Outcomes after Uterine Artery Embolization for Pedunculated Subserosal Leiomyomas

Outcome prediction for symptomatic patients with fibroids who underwent uterine artery embolization

PURPOSE

To predict the clinical outcome of symptomatic patients with uterine leiomyomas who underwent uterine artery embolization (UAE), based on clinical and radiological features.

METHODS

Patients with symptomatic uterine leiomyomas who underwent UAE from March 2010 to September 2019 were consecutively included in this retrospective study. Patients with persistent or recurrent symptoms and those who needed repeated UAE, myomectomy, or hysterectomy following the initial treatment were considered to have a poor outcome after UAE. The total and enhancing volume of the dominant leiomyoma in each location and uterine volume were obtained before and after UAE. Univariate and multivariate Cox proportional hazard analyses were used to evaluate the parameters that could predict poor outcome.

RESULTS

A total of 116 patients (mean age, 45 ± 5 years) were included. Forty-six patients (46/116, 39.7%) showed poor outcome. Cox regression analysis showed higher hazard of poor outcome for younger patients vs. older patients (HR: 0.92, p-value: 0.01), patients with adenomyosis vs. patients without adenomyosis (HR: 2.47, p-value < 0.01), patients with adenomyosis thickness > 2.5 cm before UAE vs. patients without adenomyosis (HR: 4.2, p-value < 0.01) and for patients with intramural fibroid enhancement volume > 440 cm3 compared to patients with no intramural fibroids (p-value: 0.06). Multivariate Cox regression analysis including age, the thickness of adenomyosis, and intramural leiomyoma volume of enhancement before UAE was chosen as the best model to predict the outcome.

CONCLUSIONS

Pretreatment clinical and MRI features could identify patients with a higher risk for poor outcome after UAE.

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.

Clinical outcomes of uterine artery embolization and experience of postoperative transvaginal fibroid expulsion: a retrospective analysis

PURPOSE

To explore the efficacy of uterine artery embolization (UAE) in the treatment of uterine fibroid and share the experience of transvaginal fibroid expulsion (FE) after UAE.

METHODS

We retrospectively analyzed the changes in uterine and fibroid volume in 152 patients with symptomatic uterine fibroid after UAE at Fujian Provincial Hospital and Fujian Longyan People Hospital from March 2014 to March 2020. After a 12-month follow-up, the improvement in postoperative clinical symptoms and the incidence of complications were evaluated. We also shared the clinical features and imaging findings of four patients with FE after UAE.

RESULTS

All 152 patients successfully underwent UAE. After a 12-month follow-up, the postoperative volumes of the uterus and fibroid at 3, 6, and 12 months were significantly reduced or disappeared compared to those before surgery (P < 0.05). Clinical symptoms, such as menorrhagia, dysmenorrhea, prolonged menstrual period, anemia, increased leucorrhea, pelvic discomfort, and urinary tract compression, were significantly improved after UAE. Among the 152 patients, the incidences of postoperative fever, nausea, vomiting, lower abdominal pain, and increased vaginal secretion were 7.89%, 7.24%, 3.95%, 19.08%, and 4.61%, respectively. Additionally, there were six cases of FE, with an incidence of 3.95%. Three cases of fibroid specimens and pathological images of fibroid biopsy, which were expelled through the vagina, were also provided.

CONCLUSION

UAE is a satisfactory alternative surgical method for symptomatic uterine fibroid with definitive efficacy and high safety. However, it is necessary to guard against the occurrence of postoperative complications such as FE.

Significance of changes in inflammatory parameters following uterine artery embolization in pre-menopausal females

The purpose of the present study was to describe the course of changes in laboratory inflammatory markers following bilateral uterine artery embolization (UAE) as a treatment for leiomyomas and adenomyosis. The body temperature was measured and blood samples were collected to determine white blood cell (WBC) count and C-reactive protein (CRP) levels in 270 patients on the day prior to UAE and for up to 4 days post-embolization. Aside from a single case with a non-inflammatory complication, none of the other cases had any complications. Post-UAE leukocytosis with a mean maximum value of 10.8±3.5x10⁹/l (range, 5.9-18.6x10⁹/l) was observed one-year post-intervention. The mean leukocyte numbers were indicated to be higher on day 3 post-UAE. The CRP level was also increased post-UAE, with a mean maximum value of 7.75±3.5 mg/dl. Maximum levels were reached in 8 patients on the 2nd and in 11 patients on the 3rd post-operative day. The maximum pain score was ~5.5 and reached its lowest level at the end of the 12th week post-intervention. The present study did not consider an association between the embolic material used or uterus size with the level of treatment success. No complications were observed post-UAE; however, a significant increase in the WBC count was observed within the first 3 days, indicating mild leukocytosis.

