Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial

Is uterine artery embolisation a safe and effective modality to treat submucosal fibroids?

HIGHLIGHTS

• Uterine fibroid embolization (UFE) reduced the median volume of dominant submucosal leiomyomas by 64% and achieved over 90% devascularization in 94.8% of cases.• High patient satisfaction was observed, with 84.5% of patients successfully discharged without needing further intervention.• Severe adverse events were rare, affecting only 3.2% of patients, with pelvic infections being the most significant.• Mild adverse events occurred in 16.8% of patients, including infections requiring antibiotics and persistent vaginal discharge.• A multidisciplinary approach is essential for managing patients with submucosal leiomyomas undergoing UFE to ensure optimal treatment outcomes.

Quality of life 1 year after uterine artery embolization vs hysterectomy for symptomatic adenomyosis (QUESTA study)

INTRODUCTION

Uterine artery embolization (UAE) is a less-invasive alternative for hysterectomy in therapy-resistant symptomatic adenomyosis. Comparative data are lacking. Our objective is to evaluate the non-inferiority of UAE compared with hysterectomy in improving health-related quality of life (HRQOL) for symptomatic adenomyosis, 1 year post-treatment.

MATERIAL AND METHODS

This multicenter randomized controlled trial was converted into a prospective cohort study. It was prospectively registered at 27-07-2015 (NL-OMON55436, https://onderzoekmetmensen.nl/en/trial/55436). From November 2015 to March 2022 participants with symptomatic adenomyosis eligible for hysterectomy were included and offered UAE as an alternative treatment. Primary endpoint was difference in 1-year HRQOL scores between UAE and hysterectomy, using WHO-QOL-Bref and SF-12. Non-inferiority margin was set at five points. Secondary endpoints: WHO-QOL-100 facets "Pain and Discomfort" and "Sexual Activity", adenomyosis-related symptoms, and satisfaction. Multivariable linear mixed models were used. All outcomes were analyzed in the per-protocol population, and repeated in the intention-to-treat population.

RESULTS

Of 101 participants, 51 chose hysterectomy and 50 UAE. Both treatment groups were comparable at baseline, except for employment status, dysmenorrhea score, uterine volume, hemoglobin and CA125 (all adjusted for). Both treatments led to a significant increase in all HRQOL scores after 1 year. The effect differences between UAE and hysterectomy on all HRQOL domains in the per-protocol population were: SF-12 physical β -4.20, (95% CI -9.53 to 1.12), SF-12 mental β -4.95 (95% CI -10.83 to 0.94); WHO-QOL-Bref physical β -7.42 (95% CI -18.51 to 3.68), psychological β -4.28 (95% CI -13.30 to 4.74), social relations β -2.23 (95% CI -13.09 to 8.63) and environment β 0.35 (95% CI -8.39 to 9.09). Non-inferiority of UAE was not demonstrated within the predefined margin. Both hysterectomy and UAE improved "Pain and Discomfort" and "Sexual Activity", with greater effect on pain after hysterectomy (β 17.17, 95% CI 4.94 to 29.41, p = 0.007). More participants were satisfied after hysterectomy (95%) than after UAE (73%).

CONCLUSIONS

Both UAE and hysterectomy significantly increased HRQOL for symptomatic adenomyosis. Neither non-inferiority nor inferiority of UAE could be established. One-year HRQOL scores were comparable; some secondary outcomes were in favor of hysterectomy. UAE is a valid less-invasive alternative to hysterectomy, with preservation of the uterus. Hysterectomy remains the treatment of choice for patients seeking a definite solution.

National Utilization Trends of Inpatient Procedures for Symptomatic Uterine Fibroids and Adenomyosis: A 10-Year Analysis

PURPOSE

The aim of this study was to determine changes in procedural utilization for symptomatic uterine fibroids and adenomyosis from 2011 to 2020.

METHODS

An institutional review board-exempt retrospective study of the National Inpatient Sample database from 2011 to 2020 was performed using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, diagnosis and procedural codes for uterine fibroids, adenomyosis, hysterectomy, myomectomy, uterine artery embolization (UAE), and endometrial ablation. Patients with endometriosis, uterine cancer, placenta accreta spectrum, pelvic inflammatory disease, and uterine prolapse were excluded. Data were analyzed using statistical process control and χ2 testing.

RESULTS

A total of 247,476 inpatient procedures were identified in women with fibroids and/or adenomyosis. Of those patients with only uterine fibroids (n = 212,532), 77.9% underwent hysterectomy, 18.9% underwent myomectomy, and 2.8% underwent UAE. The utilization of UAE remained stable over the decade, whereas an increased prevalence of myomectomy was offset by a decrease in hysterectomy (2011 versus 2020: hysterectomy, 81.4% versus 73.7%; myomectomy, 15.4% versus 24.0%; UAE, 2.9% versus 2.0%). Regarding adenomyosis only (n = 16,073), more women underwent hysterectomy (98.1%) compared with UAE (1.1%), with minimal change in these procedures across the decade. For combined fibroids and adenomyosis (n = 18,871), hysterectomy was the most utilized procedure, with its utilization declining from 92.0% to 85.2% during the time period.

CONCLUSIONS

The utilization of hysterectomy remains the dominant inpatient procedural intervention for the treatment of uterine fibroids and adenomyosis, but the proportion of myomectomy in the setting of fibroids is increasing. Utilization of UAE did not change from 2011 to 2020, and it remains relatively underutilized despite initiatives to increase utilization.

Associations between hysterectomy and pelvic floor disorders: a systematic review and meta-analysis

OBJECTIVE

Hysterectomy is the second most common surgery performed among women in the United States. The associations between hysterectomy and the risk of pelvic floor disorders remain unclear. The objective of this study is to systematically review the associations between hysterectomy and the likelihood of pelvic floor disorders.

DATA SOURCES

A systematic search of Medline and Embase from inception to October 11, 2024, was performed without language restrictions. The systematic review was registered in The International Prospective Register of Systematic Reviews (CRD42023443210).

STUDY ELIGIBILITY CRITERIA

Studies included randomized controlled studies and nonrandomized comparative studies (that reported adjusted analyses) of adult female individuals aged ≥18 years old who underwent a hysterectomy through any route for benign indications. At least 1 year of follow-up after hysterectomy was required. Studies of individuals undergoing concomitant surgery for pelvic floor disorders were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Twelve investigators independently screened each abstract and potentially eligible full-text article in duplicate. Data extraction, risk of bias assessment, and strength of evidence grading were conducted using standard instruments. Meta-analyses were performed using random-effects models. Outcomes included pelvic organ prolapse, urinary incontinence (nonspecific, mixed, and stress), overactive bladder, voiding dysfunction, fecal incontinence, and defecatory dysfunction. Results were stratified by time since hysterectomy (≤10 years vs >10 years).

