Complications and adverse events of high-intensity focused ultrasound in its application to gynecological field - a systematic review and meta-analysis

OBJECTIVE

To analyze and summarize the types, incidence rates and relevant influencing factors of adverse events (AEs) after high-intensity focused ultrasound ablation of gynecological diseases and provide reference and basis for handling such events in clinical practice.

METHOD

We searched PubMed, Cochrane Library, Web of Science and Embase databases to retrieve all literature since its establishment until February 2024. We evaluated the quality of included literature and publication bias and conducted a meta-analysis of single group rates for various AEs using Stata 17.0.

RESULTS

This systematic review finally included 41 articles. We summarized 34 kinds of AEs in 7 aspects and conducted a single group rate meta-analysis and sub-group analysis of 16 kinds of AEs. Among the common AEs of High-Intensity Focused Ultrasound (HIFU), the incidence of lower abdominal pain/pelvic pain is 36.1% (95% CI: 24.3%∼48.8%), vaginal bleeding is 20.6% (95% CI: 13.9%∼28.0%), vaginal discharge is 14.0% (95% CI: 9.6%∼19.1%), myoma discharge is 24% (95% CI: 14.6%∼34.8%), buttock pain is 10.8% (95% CI: 6.0%∼16.5%) and sacral pain is 10% (95% CI: 8.8%∼11.2%). Serious complications include uterine rupture, necrotic tissue obstruction requiring surgical intervention, third degree skin burns and persistent lower limb pain or movement disorders.

CONCLUSION

The common AEs after HIFU surgery are mostly mild and controllable, and the incidence of serious complications is extremely low. By reasonable prevention and active intervention, these events can be further reduced, making it a safe and effective treatment method. It is a good choice for patients who crave noninvasive treatment or have other surgical contraindications.

Long-term outcome and risk factors of reintervention after high intensity focused ultrasound ablation for uterine fibroids: a systematic review and meta-analysis

OBJECTIVES

To quantify the reintervention rate and analyze the risk factors for reintervention after high-intensity focused ultrasound (HIFU) ablation of uterine fibroids.

METHODS

Eighteen studies were selected from the seven databases. A meta-analysis was applied to synthesize the reintervention rates for fibroids across various follow-up durations. Subgroup-analysis was conducted based on the year of surgery, sample size, guide methods, and non-perfusion volume ratio (NPVR). Signal intensity of T2-weighted imaging (T2WI) was independently evaluated for reintervention risk.

RESULTS

The study enrolled 5216 patients with fibroids treated with HIFU. There were 3247, 1239, 1762, and 2535 women reaching reintervention rates of 1% (95% confidence interval (CI): 1-1), 7% (95% CI: 4-11), 19% (95% CI: 11-27), and 29% (95% CI: 14-44) at 12, 24, 36, and 60-month after HIFU. The reintervention rates of patients treated with US-guided HIFU (USgHIFU) were significantly lower than those of patients treated with MR-guided focused ultrasound surgery (MRgFUS). When the NPVR of fibroids was over 50%, the reintervention rates at 12, 36 and 60-month after HIFU were 1% (95% CI: 0.3-2), 5% (95% CI: 3-8), and 15% (95% CI: 9-20). The reintervention risk for hyper-intensity fibroids on T2WI was 3.45 times higher (95% CI: 2.7-4.39) for hypo-/iso-intensity fibroids.

CONCLUSION

This meta-analysis showed that the overall reintervention rates after HIFU were acceptable and provided consultative suggestions regarding treatment alternatives for patients with fibroids. Subgroup-analysis revealed that USgHIFU, NPVR ≥ 50%, and hypo-/iso-intensity of fibroids on T2WI were significant factors in reducing reintervention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42023456094.

Pregnancy rate and outcomes after uterine artery embolization for women: a systematic review and meta-analysis with trial sequential analysis

Objective

The assessment of the relative impacts of uterine artery embolization (UAE) treatment for female patients is a critical field that informs clinical decisions, yet there is a noticeable scarcity of high-quality, long-term comparative studies. This meta-analysis aimed to focus on the pregnancy rate and outcomes in female patients following UAE and to conduct subgroup analyses based on different patient populations or various control treatments.

Methods

A systematic literature search was conducted on 2 August 2023 through the Web of Science, PubMed, Embase, and the Cochrane Library of Clinical Trials for all potential studies. Relative risks (RRs) with 95% confidence intervals (CIs) were applied to compare pregnancy rates and outcomes between the UAE group and the control group. Heterogeneity was evaluated statistically by using the chi-square-based Cochran's Q test and Higgins I2 statistics, and 95% prediction interval (PI). Software R 4.3.1 and Stata 12.0 were used for meta-analysis. The trial sequential analysis (TSA) was performed with TSA v0.9.5.10 Beta software.

