Long-term follow up after uterine artery embolization for symptomatic uterine leiomyomas

Uterine artery embolization is one of the established treatment options for symptomatic uterine leiomyomas, with a proven effect on the size of leiomyomas and providing short-term relief of symptoms. Only few studies have addressed long-term satisfaction with the treatment. We conducted a historical cohort study of 96 patients. The patients were treated at a median age of 43years (range 23-59years). The median size of the largest myoma was 69mm (range 20-170mm). By use of a postal questionnaire (response rate 86%) and audit of patient files, we found that 53% reported full recovery of symptoms and 36% some effect on symptoms after a median of 8.9years (range 8-9.4years). Overall, 25% of the women reported a need for further treatment. The rate of eventual hysterectomy was 22%. We confirm that uterine artery embolization is a safe and well-tolerated procedure with a high long-term satisfaction rate.     

Laparoscopic uterine artery occlusion for symptomatic leiomyomas

STUDY OBJECTIVE: To describe a laparoscopic technique that safely occludes both uterine arteries, overcoming an altered surgical field resulting from scarring and/or uterine leiomyomatous growth. DESIGN: Prospective analysis (Canadian Task Force classification II-2). SETTING: Nonprofit community hospital. PATIENTS: Eight women with leiomyomas with abnormal uterine bleeding, pelvic pain or pressure, and/or anemia. INTERVENTION: Bilateral laparoscopic retroperitoneal uterine artery occlusion. MEASUREMENTS AND MAIN RESULTS: Occlusion at the initial track of the uterine artery was performed by laparoscopic coated ligature in six patients. In two obese patients with deep retroperitoneal space, vascular clips were placed endoscopically using the same dissecting technique. All patients were discharged within 20 hours after the procedure. All five women with abnormal bleeding reported satisfactory decrease; none reported amenorrhea. Of eight with preoperative pain or pressure, seven reported complete disappearance and one significant relief. All three patients with anemia had normal red cell counts after 1 month. CONCLUSION: Laparoscopic uterine artery occlusion using a lateral retroperitoneal technique is safe and effective in women with pelvic scarring and altered pelvic anatomy.     

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE: To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas. DESIGN: Medline literature review, cross-reference of published data, and review of selected meeting abstracts. RESULT(S): Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas. CONCLUSION(S): Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.     

Pathologic features of uterine leiomyomas following uterine artery embolization.

Bilateral uterine artery embolization has recently been employed as an alternative to operational treatment of uterine leiomyomas. The pathologic features induced by uterine artery embolization have not been previously described in detail. Usually patients experience symptomatic improvement with a reduction in size of the leiomyomas. This report describes the pathologic features in a series of 10 uterine leiomyomas where tissue was available for histologic examination following uterine artery embolization. Characteristic histologic features within the leiomyomas included massive necrosis, sometimes with dystrophic calcification, vascular thrombosis, and intravascular foreign material that elicited a histiocytic and foreign-body giant cell reaction. In some cases, intravascular foreign material was present elsewhere in the myometrium, the cervix, or paraovarian region. In occasional cases, there were foci of myometrial necrosis and microabscess formation beyond the confines of the leiomyomas. Foci of extrauterine inflammation were also occasionally identified. Histopathologists should be aware of these findings because the use of uterine artery embolization will possibly become more widespread in the future.     

Uterine artery embolization for symptomatic uterine leiomyoma and adenomyosis.