RESULTS

We included 60 studies (8 randomized controlled trials, 20 cohort studies, and 32 case-control studies) with 3,567,848 participants. In the first 10 years, hysterectomy was associated with higher likelihood of (nonspecific) urinary incontinence (effect size 1.29, 95% confidence interval 1.11-1.47; 25 studies), stress urinary incontinence (effect size, 1.31; 95% confidence interval, 1.06-1.56; 14 studies), overactive bladder (effect size, 1.41; 95% confidence interval, 1.25-1.58; 16 studies), and mixed urinary incontinence (effect size, 1.62; 95% confidence interval, 1.40-1.85; 3 studies). Beyond 10 years, hysterectomy was associated with higher likelihood of pelvic organ prolapse (effect size, 1.56; 95% confidence interval, 1.35-1.78; 6 studies) and stress urinary incontinence (effect size, 2.40; 95% confidence interval, 2.17-2.63; 5 studies).

CONCLUSION

Hysterectomy is associated with a statistically significant higher likelihood of urinary incontinence of all types within 10 years, as well as pelvic organ prolapse and stress urinary incontinence beyond 10 years after hysterectomy. It is important to discuss these risks at the time of counseling for hysterectomy with consideration of medical or nonhysterectomy treatment options if clinically acceptable.

A Decade Long Analysis of Healthcare Disparities and Uterine Artery Embolization: An Exploration of Social Determinants of Health

PURPOSE

To determine the extent of impact that social determinants of health have on uterine artery embolization (UAE) utilization for treatment of symptomatic uterine fibroids.

MATERIALS AND METHODS

In this institutional review board (IRB)-exempt study, data from the 2011-2020 National Inpatient Sample were used to identify patients with International Classification of Diseases, 9th and 10th editions, codes of uterine fibroids who underwent UAE. Data collected included patient demographics (race/ethnicity, income, and insurance status) and procedure location (geographic region and hospital setting). Results are presented in percentage (UAE procedures per variable) and were analyzed using chi-square test.

RESULTS

UAE utilization by race/ethnicity demonstrated the following distribution: 45.6% non-Hispanic Blacks, 28.1% non-Hispanic Whites, 14.2% Hispanics, and 5.7% Asians. The lowest quartile for income experienced no change in utilization (27.8%), while the highest quartile gradually decreased across the decade (2011, 26.7%; 2020, 19.0%; P = .01). The Northeast region of the United States (49.0% in 2011) was superseded by the South (34.8% in 2020) as the dominant geographic region for UAE. The main insurance statuses were private (55.5%) and Medicaid (26.2%), with Medicaid rates increasing throughout the decade (2011, 18.2%; 2020, 28.6%; P < .001). Urban teaching hospitals accounted for the highest rates of total UAE (82.3%) compared with urban nonteaching (16.0%) and rural hospitals (1.2%).

CONCLUSIONS

Over the past decade, UAE has been performed in a relatively equitable fashion on the basis of income level, with improved utilization within the Medicaid population and throughout the geographic regions of the United States. When accounting for U.S. population representation and unequal disease burden, non-Hispanic Blacks demonstrated a greater-than-expected utilization of UAE compared with lower-than-expected rates among non-Hispanic Whites.

Polyethylene Glycol microspheres for uterine artery embolization for the treatment of symptomatic uterine fibroids

BACKGROUND

Uterine fibroids are prevalent benign pelvic tumors, often causing debilitating symptoms that impair quality of life. Uterine fibroid embolization (UFE) is a consolidated minimally invasive treatment option. The purpose of this study is to report our experience with polyethylene glycol microspheres (HydroPearl) in UFE for symptomatic patients.

METHODS

This single-center retrospective study evaluated 37 consecutive patients with symptomatic uterine fibroids referred to our institution since November 2016 to February 2020 for UFE with HydroPearl microspheres. All patients included completed a comprehensive pre-UFE clinical assessment and underwent a magnetic resonance imaging (MRI) pre- and post-procedure. Technical success, procedure-related complications, clinical outcomes, follow-up MRI findings, and patient satisfaction were evaluated.

RESULTS

A technical success rate of 97% with complete bilateral uterine artery embolization was achieved. Significant improvements were observed in menorrhagia, bulk-type symptoms, abdominal pain, and urinary dysfunctions after UFE. Post-procedural MRI assessments demonstrated reductions in uterine and dominant fibroid volumes, indicating successful devascularization. No immediate procedural complications were reported. Symptoms interfering with everyday activities significantly improved after the procedure. Patient satisfaction was high, with 89% expressing satisfaction with the treatment and 84% indicating purpose to repeat the procedure if necessary.

CONCLUSIONS

Uterine artery embolization with HydroPearl is a safe and effective treatment option for symptomatic uterine fibroids. A significant improvement in menorrhagia and bulk-type symptoms after the procedure was observed correlated by a reduction in diameters and volumes of both the uterus and the main fibroid in post-procedural MRI.

Risk Factors of Complications After Uterine Artery Embolisation for Symptomatic Fibroids: A Case-Control Study

OBJECTIVE

We aim to clarify potential risk factors of complications after uterine artery embolisation (UAE).

SETTING

Complications after uterine artery embolisation (UAE) for symptomatic fibroids are rare, but failure of treatment occurs for approximately 13%-24% of patients at 10 years.

DESIGN

We conducted a case-control study including all complications post UAE over 15 years in our specialised unit.

POPULATION

All Grade 2 complications (or worse) for the Society of Interventional Radiology Standards of Practice Committee complications post UAE were considered. One thousand one hundred seventy-two UAE were performed.

METHODS

Complications were divided into two groups: early (< 1 month) or late (≥ 1 month) to differentiate complications from failure of procedure. Multinomial analysis was conducted to assess links between complications and potential risk factors.

RESULTS

Sixty-nine (0.06%) complications were found: 24.6% hospitalisation for pain (n = 17/69), 30.4% for infection (n = 21/69) and 2.9% expulsion of fibroid (n = 2/69). Overall, 31 patients underwent a second procedure (45%).

MAIN OUTCOME MEASURES

Intra-uterine device and multiple fibroids were strongly related to early complications (ORearly = 4.44, IC 95%: 1.5-13.3 and ORearly = 3.7, IC 95%: 1.2-11.3, respectively). The only factor that appeared to be associated with risk of early and late complications was the major fibroid's diameter (for an increased size of 25 mm, ORearly = 1.7, IC 95%: 1.1-2.6; ORlate = 1.5, IC 95%: 1.04-2.2).

CONCLUSION

Our study enlightens about the potential risk factors of UAE's complications and differentiate their impact between early and late complications.

Insurance-Based Differences in Treatment Patterns for Uterine Fibroids

PURPOSE

The aim of this study was to examine whether Medicaid versus commercial insurance and reimbursement are associated with uterine artery embolization (UAE) utilization rates for uterine fibroid treatment.

