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Cappelli A, Mosconi C, Cocozza MA, Brandi N, Bartalena L, Modestino F, Galaverni MC, Vara G, Paccapelo A, Pizzoli G, Villa G, Seracchioli R, Renzulli M. Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids of Different Sizes: A Single Center Experience. J Pers Med 2023; 13:906. [PMID: 37373895 PMCID: PMC10302260 DOI: 10.3390/jpm13060906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
The present study aimed to evaluate the clinical and radiological 1-year outcomes of uterine artery embolization (UAE) performed in a selected population of women with symptomatic myomas and who do not wish to conceive. Between January 2004 and January 2018, a total of 62 patients with pre-menopausal status and with no wish to conceive in the future underwent UAE for the treatment of symptomatic fibroids. All the patients underwent magnetic resonance imaging (MRI) and/or transvaginal ultrasonography (TV-US) before and after the procedure at 1-year follow-up. Clinical and radiological parameters were recorded, stratifying the population into 3 groups according to the size of the dominant myoma (group 1: <50 mm; group 2: ≥50 and ≤80 mm; group 3: >80 mm). Mean fibroid diameter was significantly reduced (42.6% ± 21.6%) at 1-year follow-up, with excellent improvements in terms of both symptoms and quality of life. No significant difference was observed regarding baseline dimension and the number of myomas. No major complications were reported (2.5%). The present study confirms the safety and efficacy of UAE in the treatment of symptomatic fibroids in pre-menopausal women with no desire to conceive.
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Affiliation(s)
- Alberta Cappelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Cristina Mosconi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Maria Adriana Cocozza
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Laura Bartalena
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Francesco Modestino
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Maria Cristina Galaverni
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Giulio Vara
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Alexandro Paccapelo
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
| | - Gloria Pizzoli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.P.); (G.V.); (R.S.)
| | - Gioia Villa
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.P.); (G.V.); (R.S.)
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (G.P.); (G.V.); (R.S.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (C.M.); (M.A.C.); (L.B.); (F.M.); (M.C.G.); (G.V.); (A.P.); (M.R.)
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Daniels J, Middleton LJ, Cheed V, McKinnon W, Rana D, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K. Uterine artery embolisation versus myomectomy for premenopausal women with uterine fibroids wishing to avoid hysterectomy: the FEMME RCT. Health Technol Assess 2022; 26:1-74. [PMID: 35435818 PMCID: PMC9082260 DOI: 10.3310/zdeg6110] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine fibroids are the most common tumour in women of reproductive age and are associated with heavy menstrual bleeding, abdominal discomfort, subfertility and reduced quality of life. For women wishing to retain their uterus and who do not respond to medical treatment, myomectomy and uterine artery embolisation are therapeutic options. OBJECTIVES We examined the clinical effectiveness and cost-effectiveness of uterine artery embolisation compared with myomectomy in the treatment of symptomatic fibroids. DESIGN A multicentre, open, randomised trial with a parallel economic evaluation. SETTING Twenty-nine UK hospitals. PARTICIPANTS Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolisation were recruited. Women were excluded if they had significant adenomyosis, any malignancy or pelvic inflammatory disease or if they had already had a previous open myomectomy or uterine artery embolisation. INTERVENTIONS Participants were randomised to myomectomy or embolisation in a 1 : 1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic. Embolisation of the uterine arteries was performed under fluoroscopic guidance. MAIN OUTCOME MEASURES The primary outcome was the Uterine Fibroid Symptom Quality of Life questionnaire (with scores ranging from 0 to 100 and a higher score indicating better quality of life) at 2 years, adjusted for baseline score. The economic evaluation estimated quality-adjusted life-years (derived from EuroQol-5 Dimensions, three-level version, and costs from the NHS perspective). RESULTS A total of 254 women were randomised - 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolisation (98 underwent embolisation). Information on the primary outcome at 2 years was available for 81% (n = 206) of women. Primary outcome scores at 2 years were 84.6 (standard deviation 21.5) in the myomectomy group and 80.0 (standard deviation 22.0) in the uterine artery embolisation group (intention-to-treat complete-case analysis mean adjusted difference 8.0, 95% confidence interval 1.8 to 14.1, p = 0.01; mean adjusted difference using multiple imputation for missing responses 6.5, 95% confidence interval 1.1 to 11.9). The mean difference in the primary outcome at the 4-year follow-up time point was 5.0 (95% CI -1.4 to 11.5; p = 0.13) in favour of myomectomy. Perioperative and postoperative complications from all initial procedures occurred in similar percentages of women in both groups (29% in the myomectomy group vs. 24% in the UAE group). Twelve women in the uterine embolisation group and six women in the myomectomy group reported pregnancies over 4 years, resulting in seven and five live births, respectively (hazard ratio 0.48, 95% confidence interval 0.18 to 1.28). Over a 2-year time horizon, uterine artery embolisation was associated with higher costs than myomectomy (mean cost £7958, 95% confidence interval £6304 to £9612, vs. mean cost £7314, 95% confidence interval £5854 to £8773), but with fewer quality-adjusted life-years gained (0.74, 95% confidence interval 0.70 to 0.78, vs. 0.83, 95% confidence interval 0.79 to 0.87). The differences in costs (difference £645, 95% confidence interval -£1381 to £2580) and quality-adjusted life-years (difference -0.09, 95% confidence interval -0.11 to -0.04) were small. Similar results were observed over the 4-year time horizon. At a threshold of willingness to pay for a gain of 1 QALY of £20,000, the probability of myomectomy being cost-effective is 98% at 2 years and 96% at 4 years. LIMITATIONS There were a substantial number of women who were not recruited because of their preference for a particular treatment option. CONCLUSIONS Among women with symptomatic uterine fibroids, myomectomy resulted in greater improvement in quality of life than did uterine artery embolisation. The differences in costs and quality-adjusted life-years are very small. Future research should involve women who are desiring pregnancy. TRIAL REGISTRATION This trial is registered as ISRCTN70772394. FUNDING This study was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, and will be published in full in Health Technology Assessment; Vol. 26, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Dikshyanta Rana
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
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Xu X, Desai VB, Schwartz PE, Gross CP, Lin H, Schymura MJ, Wright JD. Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact. WOMEN'S HEALTH REPORTS 2022; 3:369-384. [PMID: 35415718 PMCID: PMC8994439 DOI: 10.1089/whr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/09/2022]
Abstract
Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning. Materials and Methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature. Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY. Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.
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Affiliation(s)
- Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vrunda B. Desai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- CooperSurgical, Inc., Trumbull, Connecticut, USA
| | - Peter E. Schwartz
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Rana D, Wu O, Cheed V, Middleton LJ, Moss J, Lumsden MA, McKinnon W, Daniels J, Sirkeci F, Manyonda I, Belli AM, McPherson K. Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial. BJOG 2021; 128:1793-1802. [PMID: 34053154 DOI: 10.1111/1471-0528.16781] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of uterine artery embolisation (UAE) and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy. DESIGN Economic evaluation alongside the FEMME randomised controlled trial. SETTING 29 UK hospitals. POPULATION Premenopausal women who had symptomatic uterine fibroids amenable to UAE or myomectomy wishing to avoid hysterectomy. 254 women were randomised to UAE (127) and myomectomy (127). METHODS A within-trial cost-utility analysis was conducted from the perspective of the UK NHS. MAIN OUTCOME MEASURES Quality-adjusted life years (QALYs) measured using the EuroQoL EQ-5D-3L, combined with costs to estimate cost-effectiveness over 2 and 4 years of follow-up. RESULTS Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645; 95% CI -1381 to 2580) and lower QALYs (difference -0.09; 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Thus, UAE was dominated by myomectomy. Results of the sensitivity analyses were consistent with the base case results for both years. Over 2 years, UAE was associated with higher costs (difference £456; 95% CI -1823 to 3164) and lower QALYs (difference -0.06; 95% CI -0.11 to -0.02). CONCLUSIONS Myomectomy is a cost-effective option for the treatment of uterine fibroids. The differences in costs and QALYs are small. Women should be fully informed and have the option to choose between the two procedures.
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Affiliation(s)
- D Rana
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - O Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - V Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - L J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Moss
- School of Medicine, University of Glasgow, Glasgow, UK
| | - M-A Lumsden
- School of Medicine, University of Glasgow, Glasgow, UK
| | - W McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - F Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London, UK
| | - I Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London, UK
| | - A-M Belli
- Department of Radiology, St George's Hospital and Medical School, London, UK
| | - K McPherson
- Department of Primary Care, University of Oxford, Oxford, UK
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Maudgil DD. Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology. Clin Radiol 2020; 76:185-192. [PMID: 33081990 PMCID: PMC7568486 DOI: 10.1016/j.crad.2020.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 12/12/2022]
Abstract
Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.