Results

A total of 15 eligible studies (11 cohort studies, 3 randomized controlled trials, and 1 non-randomized clinical trial) were included in this meta-analysis. The overall results revealed that UAE significantly decreased postoperative pregnancy rate [RR (95% CI): 0.721 (0.531-0.979), 95% PI: 0.248-2.097] and was associated with an increased risk of postoperative PPH [RR (95% CI): 3.182 (1.319-7.675), 95% PI: 0.474-22.089]. Analysis grouped by population indicated that UAE decreased the risk of preterm delivery [RR (95% CI): 0.326 (0.128-0.831), p = 0.019] and cesarean section [RR (95% CI): 0.693 (0.481-0.999), p = 0.050] and increased the risk of placenta previa [RR (95% CI): 8.739 (1.580-48.341), p = 0.013] in patients with UFs, CSP, and PPH, respectively. When compared with myomectomy, HIFU, and non-use of UAE, UAE treatment was associated with the reduced risks of preterm delivery [RR (95% CI): 0.296 (0.106-0.826)] and cesarean section [(95% CI): 0.693 (0.481-0.999), p = 0.050] and increased placenta previa risk [RR (95% CI): 10.682 (6.859-16.636)], respectively.

Conclusion

UAE treatment was associated with a lower postoperative pregnancy rate and increased risk of PPH. Subgroup analysis suggested that UAE was shown to decrease the risk of preterm delivery and cesarean section and increase placenta previa risk.Systematic review registration:https://www.crd.york.ac.uk/prospero/, Identifier CRD42023448257.

Predictors and Clinical Outcomes of Fibroid Expulsion After Uterine Artery Embolization

PURPOSE

To evaluate rates of fibroid expulsion after uterine artery embolization (UAE) and risk factors.

MATERIALS AND METHODS

Single-center retrospective study of UAEs for fibroids between 2016 and 2020. Preoperative UAE and patients with incomplete follow-up were excluded. Patients underwent MRI before and 3 months after UAE and/or as indicated. Medical records were reviewed, and patient demographics, fibroid characteristics and clinical events were recorded. Fibroid expulsion included fibroid exposure to the endometrial cavity on MRI, and tissue loss/passage as observed clinically or on MRI. Symptoms were considered major if requiring additional clinic visits or treatment. Statistical tests included Chi-square, Fisher's exact test, and logistic regression models.

RESULTS

One hundred ninety-nine women were included. Symptomatic fibroid expulsion occurred after 31 (16%) procedures: 16 minor and 15 major. Symptoms included vaginal discharge (n = 23), bleeding (n = 9), tissue passage (n = 9), cramping/pain (n = 3), and fever (n = 4). Fifteen women (8%) needed additional care, of whom 6 (3%) required invasive procedures (4 elective hysterectomies, 1 hysteroscopic resection, 1 transvaginal removal of passing tissue). The International Federation of Gynecology and Obstetrics (FIGO) classification was significantly associated with symptomatic fibroid expulsion (p = 0.001). Odds ratio for symptomatic expulsion and expulsion requiring additional care for FIGO 3-7 versus 0-2 fibroids was 0.32 (95% confidence interval, 0.14-0.71, p = 0.005) and 0.28 (95% confidence interval, 0.10-0.83, p = 0.02), respectively. Other factors were not consistently associated with expulsion.

CONCLUSION

Fibroid expulsion after uterine artery embolization was more common than previously reported but mostly asymptomatic or minimally symptomatic. Women with FIGO ≤ 2 fibroids should be appropriately counseled regarding risk for expulsion.

Adverse events and complications after magnetic resonance-guided focused ultrasound (MRgFUS) therapy in uterine fibroids - a systematic review and future perspectives

OBJECTIVES

The aim of this review was to analyze and summarize the most common adverse events (AEs) and complications after magnetic resonance-guided focused ultrasound (MRgFUS) therapy in uterine fibroids (UFs) and to establish the risk factors of their occurrence.

METHODS

We searched for original research studies evaluating MRgFUS therapy in UFs with outcomes containing AEs and/or complications in different databases (PubMed/MEDLINE, SCOPUS, COCHRANE) until March 2022. Reviews, editorials, opinions or letters, case studies, conference papers and abstracts were excluded from the analysis. The systematic literature search identified 446 articles, 43 of which were analyzed.

RESULTS

According to available evidence, the overall incidence of serious complications in MRgFUS therapy is relatively low. No AEs/complications were reported in 11 out of 43 analyzed studies. The mean occurrence of all AEs in the analyzed material was 24.67%. The most commonly described AEs included pain, skin burns, urinary tract infections and sciatic neuropraxia. Major AEs, such as skin ulcerations or deep vein thrombosis, occurred in 0.41% of cases in the analyzed material.

CONCLUSION

MRgFUS seems to be safe in UF therapy. The occurrence of AEs, especially major ones, is relatively low in comparison with other methods. The new devices and more experience of their users seem to reduce AE rate. The lack of unification in AE reporting and missing data are the main issues in this area. More prospective, randomized studies with unified reporting and long follow-up are needed to determine the safety in a long-term perspective.

High-intensity focused ultrasound for the treatment of fibroids: A single-center experience in Singapore

Objectives

Uterine fibroids and adenomyosis are common gynecological conditions that often require surgical treatment. Minimally invasive interventions such as ultrasound-guided high-intensity focused ultrasound (USgHIFU) are gaining popularity as they avoid surgical morbidity and conserve the uterus. We present a single-center experience on the use of USgHIFU for the treatment of fibroids and adenomyosis.

Materials and Methods

This was a retrospective study of 167 patients who underwent USgHIFU for uterine fibroids and adenomyosis between July 2018 and December 2020. Relevant demographic data and pre- and post-intervention fibroid volume, symptom severity scores (SSS), and health-related quality of life (QOL) scores were collected and compared. The paired t-test or Wilcoxon signed-rank test was used to compare the difference before and after treatment. P < 0.001 was considered statistically significant.

