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

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.

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.

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

STUDY OBJECTIVE

To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment.

DESIGN

Retrospective cohort.

SETTING

French University Hospital.

PATIENTS

Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage.

INTERVENTIONS

All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56-4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths.

CONCLUSION

IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility.

Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India

OBJECTIVE

 To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs).

METHODS

 A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1).

RESULTS

 A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred.

CONCLUSION

 Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?

BACKGROUND

Uterine artery embolisation is well established as a treatment for symptomatic fibroids, however, there remain some uncertainties. We have carried out a focused literature review on three particularly challenging aspects - post-procedure fertility, symptomatic adenomyosis and large volume fibroids and uteri, to enable operators to utilise evidence-based guidance in patient selection, consent, and management.

REVIEW

Literature searches were performed of the PubMed/Medline, Google scholar, EMBASE and Cochrane databases. The outcomes of our analysis of studies which recorded fertility rates in women desiring pregnancy following UAE for symptomatic fibroids found an overall mean pregnancy rate of 39.4%, live birth rate of 69.2% and miscarriage rate of 22%. The major confounding factor was patient age with many studies including women over 40 years who already have lower fertility compared to younger cohorts. Miscarriage rates and pregnancy rates in the studies analysed were comparable to the age matched population. Treatment of pure adenomyosis and adenomyosis with co-existing uterine fibroids with UAE has been shown to produce symptomatic improvement with better outcomes in those with combined disease. Although the effectiveness is not as high as it is in pure fibroid disease, UAE provides a viable and safe alternative for patients seeking symptom relief and uterine preservation. Our analysis of studies assessing the outcomes of UAE in patients with large volume uteri and giant fibroids (> 10 cm) demonstrate no significant difference in major complication rates demonstrating that fibroid size should not be a contraindication to UAE.

CONCLUSION

Our findings suggest uterine artery embolisation can be offered to women desiring pregnancy with fertility and miscarriage rates comparable to that of the age-matched general population. It is also an effective therapeutic option for symptomatic adenomyosis as well as for the treatment of large fibroids > 10 cm in diameter. Caution is advised in those with uterine volumes greater than 1000cm³. It is however clear that the quality of evidence needs to be improved on with an emphasis on well-designed randomised controlled trials addressing all three areas and the consistent use of validated quality of life questionnaires for outcome assessment to enable effective comparison of outcomes in different studies.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

ACR Appropriateness Criteria® Fibroids

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR 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 in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A Systematic Review and Meta-Analysis of the Efficacy of Uterine Artery Embolization in the Treatment of Endometriosis

Objective

To compare the efficacy of uterine artery embolization (UAE) with traditional methods for treating endometriosis.

Methods

The randomized controlled trials of uterine artery embolization and other medical treatments for endometriosis in PubMed, Embase, Web of Science, Cochrane Library, China Journal Full-Text Database, Wanfang Database, VIP Database, and China Biomedical Literature Database were retrieved by computer. The search time was up to June 2022. The quality of articles was evaluated by Cochrane ROB 2.0, and meta-analysis was performed by Stata15.1 software.

Results

7 studies were finally included. Meta-analysis showed that the serum CA125 level after uterine artery embolization was significantly lower than that in the control group (SMD = -0.85, 95%CI (-1.12, -0.59)], and the postoperative visual analogue scale (VAS) of dysmenorrhea was significantly lower than that in the control group (SMD = -1.86, 95%CI (-2.21, -1.50)) There was no significant difference in the effective rate, FSH level, E2 level, and LH level between the two groups.

Conclusion

UAE can effectively reduce the VAS score of dysmenorrhea and serum CA125 level for treating endometriosis. However, due to the limitation of the quality of included articles, more large sample size and high quality RCTs are needed to provide stronger evidence-based medicine evidence for clinical practice.

Current Strategies for Prevention of Infection After Uterine Artery Embolisation

Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.

The Diagnostic Value of Superb Microvascular Imaging in Prediction of Uterine Artery Embolization Treatment Response in Uterine Leiomyomas

OBJECTIVES

We aimed to determine if superb microvascular imaging (SMI) can predict response to uterine artery embolization (UAE) as compared with power Doppler ultrasound.

METHODS

The blood flow and the volume of the dominant leiomyoma was evaluated by power Doppler ultrasonography (PDUS) and SMI 1 day before and 3 months after the UAE procedure. SMI and PDUS blood flow were classified to 4 grades of vascularity. The change in fibroid volume in Grades 0-2 (hypovascular group) was compared to the hypervascular Grade 3 group.

