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Medema AM, Zanolli NC, Cline B, Pabon-Ramos W, Martin JG. Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization. Curr Probl Diagn Radiol 2024; 53:308-312. [PMID: 38267343 DOI: 10.1067/j.cpradiol.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization. METHODS The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports. RESULTS 199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),. CONCLUSIONS When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.
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Affiliation(s)
- Alexis M Medema
- Duke University School of Medicine, Box 3808, Durham, NC 27710, USA
| | - Nicole C Zanolli
- Duke University School of Medicine, Box 3808, Durham, NC 27710, USA
| | - Brendan Cline
- Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
| | - Waleska Pabon-Ramos
- Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
| | - Jonathan G Martin
- Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA.
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Cox KR, Ferzandi TR, Dancz CE, Mandelbaum RS, Klar M, Wright JD, Matsuo K. Nationwide assessment of practice variability in the utilization of hysteropexy at laparoscopic apical suspension for uterine prolapse. AJOG GLOBAL REPORTS 2024; 4:100322. [PMID: 38586613 PMCID: PMC10994978 DOI: 10.1016/j.xagr.2024.100322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Although hysteropexy has been used to preserve the uterus during uterine prolapse surgery for a long time, there is a scarcity of data that describe the nationwide patterns of use of this surgical procedure. OBJECTIVE This study aimed to examine the national-level use and characteristics of hysteropexy at the time of laparoscopic apical suspension surgery for uterine prolapse in the United States. STUDY DESIGN This cross-sectional study used data from the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population included 55,608 patients with a diagnosis of uterine prolapse who underwent laparoscopic apical suspension surgery from 2016 to 2019. Patients who had a hysterectomy were assigned to the hysterectomy group, and those who did not have a hysterectomy were assigned to the hysteropexy group. The main outcome was clinical characteristics associated with hysteropexy, assessed using a multivariable binary logistic regression model. A classification tree was further constructed to assess the use pattern of hysteropexy during laparoscopic apical suspension procedures. The secondary outcome was surgical morbidity, including urinary tract injury, intestinal injury, vascular injury, and hemorrhage. RESULTS A hysteropexy was performed in 6500 (11.7%) patients. In a multivariable analysis, characteristics associated with increased use of a hysteropexy included (1) patient factors, such as older age, Medicare coverage, private insurance, self-pay, and medical comorbidity; (2) pelvic floor dysfunction factor of complete uterine prolapse; and (3) hospital factors, including medium bed capacity center and location in the Southern United States (all P<.05). Conversely, (1) the patient factor of higher household income; (2) gynecologic factors such as uterine myoma, adenomyosis, and benign ovarian pathology; (3) pelvic floor dysfunction factor with stress urinary incontinence; and (4) hospital factors including Midwest and West United States regions and rural setting center were associated with decreased use of a hysteropexy (all P<.05). A classification tree identified a total of 14 use patterns for hysteropexies during laparoscopic apical suspension procedures. The strongest factor that dictated the use of a hysteropexy was the presence or absence of uterine myomas; the rate of hysteropexy use was decreased to 5.6% if myomas were present in comparison with 15% if there were no myomas (P<.001). Second layer factors were adenomyosis and hospital region. Patients who did not have uterine myomas or adenomyosis and who underwent surgery in the Southern United States had the highest rate of undergoing a hysteropexy (22.6%). Across the 14 use patterns, the percentage rate difference between the highest and lowest uptake patterns was 22.0%. Patients who underwent a hysteropexy were less likely to undergo anteroposterior colporrhaphy, posterior colporrhaphy, and sling procedures (all P<.05). Hysteropexy was associated with a decreased risk for measured surgical morbidity (3.0 vs 5.4 per 1000 procedures; adjusted odds ratio, 0.57; 95% confidence interval, 0.36-0.90). CONCLUSION The results of these current, real-world practice data suggest that hysteropexies are being performed at the time of ambulatory laparoscopic apical suspension surgery for uterine prolapse. There is substantial variability in the application of hysteropexy based on patient, gynecologic, pelvic floor dysfunction, and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice may be of use.
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Affiliation(s)
- Kaily R. Cox
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Cox and Matsuo)
| | - Tanaz R. Ferzandi
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Ferzandi and Dancz)
| | - Christina E. Dancz
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Ferzandi and Dancz)
| | - Rachel S. Mandelbaum
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Mandelbaum)
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University Medical Center Freiburg, University of Freiburg Faculty of Medicine, Freiburg, Germany (Dr Klar)
| | - Jason D. Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY (Dr Wright)
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Cox and Matsuo)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (Dr Matsuo)
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Musa B, Alswang JM, Di Ioia R, Grubic L, Naif A, Mbuguje EM, Vuong V, Newsome J, Shaygi B, Ramalingam V, Gaupp FML. Uterine artery embolization in Tanzania: a procedure with major public health implications. CVIR Endovasc 2023; 6:40. [PMID: 37548779 PMCID: PMC10406993 DOI: 10.1186/s42155-023-00384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND The burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment. METHODS From June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania's first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests. RESULTS During the study period, 92.1% (n = 35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n = 3/38) for adenomyosis. All (n = 38/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p < 0.01). 100% of patients reported satisfaction with outcomes. Among the nine patients with follow-up imaging, there was a mean volumetric decrease of 35.5% (p = 0.109). CONCLUSIONS UAE for fibroids and adenomyosis can be performed with high technical success and low complication rates in a low-resource setting like Tanzania, resulting in significant symptom relief for patients. Building capacity for UAE has major public health implications not only for fibroids and adenomyosis, but can help address the region's leading cause of maternal mortality, postpartum hemorrhage.
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Affiliation(s)
- Balowa Musa
- Radiology and Imaging Department, School of Medicine, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
| | - Jared Mark Alswang
- Harvard Medical School, Harvard University, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Rose Di Ioia
- Faculty of Medicine and Health Sciences, McGill University, 2001 McGill College Avenue, Montreal, QC, H3A 1A3, Canada
| | - Lydia Grubic
- Marian University College of Osteopathic Medicine, 3200 Cold Spring Rd, Indianapolis, IN, 46222, USA
| | - Azza Naif
- Department of Radiology and Imaging, Muhimbili National Hospital, P.O. Box 65000, Dar Es Salaam, Tanzania
| | - Erick Michael Mbuguje
- Department of Radiology and Imaging, Muhimbili National Hospital, P.O. Box 65000, Dar Es Salaam, Tanzania
| | - Victoria Vuong
- Department of Radiology, University of California San Diego Medical Center, 200 W. Arbor Drive, San Diego, CA, 92103, USA
| | - Janice Newsome
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Rd, NE, Atlanta, GA, 30322, USA
| | - Behnam Shaygi
- Department of Radiology, London North West University Healthcare NHS Trust, A404 Watford Rd, Harrow, HA1 3UJ, UK
| | - Vijay Ramalingam
- Division of Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Road, Boston, MA, 02215, USA
| | - Fabian Max Laage Gaupp
- Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
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Gupta A, Balk EM, Lenger SM, Yang LC, Misal M, Balgobin S, Chang OH, Sharma V, Stuparich M, Behbehani S, Nihira M, Alas A, Jampa A, Sheyn D, Meriwether K, Antosh DD. Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review. Obstet Gynecol 2023; 142:319-329. [PMID: 37411023 DOI: 10.1097/aog.0000000000005260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/11/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To conduct a systematic review to evaluate the effect of procedural interventions for leiomyomas on pelvic floor symptoms. DATA SOURCES PubMed, EMBASE, and ClinicalTrials.gov were searched from inception to January 12, 2023, searching for leiomyoma procedures and pelvic floor disorders and symptoms, restricted to primary study designs in humans. METHODS OF STUDY SELECTION Double independent screening for studies of any study design in all languages that reported pelvic floor symptoms before and after surgical (hysterectomy, myomectomy, radiofrequency volumetric thermal ablation) or radiologic (uterine artery embolization, magnetic resonance-guided focused ultrasonography, high-intensity focused ultrasonography) procedures for management of uterine leiomyomas. Data were extracted, with risk-of-bias assessment and review by a second researcher. Random effects model meta-analyses were conducted, as feasible. TABULATION, INTEGRATION, AND RESULTS Six randomized controlled trials, one nonrandomized comparative study, and 25 single-group studies met criteria. The overall quality of the studies was moderate. Only six studies, reporting various outcomes, directly compared two procedures for leiomyomas. Across studies, leiomyoma procedures were associated with decreased symptom distress per the UDI-6 (Urinary Distress Inventory, Short Form) (summary mean change -18.7, 95% CI -25.9 to -11.5; six studies) and improved quality of life per the IIQ-7 (Incontinence Impact Questionnaire, Short Form) (summary mean change -10.7, 95% CI -15.8 to -5.6; six studies). There was a wide range of resolution of urinary symptoms after procedural interventions (7.6-100%), and this varied over time. Urinary symptoms improved in 19.0-87.5% of patients, and the definitions for improvement varied between studies. Bowel symptoms were inconsistently reported in the literature. CONCLUSION Urinary symptoms improved after procedural interventions for uterine leiomyomas, although there is high heterogeneity among studies and few data on long-term outcomes or comparing different procedures. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021272678.
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Affiliation(s)
- Ankita Gupta
- Division of Female Pelvic Medicine & Reconstructive Surgery, University of Louisville Health, and the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics, Gynecology, & Women's Health, University of Louisville School of Medicine, Louisville, Kentucky; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Northwestern Medicine, Chicago, Illinois; the Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, and the Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals, Cleveland, Ohio; the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, the Department of OBGYN, Division of Urogynecology, UT Health Science Center at San Antonio, San Antonio, and the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas; the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington; the Department of Obstetrics and Gynecology, Jacobi Medical Center, and the Albert Einstein College of Medicine, Bronx, New York; the Department of Obstetrics and Gynecology, University of California, Riverside School of Medicine, Riverside, and KPC Healthcare, Hemet, California; the Jawaharlal Nehur Medical College, Belgaum, India; and the Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico
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Kröncke T. An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus. Br J Radiol 2023; 96:20220121. [PMID: 36222200 PMCID: PMC9975358 DOI: 10.1259/bjr.20220121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/11/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.