BACKGROUND AND PURPOSE: Uterine artery embolization (UAE) is increasingly accepted as an alternative treatment for symptomatic uterine leiomyoma and adenomyosis. The purpose of this study was to compare the outcomes of UAE in 3 diagnostic categories--submucosal leiomyoma, intramural leiomyoma, and adenomyosis--to assist in patient selection for this relative new form of therapy. METHODS: The medical records of 43 patients (aged 22 to 54 years) who underwent UAE for symptomatic uterine leiomyoma or adenomyosis were retrospectively reviewed. Magnetic resonance imaging (MRI) was used for categorization of the patients into the 3 diagnostic categories, and also for objective measurement of the uterine and leiomyoma size, and subsequent imaging follow-up. UAE was performed using polyvinyl alcohol particles. Symptom improvement and complications after treatment were evaluated at gynecologist clinics using monthly questionnaires. The group differences in complete symptom resolution, uterine and leiomyoma size reduction, incidence of complications, and subsequent surgeries were analyzed. RESULTS: The mean duration of follow-up was 10.9 months. Complete resolution of symptoms was achieved in 13 out of 16 patients with submucosal leiomyoma (81%), 3 out of 15 patients (20%) with intramural leiomyoma (p = 0.002) and 3 out of 12 patients (25%) with adenomyosis (p = 0.01). The average reduction of leiomyoma size in the submucosal and intramural groups was 56% and 29%, respectively (p = 0.02). None of the patients died. Severe complications occurred in 3 of 43 patients (7%), including permanent amenorrhea in 2 and pelvic actinomycosis in 1 patient. The incidence of complications (p = 0.17) and subsequent surgery (p = 0.67) did not differ significantly among the 3 groups. CONCLUSIONS: UAE is an effective treatment for patients with symptomatic leiomyoma or adenomyosis. In this study, patients with submucosal leiomyoma had the best treatment outcome.     

Treatment of leiomyomas with uterine artery embolization. Review of literature

Embolization of the uterine artery represents a widely accepted invasive method for treatment of fibroids. It is indicated for women in perimenopause with symptomatic leiomyomas who do not require preservation of their fertility functions. The method should be used with caution excluding infectious diseases and malignancies. A experienced interventional radiologist is needed for the completion of the method. Complications are infrequent with rate reaching almost 5%. Few knowledge exists about pregnancy outcomes after uterine artery embolization. For this reason it should be used with caution in young women with symptomatic leiomyomas willing to conceive.     

GnRH analogs for the treatment of symptomatic uterine leiomyomas

Uterine leiomyomas are the most frequent benign disease of the female reproductive tract. To date, the standard treatment of uterine leiomyomas is laparotomic/laparoscopic excision in women who want to preserve their fertility, whereas the use of a more extensive surgery, such as hysterectomy, is reserved for disseminated uterine leiomyomatosis, usually in the perimenopausal period. Given the pathogenesis of uterine leiomyomas, it is clear that future treatments for leiomyomas may be medical. At present the only clinically relevant medical treatment of uterine leiomyoma is GnRH agonist administration in depot formulations. In this review, the use of GnRH agonists, with or without add-back therapy, and antagonists will be assessed.     

Squamous metaplasia of endometrium after uterine artery embolization for symptomatic leiomyomata

Uterine artery embolization (UAE) is frequently performed for symptomatic leiomyomata. There have been no reports of squamous metaplasia of endometrium after such a procedure. Squamous metaplasia of endometrium is often associated with endometrial hyperplasia and carcinoma. In our patient the disorder was diagnosed after UAE. This is the second such case we have encountered. In view of the association of squamous metaplasia with endometrial hyperplasia and carcinoma, a history of recent UAE must be considered in evaluating a patient with this finding, particularly on a biopsy specimen.     

Diagnostic imaging and vascular embolization for uterine leiomyomas

This review article explains the relatively new therapy method of vascular embolization for leiomyomas of the uterus. The current concepts of diagnostic imaging of uterine leiomyomas with emphasis on preembolization imaging and postembolization follow-up are presented.     

Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids

OBJECTIVE: To report a case of permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids. DESIGN: Case report. SETTING: Gynecologic clinic of a university hospital. PATIENT(S): A 44-year-old woman with menorrhagia and anemia caused by multiple fibroids. INTERVENTION(S): Transcatheter bilateral uterine artery embolization with polyvinyl alcohol particles, with hormonal, sonographic, and hysteroscopic follow-up procedures. MAIN OUTCOME MEASURE(S): Serum follicle-stimulating hormone (FSH) and estradiol levels were measured, and sonographic appearance of the ovaries and the endometrium at baseline and 1, 3, 6, and 12 months after treatment were recorded. Hysteroscopy was performed with endometrial biopsy at baseline and 6 months after embolization. RESULT(S): The patient remained amenorrheic from the procedure. Serial posttreatment measurements of FSH and estradiol levels and repeated ovarian imaging showed no change in ovarian function as compared with baseline. A reduction in endometrial thickness (相似文献   