Results

One hundred and sixty-seven patients with fibroids or adenomyosis were included in this study. The mean age of the cohort was 42-year-old. USgHIFU treatment led to a reduction in mean fibroid volume, improvement in SSS, and health-related QOL scores. The average reduction in mean fibroid volume was 68% and 75% at 6 and 12 months, respectively. There was a significant reduction in SSS (46.9 [pre] vs. 15.6 [post], P < 0.001) and improvement in health-related QOL scores at 6 months (58 [pre] vs. 86 [post], P < 0.001). The re-intervention rate following USgHIFU was 7.7% and successful pregnancy post USgHIFU was reported in 6 patients.

Conclusion

USgHIFU is safe and effective. In women who desire fertility or are not suitable for surgery, it is a good alternative option. It should be included in the armamentarium for the treatment of uterine fibroids and adenomyosis.

Clinical analysis of high-intensity focused ultrasound (HIFU) combined with hysteroscopy-guided suction curettage (HGSC) in patients with cervical pregnancy

OBJECTIVE

To evaluate the effectiveness of high-intensity focused ultrasound (HIFU) combined with hysteroscopy-guided suction curettage (HGSC) in treating cervical pregnancy.

MATERIALS AND METHODS

This is a retrospective study. Seven patients with cervical pregnancy who visited the Third Xiangya Hospital of Central South University from January 2015 to December 2020 were enrolled in the current study. All seven patients were treated with HIFU under conscious sedation. All of them underwent HGSC at an average of 2 ± 1 days (range: 1-3 days) after HIFU. Before the therapy, the patient's clinical characteristics were collected, including duration of amenorrhea, gravidity and parity, the patient history of cesarean section and miscarriage, and the size of the gestational sac. The levels of β-hCG and hemoglobin in serum were also reviewed. To assess the clinical outcomes of this combined treatment, the suction time of HGSC, bleeding volume, the clearance time of β-hCG, and the time with returning of menstruation were evaluated.

RESULTS

All seven patients (average age: 31 ± 6 years) have experienced amenorrhea (duration range, 48 ± 8 days) before the treatment of HIFU. The average number of pregnancies was four, and the number of deliveries was one. Previous medical history showed six patients had cesarean sections, and five patients have been miscarriages. After HIFU treatment, the fetal heartbeats were stopped in all seven patients based on the diagnosis by doppler ultrasound. The bleeding of gestational tissue decreased significantly. All patients had only mild lower abdominal pain, no fever, intestinal damage, or other complications were reported. The average operation time of operative suction curettage was 21 ± 9 min (range: 9-32 min), and the median bleeding volume was 10 ± 8 mL (range: 2-20 mL). Follow-up observations showed that the menstruations were returned in patients at an average of 38 ± 9 days (range: 30-50 days) after the treatment. The β-hCG decreased from 41773 ± 32242 mIU/mL to 13101 ± 8454 mIU/mL in 29 ± 10 days after surgery.

CONCLUSION

Based on these results with small subjects, we concluded that HIFU combined with HGSC might be an effective and safe treatment for patients with cervical pregnancy.

Tolerance and efficacy of HIFU ablation for uterine fibroids NPVR ≥ 90%: a nested case-control study

OBJECTIVE

To investigate the tolerance and efficacy of HIFU ablation for uterine fibroids with a non-perfused volume ratio (NPVR) ≥ 90%.

METHODS

A prospective cohort study of 2411 patients from 20 clinical centers was available. Contrast-enhanced MRI was used to assess the non-perfused volume ratio (NPVR). The International Society of Interventional Radiotherapy (SIR) complication grading system was used as the tolerance index. Uterine Fibroids-related Symptoms-Quality of Life (UFS-QoL) was used to evaluate the efficacy.

RESULTS

A total of 1352 patients underwent USgHIFU ablation treatment enrolled, NPVR was median 91.9% (IQR, 81.4%,100.0%). There was 761 case (56.3%) in the NPVR ≥ 90% group in which 17.5% case experienced SIR-B abdominal pain, 591 cases (43.7%) in NPVR < 90% group in which 9.3% case had SIR-B abdominal pain. There were statistically differences in the improvement degree of UFS at 12 months among the four subgroups (NPVR < 70%, 70%-80%, 80%-90%, 90%-100%) (all p < 0.05).

CONCLUSIONS

Patients with NPVR ≥ 90% had a higher incidence of SIR-B lower abdominal pain. NPVR was positively correlated with the degree of symptom relief at 12 months, and NPVR ≥ 90% was more likely to obtain better clinical symptom relief.

Evaluation of physician experience in achieving non-perfused volume ratio of high-intensity focused ultrasound ablation for uterine fibroids: a multicentre study

Objective

To evaluate the effect of different levels of physician experience on the high-intensity focused ultrasound (HIFU) ablation of uterine fibroids and to provide a reference for the use of non-perfused volume ratio (NPVR) standards during training.

Methods

This prospective multicentre study enrolled patients with uterine fibroids. The effect of the physician’s level of experience on the outcomes under different NPVR standards and the learning curve of six centres without HIFU experience were analysed. The impact of patient demographic and clinical characteristics were also evaluated.