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Affiliation(s)
- Thomas Kröncke
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany
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6
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Uimari O, Subramaniam KS, Vollenhoven B, Tapmeier TT. Uterine Fibroids (Leiomyomata) and Heavy Menstrual Bleeding. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:818243. [PMID: 36303616 PMCID: PMC9580818 DOI: 10.3389/frph.2022.818243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Uterine Fibroids, or leiomyomata, affect millions of women world-wide, with a high incidence of 75% within women of reproductive age. In ~30% of patients, uterine fibroids cause menorrhagia, or heavy menstrual bleeding, and more than half of the patients experience symptoms such as heavy menstrual bleeding, pelvic pain, or infertility. Treatment is symptomatic with limited options including hysterectomy as the most radical solution. The genetic foundations of uterine fibroid growth have been traced to somatic driver mutations (MED12, HMGA2, FH−/−, and COL4A5-A6). These also lead to downstream expression of angiogenic factors including IGF-1 and IGF-2, as opposed to the VEGF-driven mechanism found in the angiogenesis of hypoxic tumors. The resulting vasculature supplying the fibroid with nutrients and oxygen is highly irregular. Of particular interest is the formation of a pseudocapsule around intramural fibroids, a unique structure within tumor angiogenesis. These aberrations in vascular architecture and network could explain the heavy menstrual bleeding observed. However, other theories have been proposed such as venous trunks, or venous lakes caused by the blocking of normal blood flow by uterine fibroids, or the increased local action of vasoactive growth factors. Here, we review and discuss the evidence for the various hypotheses proposed.
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Affiliation(s)
- Outi Uimari
- Department of Obstetrics and Gynecology, Oulu University, Oulu, Finland
- Research Unit for Pediatrics, Pediatric Neurology, Pediatric Surgery, Child Psychiatry, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Otorhinolaryngology and Ophthalmology (PEDEGO) Research Unit and Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Kavita S. Subramaniam
- St John's Institute of Dermatology, King's College London, Guy's Hospital, London, United Kingdom
- Endometriosis CaRe Centre, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Beverley Vollenhoven
- Women's and Newborn Program, Monash Health, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Thomas T. Tapmeier
- Endometriosis CaRe Centre, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- *Correspondence: Thomas T. Tapmeier
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Das R, Wale A, Renani SA, Ratnam L, Mailli L, Chun JY, Das S, Duggal B, Manyonda I, Belli AM. Randomised Controlled Trial of Particles Used in Uterine fibRoid Embolisation (PURE): Non-Spherical Polyvinyl Alcohol Versus Calibrated Microspheres. Cardiovasc Intervent Radiol 2022; 45:207-215. [PMID: 34984488 PMCID: PMC8807446 DOI: 10.1007/s00270-021-02977-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
Purpose The PURE study is a randomised controlled trial (RCT) comparing the clinical and MRI outcomes of patients treated with non-spherical polyvinyl alcohol, ns-PVA (Contour PVA–Boston Scientific–355–500 & 500–700 microns) versus calibrated hydrogel microspheres (Embozene–Varian Inc–700 & 900 microns) for symptomatic uterine fibroids. Materials and Methods Prospective, ethically approved non-sponsored RCT in 84 patients in a single UK tertiary IR unit, ISRCTN registry trial number ISRCTN18191539 in 2013 and 2014. All patients with symptomatic fibroid disease were eligible. UAE followed a standardised protocol with UFS-QOL and contrast-enhanced MRI before and 6 months post UAE. Outcome measures included: (1) Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). (2) Percentage total and dominant fibroid infarction. (3) Uterine and dominant fibroid volume reduction. (4) Volume of embolics. Results Sixty-three patients completed the QOL follow-up (33 ns-PVA vs 30 Embozenes), the groups were equivalent at baseline. Patients were followed up for 6 months following UAE. There was no significant difference in symptom scores or HR-QOL between ns-PVA and Embozenes, p = 0.67 and 0.21, respectively. 92.7% of patients treated with ns-PVA achieved > 90% dominant fibroid infarction versus 61.8% treated with Embozenes (p = 0.0016). 66% of patients treated with ns = PVA achieved > 90% total fibroid percentage infarction compared with 35% in the Embozene group (p = 0.011). The mean vials/syringes used were 5.2 with Embozenes versus 4.1 using PVA (p = 0.08). Conclusion The PURE study informs IRs regarding the efficacy of embolic agents in UAE, with superior fibroid infarction on MRI using ns-PVA versus Embozenes however no significant difference in clinical outcomes at 6 months after UAE. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-02977-0.
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Affiliation(s)
- Raj Das
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK.
| | - Anita Wale
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Seyed Ameli Renani
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Sourav Das
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Balpreet Duggal
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
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8
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Klock J, Radakrishnan A, Runge MA, Aaby D, Milad MP. Body Image and Sexual Function Improve after Both Myomectomy and Hysterectomy for Symptomatic Fibroids. South Med J 2021; 114:733-738. [PMID: 34853847 DOI: 10.14423/smj.0000000000001326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the factors that influence the choice of myomectomy, uterine fibroid embolization (UFE), or hysterectomy in women with symptomatic uterine fibroids and to assess women's perception of body image and sexual functioning before and after treatment. METHODS In this prospective observational cohort pilot study, women scheduled to undergo hysterectomy, myomectomy, or UFE were surveyed before surgery and again at 3 to 6 months after their procedure to assess body image and sexual function using the validated 10-item Body Image Scale and 19-item Female Sexual Function Index. Logistic regression was used to determine predictive factors for surgery choice and paired t tests were used to determine changes in perceived sexual function and body image. RESULTS Of the 71 women surveyed, 69 underwent their scheduled procedure and 68 participants completed the preoperative questionnaire completely (98%). A total of 33 participants completed the postoperative questionnaire (49%). The predictive factor for hysterectomy versus myomectomy/UFE was older age (odds ratio 1.13, P = 0.017, 95% confidence interval [CI] 1.02-1.24). Regardless of surgery type, there were significant improvements in perceived body image and sexual function, including an increase in the overall sexual satisfaction of the participant (mean difference 0.50, P = 0.021, 95% CI 0.92-0.08) and less likely to feel less sexually attractive because of their menstrual bleeding problem (P < 0.0001, 95% CI 0.637-1.675). CONCLUSIONS Women of older age are more likely to choose hysterectomy over myomectomy or UFE for the treatment of symptomatic uterine fibroids. In addition, women who underwent any treatment for fibroids have increases in perception of body image and sexual functioning after their procedure.
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Affiliation(s)
- Julie Klock
- From the Creighton School of Medicine, Omaha, Nebraska, the Department of Obstetrics and Gynecology, and the Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankitha Radakrishnan
- From the Creighton School of Medicine, Omaha, Nebraska, the Department of Obstetrics and Gynecology, and the Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Megan Ada Runge
- From the Creighton School of Medicine, Omaha, Nebraska, the Department of Obstetrics and Gynecology, and the Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David Aaby
- From the Creighton School of Medicine, Omaha, Nebraska, the Department of Obstetrics and Gynecology, and the Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Magdy P Milad
- From the Creighton School of Medicine, Omaha, Nebraska, the Department of Obstetrics and Gynecology, and the Department of Preventative Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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9
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Gates M, Tang AR, Godil SS, Devin CJ, McGirt MJ, Zuckerman SL. Defining the relative utility of lumbar spine surgery: A systematic literature review of common surgical procedures and their impact on health states. J Clin Neurosci 2021; 93:160-167. [PMID: 34656241 DOI: 10.1016/j.jocn.2021.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/18/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
Degenerative lumbar spondylosis is a common indication for patients undergoing spine surgery. As healthcare costs rise, measuring quality of life (QOL) gains after surgical procedures is critical in assessing value. We set out to: 1) compare baseline and postoperative EuroQol-5D (EQ-5D) scores for lumbar spine surgery and common surgical procedures to obtain post-operative quality-adjusted life year (QALY) gain, and 2) establish the relative utility of lumbar spine surgery as compared to other commonly performed surgical procedures. A systematic literature review was conducted to identify all studies reporting preoperative/baseline and postoperative EQ-5D scores for common surgical procedures. For each study, the number of patients included and baseline/preoperative and follow-up mean EQ-5D scores were recorded, and mean QALY gained for each intervention was calculated. A total of 67 studies comprising 95,014 patients were identified. Patients with lumbar spondylosis had the worst reported QOL at baseline compared to other surgical cohorts. The greatest QALY gain was seen in patients undergoing hip arthroplasty (0.38), knee arthroplasty (0.35) and lumbar spine surgery (0.32), nearly 2.5-fold greater QALY gained than for all other procedures. The low preoperative QOL, coupled with the improvements offered with surgery, highlight the utility and value of lumbar spine surgery compared to other common surgical procedures.
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Affiliation(s)
- Marcus Gates
- Department of Neurological Surgery, Wellstar Health System, Austell, GA, United States
| | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Saniya S Godil
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Clint J Devin
- Steamboat Orthopaedic and Spine Institute, Steamboat Springs, CO, United States
| | - Matthew J McGirt
- Carolina Neurosurgery and Spine Associates, Charlotte, NC, United States
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States.