RESULTS

Twenty-eight women (mean age, 40.9 years; range, 33-53 years) were examined with PDUS and SMI before and 3 months after UAE. The volume reduction was statistically significantly higher hypervascular group (P < .05). When we accept 30% or more volume reduction as a good response to UAE, the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of SMI were 100, 64, 73.6, 100, and 82.1%, respectively. There was excellent agreement between the two blinded observers in SMI measurements.

CONCLUSIONS

SMI, with its high reproducibility, provides further microvessel information than PDUS in uterine fibroids. It may be a useful tool in prediction of response to UAE treatment and improve counseling and patient selection for UAE versus medical or surgical treatment options.

A Systematic Review of Minimally Invasive Treatments for Uterine Fibroid-Related Bleeding

Newer minimally invasive techniques provide treatment options for symptomatic uterine fibroids while allowing uterus preservation. The objective of this review was to analyze the efficacy of uterine-preserving, minimally invasive treatment modalities in reducing fibroid-related bleeding. A comprehensive search was conducted of PubMed, Embase, PsycINFO, ClinicalTrials.gov, Scopus, and Cochrane Library databases from inception to July 2020. English-language publications that evaluated premenopausal women with fibroid-related bleeding symptoms before and after treatment were considered. Randomized controlled trials were assessed for bias with the established Cochrane Risk of Bias Tool 2.0 and observational studies were assessed for quality under the New Castle-Ottawa Scale guidelines. Eighty-four studies were included in the review, including 10 randomized controlled trials and 74 observational studies. Six studies on myomectomy demonstrated overall bleeding symptom improvement in up to 95.9% of patients, though there was no significant difference between mode of myomectomy. Forty-one studies on uterine artery embolization reported significant reduction of fibroid-related bleeding, with symptomatic improvement in 79 to 98.5% of patients. Three studies suggested that embolization may be superior to myomectomy in reducing fibroid-related bleeding. Six studies reported that laparoscopic uterine artery occlusion combined with myomectomy led to greater reduction of bleeding than myomectomy alone. Fifteen studies demonstrated significantly reduced bleeding severity after radiofrequency ablation (RFA). Additional research is needed to establish the superiority of these modalities over one another. Long-term evidence is limited in current literature for magnetic resonance-guided focused ultrasound surgery, cryomyolysis, microwave ablation, and laser ablation.

Endovascular uterine artery interventions

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

Uterine Artery Embolization of Uterine Leiomyomas: Predictive MRI Features of Volumetric Response

OBJECTIVE. The purpose of this article was to evaluate MRI features of uterine leiomyomas that predict volumetric response after uterine artery embolization (UAE). MATERIALS AND METHODS. This retrospective study included 75 patients with 212 uterine leiomyomas who were successfully treated between August 2013 and December 2018. To predict uterine volumetric response, age, number of lesions, and baseline uterine volume were assessed. To predict leiomyoma volumetric response, a multivariate regression analysis was performed to evaluate six predictive factors: location, baseline leiomyoma volume, signal intensity on T1-weighted and T2-weighted MRI, heterogeneity of signal intensity on T2-weighted MRI, and vascularity on subtraction imaging (SI). A five-variable predictive ROC model was developed to evaluate the diagnostic accuracy of the signal intensity ratio on T2-weighted MRI, enhancement ratio, heterogeneity ratio on T2-weighted MRI, location, and baseline leiomyoma volume in predicting at least 40% leiomyoma volumetric response. RESULTS. Age, number of leiomyomas, and baseline uterine volume were not predictive of uterine volumetric response. A submucosal location was the best predictive factor of leiomyoma volumetric response, and it showed 32.2% more leiomyoma volumetric response compared with a nonsubmucosal location (p < .001). Hyperintensity on T2-weighted MRI was the second best predictive factor of leiomyoma volumetric response, and it showed 16.9% more volumetric response compared with hypointense leiomyomas (p = .013). A small baseline leiomyoma volume (< 58 cm³) was associated with 10.2% more leiomyoma volumetric response compared with larger leiomyomas (p = .01). Leiomyomas that were hyperintense on SI showed 7.9% more leiomyoma volumetric response compared with those that were hypointense (p = .014). The five-variable ROC model showed high diagnostic accuracy with an AUC of 0.85, sensitivity of 82%, and specificity of 71%. CONCLUSION. A submucosal location, hyperintensity on T2-weighted MRI, small baseline leiomyoma volume (< 58 cm³), and hyperintense leiomyoma on subtraction imaging are the main independent favorable predictors of leiomyoma volumetric response after UAE. An accurate predictive ROC model was developed that may help in selecting patients suitable for UAE. Quantitative assessment of heterogeneity on T2-weighted MRI showed promising results as a predictor of volumetric response, and further research in this area using texture analysis and radiomics is suggested.