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Affiliation(s)
- D D Maudgil
- Radiology Department, Wexham Park Hospital, Frimley Health Foundation Trust, Wexham Street, Slough, Berks, SL2 4HL, UK.
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Cost and Distribution of Hysterectomy and Uterine Artery Embolization in the United States: Regional/Rural/Urban Disparities. Med Sci (Basel) 2017; 5:medsci5020010. [PMID: 29099026 PMCID: PMC5635782 DOI: 10.3390/medsci5020010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/06/2017] [Accepted: 05/08/2017] [Indexed: 12/15/2022] Open
Abstract
Hysterectomy, the driving force for symptomatic uterine fibroids since 1895, has decreased over the years, but it is still the number one choice for many women. Since 1995, uterine artery embolization (UAE) has been proven by many researchers to be an effective treatment for uterine fibroids while allowing women to keep their uteri. The preponderance of data collection and research has focused on care quality in terms of efficiency and effectiveness, with little on location and viability related to care utilization, accessibility and physical availability. The purpose of this study was to determine and compare the cost of UAE and classical abdominal hysterectomy with regard to race/ethnicity, region, and location. Data from National Hospital Discharge for 2004 through 2008 were accessed and analyzed for uterine artery embolization and hysterectomy. Frequency analyses were performed to determine distribution of variables by race/ethnicity, location, region, insurance coverage, cost and procedure. Based on frequency distributions of cost and length of stay, outliers were trimmed and categorized. Crosstabs were used to determine cost distributions by region, place/location, procedure, race, and primary payer. For abdominal hysterectomy, 9.8% of the sample were performed in rural locations accross the country. However, for UAE, only seven procedures were performed nationally in the same period. Therefore, all inferential analyses and associations for UAE were assumed for urban locations only. The pattern differed from region to region, regarding the volume of care (numbers of cases by location) and care cost. Comparing hysterectomy and UAE, the patterns indicate generally higher costs for UAE with a mean cost difference of $4223.52. Of the hysterectomies performed for fibroids on Black women in the rural setting, 92.08% were in the south. Overall, data analyzed in this examination indicated a significant disparity between rural and urban residence in both data collection and number of procedures conducted. Further research should determine the background to cost and care location differentials between races and between rural and urban settings. Further, factors driving racial differences in the proportions of hysterectomies in the rural south should be identified to eliminate disparities. Data are needed on the prevalence of uterine fibroids in rural settings.
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Luttjeboer J, Setiawan D, Cao Q, Cahh Daemen T, Postma MJ. Threshold cost-effectiveness analysis for a therapeutic vaccine against HPV-16/18-positive cervical intraepithelial neoplasia in the Netherlands. Vaccine 2016; 34:6381-6387. [PMID: 27816370 DOI: 10.1016/j.vaccine.2016.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/10/2016] [Accepted: 10/13/2016] [Indexed: 11/28/2022]
Abstract
In this study, the potential price for a therapeutic vaccine against Human Papilloma Virus (HPV)-16 & 18 (pre)-malignant cervical lesions is examined. A decision tree model was built in the context of the new Dutch cervical cancer-screening program and includes a primary test for the presence of HPV. Based on data of cervical cancer screening and HPV prevalence in the Netherlands, cohorts were created with HPV-16 or 18 positive women with cervical intraepithelial neoplasia (CIN) 2 or 3 or cervical cancer stage 1A (FIGO 1A). In the base case, the vaccine price was based on equal numbers of effective treatments in the vaccine branch and the current treatments branch of the model, and parity in cost, i.e. total cost in both branches are the same. The vaccine price is calculated by subtracting the cost of the vaccine branch from cost in the standard treatment branch and divided by the total number of women in the cohort, thereby equalizing costs in both strategies. Scenario analyses were performed taking quality adjusted life years (QALYs) into account with €20,000/QALY, €50,000/QALY and €80,000/QALY as corresponding thresholds. Sensitivity analyses were specifically targeted at the characteristics of the type-specific HPV test in the screening practice and vaccine efficacy. A probabilistic sensitivity analysis (PSA) was performed to quantify the level of uncertainty of the results found in the base case. In the base case, break-even vaccine prices of €381, €568 and €1697 were found for CIN 2, CIN 3 and FIGO 1A, respectively. The PSA showed vaccine pricing below €310, €490 and €1660 will be cost saving with a likelihood of 95% for CIN 2, CIN 3 and FIGO 1A, respectively. The vaccine price proved to be very sensitive for inclusion of QALY gains, including the HPV-type specific test into the Dutch screening practice and vaccine efficacy.