Uterine artery embolization versus laparoscopic occlusion of uterine vessels for management of symptomatic uterine fibroids

Objective

To evaluate the efficacy and complications of uterine artery embolization (UAE) versus laparoscopic occlusion of uterine vessels (LOUV) in the management of symptomatic fibroids.

Methods

A pilot randomized clinical trial in which 20 patients with symptomatic fibroids were randomly allocated into two groups. Ten women underwent UAE, and 10 women underwent LOUV. Symptomatic improvement in menorrhagia and reduction in the volumes of the uterus and the fibroid were assessed at 3 and 6 months.

Results

The patients were comparable with regard to age and parity. At 6 months, there was no significant difference in the mean reduction in menstrual blood loss, uterine volume, and volume of the dominant fibroid between the two groups (P = 0.436, P = 0.796, P = 1.00, respectively). However, higher pain scores were recorded on day 1 in the UAE group compared with the LOUV group (P = 0.0002).

Conclusions

The effects of UAE and LOUV in the management of symptomatic fibroids are comparable. The main advantage of LOUV is less postoperative pain compared with UAE.     

Uterine artery embolization versus occlusion for uterine leiomyomas: a pilot randomized clinical trial

STUDY OBJECTIVE: To compare perioperative pain and institutional use for women undergoing transcatheter uterine artery embolization (UAE) and transcatheter uterine artery occlusion (UAO) for the treatment of heavy uterine bleeding associated with uterine leiomyomas. DESIGN: A pilot double-blind, randomized clinical trial (Canadian Task Force classification I). SETTING: Large, university-affiliated community hospital with multiple residency programs including obstetrics and gynecolgoy and radiology. PATIENTS: Premenopausal women with heavy uterine bleeding related to uterine leiomyomas were enrolled. INTERVENTIONS: Either a standard UAE with microspheres or UAO using vascular coils was used. The main outcome measures were analgesic use, institutional stay, and postprocedural numeric pain scales. MEASUREMENTS AND MAIN RESULTS: Sixteen women were enrolled and 14 underwent study procedures (UAE n = 8, UAO n = 6). Baseline Aberdeen Menorrhagia Severity Scale scores, also known as the Ruta scores, were similar in each group (UAE = 54, UAO = 53). Median preprocedural uterine volume was similar for each group (UAE = 557 mL, UAO = 612 mL). The median postprocedural pain scale was less for UAO than UAE (UAO 1, UAE 5; p <.05). Six patients with UAE and no patients with UAO required parenteral narcotic analgesia in the recovery room (p <.05) (median UAO 0 and UAE 1). Patients with UAE used 6 hospital nights and patients with UAO used 1 hospital night (p =.09) (median UAO 0 and UAE 1). Three-month Aberdeen Menorrhagia Severity Scale scores were reduced to a similar degree in each group (UAE = 58%, UAO = 63%). CONCLUSION: Transcatheter UAO is a promising alternative transcatheter technique for the treatment of symptoms related to uterine leiomyomas, with less postprocedural pain, reduced requirements for analgesics, and shorter hospital stays than transcatheter UAE. Although the results of the study are promising, larger-scale trials with longer follow-up are needed to both confirm these results and evaluate the long-term efficacy of transcatheter UAO.     

Comparative outcomes of hysteroscopic examinations performed after uterine artery embolization or laparoscopic uterine artery occlusion to treat leiomyomas

Hysteroscopic examination of the uterine cavity revealed that patients previously treated for intramural myoma(s) by uterine artery embolization had a significantly higher incidence of abnormal findings compared with patients treated by laparoscopic occlusion of uterine arteries (59.5% vs. 2.7%). In particular, there was a higher incidence of necrosis in the uterine cavity of patients subjected to uterine artery embolization (43.2%) compared with patients after surgical uterine artery occlusion (2.7%).     

Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri.

STUDY OBJECTIVE: To analyze initial experience with uterine artery embolization for treatment of symptomatic leiomyomata. DESIGN: Prospective, longitudinal study (Canadian Task Force classification II-2). SETTING: Private practice, university-affiliated hospital. PATIENTS: Three hundred five women (age 26-52 yrs). INTERVENTIONS: Uterine artery embolization, performed over 2 years by a single radiologist working in collaboration with a single gynecology practice. MEASUREMENTS AND MAIN RESULTS: Embolization was technically successful in 96% of patients. No major complications occurred. Average reduction in uterine volume was 48%. Control of menorrhagia was reported by 86% of patients at 3 months, 85% at 6 months, and 92% at 12 months after the procedure. Bulk symptoms were satisfactorily controlled in 64% of patients at 3 months, 77% at 6 months, and 92% at 12 months. Six women subsequently underwent hysterectomy and five had myomectomy. CONCLUSION: Uterine artery embolization appears to be a highly effective treatment for symptomatic uterine leiomyomata. Its impact on fertility and pregnancy remain to be investigated fully. (J Am Assoc Gynecol Laparosc 6(3):279-284, 1999)     

Women's decision-making determinants in choosing uterine artery embolization for symptomatic fibroids.

OBJECTIVE: To determine what symptoms of leiomyomata uteri prompted women to seek uterine artery embolization (UAE) and what factors were most frequently cited in the decision making leading to choosing UAE over other treatments. STUDY DESIGN: Eighty-four consecutive women with symptomatic leiomyoma presenting for UAE completed a questionnaire that inquired about their pelvic symptoms and the issues that were important in their decision to request UAE. All subjects previously had been told that they were surgical candidates. RESULTS: Pelvic symptoms that the 84 women most frequently noted were bleeding (n = 61), anemia (41), pelvic pain (29), frequent urination (24) and pelvic pressure (21). The majority of women (78) reported significant worry about their health from the fibroids, and (72) reported that the symptoms caused daily discomfort. Although the majority of women wanted a treatment that would give permanent relief of symptoms and thought UAE would do this, other factors frequently cited in the decision making included quality-of-life reasons, such as the desire to avoid adverse effects of other treatments (76), anticipated prolonged postoperative recovery from surgery (70) and avoiding surgery (66). Many women considered the uterus an important female organ, believed that the uterus was a source of femininity (33), stated that the uterus was necessary to maintain self-image (49) and reported that the uterus was necessary to maintain sexual image (49). CONCLUSION: In this cohort of women with symptomatic leiomyomas, treatment preferences did not interfere with the current lifestyle. In addition, the uterus was considered a source of femininity and sexuality. It is not clear whether women requesting UAE differ from women requesting surgical intervention in terms of how they assess the importance of the uterus, but these data suggest that many women still consider the uterus an important aspect of their femininity and that those seeking nonsurgical options should be thoroughly counseled about uterine function and how it relates to sexuality.     

Current indications for uterine artery embolization to treat postpartum hemorrhage

Uterine artery embolization is an interventional radiology technique successfully used for more than 30 years in the management of gynecological or obstetrical hemorrhage. Precise indications for uterine artery embolization to treat postpartum hemorrhage have been recently published. Uterine artery embolization is indicated in case of uterine atony despite medical treatment particularly after vaginal delivery, in case of vaginal thrombus or cervical tear after failed surgical repair. Embolization can also be discussed in case of persistent hemorrhage after arterial ligation or hysterectomy. Finally, arterial embolization can be attempted in case of placenta accreta to avoid hysterectomy. In all situations, pluridisciplinary management of patients with involvement of interventional radiologists, anesthesiologists and obstetricians is mandatory. Early transportation of patients for embolization should be discussed taking into consideration time of onset of hemorrhage, expected transfer time and treatment options available on site. For validated indications, success rates of arterial embolization as high as 80% can be expected in experienced hands.