Recovery of uterine and ovarian function in patients with complete placenta previa after caesarean delivery: A retrospective study

This retrospective study was designed to explore the recovery of uterine and ovarian function in patients with complete placenta previa (PP) after caesarean delivery (CD). 136 complete placenta previa patients (group completed placenta previa) and 140 patients without complete PP (group non-PP, control group) were included in this study from Jan 2016 to Dec 2018. Subgroup analysis of patients with complete PP was made to determine the impact of different hemostatic methods used during CD on the recovery of uterine function. There were no statistically significant differences between the 2 groups in postpartum menstrual cycle changes, ovarian hormone, and uterine vascular supply as measured by pulsatility index and systolic/diastolic ratio (P > .05). However, the group with complete PP had a reduced endometrial thickness (0.47 ± 0.11 vs 0.50 ± 0.12, P < .001), a lower uterine resistance index at 42nd days (0.84 ± 0.03 vs 0.90 ± 0.03, P < .001), and a delayed resumption menstruation (7.07 ± 2.61 vs 5.31 ± 2.16, P < .001) when compared with control group. Subgroup analysis showed that RI index of all subgroups in completed PP group was lower, endometrial thickness was thinner and the time to menstrual recovery was longer than that of non-PP group. In conclusion, the endometrial thickness and blood supply at 42nd days, not ovarian function, maybe affected after CD in patients with complete PP.

Pregnancy and its Outcomes in Patients After Uterine Fibroid Embolization: A Systematic Review and Meta-Analysis

Uterine artery embolization (UAE) has been introduced for uterine fibroid treatment for two decades. Most of the patients are in reproductive age and many want future pregnancy. In this study, we will assess fertility, pregnancy and its outcomes in patients who have undergone UAE. In this systematic review, a systematic search was performed on important databases including PubMed and Medline, Web of Knowledge, Google Scholar, EMBASE and Scopus. Studies reported enough data about pregnancy after UAE were considered to be enrolled in the review. We assessed obstetric indices (pregnancy and delivery rates, pregnancy losses, complications and fetal outcomes). Study evaluation was done based on STROBE checklist by two reviewers. Totally, 24 original papers were included. Data were analyzed by Stata and MedCalc softwares. Among women wishing fertility, totally 40.5% experienced at least one pregnancy after UAE (95% confidence interval [CI]: 33.3%-48.2%). Pooled estimate of pregnancy loss rate was 33.5% (95% CI: 26.3-41%). Most pregnancy losses were due to spontaneous abortion (81.3% of all losses (95% CI = 76%-86.1%)). Rate of obstetrical complications was 25.4% (95% CI = 13-40.2%) among all finished pregnancies. Pooled estimate of preterm labor was 12.8% (95% CI = 8.7%-17.5%), and pooled estimate of low birth weight (LBW) was 10% (95% CI = 6.2-14.6%). Considering the findings of the study, a safe pregnancy after UAE is obviously possible resulting to a healthy and normal baby delivery. In addition, pooled obstetrical complication rates, pregnancy losses, preterm labor and LBW seem to be mostly similar to the general population. Registration: The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) on Nov 3, 2017, and was confirmed with a registration code of CRD42017076074.

Shearwave elastographic evaluation of uterine leiomyomas after uterine artery embolization: preliminary results

Background/aim

We aimed to investigate the role of Shearwave Elastography (SWE) in the evaluation of response to uterine artery embolization (UAE) in patients with uterine leiomyomas.

Materials and methods

SWE images of the dominant uterin leiomyomas were obtained before and 1.5 months after performing UAE in 33 women suffering from symptoms due to leiomyomas (menometrorrhagia, bulk related symptoms, pelvic pain). Leiomyomas were also evaluated by 2 observers for location and longest diameter in axial plane. Interobserver agreement in the quantitative SWE analysis was calculated using intraclass correlation coefficients.

Results

Thirty-three women (mean age, 39.7 years; range, 31–48 years) were examined with SWE 1.5 months after UAE. After treatment, 3 patients (9.1%) had fever, 1 patient had nausea and 29 patients (87.9%) had no complications. The post UAE stiffness measurements of leiomyomas (mean SWE ± SD = 13.34 ± 3.9kPa) were significantly lower than the pre UAE measurements (mean SWE ± SD = 17.16 ± 4.8kPa) (P < 0.001). There was excellent agreement between the 2 blinded observers in SWE measurements.

Conclusion

SWE values of leiomyomas after UAE significantly decreased. SWE, with its high reproducibility, could become a useful tool in the follow up of uterin leiomyomas after UAE.

Predicting the Fibroid-Migratory Impact of UAE: Role of Pre-embolization MRI Characteristics

Aim

To investigate potential factors on MR imaging that could be used to predict migration of uterine fibroids post-UAE.