Results

A total of 1352 patients from 20 centres were included in the study. The median NPVRs were 92.00%, 88.10% and 92.86% in the no experience group, inexperienced group and experienced group, respectively. Posterior wall fibroids, lateral wall fibroids and fundus fibroids were inversely correlated with NPVR, while experienced physicians were positively correlated with NPVR. With NPVR ≥ 70% and NPVR ≥ 80% standards, physicians in the no experience group completed the learning curve on the 11th and 16th procedure, respectively. Physicians under a standard of an NPVR ≥ 90% did not complete the learning curve.

Conclusions

NPVR ≥ 80% is a standard that is worth using for HIFU treatment of uterine fibroids.

Extravascular Dispersion of Polyvinyl Alcohol Microsphere Particles in Uterine Artery Embolization

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

The significance of transcervical ultrasound-guided radiofrequency ablation in the treatment of symptomatic fibroids: results of an expert consensus from German-speaking countries

Uterine fibroids are one of the most common diseases in female patients, lead mainly to bleeding disorders and lower abdominal pain, and reduce the chance of having children. In recent years we have seen a trend towards more and more pharmacotherapies and minimally invasive organ-preserving treatments. One novel and innovative procedure for an organ-preserving treatment of symptomatic uterine fibroids is the transcervical ultrasound-guided radiofrequency ablation (TRFA). TRFA has been used in Germany since 2013 and later found use in other German-speaking countries as well. There have now been more than 1200 TRFA treatments performed in Germany, Austria, and Switzerland. Experts from these three countries came together for a consensus meeting to analyze the significance of the procedure in the overall concept of the treatment of symptomatic uterine fibroids.

Physician Experience in Technical Success of Achieving NPVR ≥ 80% of High-Intensity Focused Ultrasound Ablation for Uterine Fibroids: A Multicenter Study

Objective

To evaluate the experience of the physician of the technical success in high-intensity focused ultrasound (HIFU) ablation of uterine fibroids with a nonperfused volume ratio (NPVR) of at least 80%.

Methods

Patients from a 20-center prospective study were enrolled in this study. In this study, among the 20 clinical centers, five centers had physician with >3 years of HIFU experience, and the other 15 centers initiated HIFU therapy <3 years, were defined as the experienced group and the inexperienced group, respectively. Technical success was defined as achieving NPVR ≥ 80% of uterine fibroids with no major complications and it was defined as the successful group; otherwise, it was defined as the unsuccessful group.

Results

A total of 1,352 patients were included at the age of 41.32 ± 5.08 years. The mean NPVR (87.48 ± 14.91%) was obtained in the inexperienced group (86.50 ± 15.76%) and in the experienced group (89.21 ± 13.12%), respectively. The multivariate analysis showed that the volume of uterus, location of fibroids, and physician experience were significantly correlated with technical success (p < 0.05). In the experienced group, 82.20% of uterine fibroids obtained NPVR ≥ 80%, compared with 75.32% in the inexperienced group, and the difference was significant (p = 0.003). The technical success rate of the experienced group was 82.00% which was higher than 75.20% of the inexperienced group (p = 0.004).

Conclusion

In technical success of achieving NPVR ≥ 80%, experience of the physician was positively correlated with technical success; NPVR and major complications for the inexperienced group were comparable to those of the experienced group from a clinical perspective; inexperienced physicians could reach NPVR ≥ 80% of sufficient ablation and were trustworthy in efficacy. Smaller uterus and fibroids of anterior wall were correlated with better technical success; experienced physicians still have better technical success when choosing patients with larger uterus, contributing to clinical decision-making and patient referral.

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

BACKGROUND

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

METHODS

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

RESULTS

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

Temporary Internal Iliac Artery Blockage versus Uterine Artery Embolization in Patients After Laparoscopic Pregnancy Tissue Removal Due to Cesarean Scar Pregnancy

Objective

This study aims to evaluate the clinical value of laparoscopic temporary internal iliac artery blockage (TIIAB) compared with uterine artery embolization (UAE) in type III cesarean scar pregnancy (CSP).

Methods

A total of 76 patients with type III CSP admitted to the Department of Gynecology the First Affiliated Hospital of Zhengzhou University between September 2017 and June 2019 were selected for this retrospective study. Thirty-six of them in the study group received TIIAB, and the rest in control group received UAE. Laparoscopic pregnancy tissue was removed from all patients, and the uterine defects were repaired. The absence of remnants was then confirmed using ultrasonography. Follow-ups were performed in the two groups for six months, and the factors of intraoperative blood loss, operation and menelipsis time, 24-h human chorionic gonadotropin decline rate, postoperative complications, hospitalization days, hospitalization costs, peri-operative hormone levels, and ovarian function indicators were compared between the two groups and within each group.

Results

There were statistically significant differences in the hospitalization cost, menelipsis time, and postoperative complication incidence between the two groups (p < 0.05). There were statistically significant differences between ovarian function at one month and three months after surgery (p < 0.05) as well as among the follicle-stimulating hormone, luteinizing hormone, and estradiol levels at one, three, and six months after surgery in the control group (p < 0.05).

Conclusion

Compared with uterine artery embolization, laparoscopic TIIAB has the advantages of a low hospitalization cost, lower postoperative complication rate, and shorter menelipsis time. Moreover, it avoids ovarian function damage. It is a safe method worthy of clinical popularization.