METHODS

This retrospective (October 2015 to September 2023) study of women aged 30 to 59 years who underwent procedures for the treatment of uterine fibroids (hysterectomy, myomectomy, or UAE) was based on the Inovalon Insights dataset for those with Medicaid or commercial insurance. Differences in the receipt of UAE versus hysterectomy or myomectomy by insurance type and relative reimbursement were assessed using logistic regression controlling for patient characteristics and geographic differences in treatment patterns. For women with either hysterectomy or myomectomy, differences in the receipt of these procedures laparoscopically or not were assessed by insurance type and relative reimbursement controlling for patient characteristics and geographic differences in treatment patterns.

RESULTS

Medicaid compared with commercial insurance was associated with 38% higher odds of UAE (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.34-1.42). States with higher Medicaid reimbursement for hysterectomy were associated with lower odds for UAE (OR, 0.95; 95% CI, 0.92-0.98). For women with hysterectomy or myomectomy, those with Medicaid versus commercial insurance had 20% lower odds (OR, 0.80; 95% CI, 0.79-0.82) of undergoing the procedure laparoscopically.

CONCLUSIONS

Women insured by Medicaid versus commercial insurance were more likely to undergo the less invasive UAE procedure. Conversely, Medicaid patients who underwent hysterectomy or myomectomy were less likely to undergo the procedure laparoscopically. Both results are consistent with the notion that insurance status may influence both physician referral patterns and treatment options available to patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3B, Retrospective observational study.

Transarterial embolization to treat hemodynamically unstable trauma patients with splenic injuries: A retrospective multicenter observational study

PURPOSE

We described clinical outcomes for patients with blunt splenic injuries treated with transarterial embolization (TAE) based on their hemodynamic status.

MATERIALS AND METHODS

This is a retrospective two-center study of adult patients with splenic injuries who underwent emergency TAE between January 2011 and December 2022. Patients were divided into two groups; hemodynamically unstable (HDU) and hemodynamically stable (HDS) patients. HDU patients were defined as transient- or non-responders to fluid resuscitation and HDS as responders. When immediate laparotomy was not possible for HDU patients, angiography and embolization were performed. The primary outcome was the survival discharge rate. Rebleeding and splenectomy rate was also investigated.

RESULTS

Of 38 patients underwent emergency TAE for splenic trauma, 17 were HDU patients and 21 were HDS patients. The survival discharge rate was 88.2 % (15/17) in the HDU- and 100 % in HDS patients (p = 0.193). Rebleeding rate was 23.5 % (4/17) in HDU- and 5.0 % (1/21) in HDS patients (p = 0.15). Splenectomy was required for one HDU patient (5.9 %) for rebleeding.

CONCLUSION

The survival discharge rate of TAE for splenic trauma in HDU patients was acceptable with a low rate of splenectomy. Further comparative studies of TAE versus operative management in HDU patients are needed to prove the usefulness of TAE.

High-Intensity Focused Ultrasound Ablation Combined With Hysteroscopy for the Treatment of Uterine Arteriovenous Fistula Associated With Retained Products of Conception: A Prospective Cohort Study

STUDY OBJECTIVE

To evaluate the efficacy of combining high-intensity focused ultrasound (HIFU) ablation with hysteroscopic removal of retained products of conception in the presence of a uterine arteriovenous fistula (UAVF).

DESIGN

Prospective cohort study SETTING: Tertiary hospital.

PATIENTS

Seventeen patients with UAVF and retained products of conception.

INTERVENTIONS

HIFU ablation combined with hysteroscopic removal of retained products of conception.

MEASUREMENTS AND MAIN RESULTS

All patients presented with irregular vaginal bleeding following pregnancy termination and were not responsive to medical treatment. Patients were confirmed to have a UAVF along with concurrent intrauterine residue using three-dimensional color Doppler ultrasonography, uterine angiography, or pelvic-enhanced magnetic resonance imaging; and demonstrated a poor response to medical treatment. Under real-time ultrasound guidance, HIFU was used to ablate the arteriovenous malformation region. Patients underwent hysteroscopic removal of retained products of conception; the removed tissue was subjected to pathological examination. All patients underwent monthly uterine color Doppler ultrasound examinations and menstrual status follow-up within 3 months postoperatively and showed normal menstrual recovery without signs of arteriovenous malformations on ultrasonography. Pathological examination of the tissues removed during hysteroscopic clearance revealed characteristics consistent with pregnancy, with abnormal blood vessels in some tissues. All patients experienced normal menstrual recovery postoperatively, without intrauterine adhesions.

CONCLUSION

Combining HIFU ablation with postoperative hysteroscopic surgery effectively treats pregnancy-related UAVF with minimal complications and preserves fertility, it offers an additional treatment option for patients wanting future fertility.

Clinical outcomes after 2-year follow-up of transvaginal radiofrequency ablation of symptomatic uterine fibroids

AIM

The aim of this study was to evaluate the efficacy after 2 years follow-up of transvaginal radiofrequency ablation (TVRA) to treat myomas, and to identify factors predictive of the response to the treatment.

METHODS

This is a prospective cohort study of a 2-year follow-up of 65 patients who underwent TVRA for the treatment uterine fibroids at Virgen de las Nieves University Hospital in Granada, Spain. Ultrasound mean fibroid volume, symptom severity scale, total bleeding days, complications, pregnancy outcomes were recorded.

RESULTS

Statistically significant improvements in symptoms and bleeding were observed at 6, 12, and 24 months after the procedure. The mean myoma volume (cc) was significantly lower (p < 0.05) at 12 and 24 months, with a mean reduction in myoma volume of more than 80% and 60%, respectively. After a 24-month follow-up, 5 patients (7.7%) required additional surgical treatment to control symptoms. Patient age (>40 years), initial myoma size, and the timing of radiofrequency were identified as factors related to outcomes in the bivariate analysis.

CONCLUSIONS

Transvaginal radiofrequency ablation is an effective and safe technique for the treatment of myomas after 2 years of follow-up, which improves the symptoms of the patients and decreases the final volume of the myoma.

Uterine artery projection relative to anatomical bony landmarks in CT-angiographies

PURPOSE

The aim was to find bony landmarks of the pelvis for the origins and routes of uterine arteries, hoping to improve speed and safety of embolization procedures (leiomyoma, post-partum bleedings…).

METHODS

We carried out a study based on the analysis of CT-angiographies in arterial phases of whole-body scans. Two measurements were done per artery, one from the origin of uterine arteries to a first perpendicular line passing through the lowest part of the sacroiliac joint, another one from the beginning of the parametrial segment from a second parallel line passing by the acetabular roof. Mean distances across all these measurements were calculated, as were potential associations with known variables such as anatomical variants, age, parity and any pelvic surgical history.