Methods and Materials

We retrospectively reviewed patients referred for UAE having pre-procedural and 6 months post-procedural MRI, at a tertiary centre, over a 1-year period. Pre- and post-UAE images were reviewed in 64 women by two radiologists to identify the sub-type, dimensions, and infarction rate of each dominant fibroid. The shortest distance between the fibroid and the endometrial wall was measured to determine intramural fibroid movement. Paired sample T tests and two-sample T tests were used to compare between pre- and post-embolization variations and between migrated and non-migrated intramural fibroids, respectively. After preliminary results suggested potential predictors of intramural fibroids migration, we tested our findings against the non-dominant intramural fibroids in the same patients.

Results

Review of images revealed 35 dominant intramural fibroids, of which eight migrated to become submucosal fibroids, while five were either partially or completely expelled. These 13 migrated fibroids had a shorter pre-procedural minimum endometrial distance (range 1–2.4 mm) and greater maximum fibroid diameter (range 5.1–18.1 cm), when compared to non-migrating fibroids. On image reassessment, the migrated non-dominant intramural fibroids had a minimum endometrial distance and maximum fibroid diameter within the same range.

Conclusion

Intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating towards the endometrial cavity after UAE.

Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature

Females with symptomatic leiomyomas (fibroids) wishing to maintain fertility are faced with difficult treatment choices. These include uterine fibroid embolization (UFE), myomectomy, hormonal therapy, MRI high intensity focused ultrasound, and myolysis. This review focuses on UFE, one of the most commonly accepted minimally invasive procedural choices among patients with symptomatic fibroids wishing to retain the option of becoming pregnant in the future, and makes comparisons to myomectomy which has historically been the surgical choice for fertility-preserving fibroid treatment. Pubmed and Google Scholar searches using keywords such as: uterine artery embolization, uterine fibroid embolization, pregnancy, complications, infertility were performed between Jan 1, 2019 and May 10, 2019. Publications were chosen based on their inclusion of information pertaining to fertility or pregnancy after UFE without being limited to single case reports.Randomized controlled trials comparing myomectomy and UFE are limited due to study size and confounding variables, but through registry data and familiarity with referring clinicians, UFE has gained wide acceptance. Healthy pregnancies following UFE have been sporadically reported but the actual fertility rate after UFE remains uncertain. Conversely, low birth weight, miscarriage and prematurity have been associated with UFE. Despite inherent risks of possible fertility issues after UFE, the procedure remains an option for females with clinically symptomatic fibroids who desire pregnancy. However, additional research regarding rates of conception and obstetrical risks of infertility following UFE is necessary.

Comprehensive feature selection for classifying the treatment outcome of high-intensity ultrasound therapy in uterine fibroids

The study aim was to utilise multiple feature selection methods in order to select the most important parameters from clinical patient data for high-intensity focused ultrasound (HIFU) treatment outcome classification in uterine fibroids. The study was retrospective using patient data from 66 HIFU treatments with 89 uterine fibroids. A total of 39 features were extracted from the patient data and 14 different filter-based feature selection methods were used to select the most informative features. The selected features were then used in a support vector classification (SVC) model to evaluate the performance of these parameters in predicting HIFU therapy outcome. The therapy outcome was defined as non-perfused volume (NPV) ratio in three classes: <30%, 30–80% or >80%. The ten most highly ranked features in order were: fibroid diameter, subcutaneous fat thickness, fibroid volume, fibroid distance, Funaki type I, fundus location, gravidity, Funaki type III, submucosal fibroid type and urinary symptoms. The maximum F1-micro classification score was 0.63 using the top ten features from Mutual Information Maximisation (MIM) and Joint Mutual Information (JMI) feature selection methods. Classification performance of HIFU therapy outcome prediction in uterine fibroids is highly dependent on the chosen feature set which should be determined prior using different classifiers.

Impact of grayscale and Doppler ultrasound characteristics on reducing the size of tumors in the treatment of uterine fibroids by uterine artery embolization

Aim of the study

Uterine fibroids are one of the most prevalent benign tumors. This study aimed to evaluate the effect of uterine artery embolization on treating and reducing the size of symptomatic uterine fibroids.

Material and methods

Eighty patients with uterine fibroids were selected for this study. Then ultrasound and Doppler were performed by a radiologist to evaluate the size, number, echogenicity, vascularity, and location of fibroids in the uterine wall. Before performing uterine artery embolization, prothrombin time, partial thromboplastin time, international normalized ratio, blood urea nitrogen, and creatinine tests were performed for all the patients to identify background problems. Finally, SPSS 22 was used for data analysis.