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Affiliation(s)
- Jos Luttjeboer
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands.
| | - Didik Setiawan
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands
| | - Qi Cao
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands
| | - Toos Cahh Daemen
- Department of Medical Microbiology, Tumor Virology and Cancer Immunotherapy, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Pharmacy, Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), University of Groningen, Groningen, The Netherlands; Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Institute of Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Sommer EM, Balkwill A, Reeves G, Green J, Beral DV, Coffey K. Effects of obesity and hormone therapy on surgically-confirmed fibroids in postmenopausal women. Eur J Epidemiol 2015; 30:493-9. [PMID: 25784364 PMCID: PMC4485678 DOI: 10.1007/s10654-015-0016-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 03/04/2015] [Indexed: 01/27/2023]
Abstract
To examine the association between body mass index (BMI), use of menopausal hormone therapy (HT), and incidence of uterine fibroids in postmenopausal women, 610,604 postmenopausal women without prior hysterectomy or diagnosis of fibroids were followed as part of a large United Kingdom prospective cohort study. We used Cox regression models to calculate adjusted relative risks (RRs) of surgically-confirmed fibroids (defined as a hospital admission with uterine fibroids as a primary diagnosis with a related surgical procedure), in relation to BMI and use of HT. During an average of 11.4 years of follow-up, 3561 women were admitted to hospital with surgically-confirmed fibroids. Five-year incidence rates decreased with age, from 0.50% (1 in 200 women) at age 50-54, to 0.11% (1 in 1000 women) at age 75-79. The 5-year rate in postmenopausal women aged 50-54 was about a quarter that seen in premenopausal women of the same age (1 in 200 vs. 1 in 50). Compared with normal weight women, obese women had a RR of surgically-detected fibroids of 1.46 (95% CI 1.33-1.59; p < 0.0001). HT use was associated with a RR of 2.33 (95% CI 2.18-2.49; p < 0.0001) in ever versus never users. When we analysed HT use and BMI together, obese vs. normal weight never users had a RR of 2.00 (95% CI 1.77-2.26): the highest risks were seen in women who were obese and had ever used HT, RR = 3.30 (95% CI 2.88-3.79). Uterine fibroids continue to occur in postmenopausal women; obesity and hormone therapy use are important modifiable risk factors.
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Affiliation(s)
- Eva M. Sommer
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
| | - Angela Balkwill
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
| | - Gillian Reeves
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
| | - Jane Green
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
| | - Dame Valerie Beral
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
| | - Kate Coffey
- Cancer Epidemiology Unit, University of Oxford, Richard Doll Building, Roosevelt Drive, Old Road Campus, Oxford, OX3 7LF UK
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Pérez-López FR, Ornat L, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, Schenck-Gustafsson K, Simoncini T, Tremollieres F, Rees M. EMAS position statement: Management of uterine fibroids. Maturitas 2014; 79:106-16. [DOI: 10.1016/j.maturitas.2014.06.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Suo G, Sadarangani A, Tang W, Cowan BD, Wang JYJ. Telomerase expression abrogates rapamycin-induced irreversible growth arrest of uterine fibroid smooth muscle cells. Reprod Sci 2014; 21:1161-70. [PMID: 24784716 DOI: 10.1177/1933719114532839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Uterine fibroids are the most common solid tumors found in women of reproductive age. It has been reported that deregulation of the mammalian target of rapamycin (mTOR) pathway plays an important role in the etiology of leiomyoma. Here, we investigated the effect of rapamycin, an inhibitor of mTORC1, on the growth of primary fibroid smooth muscle cells (fSMCs) and human telomerase reverse transcriptase (hTERT)-transduced and immortalized fSMCs. With the primary fSMCs, a 24-hour treatment with rapamycin was sufficient to trigger a growth arrest that was not reversible upon drug removal. By contrast, the growth inhibitory effect of rapamycin on the hTERT-transduced fSMCs was readily reversible, as these cells resumed proliferation upon the withdrawal of the drug. These results suggest that rapamycin-induced irreversible growth arrest of fSMCs is dependent on the senescence barrier that is abrogated by the ectopic expression of telomerase.