Unsuccessful Uterine Artery Embolization Requiring Subtotal Hysterectomy: A Case Report

Introduction: The purpose of this case report is to present the case of a 49-year-old female individual with uterine fibroids, who underwent a subtotal hysterectomy after prior unsuccessful uterine artery embolization. Uterine artery embolization is a minimally-invasive technique used as an additional option for the treatment of symptomatic fibroids. The method is a promising technique, indicated for female individuals of reproductive age wishing to preserve their uteri.

Case Presentation: The patient presented symptoms of bloating and menorrhagia. Magnetic Resonance Imaging revealed uterine enlargement and elongation, with several fibroids and urinary bladder deformation caused by the enlarged uterus and the numerous fibroids compressing the uterine apex. She was referred for uterine artery embolization. In the three-year follow-up imaging, no alteration of the uterus’ size was observed, while two fibroids were noted, suggesting necrosis or malignancy based on imaging findings, which led to the conduction of partial hysterectomy while leaving the cervix intact.

Discussion: Uterine artery embolization is regarded as a safe and successful procedure. However, in case of ineffectiveness, full or partial hysterectomy is considered as the ultimate treatment of choice.

Conclusion: According to the available literature, uterine artery embolization is promoted to be an efficient alternative option to surgery. Patients should be offered adequate medical consultation on all the treatment options and possible complications.

Myoma Expulsion after Uterine Artery Embolization

Introduction

Uterine leiomyomas are the most common benign pelvic tumors in women over 35 years and can be symptomatic or asymptomatic. Among the main treatment strategies, there are hormone therapy, hysterectomy, myomectomy, and uterine artery embolization (UAE), a recent and promising treatment for patients who wish to avoid hysterectomy. Ideal candidates for UAE are women with symptomatic uterine leiomyomas that present no desire for pregnancy, premenopausal and heavy menstrual bleeding, or dysmenorrhea caused by intramural fibroids. Case Presentation. A 36-year-old female diagnosed with leiomyomas and an extensive history of failed previous treatments who, in order to preserve her uterus, underwent UAE and had tumor expulsion 15 days after the procedure. The patient remained eight months in amenorrhea and, currently, presents normal hormone levels and irregular periods.

Conclusion

UAE presents itself as a minimally invasive procedure and as an efficient alternative for those patients who wish to preserve their uteri and also improve their symptoms and quality of life.

MRI analysis of uterine ischaemia as a form of non-target embolisation following uterine artery embolisation: incidence, extent and outcome

AIM

To study the incidence, extent and fate of uterine ischaemia as one of the forms of non-target embolisation following uterine artery embolisation (UAE), as detected on immediate post-embolisation and contrast-enhanced magnetic resonance imaging (MRI) examinations at the 3-month follow-up.

MATERIALS AND METHODS

A retrospective study was undertaken comprising 43 women (mean age: 44.8 ± 3.79 years). MRI was performed before, immediately after (within 6 h), and 3 months after successful UAE. Areas of uterine ischaemia were identified on immediate post-embolisation MRI as regions of newly developed (compared to pre-embolisation MRI) absent enhancement within the uterus not corresponding to the location of the leiomyoma. The volume of the ischaemic region was calculated using the formula (height × length × width × 0.523).

RESULTS

Uterine ischaemia was encountered in 29 patients (67.44%). The mean volume of the ischaemic region immediately after UAE was 29.29 ± 19.15 ml (range: 7.36-87.71 ml). At 3-month follow-up, it was 0.35 ± 0.95 ml (range: 0-3.5 ml) with 25 (86%) patients showing complete resolution of the ischaemia. The mean reduction in the volume of the ischaemic region at the 3-month follow-up was 98.24 ± 5.72% (range: 72-100%). This volume reduction was statistically significant (p<0.0001).

CONCLUSION

Uterine ischaemia as a form of non-target embolisation following UAE might be encountered in up to two thirds of patients. These ischaemic areas are significantly reduced at the 3-month follow-up with up to 86% of cases showing complete reversibility of the ischaemia.

Magnetic resonance imaging parameters in predicting the ablative efficiency of high-intensity focused ultrasound for uterine fibroids

OBJECTIVE

To evaluate the role of quantitative MRI parameters in predicting HIFU ablation results for uterine fibroids.

MATERIAL AND METHODS

A total of 245 patients with uterine fibroids who underwent HIFU treatment in Chongqing Haifu Hospital were reviewed retrospectively. The patients were divided into two groups according to the non-perfused volume (NPV) ratio which was either higher or lower than 80%. The MRI parameters were measured, and a logistical regression analysis was performed to investigate the potential predictors associated with the NPV ratio. Receiver operating characteristics (ROC) analysis was used to determine the cut off value for MRI parameters in predicting a high NPV ratio.

RESULTS

The subcutaneous fat thickness in the group of patients with an NPV ratio over 80% was significantly thinner than that in the group of patients with an NPV ratio less than 80% (15 mm versus 21 mm). The signal intensity ratio of fibroids to skeletal muscle on T2WI was significantly lower in the group of patients with an NPV ratio over 80% compared with the group with an NPV ratio lower than 80% (2.46 versus 3.23). The signal intensity ratio of fibroid to skeletal muscle correlated negatively with the NPV ratio and positively with the energy efficiency factor (EEF). The cut off value of signal intensity ratio of fibroid to muscle for predicting the NPV ratio over 80% is 3.045.