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10
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Jagannathan JP, Steiner A, Bay C, Eisenhauer E, Muto MG, George S, Fennessy FM. Differentiating leiomyosarcoma from leiomyoma: in support of an MR imaging predictive scoring system. Abdom Radiol (NY) 2021; 46:4927-4935. [PMID: 34075468 DOI: 10.1007/s00261-021-03132-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/08/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to determine the Magnetic Resonance (MR) imaging features that best differentiate leiomyosarcoma (LMS) from leiomyoma, and to explore a scoring system to preoperatively identify those at highest risk of having LMS. METHODS Our Institutional Review Board approved this retrospective HIPAA-compliant study with a waiver for written informed consent. Institutional Research Patient Data Registry identified patients with histopathologically-proven LMS (n = 19) or leiomyoma (n = 25) and a pelvic MRI within six months prior to surgery. Qualitative differentiating MRI features were selected based on prior publications and clinical experience. Patient and MRI characteristics for leiomyomas versus LMS were compared using Wilcoxon rank-sum tests or Fisher's exact tests and using a basic classification tree. Hypothesis testing was two-tailed, with a p value < 0.001 used to determine inclusion of variables into an MR imaging predictive (MRP) score. Diagnostic performance [sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)] of the MRP in diagnosis of LMS used all possible scores as cutoffs. RESULTS Seven out of 15 MRI features were found to have an association with LMS. The final MRP scores ranged from 0 to 7: a score of 0-3 was associated with 100% NPV for LMS, and a MRP score of 6-7 with 100% PPV for LMS. CONCLUSION Seven qualitative MR imaging features, extracted from a standard MR imaging protocol, allow differentiation of LMS from leiomyoma. An exploratory risk stratification MRP score can be used to determine the likelihood of LMS being present.
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Affiliation(s)
- Jyothi P Jagannathan
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aida Steiner
- Department of Radiology, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Camden Bay
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Department of Medicine/Biostatistics, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric Eisenhauer
- Department of Gynecologic Oncology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02214, USA
| | - Michael G Muto
- Division of Surgical Oncology, Harvard Medical School, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Suzanne George
- Department of Medical Oncology, Harvard Medical School, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Fiona M Fennessy
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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11
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Gao H, Li T, Fu D, Wei J. Uterine artery embolization, surgery and high intensity focused ultrasound in the treatment of uterine fibroids: a network meta-analysis. Quant Imaging Med Surg 2021; 11:4125-4136. [PMID: 34476193 DOI: 10.21037/qims-20-1331] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Background To systematic review the safety and effectiveness between uterine artery embolization (UAE), surgery and high intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. Methods The PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang Data, and CNKI were electronically searched to collect relevant studies on comparing the safety and effectiveness of UAE, surgery and HIFU in the treatment of uterine fibroids from January 2000 to August 2019. After two reviewers independently screened the literature, extracted the data and evaluated the risk of bias of included studies, network meta-analysis was performed by ADDIS 1.16.8 and Stata 14 software. Results A total of 11 studies (22 articles) involving 3,646 patients were included. Compared with surgery, UAE and HIFU patients had higher quality of life (1-year follow-up) improvement, and UAE was higher than HIFU. Network meta-analysis show that patients treated with HIFU had the lowest incidence of major complications within 1 year, followed by UAE, and the highest surgery. Patients treated with HIFU and UAE have shorter hospital stays and quicker recovery time than surgery. The rate of further intervention after surgery treatment might be lower than that of UAE and HIFU. Conclusions UAE has the highest quality of life improvement (1-year follow-up) for uterine fibroids. HIFU and UAE are safer with shorter hospital stays and quicker recovery time compared with surgery. However, both UAE and HIFU have the risks of re-treatment. However, limited by the number and quality of included studies, the above conclusions need to be verified through more high-quality studies.
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Affiliation(s)
- Haijun Gao
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Tianping Li
- General Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Dianxun Fu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jun Wei
- Department of Ultrasound, Chongqing Health Center for Women and Children, Chongqing, China
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12
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Abstract
Uterine leiomyomas (fibroids) are the most common solid and symptomatic neoplasm in women. They are the leading indication for hysterectomy (1, 2), which is a definitive and effective surgical treatment for leiomyoma. However, many patients benefit from and seek out management options other than hysterectomy because they desire future childbearing or wish to retain their uterus. The purpose of this Practice Bulletin is to provide updated evidence-based recommendations for the medical, procedural, and surgical management of symptomatic leiomyomas. Discussion of the use of morcellation in the surgical management of leiomyomas is beyond the scope of this document and is addressed in a separate American College of Obstetricians and Gynecologists (ACOG) publication (3).
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13
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Bannerman D, Pascual-Gil S, Floryan M, Radisic M. Bioengineering strategies to control epithelial-to-mesenchymal transition for studies of cardiac development and disease. APL Bioeng 2021; 5:021504. [PMID: 33948525 PMCID: PMC8068500 DOI: 10.1063/5.0033710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Epithelial-to-mesenchymal transition (EMT) is a process that occurs in a wide range of tissues and environments, in response to numerous factors and conditions, and plays a critical role in development, disease, and regeneration. The process involves epithelia transitioning into a mobile state and becoming mesenchymal cells. The investigation of EMT processes has been important for understanding developmental biology and disease progression, enabling the advancement of treatment approaches for a variety of disorders such as cancer and myocardial infarction. More recently, tissue engineering efforts have also recognized the importance of controlling the EMT process. In this review, we provide an overview of the EMT process and the signaling pathways and factors that control it, followed by a discussion of bioengineering strategies to control EMT. Important biological, biomaterial, biochemical, and physical factors and properties that have been utilized to control EMT are described, as well as the studies that have investigated the modulation of EMT in tissue engineering and regenerative approaches in vivo, with a specific focus on the heart. Novel tools that can be used to characterize and assess EMT are discussed and finally, we close with a perspective on new bioengineering methods that have the potential to transform our ability to control EMT, ultimately leading to new therapies.
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14
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Middelkoop MA, Harmsen MJ, Manyonda I, Mara M, Ruuskanen A, Daniels J, Mol BWJ, Moss J, Hehenkamp WJK, Wu O. Uterine artery embolization versus surgical treatment in patients with symptomatic uterine fibroids: Protocol for a systematic review and meta-analysis of individual participant data. Eur J Obstet Gynecol Reprod Biol 2020; 256:179-183. [PMID: 33246202 DOI: 10.1016/j.ejogrb.2020.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Uterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman's quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms. DATA SOURCES PubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020. STUDY ELIGIBILITY CRITERIA We will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery. STUDY APPRAISAL AND SYNTHESIS METHODS Individual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model.
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Affiliation(s)
- Mei-An Middelkoop
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Marissa J Harmsen
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, United Kingdom
| | - Michal Mara
- Department of Obstetrics and Gynaecology, Division of Minimally Invasive Surgery, General Faculty Hospital and 1st Medical Faculty of Charles University, Apolinarska 18, 128 00, Prague 2, Czech Republic
| | - Anu Ruuskanen
- Department of Clinical Radiology, Kuopio University Hospital, P.O. Box 1777, 70211, Kuopio, Finland
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Jonathan Moss
- Department of Interventional Radiology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, United Kingdom
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, United Kingdom
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Liu S, Li W. Intra-arterial lidocaine for pain control after uterine artery embolization: a meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2020; 35:4162-4167. [PMID: 33172315 DOI: 10.1080/14767058.2020.1847079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The efficacy of intra-arterial lidocaine for pain control of uterine artery embolization remains controversial. We conduct a systematic review and meta-analysis to explore the influence of intra-arterial lidocaine versus placebo on the postoperative pain intensity of uterine artery embolization. METHODS We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials (RCTs) assessing the effect of intra-arterial lidocaine versus placebo on pain control of uterine artery embolization. This meta-analysis is performed using the random-effect model. RESULTS Three RCTs were included in the meta-analysis. Overall, compared with control group for uterine artery embolization, intra-arterial lidocaine was associated with substantially reduced pain scores at 4 h (SMD = -0.85; 95% CI = -1.31 to -0.38; p = .0003) and analgesic consumption (SMD = -0.84; 95% CI = -1.26 to -0.42; p < .0001), but has no obvious influence on pain scores at 7 h (SMD = -0.19; 95% CI = -0.63 to 0.25; p = .40) or pain scores at 24 h (SMD = -0.55; 95% CI = -1.25 to 0.16; p = .13). CONCLUSIONS Intra-arterial lidocaine is effective for pain control after uterine artery embolization.
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Affiliation(s)
- Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Wenyan Li
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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16
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A systematic review of the psychosocial impact of fibroids before and after treatment. Am J Obstet Gynecol 2020; 223:674-708.e8. [PMID: 32474012 DOI: 10.1016/j.ajog.2020.05.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/15/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Despite the high prevalence of uterine fibroids, the psychosocial impact of fibroids has not been evaluated across different quality of life indicators and compared with other chronic conditions. Here, we rigorously analyzed available evidence pertaining to the psychosocial burden of uterine fibroids in premenopausal women and compared validated quality of life and symptom scores before and after treatment. DATA SOURCES We searched PubMed, PsycINFO, ClinicalTrials.gov, Embase, and Cochrane Library for publications from January 1990 to January 2020. STUDY ELIGIBILITY CRITERIA We considered English-language publications that evaluated the association between uterine fibroids diagnosed by imaging studies in premenopausal women and quality of life by standardized and validated questionnaires at baseline and after treatment. We used a detailed list of terms related to quality of life, questionnaires, and uterine fibroids to conduct the search. METHODS Three reviewers screened titles and abstracts and then obtained full-text articles for further analysis. The reviewers assessed risk of bias using established Cochrane and Newcastle-Ottawa Scale guidelines. The quality of life scores of premenopausal women with fibroids were reviewed at baseline and compared with those of published quality of life scores in other disease populations in addition to after fibroid treatment. RESULTS A total of 57 studies were included in the review: 18 randomized controlled trials and 39 observational studies. Of note, the 36-Item Short Form Survey and European Quality of Life Five-Dimension Scale questionnaires both indicated a diagnosis of uterine fibroids to have a disability score that was similar to or exceeded (was a greater psychosocial stressor) a diagnosis of heart disease, diabetes mellitus, or breast cancer. Quality of life scores were lower at baseline than after treatment in all instruments measuring these variables in women with uterine fibroids, indicating significantly impaired psychosocial functioning. Uterine fibroids were associated with significant patient-reported health disabilities related to bodily pain, mental health, social functioning, and satisfaction with sex life. CONCLUSION A diagnosis of uterine fibroids was a significant psychosocial stressor among women at baseline and relative to other diseases. Validated quality of life instruments indicated therapeutic success and the improvement of both physical and emotional symptoms after treatment.