Results

The dominant fibroid volume before the embolization was 244.57 cm³, which decreased to 219.96 cm³, 190.58 cm³, 114.18 cm³, 140.51 cm³, and 78.86 cm³ in the first week, first month, third month, sixth month and first year after embolization, which was statistically significant (p < 0.001 in all cases). Uterine volume in multiple tumor before the embolization was 486.27 cm³, which decreased to 408.36 cm³, 387.60 cm³, 299.67 cm³, 190.00 cm³ and 172.33 cm³ after the first week, first month, third month, sixth month and first year after embolization, which in the first week and third month was statistically significant and not significant in other cases (p = 0.003, p = 0.500, p = 0.028, p = 0.068, p = 0.109). The relationships of the number of fibroid tumors, echogenicity and vascularity with volume reduction were not statistically significant (p = 0.924, p = 0.208, p = 0.455).

Conclusions

Uterine artery embolization is an effective treatment for fibroid tumors. In this study, the number of tumors, echogenicity, and vascularity of tumors had no effect on tumor volume reduction.

Managing Heavy Menstrual Bleeding in Women at Risk of Thrombosis

Management of heavy menstrual bleeding (HMB) in a woman with a history of thrombosis, or who is otherwise at high risk of thrombosis, or who takes medications for anticoagulation can present a challenge to health care providers. The goal of treating HMB is to reduce menstrual blood loss. First-line therapy is typically hormonal, and hormonal therapy can be contraindicated in women with a history of thrombosis unless they are on anticoagulation. As 70% of women on anticoagulation experience HMB, successful management of HMB may involve a modification in the anticoagulation or antiplatelet regimen, hormonal therapy tailored to the patient's situation, and/or surgical therapy.

Successful pregnancy after uterine artery embolization for uterine arterovenous malformation: a rare case report

Objective

This paper reports on a rare case of pregnancy after uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM). Debate exists about persistence of fertility in women after UAE. Adverse effects of this technique can modify both uterine echostructure, inducing necrosis and infarction, endometrial atrophy and uterine artery rupture, and ovarian reserve, causing persistent amenorrhea. Ovarian reserve appears to be affected by UAE in pre-menopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Case report

A 28-year-old woman was admitted to our department due to life-threatening uterine bleeding, resulting in tachycardia, pallor, and sweating. The patient came with a history of two spontaneous miscarriages. After sonography and computed tomography, AVMs were identified at uterine fundus and anterior wall.

Conclusion

The pathogenesis of infertility after UAE is not yet known. The peculiarity of this case was that, only few months later, the patient became pregnant and gave birth to a live fetus at 37 weeks with cesarean delivery.

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.

Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy

OBJECTIVES

Myomas are defined as benign tumours that arise from smooth muscle cells of the uterus. Clinically, they are found in 5-77% of women of reproductive age. The prevalence rate varies considerably in the literature and a large number of fibroids do not cause symptoms. The lifetime risk of acquiring myomas is 70% for Caucasian women and ≥ 80% for African American women.

MATERIALS/METHODS

The data of 265 patients undergoing surgery for symptomatic myomas by laparoscopy or laparotomy, performed in the gynaecological department of Hannover Medical School, Hannover, Germany, between 2009 and 2013, were retrospectively analysed in this retrospective design study.

RESULTS

High pregnancy rates (up to 70%) and birth rates (up to 86%) after myomectomy, regardless of the surgical approach adopted, were found in the current study. The trend was that ≥ 3 myomas and those that were ≥ 6 cm in size were almost always removed by laparotomy in our clinic. It was possible to remove up to 42 myomas without having to perform a hysterectomy. A statistically significant negative correlation was observed in relation to the association between the size of the largest myoma extracted and the pregnancy rate (p = 0.02). A statistically significant correlation between the number of removed myomas and the pregnancy rate was observed for patients who wished to bear children (p = 0.010). Elevated complication rates (of up to 50%) were reported for more than three extracted myomas with a statistically significance (p = 0.0471).

CONCLUSIONS

It is necessary to ensure sound preoperative selection of the surgical approach in order to achieve the most optimal results, especially for those patients who wished to bear children.

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.

Minimally invasive procedures in the management of uterine fibroids

Uterine fibroids are benign uterine tumors. In women during the reproductive period, uterine fibroids occur in about 25%, whereas after this time, they are observed in more than 40% of women. In the majority of women (about 20-50%), such tumors do not cause discomfort and do not require treatment. Asymptomatic uterine fibroids usually undergo only regular medical control, whereas symptomatic fibroids are an indication for treatment. Current treatment methods include surgical, pharmacological and minimally invasive treatment. Among the current commonly used methods, there are minimally invasive treatment options, which include Uterine Artery Embolization (UAE), Magnetic Resonance Guided Ultrasound Surgery (MRgFUS), MR-guided High Intensity Focused Ultrasound (MR-HIFU) and Laparoscopic Uterine Artery Occlusion (LUAO). The minimally invasive Ultrasound-guided High Intensity Focused Ultrasound method (US-HIFU) is new, but still experimental. The use of MRgFUS/MR-HIFU for the thermoablative treatment of fibroids was approved by the FDA (Food and Drug Administration) in 2004. As a minimally invasive method, it enables preservation of the uterus and eliminates the need for general anesthesia. LUAO is based on the use of the vascular clip, which is placed on the uterine artery at the level of the internal iliac artery. This procedure is performed bilaterally.