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Affiliation(s)
- Guangli Suo
- Department of Medicine, Division of Hematology/Oncology, Moores Cancer Center, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Anil Sadarangani
- Department of Medicine, Division of Hematology/Oncology, Moores Cancer Center, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Wingchung Tang
- Department of Medicine, Division of Hematology/Oncology, Moores Cancer Center, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Bryan D Cowan
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jean Y J Wang
- Department of Medicine, Division of Hematology/Oncology, Moores Cancer Center, University of California, San Diego School of Medicine, La Jolla, CA, USA
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Pynnä K, Vuorela P, Lodenius L, Paavonen J, Roine RP, Räsänen P. Cost-effectiveness of hysterectomy for benign gynecological conditions: a systematic review. Acta Obstet Gynecol Scand 2013; 93:225-32. [PMID: 24180560 DOI: 10.1111/aogs.12299] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 10/20/2013] [Indexed: 11/30/2022]
Abstract
The objective of this study was to assess the cost-effectiveness of hysterectomy performed for benign indications. Hysterectomy remains the most common major gynecological operation in the Western world. Rates of hysterectomy have not declined as expected with the introduction of new treatment options. Furthermore, use of laparoscopic techniques varies widely within the Nordic countries. We designed a systematic review in a University Central Hospital. The sample included all published studies regarding the cost-effectiveness of hysterectomy performed for benign indications (n = 1666). Medline, Cochrane Library, PsycINFO, CINAHL, and Nursing databases were searched. Inclusion criteria were the availability of pre- and post-intervention health-related quality of life measures (HRQoL) and data on costs. HRQoL, costs, and cost-effectiveness of treatment were the main outcome measures. Studies (n = 24) focused on treatment of symptomatic fibroids (n = 8), treatment of heavy menstrual bleeding (n = 10), various surgical techniques (n = 5) and the effect of various indications for hysterectomy (n = 2). Follow-up periods varied from 4 months to over 10 years. SF/RAND-36 or EQ-5D measures and societal cost perspective were most commonly used. Only 11 studies used individual patient data. HRQoL following hysterectomy was generally good but costs were high. The cost-effectiveness depended on indication, age, and duration of follow-up. The cost-effectiveness of hysterectomy has been surprisingly poorly studied. Conclusions are difficult to draw due to different study designs, indications, follow-up times, and HRQoL instruments used. Rates of hysterectomy have declined less than expected with the introduction of new treatment modalities. Costs of surgery are high. Laparoscopic hysterectomy seems to be the least cost-effective, although further data from original patient cohorts with long-term follow-up are needed.
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Affiliation(s)
- Kristiina Pynnä
- University of Helsinki, Helsinki, Finland; Department of Obstetrics and Gynecology, Lohja Hospital, Lohja, Finland
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Kahn V, Fohlen A, Pelage JP. Place de l’embolisation dans le traitement des fibromes. ACTA ACUST UNITED AC 2011; 40:918-27. [DOI: 10.1016/j.jgyn.2011.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Burke CT, Funaki BS. Authors' Reply. J Am Coll Radiol 2011. [DOI: 10.1016/j.jacr.2011.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Vo NJ, Andrews RT. Uterine artery embolization: a safe and effective, minimally invasive, uterine-sparing treatment option for symptomatic fibroids. Semin Intervent Radiol 2011; 25:252-60. [PMID: 21326515 DOI: 10.1055/s-0028-1085923] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Leiomyomas (or fibroids) are exceedingly common lesions. The indications to initiate treatment are based on the symptoms that can arise from their presence. In general, medical therapy should be considered the first line of treatment. Currently, the treatment of fibroids is in evolution. Since uterine artery embolization (UAE) was first described by Ravina et al in 1995, it has been shown to be a safe, efficacious, and cost-effective alternative to traditional surgical options, with data from long-term studies now available. Appropriate patient evaluation and selection are vital; the ideal candidate is one who is premenopausal, has symptomatic fibroids resistant to medical therapy, no longer desires fertility, and wishes to maintain her uterus. Uterine artery embolization is primarily an angiographic procedure, but periprocedural clinical management is critical for patient satisfaction. This article discusses the various embolic materials that are commonly used and available for UAE; understanding the technical nuances is critical for long-term success.