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17
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Silva NACD, Szejnfeld D, Klajner RK, Mata MVMD, Aun R, Belczak SQ. Improvement in parameters of quality of life and uterine volume reduction after uterine fibroid embolization. EINSTEIN-SAO PAULO 2020; 18:eAO5458. [PMID: 32965299 PMCID: PMC9586426 DOI: 10.31744/einstein_journal/2020ao5458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate improvement in quality of life, reduction of uterine volume, and the correlation between these two variables after uterine fibroid embolization. Methods Data on quality of life before and after uterine fibroid embolization were collected from 60 patients using the Uterine Fibroid Symptom – Quality of Life questionnaire. In 40 of these patients, uterine volume information on magnetic resonance imaging examinations performed before and after uterine fibroid embolization was collected, and compared using the nonparametric Wilcoxon test for paired data. Correlation between quality of life and uterine volume before and after procedure was measured using Spearman’s correlation coefficient. Results There was significant improvement in quality of life after uterine fibroid embolization on Uterine Fibroid Symptom – Quality of Life questionnaire, in both subscales scores and the total score. There was a significant median reduction of -37.4% after uterine fibroid embolization, but no correlations between uterine volume and quality of life scores were found before or after embolization. Conclusion Uterine embolization is an alternative to treat uterine fibroids, resulting in relief of symptoms and better quality of life. Although reduction in uterine volume plays an important role in the evaluation of therapeutic success, it does not necessarily have a definitive correlation with relief of symptoms.
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Affiliation(s)
| | | | | | | | - Ricardo Aun
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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18
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Wang C, Kuban JD, Lee SR, Yevich S, Metwalli Z, McCarthy CJ, Sheth SA, Sheth RA. Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective. J Vasc Interv Radiol 2020; 31:1552-1559.e1. [PMID: 32917502 DOI: 10.1016/j.jvir.2020.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To conduct a population-level analysis of surgical and endovascular interventions for symptomatic uterine leiomyomata by using administrative data from outpatient medical encounters. MATERIALS AND METHODS By using administrative data from all outpatient hospital encounters in California (2005-2011) and Florida (2005-2014), all patients in the outpatient setting with symptomatic uterine leiomyomata were identified. Patients were categorized as undergoing hysterectomy, myomectomy, uterine artery embolization (UAE), or no intervention. Hospital stay durations and costs were recorded for each encounter. RESULTS A total of 227,489 patients with uterine leiomyomata were included, among whom 39.9% (n = 90,800) underwent an intervention, including hysterectomy (73%), myomectomy (19%), or UAE (8%). The proportion of patients undergoing hysterectomy increased over time (2005, hysterectomy, 53.2%; myomectomy, 26.9%; UAE, 18.0%; vs 2013, hysterectomy, 80.1%; myomectomy, 14.4%; UAE, 4.0%). Hysterectomy was eventually performed in 3.5% of patients who underwent UAE and 4.1% who underwent myomectomy. Mean length of stay following hysterectomy was significantly longer (0.5 d) vs myomectomy (0.2 d) and UAE (0.3 d; P < .001 for both). The mean encounter cost for UAE ($3,772) was significantly less than those for hysterectomy ($5,409; P < .001) and myomectomy ($6,318; P < .001). Of the 7,189 patients who underwent UAE during the study period, 3.5% underwent subsequent hysterectomy. CONCLUSIONS The proportion of women treated with hysterectomy in the outpatient setting has increased since 2005. As a lower-cost alternative with a low rate of conversion to hysterectomy, UAE may be an underutilized treatment option for patients with uterine leiomyomata.
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Affiliation(s)
- Courtney Wang
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Joshua D Kuban
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Stephen R Lee
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Steven Yevich
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Zeyad Metwalli
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Colin J McCarthy
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030
| | - Sunil A Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX 77030
| | - Rahul A Sheth
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, T. Boone Pickens Academic Tower (FCT14.5092), 1515 Holcombe Blvd., Unit 1471, Houston, TX 77030.
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Farrell TP, Garvey C, Adams NC, Mulholland D, Ryan JM, Guiney M, McEniff N. Comparison of outcomes and cost-effectiveness of trisacryl gelatin microspheres alone versus combined trisacryl gelatin microspheres and gelatin sponge embolization in uterine fibroid embolization. Acta Radiol 2020; 61:1287-1296. [PMID: 31955609 DOI: 10.1177/0284185119898660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Uterine fibroid embolization (UFE) is an effective treatment for uterine leiomyomata. Optimizing the choice of embolic agents is imperative to achieve better patient outcomes with maximum resource utilization. PURPOSE To evaluate the efficacy and cost-effectiveness of trisacryl gelatin microspheres (TAGM) versus combined TAGM and gelatin sponge (GS) embolization in the treatment of symptomatic uterine leiomyomata. MATERIAL AND METHODS Between July 2007 and December 2010, 106 consecutive patients underwent UFE with TAGM. Between January 2011 and December 2016, 123 consecutive patients underwent UFE with a combination of TAGM/GS. The primary outcomes were successful infarction rate (≥90% infarction) of the dominant leiomyoma and percentage reduction in uterine and dominant leiomyoma volume on MRI at six months. Secondary outcomes included adverse event rates, pain scores, and change in clinical symptoms at six months. The embolic agents utilized per procedure were recorded and a cost-effectiveness analysis was performed. RESULTS Baseline characteristics of both groups were similar. Successful infarction was achieved in 93.2% of the TAGM group and 94.6% of the TAGM/GS group (P = 0.52). Reduction in uterine volume (TAGM 40.7%, TAGM/GS 44.4%, P = 0.16) and dominant leiomyoma volume (TAGM 47.6%, TAGM/GS 50.1%, P = 0.29) at six months was similar. No significant difference was observed in symptom improvement at six months (P = 0.8). The mean number of TAGM vials utilized and cost per procedure was 6.3 and $1688.40 for TAGM embolization and 3.6 and $979.50 for TAGM/GS embolization, respectively. CONCLUSION Primary and secondary outcomes were comparable when performing UFE with TAGM versus combined TAGM/GS. The combined use of TAGM/GS reduced the mean cost of embolic agents by 42%.
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Affiliation(s)
| | - Chris Garvey
- Department of Radiology, St James’s Hospital, Dublin, Ireland
| | - Niamh C Adams
- Department of Radiology, St James’s Hospital, Dublin, Ireland
| | | | - J Mark Ryan
- Department of Radiology, St James’s Hospital, Dublin, Ireland
| | - Michael Guiney
- Department of Radiology, St James’s Hospital, Dublin, Ireland
| | - Niall McEniff
- Department of Radiology, St James’s Hospital, Dublin, Ireland
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20
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Cronan J, Horný M, Duszak R, Newsome J, Carlos R, Hughes DR, Memula S, Kokabi N. Invasive Procedural Treatments for Symptomatic Uterine Fibroids: A Cost Analysis. J Am Coll Radiol 2020; 17:1237-1244. [PMID: 32360526 DOI: 10.1016/j.jacr.2020.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate the contemporary use of procedural interventions to treat symptomatic uterine fibroids and assess associated health care system costs. METHODS Using the IBM Watson MarketScan Commercial Claims and Encounters database for 2009 to 2015 and relevant International Classification of Diseases diagnosis codes, women aged 18 to 55 years with clinically significant uterine fibroids were identified. Using Current Procedural Terminology codes, relevant procedural interventions were identified (hysterectomy, endometrial ablation, myomectomy, and uterine fibroid embolization [UFE]). Costs were defined as total actual payments by insurers and patients (per procedure and per episode of care) and were adjusted and compared using generalized linear models. RESULTS Of 241,757 invasive procedures for fibroids, hysterectomy was most common (76.5%), followed by endometrial ablation (14.5%), myomectomy (4.7%), and UFE (4.3%). Hysterectomy was more common in older women and those in rural areas (65.2% of patients <40 years of age, 77.6% of those 40-49 years of age, and 83.6% of those 50-55 years of age; 83.9% of patients outside versus 75.3% within metropolitan statistical areas). Per procedure, adjusted mean costs were $3,188 (95% confidence interval [CI], $3,114-$3,264) for hysterectomy, $2,781 (95% CI, $2,695-$2,870) for ablation, $4,436 (95% CI, $4,256-$4,623) for myomectomy, and $6,161 (95% CI, $5,736-$6,617) for UFE. Adjusted mean costs for entire episodes of care were $14,676 (95% CI, $14,496-$14,858) for hysterectomy, $6,702 (95% CI, $6,534-$6,875) for endometrial ablation, $14,791 (95% CI, $14,465-$15,125) for myomectomy, and $13,873 (95% CI, $13,182-$14,599) for UFE. CONCLUSIONS Of invasive procedures for symptomatic uterine fibroids, hysterectomy was used more frequently than endometrial ablation, myomectomy, and UFE combined. Per procedure and per episode, ablation was least costly. Costs per episode were similar for hysterectomy, myomectomy, and UFE.
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Affiliation(s)
- Julie Cronan
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Janice Newsome
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Ruth Carlos
- Department of Radiology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Danny R Hughes
- Health Economics and Analytics Lab, School of Economics, Georgia Institute of Technology, Atlanta, Georgia
| | - Savitha Memula
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.
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21
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Zheng MQ, Weng C, Hu W, Shen CQ, Tao Y, Pan ZW. Efficacy assessment of acupuncture in improving symptoms of uterine fibroids: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e20016. [PMID: 32358379 PMCID: PMC7440313 DOI: 10.1097/md.0000000000020016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/27/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Uterine fibroids are a common benign genital tumor disease in gynecological diseases. It is mainly a change in physical function caused by the growth of smooth muscle cells in the factor uterus. Modern medicine's treatment of this disease is based on the dependence of uterine fibroids on sex hormones. Treatment with antiprogestin and estrogen drugs can reduce the volume of fibroids or slow the rate of increase in volume, thereby achieving the goal of alleviating clinical symptoms. In order to meet the needs of the majority of women of childbearing age and to maintain fertility, acupuncture treatment of uterine fibroids has a broad prospect for development. METHODS/DESIGN This study plans to select 60 cases that meet the corresponding selection criteria. According to the random principle, they will be divided into intervention group and control group, with 30 cases in each group. The general information, fibroid size, and TCM syndrome scores of the two groups of patients will be compared before treatment. In terms of treatment, the intervention group will be given acupuncture combined therapy; the control group will be given Chinese patent medicine. The treatment cycles in both groups will be three menstrual cycles. After the treatment is completed, the data of the relevant curative effect indicators are analyzed by using SPSS software to draw conclusions. DISCUSSION We aim to provide higher evidence-based medical evidence for acupuncture treatment of uterine fibroids. TRIAL REGISTRATION ClinicalTrials.gov, ChiCTR2000030438, Registered on March 01, 2020.