The use of UAE in obstetrics and gynecology was first described in 1987 as an effective method in the treatment of hemorrhage, which allows avoiding surgical intervention and enables the uterus to be preserved. An appropriate qualification of patients is crucial for high clinical efficacy and prevention of complications after UAE. The candidates should be women with symptomatic uterine fibroids, without other pathologies within the pelvis, who do not plan to get pregnant in the future.

The variety of uterine fibroids as for the location, size, and symptoms they can evoke, has enforced a very individual approach to each patient, to begin with observation and regular gynecological control, through a number of pharmacological and minimally invasive treatment methods, and ending with the removal of the uterus. It gives the doctors the tools, which, if used properly, can manage uterine fibroids and fulfil the expectations of the patient.

Fertility after uterine artery embolization of fibroids: a systematic review

PURPOSE

The impact of uterine artery embolization (UAE) for the purpose of diminishing the effect of uterine fibroids on fertility is unclear. We have investigated the reported rates of pregnancy and miscarriage after treatment of uterine fibroids with UAE.

MATERIALS AND METHODS

We searched for relevant information in PubMed and Embase for randomized controlled trials (RCT), controlled clinical trials, comparative before-after trials, cohort studies, case-control studies and case series where UAE treatment of premenopausal women was performed for uterine fibroids with and where a control intervention was included. The PRISMA guideline was used to do a systematic review using the main outcomes pregnancy rate and miscarriage rate. Risk of bias was assessed by the Cochrane risk of bias tool or by ROBINS-I. The quality of evidence was assessed by the GRADE approach.

RESULTS

We included 17 studies (989 patients): 1 RCT, 2 cohort studies, and 14 case series. Pregnancy rates after UAE were 50% in the RCT and 51 and 69% in the cohort studies. Among the case series median pregnancy rate was 29%. Miscarriage rates were 64% in the RCT. Miscarriage rates at 56 and 34% were found in the cohort studies after UAE. The median miscarriage rate was 25% in the case series.

CONCLUSION

Pregnancy rate was found to be lower and miscarriage rate higher after UAE than after myomectomy. However, we found very low quality of evidence regarding the assessed outcomes and the reported proportions are uncertain. There is a need for improved prospective randomized studies to improve the evidence base. Systematic review registration number: CRD42016036661.

Uterine artery embolization: A review of current concepts

Uterine artery embolization (UAE) has gained traction as a safe and effective treatment modality for symptomatic uterine leiomyomata since its introduction nearly two decades ago. This review includes an overview of current concepts with regard to patient selection, technique, and outcomes following UAE. Specific topics also include the impact of this procedure on fertility and pregnancy, the emerging role of UAE in the treatment of adenomyosis, and how UAE compares with surgical intervention for the treatment of symptomatic leiomyomata.

Pregnancy outcomes in nulliparous women after ultrasound ablation of uterine fibroids: A single-central retrospective study

To explore the impact of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids in nulliparous women on subsequent pregnancy and delivery. A retrospective analysis was conducted of nulliparous women who received HIFU treatment at Chongqing Medical University, Chongqing,China, from January 1, 2010, to January 1, 2015. A total of 189 cases were enrolled, the median follow-up time was three years. Among them,there were 131 cases pregnancy with a total of 133 times,the pregnancy rate was 69.3% (131/189),and the spontaneous conception rate was 95.4% (125/131). Of 131 pregnant women, 19 were on-going pregnancy, terminated pregnancy 114 times,which include 93 times successfully delivery with a 76.3% (87/114) full-term birth rate,and the cesarean section rate was 72.0% (67/93). Of 94 newborns,the average birth weight was (3.3 ± 0.4)kg (range:1.5–4.8 kg), and a pair of them were identical twins. The incidence of complications during pregnancy and delivery were 10.8% (10/93) and 7.5% (7/93),respectively,except one woman failed on-going pregnancy and one woman suffered hysterectomy due to the complications,others all successful pregnant and delivered. Multiple-factor regression analysis found that age and infertility history were the important factors that may affect pregnancy after HIFU (P < 0.01). Nulliparous women who undergo HIFU treatment for uterine fibroids can subsequently have successful pregnancy and delivery safely.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

Controlled-release oxycodone improves pain management after uterine artery embolisation for symptomatic fibroids

AIM

To evaluate if pre- and post-procedure administration of controlled-release oxycodone (CRO) in combination with standard analgesia improves pain control and decreases the amount of required post-procedure opioids in uterine fibroid embolisation (UFE).