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Affiliation(s)
- Nghia-Jack Vo
- Department of Radiology, Section of Vascular and Interventional Radiology University of Washington, Seattle, Washington
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Shi JF, Canfell K, Lew JB, Zhao FH, Legood R, Ning Y, Simonella L, Ma L, Kang YJ, Zhang YZ, Smith MA, Chen JF, Feng XX, Qiao YL. Evaluation of primary HPV-DNA testing in relation to visual inspection methods for cervical cancer screening in rural China: an epidemiologic and cost-effectiveness modelling study. BMC Cancer 2011; 11:239. [PMID: 21668946 PMCID: PMC3141766 DOI: 10.1186/1471-2407-11-239] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/13/2011] [Indexed: 12/11/2022] Open
Abstract
Background A new lower-cost rapid-throughput human papillomavirus (HPV) test (careHPV, Qiagen, Gaithersburg, USA) has been shown to have high sensitivity for the detection of high grade cervical intraepithelial neoplasia. Methods We assessed the outcomes and cost-effectiveness of careHPV screening in rural China, compared to visual inspection with acetic acid, when used alone (VIA) or in combination with Lugol's iodine (VIA/VILI). Using data on sexual behaviour, test accuracy, diagnostic practices and costs from studies performed in rural China, we estimated the cost-effectiveness ratio (CER) and associated lifetime outcomes for once-lifetime and twice-lifetime screening strategies, and for routine screening at 5-yearly, 10-yearly and IARC-recommended intervals. The optimal age range for once-lifetime screening was also assessed. Results For all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of ~70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US$557 (for VIA) to $959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of $2,975. Correspondingly, regular screening with an age-standardised participation rate of 62% (which has been shown to be achievable in this setting) would reduce cervical cancer mortality by 19-28% (for 10-yearly screening) to 43-54% (using IARC-recommended intervals), with corresponding CERs ranging from $665 (for 10-yearly VIA) to $2,269 (for IARC-recommended intervals using careHPV@1.0) per LYS. Conclusions This modelled analysis suggests that primary careHPV screening compares favourably to visual inspection screening methodologies in rural China, particularly if used as part of a regular screening program.
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Affiliation(s)
- Ju-Fang Shi
- Department of Cancer Epidemiology, Cancer Institute, Chinese Academy of Medical Sciences, Peking Union Medical College, 17, South Panjiayuan LN, PO Box 2258, Beijing 100021, China
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Moss JG, Cooper KG, Khaund A, Murray LS, Murray GD, Wu O, Craig LE, Lumsden MA. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG 2011; 118:936-44. [DOI: 10.1111/j.1471-0528.2011.02952.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Burke CT, Funaki BS, Ray CE, Kinney TB, Kostelic JK, Loesberg A, Lorenz JM, Millward SF, Nemcek AA, Owens CA, Shaw H, Silberzweig JE, Vatakencherry G. ACR Appropriateness Criteria ® on Treatment of Uterine Leiomyomas. J Am Coll Radiol 2011; 8:228-34. [DOI: 10.1016/j.jacr.2010.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 12/21/2010] [Indexed: 11/25/2022]
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Kirby JM, Burrows D, Haider E, Maizlin Z, Midia M. Utility of MRI Before and After Uterine Fibroid Embolization: Why to Do It and What to Look For. Cardiovasc Intervent Radiol 2010; 34:705-16. [DOI: 10.1007/s00270-010-0029-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 10/20/2010] [Indexed: 01/02/2023]
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Nicholson AA, Hammond CJ. Emergency radiology. IMAGING 2009. [DOI: 10.1259/imaging/17355050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Fernandez H, Farrugia M, Jones SE, Mauskopf JA, Oppelt P, Subramanian D. Rate, type, and cost of invasive interventions for uterine myomas in Germany, France, and England. J Minim Invasive Gynecol 2008; 16:40-6. [PMID: 18996060 DOI: 10.1016/j.jmig.2008.09.581] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Revised: 08/31/2008] [Accepted: 09/06/2008] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The objective of our study was to quantify the rate, type, and cost of interventions for uterine myomas to payers in Germany, France, and England. DESIGN Computations using data from national hospital activity databases. DESIGN CLASSIFICATION II-3. SETTING Hospital admissions in Germany, France, and England. PATIENTS Women admitted for a surgical or radiologic intervention for uterine myomas. INTERVENTIONS Surgical or radiologic interventions for uterine myomas. MEASUREMENTS