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Affiliation(s)
- Min-Qin Zheng
- Fuzhou Hospital of Traditional Chinese Medicine, Fuzhou 350013
| | - Cai Weng
- Fujian University of Traditional Chinese Medicine, Fuzhou 350100
| | - Wei Hu
- The Second Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350013
| | - Chong-Qing Shen
- The Second Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350013
| | - Yun Tao
- Department of Dermatology, Huabei Petroleum General Hospital, Renqiu 062550
| | - Zheng-Wei Pan
- Fujian University of Traditional Chinese Medicine Subsidiary Rehabilitation Hospital, Fuzhou 350013, China
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22
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Intra-arterial lidocaine administration during uterine fibroid embolization to reduce the immediate postoperative pain: a prospective randomized study. CVIR Endovasc 2020; 3:10. [PMID: 32037475 PMCID: PMC7008106 DOI: 10.1186/s42155-020-0099-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background To investigate if intra-arterial lidocaine administrated immediately after the embolisation endpoint reduces the pain. Methods Forty patients were randomised and 36 completed the study for purposes of analysis. In one group, the patients got 1% 10 ml lidocaine (100 mg) administered into each uterine artery immediately after embolisation with microspheres. The other group was embolised without supplementary lidocaine. The patients scored their pain on a visual analogue scale (VAS) 2 h, 4 h, 7 h, 10 h and 24 h after embolisation, and the total amount of used morphine was noted. Three-month follow-up MRI control was scheduled for all the patients to investigate the infarction rate. Results Embolisation was performed without any complications and with embolisation of both uterine arteries in all cases. Intra-arterial lidocaine was administered in all 20 patients without complications, and 20 patients in a control group did not receive lidocaine intra-arterial. VAS schemes showed a significant reduction in pain experience 2 h after UFE where mean pain score in the lidocaine group was 42.7 ± 21.4 compared with the control group in which the mean pain score was 61.1 ± 20.4 (p < 0.02). There was no significant difference in pain score 4 h, 7 h, 10 h and 24 h after UFE. In the lidocaine group, the mean amount of used morphine was significantly less with 11.2 mg compared with 20.2 mg in the control group (p < 0.03). Three months of MR follow-up control showed no significant difference in the grade of fibroid infarction. Conclusion Intra-arterial Lidocaine administration after embolisation is safe and effective in reducing post-procedural pain in the early hours and opioid usage in the first 24 h following UAE.
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23
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Mailli L, Auyoung EY, Angileri SA, Ameli-Renani S, Ratnam L, Das R, Chun JY, Das S, Manyonda I, Belli AM. Predicting the Fibroid-Migratory Impact of UAE: Role of Pre-embolization MRI Characteristics. Cardiovasc Intervent Radiol 2019; 43:453-458. [PMID: 31650245 PMCID: PMC6997258 DOI: 10.1007/s00270-019-02348-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/30/2019] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Leto Mailli
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK.
| | - Eric Y Auyoung
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Salvatore A Angileri
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, San Paolo Hospital, University of Milan, Milan, Italy
| | - Seyed Ameli-Renani
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Lakshmi Ratnam
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Raj Das
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Joo-Young Chun
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Sourav Das
- Department of Obstetrics and Gynaecology, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Isaac Manyonda
- Department of Obstetrics and Gynaecology, St George's University Hospital and NHS Foundation Trust, London, UK
| | - Anna-Maria Belli
- Diagnostic and Interventional Radiology Department, St George's University Hospital and NHS Foundation Trust, London, UK
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de Bruijn AM, Huisman J, Hehenkamp WJK, Lohle PNM, Reekers JA, Timmermans A, Twijnstra ARH. Implementation of uterine artery embolization for symptomatic fibroids in the Netherlands: an inventory and preference study. CVIR Endovasc 2019; 2:18. [PMID: 32026034 PMCID: PMC6966393 DOI: 10.1186/s42155-019-0061-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/22/2019] [Indexed: 12/04/2022] Open
Abstract
Background and purpose The Dutch national guideline on heavy menstrual bleeding was updated and published in 2013. It recommended (for the first time) that uterine artery embolization (UAE) should be part of counseling of women with symptomatic fibroids. We aimed to evaluate the implementation of UAE for symptomatic uterine fibroids in the Netherlands and to investigate gynecologists preference and other influential factors. Methods The primary outcome was to examine the UAE/hysterectomy ratio before and after introduction of the 2013 guideline by the use of annual hospital reports. The secondary outcome assessed factors that could influence implementation by means of a questionnaire to gynecologists. Results A total of 29/30 (97%) UAE+ hospitals and 36/52 (69%) UAE- hospitals sent their annual reports. The UAE/hysterectomy percentages in 2012, 2013 and 2014 were 7,0%, 7.0% and 6.9%, respectively. Regarding the questionnaire, the response rates were 88% and 91%, respectively. In both groups we observed a high self-perceived tendency for UAE counseling (90% versus 70%, p = .001). Approximately 50% of gynecologists from UAE- hospitals indicate they have insufficient information about UAE for appropriate counseling and 40% doubts the effectiveness of UAE. Furthermore, in the majority of gynecologists some ‘urban myths’ about the effectiveness and side-effects of UAE seem to persevere. Conclusion Adding UAE as a treatment option to the national guideline did not change the number of performed UAEs for symptomatic fibroids. It might be useful to develop an option grid in order to offer appropriate, independent counseling and encourage shared decision making. Electronic supplementary material The online version of this article (10.1186/s42155-019-0061-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annefleur M de Bruijn
- Department of Gynecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands.
| | - Jolijn Huisman
- Faculty of Medicine, VU University, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Gynecology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands
| | - Paul N M Lohle
- Department of Radiology, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Jim A Reekers
- Department of Radiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anne Timmermans
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Andries R H Twijnstra
- Leiden University Medical Center, Albinusdreef 2, 2300-2333 ZA, Leiden, the Netherlands
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Shaffer RK, Dobberfuhl AD, Vu KN, Fast AM, Dababou S, Marrocchio C, Lum DA, Hovsepian DM, Ghanouni P, Chen B. Are fibroid and bony pelvis characteristics associated with urinary and pelvic symptom severity? Am J Obstet Gynecol 2019; 220:471.e1-471.e11. [PMID: 30711512 DOI: 10.1016/j.ajog.2019.01.230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 01/16/2019] [Accepted: 01/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urinary and pelvic floor symptoms often are attributed to size and location of uterine fibroid tumors. However, direct supporting evidence that links increased size to worsening symptoms is scant and limited to ultrasound evaluation of fibroid tumors. Because management of fibroid tumors is targeted towards symptomatic relief, the identification of fibroid and pelvic characteristics that are associated with worse symptoms is vital to the optimization of therapies and prevention needless interventions. OBJECTIVE We examined the correlation between urinary, pelvic floor and fibroid symptoms, and fibroid size and location using precise uterine fibroid and bony pelvis characteristics that were obtained from magnetic resonance imaging. STUDY DESIGN A retrospective review (2013-2017) of a multidisciplinary fibroid clinic identified 338 women who had been examined via pelvic magnetic resonance imaging, Pelvic Floor Distress Inventory questionnaire (score 0-300), and a Uterine Fibroid Symptoms questionnaire (score 1-100). Multiple linear regression analysis was used to assess the influence of clinical factors and magnetic resonance imaging findings on scaled Pelvic Floor Distress Inventory and Uterine Fibroid Symptoms scores. Data were analyzed with statistical software. RESULTS Our cohort of 338 women had a median Pelvic Floor Distress Inventory of 72.7 (interquartile range, 41-112.3). Increased Pelvic Floor Distress Inventory score was associated with clinical factors of higher body mass index (P<.001), noncommercial insurance (P<.001), increased parity (P=.001), and a history of incontinence surgery (P=.003). Uterine volume, dominant fibroid volume, dimension and location, and fibroid tumor location relative to the bony pelvis structure did not reach significance when compared with pelvic floor symptom severity. The mean Uterine Fibroid Symptoms score was 52.0 (standard deviation, 23.5). An increased Uterine Fibroid Symptoms score was associated with dominant submucosal fibroid tumors (P=.011), body mass index (P<.0016), and a clinical history of anemia (P<.001) or any hormonal treatment for fibroid tumors (P=.009). CONCLUSION Contrary to common belief, in this cohort of women who sought fibroid care, size and position of fibroid tumors or uterus were not associated with pelvic floor symptom severity. Whereas, bleeding symptom severity was associated with dominant submucosal fibroid tumor and previous hormonal treatment. Careful attention to clinical factors such as body mass index and medical history is recommended when pelvic floor symptoms are evaluated in women with uterine fibroid tumors.
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Affiliation(s)
| | | | | | | | - Susan Dababou
- Department of Radiology, Sapienza University, Rome, Italy
| | | | | | | | | | - Bertha Chen
- Department of Obstetrics & Gynecology, Stanford, CA.
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Dessouky R, Gamil SA, Nada MG, Mousa R, Libda Y. Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy. Insights Imaging 2019; 10:48. [PMID: 31030317 PMCID: PMC6486932 DOI: 10.1186/s13244-019-0732-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/14/2019] [Indexed: 12/31/2022] Open
Abstract
Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.