RESULTS

Two hundred uterine arteries were analyzed. Concerning the origin, 83.5% of uterine arteries were located approximately one centimeter around the first line defined above, with a mean distance of + 4.8 mm. Concerning parametrial segment beginning, 88% were located approximately one centimeter around the second line defined, with a mean distance of only + 3.9 mm above the acetabular roof. Some significant differences were observed in subgroups, notably with a small trend to higher arising of uterine arteries in patients who had at least one childbirth, and expectedly lower arising in distal anatomical variants.

CONCLUSION

Clear pelvic anatomic landmarks exist and could help the guidance of arteries catheterization, and therefore indirectly lead to faster embolization and optimize procedures safety.

Retrospective case-control study on radiation dose for uterine artery embolization procedures

INTRODUCTION

Uterine artery embolization is performed in pre-menopausal women. Understanding the contribution of radiation dose at each stage of the procedure is important for potential dose reduction. The aim was to retrospectively analyse radiation dose on a per-procedural-stage basis, comparing digital subtraction angiography (DSA) and conventional roadmap (CRM).

METHODS

Group A consisted of 50 patients where DSA was used for road mapping at all stages: (I) Aortogram, (II) Left internal iliac artery (IIA) DSA, (III) Left uterine artery (UA) DSA, (IV) Right IIA DSA and (V) Right UA DSA. Group B included 50 patients, where CRM was used for road mapping at stages (II) and (IV).

RESULTS

For Group A, mean total dose-area product (DAP) was 39.7 Gy·cm2; mean DAP for each stage were (I) Aortogram = 3.4 Gy·cm2, (II) Left IIA DSA = 5.9 Gy·cm2, (III) Left UA DSA = 3.2 Gy·cm2, (IV) Right IIA DSA = 5.5 Gy·cm2 and (V) Right UA DSA = 3.0 Gy·cm2. For Group B, mean total DAP was 33.6 Gy·cm2, mean DAP for each stage were (I) Aortogram = 3.3 Gy·cm2, (II) Left IIA CRM = 1.5 Gy·cm2, (III) Left UA DSA = 3.3 Gy·cm2, (IV) Right IIA CRM = 1.5 Gy·cm2 and (V) Right UA DSA = 3.3 Gy·cm2. Fluoroscopy time was 10 and 9.4 min for Groups A and B, respectively.

CONCLUSION

The highest road-mapping radiation dose contribution was from bilateral IIA DSA. The use of CRM, intermittent fluoroscopy and elimination of the aortogram is recommended to further reduce procedural radiation dose.

Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register-based study in the Netherlands

INTRODUCTION

Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice.

MATERIAL AND METHODS

We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions.

RESULTS

Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (β = 0.11; P = 0.21) and therapeutic hysteroscopy rates (β = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (β = 0.10; P = 0.34) and negatively associated with both embolization rates (β = -0.08; P = 0.08) and myomectomy rates (β = -0.03; P = 0.82).

CONCLUSIONS

Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update

Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Recurrence of Uterine Fibroids After Conservative Surgery or Radiological Procedures: a Narrative Review

The present narrative review aims to discuss the available data on the incidence and the risk factors of uterine fibroids (UFs) recurrence after different types of conservative surgical or radiologic procedures in women wishing to preserve their uterus. UFs are the most common benign tumors in women all over the world. Clinical presentation, including abnormal uterine bleeding (AUB), pelvic pain, bulky symptoms, and infertility affect patients' quality of life, and a large variety of conservative treatments are available especially for those with desire of pregnancy. Fertility sparing surgery, by either laparoscopy, hysteroscopy or laparotomy, or radiological interventions (uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound), are the most common therapeutic approaches. However, the genetic or acquired predisposition to UFs remain despite the treatments, and the recurrences are frequently described in a large percentage of patients. The most relevant risk factors for recurrence of UFs are young age at the first surgery, incomplete fibroid resection, the presence of multiple lesions, an enlarged uterus, and the coexistence with other pelvic diseases. The discussion on the possible medical strategy to reduce the recurrence is an open field of clinical investigation, in particular by using hormonal drugs.

Periostin's role in uterine leiomyoma development: a mini-review on the potential periostin poses as a pharmacological intervention for uterine leiomyoma

Uterine leiomyomas, also known as fibroids or myomas, occur in an estimated 70-80% of reproductive aged women. Many experience debilitating symptoms including pelvic pain, abnormal uterine bleeding (AUB), dyspareunia, dysmenorrhea, and infertility. Current treatment options are limited in preserving fertility, with many opting for sterilizing hysterectomy as a form of treatment. Currently, surgical interventions include hysterectomy, myomectomy, and uterine artery embolization in addition to endometrial ablation to control AUB. Non-surgical hormonal interventions, including GnRH agonists, are connotated with negative side effects and are unacceptable for women desiring fertility. Periostin, a regulatory extra cellular matrix (ECM) protein, has been found to be expressed in various gynecological diseases including leiomyomas. We previously determined that periostin over-expression in immortalized myometrial cells led to the development of a leiomyoma-like cellular phenotype. Periostin is induced by TGF-β, signals through the PI3K/AKT pathway, induces collagen production, and mediates wound repair and fibrosis, all of which are implicated in leiomyoma pathology. Periostin has been linked to other gynecological diseases including ovarian cancer and endometriosis and is being investigated as pharmacological target for treating ovarian cancer, post-surgical scarring, and numerous other fibrotic conditions. In this review, we provide discussion linking pathological inflammation and wound repair, with a TGF-β-periostin-collagen signaling in the pathogenesis of leiomyomas, and ultimately the potential of periostin as a druggable target to treat leiomyomas.

Evaluation of Uterine Fibroid Vascularity Using Contrast-Enhanced Ultrasound in Comparison with Contrast-Enhanced Magnetic Resonance Imaging

OBJECTIVE

The aim of the work described here was to assess uterine fibroid vascularity using contrast-enhanced ultrasound (CEUS) as compared with magnetic resonance imaging (MRI).

METHODS

Forty women diagnosed with symptomatic uterine fibroids scheduled for uterine artery embolization (UAE) were enrolled in this institutional review board-approved study. Before UAE, participants underwent CEUS examination with an Aplio i800 scanner (Canon Medical Systems, Tustin, CA, USA) with curvilinear array (8C1). CEUS was performed using 2.0 mL of the ultrasound contrast agent Lumason (Bracco, Milan, Italy) administered intravenously. Digital CEUS clips were acquired and randomized offline, and fibroids were characterized as hyper- or hypovascular. MRI was used as reference standard for fibroid vascularity and compared with CEUS. Results were analyzed using McNemar's test.

RESULTS

Forty participants were enrolled in the trial. One patient did not proceed with the UAE procedure and one patient refused pre-procedure MRI because of claustrophobia. Therefore, 38 participants underwent CEUS and MRI examinations before UAE. Hypervascular fibroids were seen on MRI and CEUS in 24 and 26 participants, respectively. Hypovascular fibroids were seen with MRI and CEUS in 14 and 12 participants, respectively. Fibroids characterized as hypovascular in two participants by MRI were characterized as hypervascular by CEUS. CEUS and MRI findings were similar in 36 of 38 participants, corresponding to an accuracy of 95% (p = 0.62).

