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

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.

Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates

PURPOSE

To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals.

MATERIALS AND METHODS

40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables.

RESULTS

202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups.

CONCLUSION

Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.

8Spheres conformal microspheres as embolic agents for symptomatic uterine leiomyoma therapy in uterine artery embolization (UAE): A prospective clinical trial

To evaluate the treatment efficacy of uterine artery embolization (UAE) using 8Spheres conformal microspheres for symptomatic uterine leiomyoma. In this prospective observational study, 15 patients were enrolled and underwent UAE by 2 experienced interventionalists from September 1, 2018, to September 1, 2019. All patients underwent menstrual bleeding scores, the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores (with lower scores indicating mild symptoms), pelvic contrast-enhanced magnetic resonance imaging, ovarian reserve tests (estradiol, prolactin, testosterone, follicle-stimulating, luteinizing, and progesterone), and other appropriate preoperative examinations within 1 week before UAE. During follow-up, menstrual bleeding scores and the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores were recorded at 1, 3, 6, and 12 months after UAE to assess the efficacy of symptomatic uterine leiomyoma. Pelvic contrast-enhanced magnetic resonance imaging was performed 6 months after the interventional therapy. Biomarkers of ovarian reserve function were reviewed at 6 and 12 months after treatment. All 15 patients successfully underwent UAE, without severe adverse effects. Six patients experienced abdominal pain, nausea, or vomiting, all of which improved significantly after symptomatic treatment. The menstrual bleeding scores declined from baseline (350.2 ± 61.9 mL) to (131.8 ± 42.7 mL), (140.3 ± 42.4 mL), (68.0 ± 22.8 mL), and (64.43 ± 17.0 mL) at 1, 3, 6, and 12 months, respectively. The symptom severity domain scores at 1, 3, 6, and 12 months postoperatively were significantly lower and statistically significant compared to the preoperative scores. The uterus and dominant leiomyoma volumes decreased from baseline (340.0 ± 35.8 cm3), (100.6 ± 24.3 cm3) to (266.6 ± 30.9 cm3), (56.1 ± 17.3 cm3) at 6 months after UAE, respectively. Moreover, the ratio of leiomyoma volumes and uterus decreased from (27.4 ± 4.5%) to (18.7 ± 3.9%). At the same time, there was no significant effect on changes in the biomarkers of ovarian reserve levels. Only the changes in testosterone levels before and after UAE were statistically significant (P < .05). 8Spheres conformal microspheres are ideal embolic agents for UAE therapy. This study showed that 8Spheres conformal microsphere embolization for symptomatic uterine leiomyoma could effectively relieve heavy menstrual bleeding, improve the symptom severity of patients, reduce the volume of leiomyoma, and have no significant effect on ovarian reserve function.

Reproductive and Obstetric Outcomes after UAE, HIFU, and TFA of Uterine Fibroids: Systematic Review and Meta-Analysis

Novel treatment options for uterine fibroids, such as uterine artery embolization (UAE), ultrasound-guided and magnetic resonance-guided high-intensity focused ultrasound (USgHIFU and MRgHIFU), and transcervical radiofrequency ablation (TFA) methods, are widely used in clinical practice. This systematic review and meta-analysis (CRD42022297312) aims to assess and compare reproductive and obstetric outcomes in women who underwent these minimally invasive approaches for uterine fibroids. The search was performed in PubMed, Google Scholar, ScienceDirect, Cochrane Library, Scopus, Web of Science and Embase. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Cochrane guidelines. The articles were selected to meet the following eligibility criteria: (1) research article, (2) human subject research, and (3) the study of pregnancy outcomes after the treatment of uterine fibroids by either one of three methods-UAE, HIFU, and TFA. The analysis of 25 eligible original articles shows a similar rate of live births for UAE, USgHIFU, MRgHIFU, and TFA (70.8%, 73.5%, 70%, and 75%, respectively). The number of pregnancies varied considerably among these studies, as well as the mean age of pregnant women. However, the results of pregnancy outcomes for TFA are insufficient to draw firm conclusions, since only 24 women became pregnant in these studies, resulting in three live births. The miscarriage rate was highest in the UAE group (19.2%). USgHIFU was associated with a higher rate of placental abnormalities compared to UAE (2.8% vs. 1.6%). The pooled estimate of pregnancies was 17.31% to 44.52% after UAE, 18.69% to 78.53% after HIFU, and 2.09% to 7.63% after TFA. The available evidence confirmed that these minimally invasive uterine-sparing treatment options for uterine fibroids are a good approach for patients wishing to preserve their fertility, with comparable reproductive and obstetric outcomes among the different techniques.

Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning

Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.

Occurrence of adverse events after magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) therapy in symptomatic uterine fibroids-a retrospective case-control study

OBJECTIVES

Our study aims at the comprehensive analysis of adverse events (AEs) in patients with symptomatic uterine fibroids (UFs) who underwent magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) in the last 6 years in one of the major Polish centers performing this type of therapy.

METHODS

The presented retrospective case-control study was conducted in the Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszów in cooperation with the Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw. The study enrolled 372 women with symptomatic UFs who underwent MR-HIFU and reported AEs during or after the procedure. The occurrence of particular AEs was analyzed. Statistical comparison of two cohorts (patients with and without AEs) was conducted based on epidemiological factors, UF characteristics, fat layer thickness, the presence of abdominal scars and technical parameters of the procedure.