CONCLUSION

The signal intensity ratio of fibroid to skeletal muscle on T2WI can be used as a factor for predicting the effectiveness of HIFU ablation of uterine fibroids.

Can uterine artery embolization be an alternative to plastic and reconstructive uterus operation by minimally invasive surgery?

Introduction: Plastic and reconstructive minimally invasive surgery has been established as gold standard in myomectomy. Therapy failure eventually leads to future surgical interventions or hysterectomy: surgeons and patients should be aware of the risks and benefits. We conducted a systematic review to analyse the evidence on the therapeutic indications and adverse events associated with uterine artery embolization and thereby evaluating if this method could be a valid alternative therapy. Methods: In concordance with PRISMA guidelines, literature research was made in PubMed, Cochrane Library, UpToDate, Amboss and Medline databases. Clinical trials, reviews and case reports published in English between January 2010 and June 2020 were included. Results: 44 articles were included out of 838 papers identified at initial search. Regarding uterine fibroids, three original papers and one Cochrane review reported the benefits of the procedure as an alternative to surgery, even in large and giant fibroids. Furthermore, several studies discussed the use of embolization for postpartum haemorrhage to decrease rates of hysterectomy after other haemostatic methods were exhausted, because of the potential risk of abnormal placentation in a future pregnancy. The procedure can also be successfully used as prophylactic method in different obstetrical procedures. Conclusions: The use of embolization in different uterine pathologies is a minimally invasive procedure as an alternative to surgery, especially in women who desire to preserve their uterus. Its related complications are described and can be avoided by a stringent indication of the procedure. More evidence regarding fertility after UAE, use of the procedure prophylactically in obstetrical haemorrhage or in adenomyosis is needed.

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

OBJECTIVE

This study aimed to compare the clinical effects of uterine artery embolization (UAE) with those of high-intensity focused ultrasound (HIFU) ablation for the treatment of symptomatic uterine myomas.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, and ClinicalTrials.gov for studies from January 2000 to August 2020. Related articles and relevant references of the included studies were also searched.

METHODS OF STUDY SELECTION

Two researchers independently performed the data selection. We included comparative studies that compared the clinical outcomes of UAE with those of HIFU ablation in women with myomas.

TABULATION, INTEGRATION, AND RESULTS

We assessed the study quality using the Cochrane Handbook for Systematic Reviews of Interventions for evaluating the risk of bias. Two independent researchers performed the article selection according to the screening criteria and rated the quality of evidence for each article. We calculated pooled mean difference with 95% confidence interval (CI) for continuous data and relative risk (RR) with 95% CI for dichotomous data. The systematic review registration number is CRD42020199630 on the International Prospective Register of Systematic Reviews. A total of 7 articles (5 trials), involving 4592 women with symptomatic uterine myomas, were included in the meta-analysis. Compared with the HIFU ablation group, the decrease in "uterine fibroid symptom" scores as well as the increase in quality-of-life scores at the time of follow-up were higher in the UAE group, with overall mean difference 19.54 (95% CI, 15.21-23.87; p <.001) and 15.72 (95% CI, 8.30-23.13; p <.001), respectively. The women in the UAE group had a significantly lower reintervention rate (RR 0.25; 95% CI, 0.15-0.42; p <.001). The women undergoing UAE had a significantly lower pregnancy rate than those undergoing HIFU ablation (RR 0.06; 95% CI, 0.01-0.45; p = .006). The difference in the incidence of adverse events between the 2 groups was not statistically significant (p = .53).

CONCLUSION

Compared with HIFU ablation, UAE provided more significant alleviation of symptoms and improvement in quality of life, lower postoperative reintervention rate, and lower pregnancy rate for women with uterine myomas. However, we cannot conclude that HIFU ablation is more favorable for desired pregnancy than UAE because of the confounding factors.

Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective

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.

Uterine Myomas: Focused Ultrasound Surgery

Uterine fibroids are the most common neoplasm in women. These lesions may be associated with impaired fertility and adverse obstetric outcomes. Medical treatment, myomectomy, hysterectomy and uterine artery embolization have been employed for the management of uterine fibroids. Focused ultrasound surgery (FUS) is a relatively recent technique that relies on mechanical and thermal energy of ultrasound for the ablation of a target tissue under an imaging guidance, that can be either ultrasound (US-guided FUS, USgFUS) or magnetic resonance (MR-guided FUS, MRgFUS). Pre- and peri-menopausal women are potential candidates for treatment; however, individual criteria need to be evaluated in order to establish the eligibility for the procedure. FUS procedure can be performed in an outpatient setting; it is a safe and effective treatment that has demonstrated to reduce symptoms associated with uterine fibroids. The adverse event rate is 8.7% and only 0.2% of patients experiences major complications. Pregnancy is possible after the treatment, and no damage to the endometrium has been observed following FUS procedure.

Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates

PURPOSE

To evaluate the effect of routine administration of post-procedural antibiotics following elective uterine artery embolization (UAE) on infectious complication rates.