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Affiliation(s)
- Riham Dessouky
- Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob Street, Zagazig, 44519, Egypt.
| | - Sherif A Gamil
- Radiology Department, Al-Ahrar Teaching Hospital, Zagazig, Egypt
| | - Mohamad Gamal Nada
- Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob Street, Zagazig, 44519, Egypt
| | - Rola Mousa
- Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob Street, Zagazig, 44519, Egypt
| | - Yasmine Libda
- Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob Street, Zagazig, 44519, Egypt
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27
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Koch M, Rauchenwald T, Kivaranovic D, Schwab S, Umek W, Koelbl H, Rauchenwald M, Helmy S. Association of uterine leiomyoma and overactive bladder syndrome. Int J Gynaecol Obstet 2018; 142:365-369. [DOI: 10.1002/ijgo.12545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/17/2018] [Accepted: 06/01/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Marianne Koch
- Department of Obstetrics and Gynecology; Clinical Division of General Gynecology and Gynecologic Oncology; Medical University of Vienna; Vienna Austria
- Karl Landsteiner Institut fuer Spezielle Gynaekologie und Geburtshilfe; Vienna Austria
| | - Tina Rauchenwald
- Department of Obstetrics and Gynecology; Clinical Division of General Gynecology and Gynecologic Oncology; Medical University of Vienna; Vienna Austria
| | - Danijel Kivaranovic
- Center for Medical Statistics, Informatics and Intelligent Systems; Medical University of Vienna; Vienna Austria
| | - Stephanie Schwab
- Department of Obstetrics and Gynecology; St. Josef Spital; Vienna Austria
- Karl Landsteiner Institut fuer Diagnostik und Therapie in der Frauenheilkunde; Vienna Austria
| | - Wolfgang Umek
- Department of Obstetrics and Gynecology; Clinical Division of General Gynecology and Gynecologic Oncology; Medical University of Vienna; Vienna Austria
- Karl Landsteiner Institut fuer Spezielle Gynaekologie und Geburtshilfe; Vienna Austria
| | - Heinz Koelbl
- Department of Obstetrics and Gynecology; Clinical Division of General Gynecology and Gynecologic Oncology; Medical University of Vienna; Vienna Austria
| | - Michael Rauchenwald
- Department of Urology and Andrology; Sozialmedizinisches Zentrum Ost- Donauspital; Vienna Austria
| | - Samir Helmy
- Department of Obstetrics and Gynecology; Clinical Division of General Gynecology and Gynecologic Oncology; Medical University of Vienna; Vienna Austria
- Karl Landsteiner Institut fuer Diagnostik und Therapie in der Frauenheilkunde; Vienna Austria
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Knuttinen MG, Stark G, Hohenwalter EJ, Bradley LD, Braun AR, Gipson MG, Kim CY, Pinchot JW, Scheidt MJ, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Uterine Leiomyomas. J Am Coll Radiol 2018; 15:S160-S170. [PMID: 29724419 DOI: 10.1016/j.jacr.2018.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
| | | | - Gregory Stark
- Research Author, University of Illinois at Chicago, Chicago, Illinois
| | - Eric J Hohenwalter
- Panel Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda D Bradley
- Cleveland Clinic, Cleveland, Ohio; American Congress of Obstetricians and Gynecologists
| | - Aaron R Braun
- St. Elizabeth Regional Medical Center, Lincoln, Nebraska
| | | | - Charles Y Kim
- Duke University Medical Center, Durham, North Carolina
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29
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de Bruijn AM, Lohle PN, Huirne JA, de Vries J, Twisk M, Hehenkamp WJ. Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial. JMIR Res Protoc 2018; 7:e47. [PMID: 29496654 PMCID: PMC5856934 DOI: 10.2196/resprot.8512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 12/13/2022] Open
Abstract
Background Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking. Objective With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis. Methods This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)–confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE. Results Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started. Conclusions This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients’ wellbeing and quality of life. Trial Registration Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)
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Affiliation(s)
- Annefleur Machteld de Bruijn
- Department of Gynaecology and Obstetrics, Vrije Universiteit Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - Paul Nm Lohle
- Department of Radiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Netherlands
| | - Judith Af Huirne
- Department of Gynaecology and Obstetrics, Vrije Universiteit Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands.,Department of Medical and Clinical Psychology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Netherlands
| | - Moniek Twisk
- Department of Gynecology, Medical Center Zuiderzee, Lelystad, Netherlands
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- Department of Gynaecology and Obstetrics, Vrije Universiteit Medical Center, Vrije Universiteit, Amsterdam, Netherlands
| | - Wouter Jk Hehenkamp
- Department of Gynaecology and Obstetrics, Vrije Universiteit Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Vrije Universiteit, Amsterdam, Netherlands
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Brennan A, Hickey M. Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas. Med J Aust 2018; 208:90-95. [PMID: 29385977 DOI: 10.5694/mja17.00726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/26/2017] [Indexed: 01/30/2023]
Abstract
Abnormal uterine bleeding refers to any change in the regularity, frequency, heaviness or length of menstruation. There are several potential causes for bleeding disturbance, the two most common being primary endometrial dysfunction and fibroids. Management of abnormal uterine bleeding involves both medical and surgical options and will largely depend on a patient's fertility plans. The use of levonorgestrel-releasing intrauterine devices for heavy menstrual bleeding is increasing in Australia, and they are considered first-line medical management for women accepting of hormonal therapies. Tranexamic acid, non-steroidal anti-inflammatory drugs, the combined oral contraceptive pill and oral progestins offer alternatives. Hysterectomy offers a definitive surgical approach to abnormal uterine bleeding and is associated with high levels of patient satisfaction. Women wishing to preserve their fertility, or avoid hysterectomy, may be offered myomectomy. Submucosal fibroids should be removed via hysteroscopy in symptomatic or infertile patients. Intramural and subserosal fibroids may be removed via an open or laparoscopic approach. There are several minimally invasive options, including uterine artery embolisation, magnetic resonance-guided focused ultrasound and endometrial ablation, but patients should be aware that there is insufficient evidence to ensure fertility preservation with these procedures and further research is needed. Areas for additional research include cost-effectiveness of treatments and quality of life comparisons between management options using patient reported outcome measures to evaluate patient satisfaction.
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Keung JJ, Spies JB, Caridi TM. Uterine artery embolization: A review of current concepts. Best Pract Res Clin Obstet Gynaecol 2017; 46:66-73. [PMID: 29128204 DOI: 10.1016/j.bpobgyn.2017.09.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/11/2017] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
| | - James B Spies
- MedStar Georgetown University Hospital, Washington, DC, USA
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Duvnjak S, Ravn P, Green A, Andersen P. Assessment of uterine fibroid infarction after embolization with tris-acryl gelatin microspheres. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1360543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- S. Duvnjak
- Department of Radiology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark
- OPEN, Odense Patient data Explorative Network, Odense University Hospital/University of Southern Denmark, J.B. Winslows Vej 9 A, DK-5000, Odense C, Denmark
| | - P. Ravn
- Department of Gynecology and Obstetrics, Odense University Hospital, Sdr. Boulevard 29, DK-5000, Odense C, Denmark
| | - A. Green
- OPEN, Odense Patient data Explorative Network, Odense University Hospital/University of Southern Denmark, J.B. Winslows Vej 9 A, DK-5000, Odense C, Denmark
| | - P.E. Andersen
- Department of Radiology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark
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Duvnjak S, Ravn P, Green A, Andersen PE. Uterine fibroid embolization with acrylamido polyvinyl microspheres: prospective 12-month clinical and MRI follow-up study. Acta Radiol 2017; 58:952-958. [PMID: 27872351 DOI: 10.1177/0284185116679458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Uterine fibroid embolization (UFE) is an effective minimally invasive treatment aimed to obtain complete fibroid infarction. Purpose To evaluate the degree of fibroid infarction after embolization with acrylamido polyvinyl alcohol microspheres (Bead Block). Material and Methods This prospective study included 26 pre-menopausal women in the period October 2013 to January 2015. UFE with the use of Bead Block microspheres 700-900 µm was obtained until flow stasis was achieved. Contrast-enhanced magnetic resonance imaging (MRI) was used to define residual contrast enhancement in the total fibroid burden and enhancement >10% was defined as insufficient embolization. The dominant fibroid volume and total uterine volume changes were assessed. Clinical outcome was analyzed using the quality of life questionnaire (UFS-QOL). Results Twenty-four of the 26 patients (92%) had a technically successful UFE with complete flow-stop in both uterine arteries. Twenty-two of the 26 patients (85%) completed 3 months of MRI control and 20 patients (77%) completed 12 months of MRI control. There were 16 of 22 patients (73%) with complete fibroid burden infarction and/or without residual contrast enhancement of the fibroids of more than 10% at 3 months of control. Six of 22 patients (27%) had insufficient fibroid burden infarction with residual contrast enhancement of more than 10%. Twenty-two and 18 of 26 patients completed the 3-month and 12-month questionnaire, respectively. UFS-QOL analyses showed that 91% of the patients had significant clinical improvement. Conclusion Sixteen of the 22 patients had complete fibroid burden infarction using Bead Block microspheres (700-900 µm); however, unacceptably high insufficient fibroid burden infarction in almost one-fourth of the patients were recorded.
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Affiliation(s)
- Stevo Duvnjak
- Department of Radiology, Odense University Hospital, Odense, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | - Pernille Ravn
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Anders Green
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital/University of Southern Denmark, Odense, Denmark
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Silberzweig JE, Powell DK, Matsumoto AH, Spies JB. Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques. Radiology 2017; 280:675-92. [PMID: 27533290 DOI: 10.1148/radiol.2016141693] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- James E Silberzweig
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - Daniel K Powell
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - Alan H Matsumoto
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
| | - James B Spies
- From the Department of Radiology, Mount Sinai Beth Israel, New York, NY (J.E.S.); West Cancer Center, University of Tennessee Health Science Center, 7945 Wolf River Boulevard, Germantown, TN 38138 (D.K.P.); Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Va (A.H.S.); and Department of Radiology, MedStar Georgetown University Hospital, Washington, DC (J.B.S.)