RESULTS

The overall mean occurrence rate of AEs was 8.9% (n = 33). No major AEs were reported. The only statistically significant risk factor of AEs was the treatment of type II UFs according to Funaki (OR 2.12, CI 95%, p = 0.043). Other investigated factors did not have a statistically significant influence on AE occurrence. Abdominal pain was the most common AE.

CONCLUSION

Our data showed that MR-HIFU seemed to be a safe procedure. The AE rate after the treatment is relatively low. According to the obtained data it seems that the occurrence of AEs does not depend on the technical parameters of the procedure and the volume, position and location of UFs. Further prospective, randomized studies and with long follow-up are necessary to confirm the final conclusions.

Therapeutic Outcome of MR-Guided High-Intensity Focused Ultrasound (MR-HIFU) in Solitary versus Multiple Uterine Fibroids

MR-guided high-intensity focused ultrasound (MR-HIFU) is an effective method for treating symptomatic uterine fibroids, especially solitary lesions. The aim of our study was to compare the clinical and morphological outcomes of patients who underwent MR-HIFU due to solitary fibroid (SF) or multiple fibroids (MFs) in a prospective clinical trial. We prospectively included 21 consecutive patients with SF (10) and MF (11) eligible for MR-guided HIFU. The morphological data were assessed using mint Lesion™ for MRI. The clinical data were determined using the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire before and 6 months after treatment. Unpaired and paired Wilcoxon-test and t-tests were applied, and Pearson’s coefficient was used for correlation analysis. A p-value of 0.05 was considered statistically significant. The volume of treated fibroids significantly decreased in both the SF (mean baseline: 118.6 cm³; mean 6-month follow-up: 64.6 cm³) and MF (107.2 cm³; 55.1 cm³) groups. The UFS-QOL showed clinical symptoms significantly improved for patients in both the SF and MF groups regarding concern, activities, energy/mood, and control. The short-term outcome for the treatment of symptomatic fibroids in myomatous uterus by MR-guided HIFU is clinically similar to that of solitary fibroids.

Extravascular Dispersion of Polyvinyl Alcohol Microsphere Particles in Uterine Artery Embolization

Uterine artery embolization (UAE) is a common minimally invasive treatment of different uterine pathologies, such as fibroids, adenomyosis, and menorrhagia. The procedure involves the injection of embolic agents into the uterine arteries, whereby various particles can be used, such as polyvinyl alcohol (PVA). Complication of UAE is the dispersion of polyvinyl alcohol (PVA) microsphere particles in the uterine body which can lead to a granular vaginal discharge. We report the management of complications of PVA microspheres dispersed from the uterine body causing postprocedural discomfort due to the vaginal passage of microspheres or because of an induced fibroid-size enlargement. The dispersion of the PVA microspheres is one example of a minor UAE complication, which nevertheless causes significant distress to the patient and eventfully requires further surgical interventions.

Comparison of two invasive non-surgical treatment options for uterine myomas: uterine artery embolization and magnetic resonance guided high intensity focused ultrasound-systematic review

BACKGROUND

Uterine Artery Embolization (UAE) and Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) are two noninvasive treatments for uterine leiomyoma.

METHODS

This systematic review, following PRISMA guidelines, analyzed the effectiveness of two treatments by comparing percent fibroid volume shrinkage immediately after the procedure and after 3, 6, 12 and 24 months of follow-up and also assessed and compared common complications following treatment. The search utilized Science Direct, PubMed, MEDLINE, Google Scholar and BioMed Central databases, selecting manuscripts published during the period 2000 and 2020. Studies with premenopausal patients with previous treatments for uterine leiomyoma and/or with other pelvic diseases were excluded.

RESULTS

Twenty-nine papers satisfied inclusion and exclusion criteria. Results were pooled and stratified by treatment and follow-up time. Weighted fibroid volume percent shrinkage after UAE was statistically significantly greater than MRgHIFU at 6, 12, and 24 months follow-up times. However, UAE had statistically significantly more complications, such as pain, nausea and vomiting. However, this study cannot conclude that UAE is more effective than MRgHIFU due to confounding factors.

Should Ultrasound-Guided High Frequency Focused Ultrasound Be Considered as an Alternative Non-Surgical Treatment of Uterine Fibroids in Non-Asiatic Countries? An Opinion Paper

Minimally invasive interventions for myomata treatment have gained acceptance due to the possibility of preserving fertility with reduced trauma induced by laparotomy as way of entrance. There are insufficient data regarding outcomes of high intensity focused ultrasound (HIFU) in non-Asiatic women. Therefore, we revised the available evidence to present an expert opinion that could support physicians, patients and policy-makers for considering this approach in other populations. We revisited systematic reviews, randomized controlled trials and cohort studies from January 2018 to August 2021 using PubMed and Google scholar, regarding short and long term outcomes after ablation with focused ultrasound waves. In total, 33 studies, including 114,810 adult patients showed that outcomes of this approach depend on several parameters directly related with resistance to thermal ablation, especially fibroid size and vascularization. Two studies report satisfactory outcomes in Afro-American women. In accordance to the technique used, fibroid volume reduction showed to be higher in fibroids <300 cm3 after ultrasound guided HIFU than after MRI guided. Compared to myomectomy and uterine artery embolization, HIFU seems to have shorter hospital stay, higher pregnancy rates and similar adverse events rates, with skin burn being the most reported. Symptoms and quality of life improvement is similar to myomectomy but lower than embolization, however reintervention rate is higher after HIFU. Lacks evidence about long-term sarcoma risk after ablation. Available evidence shows that HIFU can be considered as a uterine sparing treatment for women of different ethnicities suffering of uterine myomatosis, especially for those wishing to preserve their fertility.