MATERIALS AND METHODS

The charts of patients who underwent UAE between January 2013 and September 2019 were retrospectively reviewed. Prior to January 15, 2016, all patients received post-procedural antibiotics with 500 mg of ciprofloxacin twice a day orally for 5 days. After January 15, 2016, none of the patients received post-procedural antibiotics. All patients in both groups received pre-procedural intravenous antibiotics. The post-procedural antibiotics group included 217 patients (age, 44.7 ± 6 years); the no-antibiotics group included 158 patients (age, 45.4 ± 5.6 years). Patients in the no-antibiotics group had a significantly higher rate of diabetes mellitus (P = .03) but fewer cases of adenomyosis (P = .048). Otherwise, demographic and fibroid characteristics were similar between the groups.

RESULTS

Six infectious complications (6/375, 1.6%) were recorded. No statistically significant difference (P = .66) was observed in the number of infections between the post-procedural antibiotics group (4/217, 1.8%) and the no-antibiotics group (2/158, 1.3%). Three of the 6 infectious complications presented with malodorous vaginal discharge (3/375, 0.8%) and received nominal therapy. The 3 remaining complications (0.8%) were considered major and included 2 patients (0.5%) who underwent hysterectomy and 1 patient (0.3%) who underwent myomectomy. The major infection rate was 0.9% (2/217) in the post-procedural antibiotics group and 0.7% (1/158) in the no-antibiotics group (P = 1). There were no 90-day post-procedural mortalities.

CONCLUSIONS

Discontinuation of routine post-procedural antibiotics with ciprofloxacin after elective UAE did not result in increased rates of infectious complications within the first 90 days post procedure.

Impending fibroid expulsion on MRI after uterine fibroid embolization

Uterine fibroids are common benign tumors seen in women and can be managed with a variety of treatment options, including hysterectomy, myomectomy, and uterine fibroid embolization (UFE). UFE is an acceptable alternative to surgical treatment in well-selected cases and offers the added benefit of decreased hospital stay and avoidance of general anesthesia risk. Like any other procedure, UFE carries risks and complications. Post-UFE fibroid expulsion is one of them.

We present a case of impending fibroid expulsion pre-emptively identified on magnetic resonance imaging at 6-month follow-up after UFE. While the majority of fibroid expulsions occur spontaneously by 3 months post-UFE, delayed expulsions have been reported as late as 4 years following the procedure. Therefore, a high degree of clinical suspicion is paramount for early diagnosis of this complication in UFE patients.

Systematic Review of the Literature: Best Practices

Reviews of published scientific literature are a valuable resource that can underline best practices in medicine and clarify clinical controversies. Among the various types of reviews, the systematic review of the literature is ranked as the most rigorous since it is a high-level summary of existing evidence focused on answering a precise question. Systematic reviews employ a pre-defined protocol to identify relevant and trustworthy literature. Such reviews can accomplish several critical goals that are not easily achievable with typical empirical studies by allowing identification and discussion of best evidence, contradictory findings, and gaps in the literature. The Association of University Radiologists Radiology Research Alliance Systematic Review Task Force convened to explore the methodology and practical considerations involved in performing a systematic review. This article provides a detailed and practical guide for performing a systematic review and discusses its applications in radiology.

Acute pulmonary embolism in a patient with cesarean scar pregnancy after receiving uterine artery embolization: a case report

Uterine artery embolization (UAE) is considered to be an effective treatment for patients with cesarean scar pregnancy, especially for those presenting uncontrollable hemorrhage. However, it can also cause some potential complications. Pulmonary embolism is a rare but fatal complication in patients treated with UAE. Here, we report a case of a woman who was diagnosed with cesarean scar pregnancy presenting with pulmonary embolism during the operation of dilation and curettage after UAE treatment. Prompt resuscitation was carried out and the patient received anticoagulant treatment immediately. During the follow-up, she recovered well without any complications. We present the clinical details and imaging findings, followed by discussions of the etiology, treatments, and prevention strategies.

Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study

BACKGROUND

To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed.

MATERIALS AND METHODS

A retrospective review was conducted for thirteen patients (mean age 35.2 years; range 28-41 years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications.

RESULTS

Median follow-up period was 172.5 days (range 30-600 days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P = 0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications.

CONCLUSION

UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids

PURPOSE

To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids.

METHODS

Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years.

RESULTS

Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests.

CONCLUSIONS

Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

Uncommon Complication of Uterine Artery Embolization: Expulsion of Infarcted Myoma and Uterine Sepsis

Uterine leiomyomas are the most common benign tumors in young females and leading cause of hysterectomy. Uterine artery embolization is a safe option for women who wish to retain their uterus. Several complications have been reported including expulsion and sepsis. MRI is a useful pretreatment tool to predict results and outcomes. We report a case of a 44-year-old female with a history of uterine fibroids with the largest one being intracavitary. Patient underwent uterine artery embolization that was complicated by endomyometritis that failed antibiotics, leading to sepsis and hysterectomy.

Loss of Limb by Inadvertent Embolization of the Persistent Sciatic Artery

Persistent sciatic artery (PSA) is a rare anatomic variant and is normally clinically silent. It can be found occasionally during uterine arteries embolization (UAE) and can lead to technical failure or complications. The authors present a patient with bilateral PSAs who was referred for emergency UAE because of uncontrollable postabortion hemorrhage. Inadvertent embolization of the right PSA led to unsalvageable ischemia and amputation of the right lower limb 12 days later.