CONCLUSION

Contrast-enhanced ultrasound can accurately assess uterine fibroid vascularity, serving as a potential alternative to MRI in determination of the vascularity of uterine fibroids.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

Role of interventional radiology in obstetrics and gynaecology: a clinical review of an experience in a quaternary care centre

OBJECTIVE

The study aims to equip both Obstetricians and Gynaecologists with the knowledge of clinical conditions that will benefit from interventional radiology, equipment and materials that are commonly used, benefits, complications and the side effects of these techniques.

METHODS

It was a single-centre, retrospective cohort study with examples from hospital practice during the period of 2015 to 2021, acquired through computerised database including all obstetrics and gynecological cases in which interventional radiology techniques were used. No statistical analysis of data was applicable as it was a single-centre retrospective analysis of cases.

RESULTS

We had a total of 35 cases, including but not limited to placenta accreta spectrum disorders, fibroid, pelvic congestion syndrome and arteriovenous malformation who underwent various interventional radiological procedures ranging from embolization of uterine artery, peripheral angiography, embolization, and internal iliac artery balloon placement to ovarian vein embolization and coil insertion.

CONCLUSION

Increased collaborative efforts between interventional radiology and gynaecology would allow patients to be fully informed on the complete spectrum of surgical and nonsurgical treatment options available to them.

In vivo revascularization and tissue effects of uterine artery embolization with starch microspheres in sheep

OBJECTIVE

In uterine artery embolization (UAE) for the treatment of fibroids, nondegradable particles permanently occlude the uterine artery (UA). These particles remain in the vessels and can cause secondary undesirable effects, such as severe pain after embolization and fertility issues. In this prospective experimental study, we aimed to evaluate the angiographic recanalization, local and systemic reactions, and uterine damage occurring after performing UAE with newly developed degradable starch microspheres (DSMs) in sheep.

MATERIALS AND METHODS

Under general anesthesia, eight nonpregnant sheep underwent bilateral UAE using DSMs to achieve stasis. Angiographic evaluation was performed on days 1, 3 and 7 after embolization to assess in vivo recanalization. In addition, the angiographic series were scored via a modified embolization score. A postmortem tissue examination was performed to determine whether DSMs and foreign body inflammatory reactions were present and to assess uterine necrosis.

RESULTS

Complete bilateral embolization of the UA and cervicovaginal branches was achieved in all treated animals. Recanalization of the occluded arteries was evident in 25 of 27 arteries during the angiographic evaluation. In all sheep, there were multifocal areas of uterine necrosis, and some uterine vessels contained intraluminal material consistent with DSMs. The average weight of both uterine horns was significantly correlated with both the number of microspheres needed for complete embolization (r = 0.69, ρ<0.01) and the average percentage of necrosis in both uterine horns (r = 0.64, ρ<0.05).

CONCLUSIONS

Our findings demonstrated the efficacy of vascular embolization with DSM by inducing ischemic changes in the uterus and subsequent recanalization of previously occluded arteries.

Incidence and changes in endometrial-leiomyoma fistula following uterine artery embolization: a single-center retrospective analysis

OBJECTIVES

To investigate whether the number and size of endometrial-leiomyoma fistulas (ELFs) change following uterine artery embolization (UAE) for leiomyoma and the correlation between ELFs and vaginal discharge (VD).

MATERIALS & METHODS

This study was a retrospective analysis of 100 patients who underwent UAE at a single institution between May 2016 and March 2021. They all underwent MRI at baseline, 4 months, and 1 year after UAE. The number and size of the ELFs were compared with the MRI images each time. The ELF tumor characteristics and the correlation between the ELFs and VD were assessed. Additional gynecologic interventions due to VD associated with ELFs were evaluated.

RESULTS

No ELF was observed at baseline. Ten ELFs were noted in nine patients at 4 months, and 35 ELFs were noted in 32 patients 1 year after UAE. The ELFs significantly increased over time (p = 0.004, baseline vs. 4 months; p < 0.001, 4 months vs. 1 year). The ELF size did not significantly change over time (p = 0.941). The tumors developing ELFs after UAE were mainly located at the submucosal or intramural area contacting the endometrium at baseline, with a mean size of 7.1 (2.6) cm. Nineteen patients (19%) had VD 1 year after UAE. There was no significant correlation between VD and the number of ELFs (p = 0.80). No patients underwent additional gynecologic interventions due to VD associated with ELFs.

CONCLUSION

ELFs increased in number and did not disappear over time after UAE in most tumors.

CLINICAL RELEVANCE STATEMENT

Despite the MR imaging findings, within the limited data of this study, ELFs were not seemingly associated with clinical symptoms, including VD.

KEY POINTS

• Endometrial-leiomyoma fistula (ELF) is a complication of uterine artery embolization (UAE). • ELFs increased in number over time after UAE and did not disappear in most tumors. • Most tumors developing ELFs after UAE were located near/contacted the endometrium and were larger.

Superior Hypogastric Nerve Blockade for Uterine Artery Embolization: A Systematic Review

Superior hypogastric nerve block (SHNB) has potential to reduce pain following uterine artery embolization (UAE). However, existing studies are limited by design, sample size, or conflicting results. A systematic review of the literature was performed. Outcomes included technical success, time to complete SHNB, time under fluoroscopy, procedure time, time to recovery, needle repositioning, same-day discharge, readmission, pain, analgesic consumption, and adverse events. Of 15 included studies, the same-day discharge rate was 98.8%, and readmission rate was 6.9%. The mean pain score was 3.4 in patients who received SHNB compared to 4.3 among controls. Of patients who received SHNB, 46.7% did not require further pain medication. Major adverse events occurred in 0.4% of patients. Early clinical studies suggest that SHNB appears to reduce pain and analgesic consumption in patients undergoing UAE. Additional randomized trials are needed to confirm these findings.

Our Experience with Hydrogel-Coated Trisacryl Microspheres in Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids and Adenomyosis: A Follow-Up of 11 Years

Uterine artery embolization (UAE) for the treatment of symptomatic uterine fibroids and non-controllable adenomyosis symptoms is a relatively new procedure for organ-preserving therapy. These benign conditions can become symptomatic in about 30% of women between the ages of 35 and 50. The purpose of the UAE either for fibroids or adenomyosis is the elimination of blood loss, the reduction in pain, and bulky or rectal pressure symptoms. The purpose of this study is to present our experience in UAE with the use of hydrogel-coated tris acryl microspheres for the treatment of symptomatic uterine fibroids and adenomyosis.

Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review

Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted.

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

OBJECTIVE

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

DESIGN

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

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Contrast-Enhanced Ultrasound and High Sensitive Doppler for Monitoring Outcomes of Uterine Artery Embolization

RATIONALE AND OBJECTIVES

To monitor fibroid microvascularity using contrast-enhanced ultrasound (CEUS) and a new high-sensitive Doppler mode (SMI) for assessment of uterine artery embolization (UAE) outcomes.

