCLUSION

Poor satisfaction in this preliminary study suggests that symptomatic adenomyosis may not be effectively treated by laparoscopic uterine artery ligation.

Magnetic resonance imaging outcome after uterine artery embolization for leiomyomata with use of tris-acryl gelatin microspheres

PURPOSE

To determine the imaging outcome after uterine artery embolization (UAE) with use of tris-acryl gelatin microspheres (Embospheres).

MATERIALS AND METHODS

A retrospective analysis of magnetic resonance (MR) images was performed comparing studies completed 3-4 months after UAE to those performed before UAE. Twenty-three patients with 61 leiomyomata (as many as three fibroids per patient) were examined. Orthogonal T2, axial T1-weighted fat-saturated, sagittal T2 fast spin-echo, and dynamic T1-weighted sagittal images after Gadolinium injection were analyzed. Two abdominal imaging specialists examined the volume and uterine and leiomyoma perfusion. The Wilcoxon signed-rank test was used for inferences in leiomyoma size difference, infarction, and volume of fibroid tissue perfused.

RESULTS

Median volume of all leiomyomata (n = 61) decreased by 52% (P <.001). For dominant fibroids alone (n = 23), a median 52% volume decrease (P <.001) was also noted, whereas the median uterine volume decreased 32%. Median perfused volume of all fibroids decreased from 31 mL to 0 mL, signifying a 100% decrease (P <.001). For dominant fibroids, a 100% median perfused volume decrease from 116 mL to 0 mL was noted (P <.001). Fifty-two of 61 fibroids (85%) and 20 of 23 dominant fibroids (87%) were completely devascularized and two fibroids disappeared. There was no myometrial ischemia identified.

CONCLUSIONS

Tris-acryl gelatin microspheres (Embospheres) are an effective embolic agent for UAE, causing infarction and significant decrease in leiomyoma volume.

Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata

OBJECTIVE

To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure.

DESIGN

Case report and literature review.

SETTING

University-affiliated private practice.

PATIENT(S)

A 35-year-old woman with symptomatic leiomyomata.

INTERVENTION(S)

Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow.

MAIN OUTCOME MEASURE(S)

Ovarian function.

RESULT(S)

Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance.

CONCLUSION(S)

Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.

Lack of suitability of the rabbit model for particulate uterine artery embolization

PURPOSE

The goal of this study was to evaluate the rabbit model for studies of particulate uterine artery embolization (UAE). Rabbits were chosen because it was believed that their year-round breeding time and short duration of pregnancy would be useful in studies of fertility and pregnancy after UAE.

MATERIALS AND METHODS

Bilateral UAE was performed in 12 adult female New Zealand White rabbits weighing 4-5.2 kg. All animals were proven to be breeders before treatment. Each uterine artery was embolized to stasis with use of 180-300- microm polyvinyl alcohol (PVA) particles (n = 9 animals), 500-710- microm PVA particles (n = 1), or tris-acryl 500-700- microm gelatin microspheres (n = 2).

RESULTS

Two rabbits died 7 days after embolization and the other 10 rabbits had to be killed because of malaise and weight loss 4-8 d after embolization. In all animals, necropsy demonstrated extensive uterine necrosis sparing only the tip of the uterine horn.

CONCLUSION

Rabbits are an unsuitable model for studies of UAE with the embolic agents in clinical use.

Uterine artery embolization: sonographic imaging findings

OBJECTIVE

To examine the sonographic and angiographic imaging findings before and after uterine fibroid embolization for symptomatic leiomyoma.

METHODS

This prospective study involved 14 premenopausal women who underwent uterine fibroid embolization for symptomatic leiomyoma. Preprocedure sonography with color Doppler imaging was performed. Bilateral uterine artery embolization was successfully performed with the use of polyvinyl alcohol. Follow-up sonographic examinations were performed between 1 and 3 months after the procedure. The correlation between the sonographic appearance before and after embolization and the degree of decrease in uterine size was evaluated by using the Jonckheere-Terpstra 2-sided P test.

RESULTS

Preprocedure sonographic imaging showed a varied appearance to the fibroids. Color Doppler imaging primarily showed the fibroids to be vascular with marked peripheral blood flow. Postprocedure sonographic imaging showed decreased uterine size and echogenicity. Color Doppler imaging showed a marked decrease in the blood flow to the leiomyoma. There was no statistical significance in the relationship between echogenicity and vascularity shown before the procedure and the percent decrease in the size of the uterus.

CONCLUSIONS

Although sonography is an efficient method for identifying leiomyomata and determining the reduction in size after uterine artery embolization, we were unable to identify any predictive characteristics of success for aiding the preprocedural assessment.