Uterine artery embolization in the treatment of symptomatic fibroids - state of the art 2018

Uterine fibroids are considered to be the most common benign tumours in females. The vast majority of these tumours are incidental findings and do not require any treatment. Symptomatic fibroids, with ailments such as abnormal uterine bleeding, dysmenorrhoea, pelvic pain, impaired urination, bowel dysfunction, infertility, and recurrent pregnancy loss, are indicated for medical treatment. Surgery remains a first-line treatment of symptomatic uterine fibroids; however, minimally invasive techniques and pharmacological management have become more available and popular. Among minimally invasive techniques uterine artery embolization (UAE) is the most well-established uterine preserving treatment. UAE was first introduced in obstetrics and gynaecology in 1987 and since then many studies have shown the safety and efficacy of UAE in fibroid treatment with low rates of complications. In this review we present a novel approach to UAE, which reflects the current state of knowledge based on recent clinical trials and long-term post-procedural follow-up.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas

OBJECTIVE

The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas.

METHODS

Guidelines for imaging uterine leiomyomas were defined based on a survey distributed to all members of the working group, an expert consensus meeting at European Congress of Radiology (ECR) 2017 and a critical review of the literature.

RESULTS

The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed.

CONCLUSIONS

MRI offers an outstanding and reproducible map of the size, site and distribution of leiomyomas. A standardised imaging protocol and method of reporting ensures that the salient features are recognised. These imaging guidelines are based on the current practice among expert radiologists in the field of female pelvic imaging and also incorporate essentials of the current published MR literature of uterine leiomyomas.

KEY POINTS

• MRI allows comprehensive mapping of size and distribution of leiomyomas. • Basic MRI comprise T2W and T1W sequences centered to the uterus. • Standardized reporting ensures pivotal information on leiomyomas, the uterus and differential diagnosis. • MRI aids in differentiation of leiomyomas from other benign and malignant entities, including leiomyosarcoma.

ACR Appropriateness Criteria® Radiologic Management of Uterine Leiomyomas

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Updates on Uterine Artery Embolization

Uterine fibroids (leiomyomas) are the most common benign neoplasm of the female pelvis and have a lifetime prevalence exceeding 80% among African American women and approaching 70% among Caucasian women. Approximately 50% of women with fibroids experience symptoms which may include menorrhagia that may result in anemia, bulk symptoms with bladder and bowel dysfunction and abdominal protrusion, dysmenorrhea, and infertility. Hysterectomy remains the most common treatment option for fibroids and concerns have been raised about the overuse of this procedure. Uterine artery embolization (UAE) is now a well-established uterine preserving and minimally invasive therapy for symptomatic fibroids. Since its introduction, strong evidence for safety and efficacy of UAE has been generated with low rates of complications. This review will discuss UAE for the management of symptomatic uterine fibroids with special focus on emerging technical approaches and novel periprocedural patient care.

Uterine Artery Embolization for Pedunculated Subserosal Leiomyomas: Evidence of Safety and Efficacy

PURPOSE

To evaluate safety and efficacy of uterine artery embolization (UAE) for pedunculated subserosal (PS) leiomyomas.

MATERIALS AND METHODS

Of 1,069 patients who underwent UAE for symptomatic leiomyomas or adenomyosis from 2007 to 2016, 55 patients (mean age 40.3 y ± 4.8) with 66 PS leiomyomas (mean diameter 6.61 cm ± 2.04) were enrolled. Each PS leiomyoma was categorized into 1 of 2 groups: high-risk PS leiomyoma (stalk diameter < 25% of diameter of leiomyoma) and low-risk PS leiomyoma (stalk diameter 25%-50% of diameter of leiomyoma). MR imaging was performed 3 months after UAE. Rates of infarction and volume reduction were compared between PS leiomyomas and non-PS dominant leiomyomas and between high-risk and low-risk PS leiomyomas. Complications related to PS leiomyomas were assessed.

RESULTS

At a median follow-up of 96 days (range, 36-348 d) after UAE, none of the patients (0%) had complications related to PS leiomyomas, even among high-risk cases. Mean volume reductions of 38.2% and 38.4% were achieved for PS leiomyomas and non-PS dominant leiomyomas, respectively (P = .953). There were 3 (5.5%) minor adverse events, but none were related to PS leiomyoma. There was no significant difference in volume reduction and infarction rates between low-risk and high-risk PS leiomyomas.

CONCLUSIONS

UAE is safe and effective in patients with PS leiomyomas even for high-risk cases (stalk diameter < 25% of diameter of leiomyoma). PS leiomyoma should not be considered a contraindication for UAE.