MATERIALS AND METHODS

Forty women with symptomatic uterine fibroids scheduled for UAE were enrolled in this Institutional Review Board-approved study. Subjects underwent three examinations (day 0, 15, and 90 post-UAE) with Color Doppler (CDI), power Doppler (PDI), color and monochrome SMI (cSMI and mSMI), and CEUS imaging of the fibroids. Clips were assessed by two radiologists classifying fibroids based on their vascularity. Fibroid fractional vascularity (FV; % of enhanced pixels within the fibroid) and flow intensity (as mean brightness level of the enhanced pixels) were quantified. Results were analyzed using repeated measures ANOVA and nonparametric Wilcoxon sign rank tests. Inter-reader agreement was assessed with κ-values.

RESULTS

There was overall agreement between readers for all imaging modalities and examination times (P = .25; κ = 0.70). The FV analysis showed statistically significant differences between CEUS and the Doppler imaging modes (CDI, PDI, cSMI, and mSMI) for the three examination times were compared (P < .0001). The comparison using CDI, PDI, and cSMI showed no statistically significant difference (P = .53). The flow intensity analysis comparison between the Doppler imaging modes (CDI, PDI, cSMI and mSMI) and examination times showed statistically significant differences between all the Doppler imaging modalities (P = .02), except for the 90days post-UAE (P = .34). When the comparison was made for CDI, PDI, and cSMI there was no statistically significant differences (P < .47).

CONCLUSION

CEUS and SMI can accurately evaluate fibroid microvascularity, and therefore, can be a noninvasive and accurate method for monitoring outcomes following UAE treatment.

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

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

Uterine artery embolization in Tanzania: a procedure with major public health implications

BACKGROUND

The burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment.

METHODS

From June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania's first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests.

RESULTS

During the study period, 92.1% (n = 35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n = 3/38) for adenomyosis. All (n = 38/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p < 0.01). 100% of patients reported satisfaction with outcomes. Among the nine patients with follow-up imaging, there was a mean volumetric decrease of 35.5% (p = 0.109).

CONCLUSIONS

UAE for fibroids and adenomyosis can be performed with high technical success and low complication rates in a low-resource setting like Tanzania, resulting in significant symptom relief for patients. Building capacity for UAE has major public health implications not only for fibroids and adenomyosis, but can help address the region's leading cause of maternal mortality, postpartum hemorrhage.

Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review

OBJECTIVE

To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans.

METHODS OF STUDY SELECTION

Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible.

TABULATION, INTEGRATION, AND RESULTS

Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature.

CONCLUSION

Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272678.

New treatment options for nonsurgical management of uterine fibroids

PURPOSE OF REVIEW

Uterine fibroids is a common problem in reproductive-age individuals, frequently causing abnormal uterine bleeding, bulk symptoms, and adverse reproductive outcomes. Traditionally, almost half of the women with symptomatic fibroids received surgery for definitive treatment. There are a growing number of nonsurgical options for treatment that have become available for patients who desire conservative treatment or those with contraindications to surgery.

RECENT FINDINGS

The introduction of oral gonadotropin-releasing hormone antagonists in combination with low-dose physiologic hormonal therapy demonstrated improvement in heavy menstrual bleeding, pain, and quality of life with preservation of bone density and a modest reduction in uterine volume with few hypogonadal side effects. Magnetic resonance-guided focused ultrasound surgery and uterine artery embolization continue to be minimally invasive procedural alternatives to hysterectomy that are safe and effective.

SUMMARY

As more options for conservative management of uterine fibroids became available, it is important to counsel patients on possible options based on the size, location, and number of the fibroids as well as severity of the symptoms, plans for pregnancy, how close they are to menopause and their treatment goals.

Intravoxel incoherent motion diffusion-weighted MRI for predicting the efficacy of high-intensity focused ultrasound ablation for uterine fibroids

Purpose

To evaluate the significance of magnetic resonance (MR) intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) quantitative parameters in predicting early efficacy of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids before treatment.

Method

64 patients with 89 uterine fibroids undergoing HIFU ablation (51 sufficient ablations and 38 insufficient ablations) were enrolled in the study and completed MR imaging and IVIM-DWI before treatment. The IVIM-DWI parameters, including D (diffusion coefficient), D* (pseudo-diffusion coefficient), f (perfusion fraction) and relative blood flow (rBF) were calculated. The logistic regression (LR) model was constructed to analyze the predictors of efficacy. The receiver operating characteristic (ROC) curve was drawn to assess the model's performance. A nomograph was constructed to visualize the model.

Results

The D value of the sufficient ablation group (931.0(851.5-987.4) × 10-6 mm2/s) was significantly lower than that of the insufficient ablation group (1052.7(1019.6-1158.7) × 10-6 mm2/s) (p<0.001). However, differences in D*, f, and rBF values between the groups were not significant (p>0.05). The LR model was constructed with D value, fibroid position, ventral skin distance, T2WI signal intensity, and contrast enhanced degree. The area under the ROC curve, specificity, and sensitivity of the model were 0.858 (95% confidence interval: 0.781, 0.935), 0.686, and 0.947. The nomogram and calibration curves confirmed that the model had excellent performance.

Conclusion

The IVIM-DWI quantitative parameters can be used to predict early effects of HIFU ablation on uterine fibroids. A high D value before treatment may indicate that the treatment will be less effective in the early stages.

Comparison of Recurrence and Quality of Life Between Myoma Embolization and Myomectomy

INTRODUCTION

Uterine myomas represent the most frequently diagnosed tumors among women of childbearing age. Symptoms often include profuse menstrual bleeding, diminished quality of life, and in some cases, infertility. The size and position of the fibroids typically influence the condition's manifestations. Moreover, symptomatology often varies depending on the fibroids' location. This investigation aimed to discern if there exists a significant correlation between life quality, reoccurrence rate, quality of life, and recurrence levels among patients who have undergone myomectomy and uterine fibroid embolization, respectively.

METHODOLOGY

A retrospective cross-sectional study was conducted to compare the rates of recurrence and impacts on life quality between uterine fibroid embolization and myomectomy in women diagnosed with uterine myomas. Data were collected from 152 women who sought treatment at the Obstetrics and Gynecology clinic and also the Interventional Radiology clinic between January 2009 and January 2021. Thirteen participants were excluded due to the inability to maintain contact. The trial encompassed 76 patients who underwent myomectomy and 63 who had uterine fibroid embolization. In both groups, the life quality of 50 patients, five years postsurgery, was assessed using the UFS-QOL measure. Eligible participants were females between 20 and 40 years, with symptomatic Type 3-5 fibroids as per the FIGO classification, and with no comorbidities. Individuals under 20 or over 40 years, or those with fibroids classified as FIGO types 1,2,6,7,8, were not included. Other exclusion criteria included pregnancy status, abnormal endometrial biopsy results, abnormal smear tests, polyps, cancer, adenomyosis and coagulation disorders.