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Role of robotic surgery in treating fibroids and benign uterine mass. Best Pract Res Clin Obstet Gynaecol 2017; 45:48-59. [PMID: 28551090 DOI: 10.1016/j.bpobgyn.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/22/2017] [Accepted: 04/14/2017] [Indexed: 12/31/2022]
Abstract
Fibroid uterus can be managed medically, surgically, or through non-extirpative procedures, depending on the clinical situation. Myomectomy may be beneficial, especially to those desiring to preserve the uterus and/or fertility, with outcomes comparable to those of hysterectomy, with a laparoscopic approach being favored when feasible. For definitive therapy, hysterectomy can be pursued where the surgical approach should be individualized. Comparison of robotic-assisted laparoscopic approach shows that the robotic approach may be favored for cases with higher complexity and multiple fibroids in myomectomy; however, no clear advantage is seen with hysterectomy at this time, necessitating further research in the area of robotics for hysterectomy in benign uterine mass treatment to justify the cost.
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Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M. Evaluation of Changes in Sexual Function Related to Uterine Fibroid Embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol 2017; 40:1169-1175. [DOI: 10.1007/s00270-017-1615-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/02/2017] [Indexed: 12/01/2022]
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Noel-Lamy M, Tan KT, Simons ME, Sniderman KW, Mironov O, Rajan DK. Intraarterial Lidocaine for Pain Control in Uterine Artery Embolization: A Prospective, Randomized Study. J Vasc Interv Radiol 2017; 28:16-22. [DOI: 10.1016/j.jvir.2016.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/13/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022] Open
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de Bruijn AM, Ankum WM, Reekers JA, Birnie E, van der Kooij SM, Volkers NA, Hehenkamp WJ. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol 2016; 215:745.e1-745.e12. [PMID: 27393268 DOI: 10.1016/j.ajog.2016.06.051] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/17/2016] [Accepted: 06/27/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since 1995 uterine artery embolization has been described as an alternative for hysterectomy in patients with symptomatic fibroids. Many studies including several randomized controlled trials established uterine artery embolization as a valuable treatment. These randomized controlled trials reported outcomes in terms of health-related quality of life, clinical outcomes, efficacy, and cost-effectiveness after 1, 2, and 5 years of follow-up. OBJECTIVE The purpose of this study was to compare clinical outcome and health-related quality of life 10 years after uterine artery embolization or hysterectomy in the treatment of heavy menstrual bleeding caused by uterine fibroids in a randomized controlled trial. STUDY DESIGN In all, 28 Dutch hospitals recruited patients with symptomatic uterine fibroids who were eligible for hysterectomy. Patients were 1:1 randomly assigned to uterine artery embolization or hysterectomy. The outcomes assessed at 10 years postintervention were reintervention rates, health-related quality of life, and patient satisfaction, which were obtained through validated questionnaires. Study outcomes were analyzed according to original treatment assignment (intention to treat). RESULTS A total of 177 patients were randomized from 2002 through 2004. Eventually 81 uterine artery embolization and 75 hysterectomy patients underwent the allocated treatment shortly after randomization. The remaining patients withdrew from the trial. The 10-year questionnaire was mailed when the last included patient had been treated 10 years earlier. The mean duration of follow-up was 133 months (SD 8.58) accompanied by a mean age of 57 years (SD 4.53). Questionnaires were received from 131 of 156 patients (84%). Ten years after treatment, 5 patients underwent secondary hysterectomy resulting in a total of 28 of 81 (35%) (24/77 [31%] after successful uterine artery embolization). Secondary hysterectomies were performed for persisting symptoms in all cases but 1 (for prolapse). After the initial treatment health-related quality of life improved significantly. After 10 years, generic health-related quality of life remained stable, without differences between both groups. The urogenital distress inventory and the defecation distress inventory showed a decrease in both groups, probably related to increasing age, without significant differences between study arms. Satisfaction in both groups remained comparable. The majority of patients declared being (very) satisfied about the received treatment: 78% of the uterine artery embolization group vs 87% in the hysterectomy group. CONCLUSION In about two thirds of uterine artery embolization-treated patients with symptomatic uterine fibroids a hysterectomy can be avoided. Health-related quality of life 10 years after uterine artery embolization or hysterectomy remained comparably stable. Uterine artery embolization is a well-documented and less invasive alternative to hysterectomy for symptomatic uterine fibroids on which eligible patients should be counseled.
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Kim CW, Shim HS, Jang H, Song YG. The effects of uterine artery embolization on ovarian reserve. Eur J Obstet Gynecol Reprod Biol 2016; 206:172-176. [PMID: 27697621 DOI: 10.1016/j.ejogrb.2016.09.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/30/2016] [Accepted: 09/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effects of UAE for symptomatic uterine fibroids on ovarian reserve based on AMH. STUDY DESIGN This was a retrospective study conducted between March 2011 and October 2014. All women underwent UAE. At baseline and at the 3-month and 12-month follow-up visits, serum anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels were assessed, and ovarian volume and antral follicle count (AFC) were evaluated in each patient. RESULTS There were no statistically significant differences in serum E2, LH, or FSH levels or in ovarian volume 3 or 12 months after UAE (P=0.8194, P=0.3976, P=0.4766, and P=0.6822, respectively). However, AMH and AFC were significantly different 3 and 12 months after the procedure (P=0.00, P=0.029 and P=0.00, P=0.00, respectively). AMH levels remained low after 12 months of follow-up compared to the expected AMH levels. A statistically significant recovery of serum AMH at 12 months compared to at 3 months in those <40 years of age (P=0.00), but not in those ≥40 years (P=0.837). CONCLUSIONS Ovarian reserve appears to be affected by UAE in premenopausal 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.
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Affiliation(s)
- Chang-Woon Kim
- Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Haeng Seon Shim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Hong Jang
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Yun Gyu Song
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
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Affiliation(s)
- Dawn Bannerman
- Graduate Program in Biomedical Engineering, University of Western Ontario, London, Ontario, Canada
| | - Wankei Wan
- Graduate Program in Biomedical Engineering, University of Western Ontario, London, Ontario, Canada
- Department of Chemical and Biochemical Engineering, University of Western Ontario, London, Ontario, Canada
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Zupi E, Centini G, Sabbioni L, Lazzeri L, Argay IM, Petraglia F. Nonsurgical Alternatives for Uterine Fibroids. Best Pract Res Clin Obstet Gynaecol 2015; 34:122-31. [PMID: 26711881 DOI: 10.1016/j.bpobgyn.2015.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/18/2015] [Indexed: 12/31/2022]
Abstract
Uterine leiomyomata are the direct cause of a significant health-care burden for women, their families, and society as a whole. Because of the long experience with the mode of treatment, surgical myomectomy remains the gold standard for treating reproductive-age women; however, in the recent years, the wide evolution of less invasive approaches led to a change in the options used by the clinician to treat symptomatic fibroids. Minimally invasive procedures such as uterine artery embolization (UAE) are increasingly used to treat symptomatic fibroids. Other alternative treatments are becoming more diffuse, such as magnetic resonance-guided high-frequency focused ultrasound surgery (MRgFUS), cryomyolysis, vaginal occlusion, and laparoscopic closure of the uterine arteries. Both advantages and limitations of these techniques under development must be taken into account, but this wider range of choices is being increasingly considered for a tailored treatment. This article aims to enable health-care providers with the tools to provide the latest evidence-based care in the minimally invasive or noninvasive management of this common problem.
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Affiliation(s)
- Errico Zupi
- Department of Biomedicine and Prevention University of Tor Vergata, Rome, Italy.
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Lorenzo Sabbioni
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - István Máté Argay
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Felice Petraglia
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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Thiburce AC, Frulio N, Hocquelet A, Maire F, Salut C, Balageas P, Bouzgarrou M, Hocké C, Trillaud H. Magnetic resonance-guided high-intensity focused ultrasound for uterine fibroids: Mid-term outcomes of 36 patients treated with the Sonalleve system. Int J Hyperthermia 2015; 31:764-70. [DOI: 10.3109/02656736.2015.1063169] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Izumi Y, Ikeda S, Kitagawa A, Katsuda E, Hagihara M, Kamei S, Ota T, Ishiguchi T. Uterine artery embolization by use of porous gelatin particles for symptomatic uterine leiomyomas: comparison with hand-cut gelatin sponge particles. Jpn J Radiol 2015; 33:461-70. [DOI: 10.1007/s11604-015-0445-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/07/2015] [Indexed: 12/21/2022]
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Czuczwar P, Wozniak S, Szkodziak P, Milart P, Wozniakowska E, Wrona W, Paszkowski T. Influence of ulipristal acetate therapy compared with uterine artery embolization on fibroid volume and vascularity indices assessed by three-dimensional ultrasound: prospective observational study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:744-750. [PMID: 25251811 DOI: 10.1002/uog.14668] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/28/2014] [Accepted: 09/05/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To compare the effects of two alternative treatment options for uterine fibroids, ulipristal acetate (UPA) and uterine artery embolization (UAE), on fibroid volume and vascularity at 3-month follow-up. METHODS Premenopausal patients with symptomatic, intramural uterine fibroids were included in this prospective case-control study. Seventeen patients who qualified for preoperative UPA treatment were pair-matched with patients of similar age (± 5 years) and fibroid volume (± 10% of volume) who qualified for UAE. Patients undergoing UPA treatment received 5 mg/24 h of oral UPA for 3 months. UAE was performed in patients bilaterally by an interventional radiologist. To estimate dominant fibroid volume, Virtual Organ Computer-aided AnaLysis (VOCAL™) was used. The VOCAL program was also used to calculate three-dimensional power Doppler vascular indices: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Dominant fibroid volumes and VI, FI and VFI values were assessed before commencement of UPA treatment or UAE procedure and again at 3 months afterwards. RESULTS In both the UPA and UAE groups, fibroid volumes decreased significantly after treatment in comparison with baseline volumes obtained prior to treatment. The percentage of fibroid volume reduction after 3 months of UPA therapy (48.1%) was not significantly different from the reduction seen 3 months after the UAE procedure (47.3%). All vascular indices decreased significantly after treatment by UPA or UAE. The percentage reduction in VI and VFI 3 months after UAE (95.4% for both) was significantly greater than the percentage reduction in patients after 3 months of UPA therapy (51.5% and 62.5%, respectively); however the difference in FI reduction between treatment groups did not reach significance (54.3% for UAE and 30.9% for UPA). No significant side-effects were observed in either treatment group. CONCLUSIONS Fibroid treatment by UPA therapy results in a decrease in fibroid volume, comparable with that after UAE, and decreases fibroid vascularization, although to a lesser extent than does UAE.