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

OBJECTIVE

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

METHODS/MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Preprocedural MRI and MRA in planning fibroid embolization

This pictorial review aims to discuss and illustrate the up-to-date use of preprocedural magnetic resonance imaging (MRI) in selecting patients and planning uterine artery embolization (UAE). The merits of magnetic resonance angiography (MRA) in demonstrating the pelvic vasculature to guide UAE are highlighted. MRI features of fibroids and their main differential diagnoses are presented. Fibroid characteristics, such as location, size, and enhancement, which may impact patient selection and outcome, are presented based on recent literature. Pelvic arterial anatomy relevant to UAE, including vascular variants are illustrated, with conventional angiography and MRA imaging correlation. MRA preprocedural determination of the optimal projection angles for uterine artery catheterization is straightforward and constitutes an important strategy to minimize ionizing radiation exposure during UAE. A reporting template for MRI/MRA preassessement of UAE for fibroid treatment is provided.

Nonsurgical Alternatives for Uterine Fibroids

Uterine leiomyomata are the direct cause of a significant health-care burden for women, their families, and society as a whole. Because of the long experience with the mode of treatment, surgical myomectomy remains the gold standard for treating reproductive-age women; however, in the recent years, the wide evolution of less invasive approaches led to a change in the options used by the clinician to treat symptomatic fibroids. Minimally invasive procedures such as uterine artery embolization (UAE) are increasingly used to treat symptomatic fibroids. Other alternative treatments are becoming more diffuse, such as magnetic resonance-guided high-frequency focused ultrasound surgery (MRgFUS), cryomyolysis, vaginal occlusion, and laparoscopic closure of the uterine arteries. Both advantages and limitations of these techniques under development must be taken into account, but this wider range of choices is being increasingly considered for a tailored treatment. This article aims to enable health-care providers with the tools to provide the latest evidence-based care in the minimally invasive or noninvasive management of this common problem.

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

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

Bland embolization in the treatment of hepatic adenomas: preliminary experience

The study presents preliminary, retrospective experience with bland embolization for hepatic adenomas (HAs) with the use of tris-acryl gelatin microspheres. Eight patients underwent bland embolization for biopsy-proven HAs. A biopsy specimen was taken from only one lesion when multiple lesions were present. Seventeen embolizations were performed for abdominal pain, active bleeding, or prophylaxis against bleeding. Five patients underwent multiple procedures. Technical success rate was 100%. Median follow-up was 24 months (range, 10-40 mo). No growth was observed at follow-up in any treated lesion, and many lesions (13 of 16) regressed. Bland embolization may be safely used for treatment of abdominal pain and bleeding from HAs.

Spontaneous vaginal expulsion of uterine myoma after magnetic resonance-guided focused ultrasound surgery

Uterine myomas are common benign uterine tumors in women of reproductive age. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a minimally invasive procedure that produces coagulative necrosis at a precise focal point within the body. MRgFUS regarded as an effective and safe treatment modality in women with symptomatic uterine myomas. Vaginal passage of treated myoma tissue has been reported during other therapeutic procedures such as uterine artery embolization or during puerperium. This study is the first to report a case of vaginal expulsion of uterine myoma after MRgFUS, with complete endometrial recovery on follow-up.

Safety and effectiveness of uterine artery embolization in patients with pedunculated fibroids

PURPOSE

To assess complications and outcomes of uterine artery embolization (UAE) in women with pedunculated fibroids in a large single-center patient cohort.

MATERIALS AND METHODS

From a database with prospectively collected data from 716 women treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids. Magnetic resonance images obtained before and 3 months after UAE were used to calculate stalk diameter change and volume reduction of both the pedunculated fibroid and uterus. Two observers assessed the overall percentage infarction and infarction of pedunculated fibroid. Complications were recorded and long-term clinical follow-up (mean, 33 months; range, 10-78 months) assessed with use of a questionnaire.

RESULTS

The mean reduction in uterine and pedunculated fibroid volume was 37% and 33%, respectively. The mean reduction in stalk diameter was 0.3 cm (95% confidence interval [CI]: 0.18, 0.52 cm) or 13% from initial mean diameter. Stalk enhancement was not affected by UAE. The mean pedunculated fibroid infarction and mean overall infarction rates were 87% and 92%, respectively, for observer 1 and 88% and 92% for observer 2, with good interobserver variability. All women returned the questionnaire and no early or late complications of UAE were reported (0%; 95% CI: 0.0%-13.9%).

CONCLUSIONS

In this small series of pedunculated subserosal fibroids treated with UAE, no complications occurred. The findings suggest that the use of UAE to treat pedunculated subserosal fibroids may be safe and effective.