RESULTS

The recurrence of fibroids was identified through symptomatology and diagnostic radiological methods. The recurrence rate was found to be 31.6% (n=24) for myomectomy patients and 14.3% (n=9) for those who underwent uterine fibroid embolization, with no statistically significant difference between the two groups (p > 0.05). The group subjected to myomectomy exhibited fewer symptoms, lower anxiety, and better physical mood scores. The myomectomy group displayed higher average anxiety scores (p<0.01). There were no significant disparities in control, consciousness, sexual function, or overall scores between the two groups. Symptoms and anxiety saw a marked reduction in the first postoperative year compared to the preoperative period (p<0.01). Compared to presurgery, energy, mood, awareness, and sexual function exhibited significant improvements in the first and fifth postoperative years (p<0.01).

CONCLUSIONS

Our findings suggest a nonsignificant recurrence rate in the myomectomy group compared to the uterine artery embolization group. Notably, the decrease in symptom occurrence and anxiety following myomectomy was significantly favorable in terms of quality of life. While embolization was offered as a therapeutic option, myomectomy yielded more favorable results concerning quality of life.

Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids of Different Sizes: A Single Center Experience

The present study aimed to evaluate the clinical and radiological 1-year outcomes of uterine artery embolization (UAE) performed in a selected population of women with symptomatic myomas and who do not wish to conceive. Between January 2004 and January 2018, a total of 62 patients with pre-menopausal status and with no wish to conceive in the future underwent UAE for the treatment of symptomatic fibroids. All the patients underwent magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TV-US) before and after the procedure at 1-year follow-up. Clinical and radiological parameters were recorded, stratifying the population into 3 groups according to the size of the dominant myoma (group 1: <50 mm; group 2: ≥50 and ≤80 mm; group 3: >80 mm). Mean fibroid diameter was significantly reduced (42.6% ± 21.6%) at 1-year follow-up, with excellent improvements in terms of both symptoms and quality of life. No significant difference was observed regarding baseline dimension and the number of myomas. No major complications were reported (2.5%). The present study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids in pre-menopausal women with no desire to conceive.

A Comparative Analysis of Health-Related Quality of Life 1 Year Following Myomectomy or Uterine Artery Embolization: Findings from the COMPARE-UF Registry

Objective: To compare 12-month post-treatment health-related quality of life (HR-QoL) and symptom severity (SS) changes among patients with symptomatic uterine fibroids (SUF) not seeking fertility and undergo a hysterectomy, abdominal myomectomy (AM), or uterine artery embolization (UAE). Materials and Methods: The Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF) Registry is a multi-institutional prospective observational cohort study of patients treated for SUF. A subset of 1465 women 31-45 years of age, who underwent either hysterectomy (n = 741), AM (n = 446), or UAE (n = 155) were included in this analysis. Demographics, fibroid history, and symptoms were obtained by baseline questionnaires and at 1 year post-treatment. Results were stratified by all treatments and propensity score weighting to adjust for differences in baseline characteristics. Results: Women undergoing UAE reported the lowest baseline HR-QoL and highest SS scores (mean = 40.6 [standard deviation (SD) = 23.8]; 62.3 [SD = 24.2]) followed by hysterectomy (44.3 [24.3]; 59.8 [SD = 24.1]). At 12 months, women who underwent a hysterectomy experienced the largest change in both HR-QoL (48.7 [26.2]) and SS (51.9 [25.6]) followed by other uterine-sparing treatments. Propensity score weighting revealed all treatments produced substantial improvement, with hysterectomy patients reporting the highest HR-QoL score (92.0 [17.8]) compared with myomectomy (86.7 [17.2]) and UAE (82.6 [21.5]) (p < 0.0001). Similarly, hysterectomy patients reported the lowest SS scores (8.2 [15.1]) compared with myomectomy (16.5 [15.1]) and UAE (19.6 [17.5]) (p < 0.0001). Conclusion: All procedures showed improvement in HR-QoL and reduction in SS score at 12 months, hysterectomy showing maximum improvement. Of importance, at 12 months, patients who underwent either a myomectomy or UAE reported comparable symptom relief and HR-QoL. Clinicaltrials.Gov Identifier: NCT02260752.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

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

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

Uterine Fibroid Embolization or Myomectomy: How Much Marketing Is Enough? Comparative Analysis of Public Search Trends in Google and Medical Publications in PubMed

To compare public popularity and volume of scientific publications regarding uterine fibroid embolization (UFE) and myomectomy. Google Trends and PubMed data were queried to assess temporal variations in online public search volumes and number of research publications for UFE and myomectomy. Time series analysis was used to identify meaningful temporal trends and forecast a future trend. Compared with UFE, myomectomy had significantly higher volumes of public online search and research publications, with an increasing trend over time (P < .0001). The forecasting models predicted a continuing increase in both public search volumes and number of research publications for myomectomy and static future trends in these metrics for UFE. This study signals significantly lower public popularity and research efforts for UFE compared with myomectomy for uterine fibroids. More effective marketing strategies and further research support will be needed to fill this gap.

Combination of microspheres and gadoteridol for the determination of non-target ovarian embolization during uterine artery embolization. A case series

Background. Uterine myoma is the most common benign tumor of the pelvic organs in women. One of the effective therapies for myomas is uterine artery embolization (UAE), which can be associated with unintended ovarian embolization. However, there is no certainty about the effect of unintended ovarian embolization on fertility and ovarian function since no precise evidence-based ways of identifying unintended embolization have been described. Aim. To develop a highly accurate method for identifying unintended ovarian embolization during UAE. Materials and methods. A series of clinical cases of the utilization of combined embolization material based on the paramagnetic contrast agent gadoteridol and saturable HepaSphere microspheres are presented. Results. On admission, patients underwent magnetic resonance imaging (MRI) of the pelvic organs with contrast enhancement. After UAE with this combined embolization material, another pelvic MRI without contrast enhancement was performed on the in-hospital day 2. In the first clinical case, no hyperintensive zones were detected in the ovarian stroma. However, in the second case, a previously undetected hyperintensive signal up to 6 mm in diameter was seen in the stroma of the left ovary by repeat MRI. Conclusion. Using this combined material during UAE significantly increases the accuracy of possible unintended ovarian embolization detection as soon as in the early postoperative period.

Safety and effectiveness of uterine fibroid embolization in patients with scarred uterus

AIM

To evaluate the safety and effectiveness of uterine fibroid embolization (UFE) in patients with a scarred uterus caused by a previous myomectomy or cesarean section.