MATERIALS AND METHODS

Between January 2009 and March 2010, 60 consecutive women were prospectively randomised in two groups for UFE: the control group, in which 30 patients underwent the standard anaesthetic procedure and the CRO group, in which 30 patients underwent the standard anaesthetic procedure with the addition of CRO. Age, pain, nausea/vomiting, fibroid volume, length of hospital stay, and use and dose of morphine received via the patient-controlled analgesia (PCA) device in both groups were evaluated to compare the two methods of pain control. Fibroid volume as measured at magnetic resonance imaging (MRI) was evaluated for correlation with post-embolisation pelvic pain over a period of 24 hours.

RESULTS

A significant difference was seen in the pain scores at 24 hours (p=0.029), with less pain in the CRO group. More patients from the control group required morphine (p=0.017), and at higher levels (p=0.130). Pruritus was lower in patients of the CRO group, probably because they received less morphine (p=0.029). No correlation was seen between leiomyoma volume and pain levels over 24 hours (Spearman's ρ=0.02; p=0.881). Length of hospital stay was not different between the two groups.

CONCLUSION

The addition of CRO to standard analgesia for UFE provides more effective analgesia, with a reduction in pain scores in 24 hours, less morphine use, and decreased side effects, mainly pruritus.

Heavy menstrual bleeding: work-up and management

Heavy menstrual bleeding (HMB), which is the preferred term for menorrhagia, affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on anticoagulation. HMB can be predicted on the basis of clots of ≥1 inch diameter, low ferritin, and "flooding" (a change of pad or tampon more frequently than hourly). The goal of the work-up is to determine whether there is a uterine/endometrial cause, a disorder of ovulation, or a disorder of coagulation. HMB manifest by flooding and/or prolonged menses, or HMB accompanied by a personal or family history of bleeding is very suggestive of a bleeding disorder and should prompt a referral to a hematologist. The evaluation will include the patient's history, pelvic examination, and/or pelvic imaging, and a laboratory assessment for anemia, ovulatory dysfunction, underlying bleeding disorder, and in the case of the patient on anticoagulation, assessment for over anticoagulation. The goal of treatment is to reduce HMB. Not only will the treatment strategy depend on whether there is ovulatory dysfunction, uterine pathology, or an abnormality of coagulation, the treatment strategy will also depend on the age of the patient and her desire for immediate or long-term fertility. Hemostatic therapy for HMB may serve as an alternative to hormonal or surgical therapy, and may even be life-saving when used to correct an abnormality of coagulation.

The safety and effectiveness of volumetric magnetic resonance-guided high-intensity focused ultrasound treatment of symptomatic uterine fibroids: early clinical experience in China

BACKGROUND

Uterine fibroids are the most common benign tumor in women, and surgical intervention is still the main fibroid treatment. Patient demands have encouraged development of less-invasive methods such as high-intensity focused ultrasound (HIFU). This study aimed to evaluate the safety and effectiveness of magnetic resonance-guided high-intensity focused ultrasound therapy using a volumetric ablation technique in the treatment of symptomatic uterine fibroids in China.

METHODS

One hundred and seven patients were enrolled and treated with magnetic resonance-guided high-intensity focused ultrasound in this study. Clinical efficacy was based on the proportion of patients with fibroid shrinkage (10 % volume reduction or more compared to baseline) at 6 months post treatment as measured with magnetic resonance imaging. The quality of life and symptom outcome was assessed using the uterine fibroid symptom and quality of life questionnaire with symptom severity scoring. Safety was primarily assessed by evaluating the reported adverse events.

RESULTS

Ninety nine of the 107 treated patients had fibroid shrinkage at 6 months post treatment. Resulting in an overall 93 % (95 % confidence interval 86-97 %) treatment success rate, p value <0.001; the symptom severity scoring and health-related quality of life at 6 months was statistically different from the screening symptom severity scoring at 0.05 level. Of 366 adverse events reported, there were no study procedure-related or device-related serious adverse events were in the study.

CONCLUSIONS

This study demonstrated that the volumetric magnetic resonance-guided high-intensity focused ultrasound device is safe and technically effective and can be utilized in clinically efficient treatments of symptomatic uterine fibroids.

TRIAL REGISTRATION

NCT01588899.