Pitfalls of Systematic Reviews and Meta-Analyses in Imaging Research

Systematic reviews of imaging research represent a tool to better understand test accuracy or the efficacy of interventions. Like any type of research, appropriate methods must be applied to optimize quality. The purpose of this review is to outline common pitfalls in performing systematic reviews of imaging research, with a focus on challenges particular to performing reviews of diagnostic accuracy studies. The following challenges are highlighted: posing relevant review questions, conducting comprehensive literature searches, assessing for bias in included studies, testing for heterogeneity and publication bias, pooling results across studies, and forming appropriate conclusions. By guiding authors on how to overcome these, the hope is that published reviews in imaging research will be of higher quality and have a positive impact on clinical practice. In addition, the review aims to educate readers of reviews so they become aware of crucial elements of systematic reviews that could bias review results.

Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy

Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.

Prevention and management of infectious complications of percutaneous interventions

Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.

Post-uterine artery embolization pain and clinical outcomes for symptomatic myomas using gelfoam pledgets alone versus embospheres plus gelfoam pledgets: a comparative pilot study

BACKGROUND

To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids.

METHOD

We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months.

RESULTS

A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal.

CONCLUSION

Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.

The conservative and interventional treatment of fibroids

BACKGROUND

Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures.

METHODS

Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews.

RESULTS

Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators.

CONCLUSION

Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.

MRI predictors of clinical success in MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids: results from a single centre

OBJECTIVES

To assess the technical and clinical results of MRgFUS treatment and factors affecting clinical treatment success.

MATERIALS AND METHODS

A total of 252 women (mean age, 42.1 ± 6.9 years) with uterine fibroids underwent MRgFUS. All patients underwent MRI before treatment. Results were evaluated with respect to post-treatment nonperfused volume (NPV), symptom severity score (SSS), reintervention rate, pregnancy and safety data.

RESULTS

NPV ratio was significantly higher in fibroids characterized by low signal intensity in contrast-enhanced T1-weighted fat saturated MR images and in fibroids distant from the spine (>3 cm). NPV ratio was lower in fibroids with septations, with subserosal component and in skin-distant fibroids (p < 0.001). NPV ratio was highly correlated with clinical success: NPV of more than 80 % resulted in clinical success in more than 80 % of patients. Reintervention rate was 12.7 % (mean follow-up time, 19.4 ± 8 months; range, 3-38). Expulsion of fibroids (21 %) was significantly correlated with a high clinical success rate. No severe adverse events were reported.

CONCLUSIONS

Adequate patient selection and correct treatment techniques, based on the learning curve of this technology, combined with technical advances of the system, lead to higher clinical success rates with low complications rate, comparable to other uterine-sparing treatment options.

KEY POINTS

• MRgFUS appears to be a valid alternative to other uterus-preserving therapies • Patient selection is a significant factor in achieving high NPV ratios • MRI screening parameters correlate with the amount of fibroid ablation in MRgFUS • NPV results of more than 80 % correlate with higher clinical success rates.

Incidence and predictive factors for complications after uterine leiomyoma embolization

STUDY QUESTION

What is the risk of complications after uterine leiomyoma embolization and what are the factors associated with complications?

SUMMARY ANSWER

The cumulative risk of complications after embolization is relatively low even in the long term, but submucosal leiomyoma location may increase the risk.

WHAT IS KNOWN ALREADY

A broad spectrum of complications after leiomyoma embolization have been described with widely varying rates. There is uncertainty over the actual risk of complications and the factors associated with this risk.

STUDY DESIGN, SIZE, DURATION

This was a prospective cohort study of 288 consecutive women undergoing leiomyoma embolization in the general gynaecology clinic of a university teaching hospital between January 2001 and December 2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Complications occurring after embolization were categorized as major or minor according to the severity of their impact on health, the level of care required and the outcome. Cumulative complication rates were estimated by survival analysis and log-rank tests according to baseline variables. Multivariable Cox proportional hazards analysis was performed to adjust for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 48 patients who experienced a complication at a median of 5 months (95% confidence interval, 4.1-11.4) after embolization. Complications were minor in 38 patients and major in 10 patients. The cumulative overall complication rate was 13% (95% CI, 9.0-17.0) at 6 months, 16% (95% CI, 11.0-20.0) at 1 year, 17% (95% CI, 12.0-22.0) at 3 years and 18% (95% CI, 12.9-22.8) at 5 years. The most frequent complication (19/48, 39.6%) was leiomyoma expulsion, which occurred spontaneously in 13 (68.4%) of these cases and required assistance in 6 (31.6%) cases. Eight (2.8%) patients underwent re-intervention, including six hysteroscopic myomectomies, one laparoscopic myomectomy and one hysteroscopic adhesiolysis, as a result of a complication. Submucosal leiomyoma location was the only baseline variable associated with an increased risk for complications [Hazard ratio (HR), 2.28, 95% CI, 1.24-4.18, P = 0.008].

LIMITATIONS, REASONS FOR CAUTION

Our population did not include women of African descent, who have been reported to be at higher risk of post-procedural complications compared with Causcasian women. If such women were involved in the study, higher morbidity rates might have been observed.

WIDER IMPLICATIONS OF THE FINDINGS

Women with submucosal leiomyomas at the time of embolization are more likely to have post-procedural complications. This is important new information for counselling patients contemplating this therapeutic approach.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare. The study was not supported by any external grant.