METHODS

A total of 140 patients who underwent embolization for symptomatic fibroids were included in this retrospective study. The patients were divided into two groups, those with a history of myomectomy and/or cesarean section (scarred uterus group, n = 56), and those without surgical history involving the uterus (no-scar group, n = 84). Demographics, embolization details, outcomes, and complications were analyzed.

RESULTS

The overall clinical success rate was 89.28% in the scarred uterus group and 95.24% in the no-scar group. There was no statistical difference in infarction rate or change in fibroid volume in follow-up magnetic resonance imaging between the groups. There was one major complication in the no-scar group, but there was no statistical difference in complications between the groups. The mean follow-up period was 25.9 months. The mean symptom-free time was 27.2 months in the scarred uterus group and 21.9 months in the no-scar group without a significant difference. There were no statistically significant differences in symptom changes, recurrence, and complication rates between the groups. Recurrence seen on imaging or regrowth was more common in the group with myomectomy history. However, there was no significant difference in symptom recurrence rates.

CONCLUSION

No statistically significant difference in technical and clinical outcomes was observed between the two groups. There was no significant increase in complication rates of UFE in scarred uterus group.

Embolization for the treatment of large, complex fibroids in an outpatient setting: A report of 2 cases

Uterine leiomyomas are the most common benign pelvic tumors in premenopausal women, causing significant morbidity. Uterine fibroid embolization is a minimally invasive alternative to traditional open or laparoscopic surgeries for the management of symptomatic uterine leiomyoma. For large fibroids, hospitalization after treatment is often required. However, there are limited data on patients with large, complex uterine leiomyomas treated by embolization. This report of 2 cases describes 2 females with large, complex fibroids causing pain and decreased quality of life who were evaluated and treated with embolization in the outpatient setting. Each patient underwent transradial cannulation and uterine artery embolization under local anesthesia or conscious sedation and returned home without complication. For women wishing to preserve their uterus, uterine fibroid embolization is an effective nonsurgical alternative to hysterectomy and myomectomy in an outpatient setting. If standard protocols are followed, embolization by way of transradial artery catheterization is safe for the treatment of large, complex, symptomatic fibroids in the outpatient setting; however, additional studies with larger cohorts are warranted. Accessing the uterine arteries transradially reduces the risk of intra- and post-operative complications for patients, reduces their time spent in a hospital, and minimizes operating costs.

Life Quality in Premenopausal Women after Embolization of Uterine Myomas

Objectives: Fibroids cause significant morbidity and are the most common indication for hysterectomies worldwide, delimiting a major public health problem. Uterine artery embolization (UAE) is an alternative therapy to surgical treatment of symptomatic fibroids; it has satisfactory long-time results and is no longer considered investigational for the treatment of symptomatic fibroids. This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after UAE and to optimize the assessment of safety and outcomes measures for participants who receive UAE to objective compare UAE and surgical alternatives for therapy of symptomatic fibroids. Study design: The analysis was based on questionnaires completed by 270 pre-menopausal females with a mean age of 42 years (range, 38-50 years) who underwent UAE for uterine leiomyomas and/or adenomyosis from November 2013 through December 2019. Only symptomatic women were selected whose symptoms were not improving with medication and who did not wish to have children. The primary outcome measure was a change in fibroid symptoms and HRQOL (health related quality of life) after UAE. Secondary outcomes included the decrease in uterine volume after UAE. Results: Questionnaires were completed by 270 women (100%) at a mean of 12.1 months from UAE. The median follow-up period was two years. Uterine fibroid embolization led to a shrinkage at three months for the 90% of the participants. A reduction of bleeding symptoms, pain and bulk-related symptoms was observed in 89.7%, 88.9%, and 89.5% of the patients, respectively. In the long term, there was no significant difference in parameters assessed compared with the midterm follow-up findings. A total of 6 patients (2.3%) underwent fractional curettage an average of 32.1 months after intervention due to necrotic changes in submucosal fibroids. All participants continued to be satisfied with the intervention, and 240 patients (88.9%) answered that they would recommend uterine fibroid embolization to other patients. Conclusions: Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL which is associated with high levels of satisfaction with the procedure (even when subsequent therapies are pursued).

Uterine Artery Embolisation of Fibroids and the Phenomenon of Post-Embolisation Syndrome: A Systematic Review

Post-embolisation syndrome (PES) is a prevalent complication that occurs in patients following uterine artery embolisation (UAE) for the treatment of uterine fibroids. The aetiology of PES remains incompletely understood, although postulated to result secondary to tissue infarction resulting in release of inflammatory mediators. We followed PRISMA guidelines and performed a systematic review of studies of PES following UAE from inception to October 2022. Our published protocol was prospectively registered. Our search yielded 54 results. We reviewed 22 full texts, and nine articles were included. Observational studies comprised 6/9 relevant studies, with 5/9 retrospective design. The rate of PES was documented in 5/8 studies (excluding case report) with a reported incidence ranging from 4-34.6%. Five of the nine studies studies postulated that the aetiological basis of PES is inflammatory related. Further research is necessary to advance our understanding of PES to define the biological basis of the syndrome with more certainty and gain a consensus on peri-procedure management to reduce incidence and improve patient outcomes.

A Systematic Review of Minimally Invasive Approaches to Uterine Fibroid Treatment for Improving Quality of Life and Fibroid-Associated Symptoms

Improvement in symptom severity and quality of life (QoL) are critical concerns for women with fibroids as they evaluate treatment options. This systematic review analyzed available evidence regarding minimally invasive approaches to fibroid treatment and compared validated QoL and fibroid-associated symptom scores before and after treatment. A comprehensive search was conducted using PubMed, Embase, Cochrane Library, and Scopus from January 1990 to July 2020. English-language publications were included if they evaluated associations between minimally invasive approaches to fibroid treatment and QoL or fibroid-associated symptoms, and they used validated questionnaires before and after treatment. QoL or fibroid-associated symptom scores were compared and summarized for each minimally invasive approach. Thirty-seven studies were ultimately included in this review: 26 evaluating individual approaches and 11 which were comparative studies of minimally invasive approaches and surgical interventions. Radiofrequency ablation (RFA) and ultrasound-guided sclerotherapy (USGS) significantly improved overall QoL. Uterine artery embolization (UAE) and ultrasound-guided high-intensity frequency ultrasound (US-HIFU) improved overall QoL to a similar extent as surgical interventions. Twenty-eight studies assessed fibroid-associated symptoms with the Uterine Fibroid Symptoms Quality of Life Questionnaire (UFS-QoL). UAE, magnetic resonance imaging-guided high-intensity frequency ultrasound (MR-HIFU), US-HIFU, RFA, and percutaneous microwave ablation (PMWA) significantly decreased Symptom Severity Score by a range of 21 to 39 points (out of 100) at 6 months. Minimally invasive approaches to treat fibroids were effective alternatives to surgical interventions for improving quality of life, fibroid-associated symptoms, and pain. Outcomes among minimally invasive approaches were similar, presenting patients with numerous options for fibroid treatment.