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Affiliation(s)
- P Czuczwar
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - S Wozniak
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - P Szkodziak
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - P Milart
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - E Wozniakowska
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - W Wrona
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - T Paszkowski
- 3rd Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
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Intermediate and long-term outcomes following uterine artery fibroid embolization. Eur J Obstet Gynecol Reprod Biol 2015; 191:33-8. [PMID: 26070125 DOI: 10.1016/j.ejogrb.2015.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/02/2015] [Accepted: 05/19/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess patients' satisfaction and the intermediate and long-term patterns of symptom progression following uterine artery fibroid embolization (UAE). STUDY DESIGN Intermediate (2-6 years) and long-term (9-14 years) follow-up questionnaire survey to women who underwent UAE during the period 1996-2000, at a tertiary referral centre. RESULTS The mean (SD) age of women at the time of embolization was 43 (5.58) years. A total of 142/197 (72.1%) women had the embolization in view of heavy menstrual periods, while 87/197 (44%) indicated a desire to retain fertility. 160/197 (81.7%) women who completed Q1 reported an improvement in menstrual symptoms compared to 41/80 (51.2%) for Q2 [p<0.01]. The majority indicated they would recommend the procedure to a friend (Q1: 165 (83.8%), Q2: 62/80 (77.5%)) [p=0.75]. 23/80 (28.8%) required further surgical treatment following UAE, and within the latter group, only 7/23 (30.4%) were satisfied with the embolization. 22/80 (27.5%) tried for a pregnancy following the procedure, and of these 3/22 (13.6%) had a live birth. The mean (SD) age at the menopause for women who returned Q2 was 49.1 (4.91) years. CONCLUSIONS The majority of women were satisfied with the embolization and noted an improvement in menstrual symptoms. However, this improvement diminished over time following the embolization, and over a quarter of women required further surgical intervention. Findings from this study may provide useful information in counselling women undergoing UAE and help guide clinicians in their patient selection criteria when discussing the procedure.
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Chapiro J, Duran R, Lin M, Werner JD, Wang Z, Schernthaner R, Savic LJ, Lessne ML, Geschwind JF, Hong K. Three-Dimensional Quantitative Assessment of Uterine Fibroid Response after Uterine Artery Embolization Using Contrast-Enhanced MR Imaging. J Vasc Interv Radiol 2015; 26:670-678.e2. [PMID: 25638750 DOI: 10.1016/j.jvir.2014.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 10/31/2014] [Accepted: 11/10/2014] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the clinical feasibility and diagnostic accuracy of three-dimensional (3D) quantitative magnetic resonance (MR) imaging for the assessment of total lesion volume (TLV) and enhancing lesion volume (ELV) before and after uterine artery embolization (UAE). MATERIALS AND METHODS This retrospective study included 25 patients with uterine fibroids who underwent UAE and received contrast-enhanced MR imaging before and after the procedure. TLV was calculated using a semiautomated 3D segmentation of the dominant lesion on contrast-enhanced MR imaging, and ELV was defined as voxels within TLV where the enhancement exceeded the value of a region of interest placed in hypoenhancing soft tissue (left psoas muscle). ELV was expressed in relative (% of TLV) and absolute (in cm(3)) metrics. Results were compared with manual measurements and correlated with symptomatic outcome using a linear regression model. RESULTS Although 3D quantitative measurements of TLV demonstrated a strong correlation with the manual technique (R(2) = 0.93), measurements of ELV after UAE showed significant disagreement between techniques (R(2) = 0.72; residual standard error, 15.8). Six patients (24%) remained symptomatic and were classified as nonresponders. When stratified according to response, no difference in % ELV between responders and nonresponders was observed. When assessed using cm(3) ELV, responders showed a significantly lower mean ELV compared with nonresponders (4.1 cm(3) [range, 0.3-19.8 cm(3)] vs 77 cm(3) [range, 11.91-296 cm(3)]; P < .01). CONCLUSIONS The use of segmentation-based 3D quantification of lesion enhancement is feasible and diagnostically accurate and could be considered as an MR imaging response marker for clinical outcome after UAE.
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Affiliation(s)
- Julius Chapiro
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287; Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Berlin, Germany
| | - Rafael Duran
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - MingDe Lin
- Clinical Informatics, Interventional, and Translational Solutions, Philips Research North America, Briarcliff Manor, New York
| | - John D Werner
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Zhijun Wang
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Rüdiger Schernthaner
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Lynn Jeanette Savic
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287; Department of Diagnostic and Interventional Radiology, Charité Universitätsmedizin, Berlin, Germany
| | - Mark L Lessne
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Jean-François Geschwind
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Kelvin Hong
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287.
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Prediction of early response to uterine artery embolization in fibroids: Value of MR signal intensity ratio. Magn Reson Imaging 2015; 33:51-5. [DOI: 10.1016/j.mri.2014.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/28/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Uterine fibroids cause heavy prolonged bleeding, pain, pressure symptoms and subfertility. The traditional method of treatment has been surgery as medical therapies have not proven effective. Uterine artery embolization has been reported to be an effective and safe alternative to treat fibroids in women not desiring future fertility. There is a significant body of evidence that is based on case controlled studies and case reports. This is an update of the review previously published in 2012. OBJECTIVES To review the benefits and risks of uterine artery embolization (UAE) versus other medical or surgical interventions for symptomatic uterine fibroids. SEARCH METHODS We searched sources including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries. The search was last conducted in April 2014. We contacted authors of eligible randomised controlled trials to request unpublished data. SELECTION CRITERIA Randomised controlled trials (RCTs) of UAE versus any medical or surgical therapy for symptomatic uterine fibroids. The primary outcomes of the review were patient satisfaction and live birth rate (among women seeking live birth). DATA COLLECTION AND ANALYSIS Two of the authors (AS and JKG) independently selected studies, assessed quality and extracted data. Evidence quality was assessed using GRADE methods. MAIN RESULTS Seven RCTs with 793 women were included in this review. Three trials compared UAE with abdominal hysterectomy, two trials compared UAE with myomectomy, and two trials compared UAE with either type of surgery (53 hysterectomies and 62 myomectomies).With regard to patient satisfaction rates, our findings were consistent with satisfaction rates being up to 41% lower or up to 48% higher with UAE compared to surgery within 24 months of having the procedure (odds ratio (OR) 0.94; 95% confidence interval (CI) 0.59 to 1.48, 6 trials, 640 women, I(2) = 5%, moderate quality evidence). Findings were also inconclusive at five years of follow-up (OR 0.90; 95% CI 0.45 to 1.80, 2 trials, 295 women, I(2) = 0%, moderate quality evidence). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy, but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution (live birth: OR 0.26; 95% CI 0.08 to 0.84; pregnancy: OR 0.29; 95% CI 0.10 to 0.85, 1 study, 66 women).Similarly, for several safety outcomes our findings showed evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups. This applied to intra-procedural complications (OR 0.91; 95% CI 0.42 to 1.97, 4 trials, 452 women, I(2) = 40%, low quality evidence), major complications within one year (OR 0.65; 95% CI 0.33 to 1.26, 5 trials, 611 women, I(2) = 4%, moderate quality evidence) and major complications within five years (OR 0.56; CI 0.27 to 1.18, 2 trials, 268 women). However, the rate of minor complications within one year was higher in the UAE group (OR 1.99; CI 1.41 to 2.81, 6 trials, 735 women, I(2) = 0%, moderate quality evidence) and two trials found a higher minor complication rate in the UAE group at up to five years (OR 2.93; CI 1.73 to 4.93, 2 trials, 268 women).UAE was associated with a higher rate of further surgical interventions (re-interventions within 2 years: OR 3.72; 95% CI 2.28 to 6.04, 6 trials, 732 women, I(2) = 45%, moderate quality evidence; within 5 years: OR 5.79; 95% CI 2.65 to 12.65, 2 trials, 289 women, I(2) = 65%). If we assumed that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE.The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery (OR 0.07; 95% CI 0.01 to 0.52, 2 trials, 277 women, I(2) = 0%). UAE was also associated with a shorter procedural time (two studies), shorter length of hospital stay (seven studies) and faster resumption of usual activities (six studies) in all studies that measured these outcomes; however, most of these data could not be pooled due to heterogeneity between the studies.The quality of the evidence varied, and was very low for live birth, moderate for satisfaction ratings, and moderate for most safety outcomes. The main limitations in the evidence were serious imprecision due to wide confidence intervals, failure to clearly report methods, and lack of blinding for subjective outcomes. AUTHORS' CONCLUSIONS When we compared patient satisfaction rates at up to two years following UAE versus surgery (myomectomy or hysterectomy) our findings are that there is no evidence of a difference between the interventions. Findings at five year follow-up were similarly inconclusive. There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE, but this information was only available from a selected subgroup in one small trial.We found no clear evidence of a difference between UAE and surgery in the risk of major complications, but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. If we assume that 7% of women will require further surgery within two years of hysterectomy or myomectomy, between 15% and 32% will require further surgery within two years of UAE. This increase in the surgical re-intervention rate may balance out any initial cost advantage of UAE. Thus although UAE is a safe, minimally invasive alternative to surgery, patient selection and counselling are paramount due to the much higher risk of requiring further surgical intervention.
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Affiliation(s)
- Janesh K Gupta
- Academic Department of Obstetrics and Gynaecology, University of Birmingham, Birmingham Women’s Hospital, Edgbaston, Birmingham, B15 2TG, UK.
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