Ovarian down Regulation by GnRF Vaccination Decreases Reproductive Tract Tumour Size in Female White and Greater One-Horned Rhinoceroses

Reproductive tract tumours, specifically leiomyoma, are commonly found in female rhinoceroses. Similar to humans, tumour growth in rhinoceroses is thought to be sex hormone dependent. Tumours can form and expand from the onset of ovarian activity at puberty until the cessation of sex-steroid influences at senescence. Extensive tumour growth results in infertility. The aim of this study was to down regulate reproductive function of tumour-diseased and infertile females to stop further tumour growth using a Gonadotropin releasing factor (GnRF) vaccine. Four infertile southern white (Ceratotherium simum simum) and three Greater one-horned rhinoceroses (rhinoceros unicornis) with active ovaries and 2.7 ± 0.9 and 14.0 ± 1.5 reproductive tract tumours respectively were vaccinated against GnRF (Improvac®, Zoetis, Germany) at 0, 4 and 16 weeks and re-boostered every 6-8 months thereafter. After GnRF vaccination ovarian and luteal activity was suppressed in all treated females. Three months after vaccination the size of the ovaries, the number of follicles and the size of the largest follicle were significantly reduced (P<0.03). Reproductive tract tumours decreased significantly in diameter (Greater-one horned rhino: P<0.0001; white rhino: P<0.01), presumably as a result of reduced sex-steroid influence. The calculated tumour volumes were reduced by 50.8 ± 10.9% in Greater one-horned and 48.6 ± 12.9% in white rhinoceroses. In conclusion, GnRF vaccine effectively down regulated reproductive function and decreased the size of reproductive tract tumours in female rhinoceros. Our work is the first to use down regulation of reproductive function as a symptomatic treatment against benign reproductive tumour disease in a wildlife species. Nonetheless, full reversibility and rhinoceros fertility following GnRF vaccination warrants further evaluation.

Uterine Artery Embolization for Symptomatic Myomata

Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.

Pyomyoma after abortion: Uterus conserving surgery is possible to maintain fertility. Case report

•

If initial treatment of endometritis is unsuccessful consider a differential diagnosis of a pyomyoma.

•

We can maintain patient’s fertility with a myomectomy and future pregnancy can be possible.

•

The post abortion period is a risk factor for pyomyoma even in cases of spontaneous miscarriage.

Introduction

Pyomyoma is a rare complication associated with high rates of morbidity and mortality.

Presentation of case

We report the case of a 28-year-old nulligravida patient presenting pyomyoma following a spontaneous abortion at fourteen weeks and four days. Fourteen days following spontaneous miscarriage she was referred to the hospital with abdominal pain and fever. An antibiotic treatment was initiated. However, after ten days, the patient’s condition deteriorated and a decision for an emergency laparotomy made. The pyomyoma was successfully resected and the patient’s postoperative recovery was uneventful. A new pregnancy was confirmed two years later.

Discussion

The diagnosis of pyomyoma can be difficult but surgical treatment is often indicated. Performing a prompt myomectomy avoids the need for hysterectomy, preserving future fertility.

Conclusion

Pregnancy is possible following uterine sparing treatment of pyomyoma.

Randomized comparison of long and short vascular sheaths in reduction of the operator radiation exposure during uterine artery embolization

OBJECTIVE

To introduce a method in which a long sheath is used instead of the traditional short sheath, to reduce the radiation exposure of operators in uterine artery embolization (UAE).

METHODS

52 patients undergoing UAE were randomly divided into two groups before the procedure: an 11-cm short sheath was used in Group A (n = 25), and a 45-cm-long sheath was used in Group B (n = 27); the 45-cm-long sheath was only partly inserted such that the hub of the sheath was approximately 34 cm caudal to the groin puncture site. All the procedures were standard bilateral UAE operations through unilateral approach. The other parameters of the two groups were kept the same, including the fluoroscopy conditions and the pelvic radiation field size. The thermoluminescent personal dosemeters were attached to the left wrist and left outer side of the thyroid collar of the operator during each operation. The radiation exposure of the operator, procedure duration and fluoroscopy time of each procedure were recorded. Statistical analysis was performed using independent samples t-test.

RESULTS

The radiation exposure of both the left hand and thyroid of the operator was significantly reduced with the long sheath compared with the short sheath (89.5 ± 7.2 μGy vs 186.7 ± 12.6 μGy, p < 0.001, and 54.1 ± 5.5 μGy vs 63.9 ± 7.4 μGy, p < 0.001, respectively). No significant differences were found in the procedure duration and fluoroscopy time between the two groups (p > 0.1).

CONCLUSION

Using a long sheath in UAE could significantly reduce the radiation exposure to the interventionists without extending the procedure duration or fluoroscopy time.

ADVANCES IN KNOWLEDGE

For the first time, we introduce a simple and convenient method to reduce the radiation exposure of the operator in the UAE procedure.