AND MAIN RESULTS We identified the number and type of hospital admissions involving surgical or radiologic interventions for uterine myomas, through the analysis of national hospital activity databases from each country. We calculated the costs of these hospitalizations to payers in these countries using the diagnosis-related group reimbursement rates. In 2005, the number (rate) of hospital admissions involving interventions for uterine myomas was 64 299 (1.53/1000 women) in Germany, 37 787 (1.17/1000 women) in France, and 18 274 (0.71/1000 women) in England. The annual costs of these interventions to payers were euro212 313 090 in Germany, euro73 278 270 in France (excluding surgeon and anesthetist fees for interventions in the private sector), and euro52 674 672 in England. The percentage of interventions for uterine myomas that included a hysterectomy was 84.9% in Germany, 59.7% in France, and 64.1% in England. CONCLUSION The number of admissions and costs associated with interventions for uterine myomas are substantial in the 3 European countries studied. Hysterectomy is the most frequent surgical intervention used to treat uterine myomas. The results in this article provide useful information for policy makers wishing to evaluate the cost effectiveness and budget impact of new, less invasive interventions.
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HICKEY M, HAMMOND I. What is the place of uterine artery embolisation in the management of symptomatic uterine fibroids? Aust N Z J Obstet Gynaecol 2008; 48:360-8. [DOI: 10.1111/j.1479-828x.2008.00886.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bratby M, Belli AM. Radiological treatment of symptomatic uterine fibroids. Best Pract Res Clin Obstet Gynaecol 2008; 22:717-34. [DOI: 10.1016/j.bpobgyn.2008.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mirsadraee S, Tuite D, Nicholson A. Uterine artery embolization for ureteric obstruction secondary to fibroids. Cardiovasc Intervent Radiol 2008; 31:1094-9. [PMID: 18574626 DOI: 10.1007/s00270-008-9381-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 04/03/2008] [Accepted: 05/02/2008] [Indexed: 12/01/2022]
Abstract
This case series examines the safety and efficacy of uterine artery embolization (UAE) in the treatment of obstructive nephropathy caused by large fibroids. Between 2004 and 2007, 10 patients referred with symptomatic uterine fibroids that were found to be causing either unilateral (7 patients) or bilateral (3 patients) hydronephrosis were treated by UAE. Presenting complaints included menorrhagia, dysmenorrhea, bulk symptoms, loin pain, postobstructive atrophy, and mild renal impairment. All had posterior intramural dominant fibroids >11 cm in maximum sagittal diameter and uterine volumes between 3776 and 15,625 ml. Outcome measures at between 12 and 36 months included procedural success, repeat intervention, relief of symptoms, resolution of hydronephrosis, stable renal function and size, and avoidance of hysterectomy. In all cases the cause of renal obstruction was confirmed to be a giant fibroid compressing the ureter at the pelvic brim. In all cases UAE was technically successful, though two patients required a repeat procedure. In eight patients hydronephrosis resolved and the obstruction was relieved, though two still had some bulk symptoms not requiring further treatment. Renal function improved or was stable in all cases. Renal size was stable in all cases. Where menorrhagia was part of the symptom complex it was relieved in all cases. Two patients diagnosed as having postobstructive atrophy of one kidney underwent retrograde ureteric stenting on the nonatrophied side prior to UAE. This was unsuccessful in one of the cases due to the distortion caused by the fibroid. Despite improvement in hydronephrosis this patient underwent hysterectomy at 7 months after a renogram demonstrated persistent obstruction at the pelvic brim. In the second patient a double pigtail stent was inserted with difficulty and eventually removed at 8 months. This patient has had stable renal function and size for 3 years post-UAE. We conclude that UAE is safe and effective in treating patients with obstructive hydronephrosis caused by large fibroids.
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Keeling AN, Reidy JF. Imaging and treatment of uterine fibroids, including the role of uterine artery embolization. IMAGING 2007. [DOI: 10.1259/imaging/80403836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Dutton S, Hirst A, McPherson K, Nicholson T, Maresh M. A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. BJOG 2007; 114:1340-51. [DOI: 10.1111/j.1471-0528.2007.01526.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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