Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study

Objectives  To evaluate the relative cost-effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS.
Design  Cost-utility analysis.
Setting  Eighteen UK NHS hospital trusts.
Population or sample  Women who underwent UAE ( n = 649; average follow up of 8.6 years) or hysterectomy ( n = 459; average follow up of 4.6 years) for the treatments of symptomatic fibroids.
Methods  A probabilistic decision model was carried out based on data from a large comparative cohort and the literature. The two interventions were evaluated over the time horizon from the initial procedure to menopause. Extensive sensitivity analysis was carried out to test model assumptions and parameter uncertainties.
Main outcome measures  Costs of procedures and complications and quality of life expressed as quality-adjusted life years (QALYs).
Results  Overall, UAE was associated with lower mean cost (£2536 versus £3282) and a small reduction in quality of life (8.203 versus 8.241 QALYs) when compared with hysterectomy. However, when the quality of life associated with the conservation of the uterus was incorporated in the model, UAE was shown to be the dominant strategy—lower costs and greater QALYs.
Conclusions  UAE is a less expensive option to the health service compared with hysterectomy, even when the costs of repeat procedures and associated complications are factored in. The quality of life implications in the short term are also predicted to favour UAE; however, this advantage may be eroded over time as women undergo additional procedures to deal with recurrent fibroids. Given the hysterectomy is the current standard treatment for symptomatic fibroids, offering women UAE as an alternative treatment for fibroids is likely to be highly cost-effective for those women who prefer uterus-conserving treatment.     

Treatment of uterine fibroids for abnormal uterine bleeding: myomectomy and uterine artery embolization

Uterine myoma is a common benign tumour in women and most cases do not require treatment. Excessive uterine bleeding is usually due to a submucous myoma or an intramural myoma that is encroaching into the uterine cavity. After eliminating endometrial malignancy, perimenopausal women could be managed expectantly or with gonadotrophin-releasing hormone agonist until menopause. Hysteroscopic myomectomy is highly effective in controlling menorrhagia that is related to submucous myoma. Concomitant endometrial ablation improves menorrhagia; however, the subsequent hysterectomy rate remains the same. For those with an intramural myoma, abdominal myomectomy results in good bleeding control. It could also be done by laparoscopic approach; however, the surgeon should have expertise in laparoscopic suturing and the uterine incision should be properly sutured. In women who have completed their family, hysterectomy remains the most effective treatment for excessive uterine bleeding. Compared with uterine artery embolization (UAE), it is associated with better improvement in pelvic pain. Nevertheless, UAE is a good alternative to hysterectomy.     

Uterine artery embolisation for the treatment of symptomatic uterine fibroids: short-term results of work in progress

Bilateral uterine artery embolisation (UAE) was used to treat 11 women with symptomatic uterine fibroids. Uterine volume and dominant fibroid volume were assessed quantitatively by ultrasonography both before and at two and six months post procedure. Both uterine arteries were occluded effectively in all of the women, and the procedure was well tolerated, with hospital stays limited to 24-48 hours in all cases. An improvement of symptoms occurred in 10 of the 11 women. There were no significant complications. The mean percentage reductions in uterine volume and dominant fibroid volume at six months following the procedure were 45.32% and 56.34%, respectively. Bilateral uterine artery embolisation for the treatment of uterine fibroids is a minimally invasive technique with very good clinical results. This procedure may be considered as an alternative to hysterectomy, or myomectomy in properly selected cases.     

Prospective comparison of laparoscopic uterine artery occlusion plus myomectomy with classic intrafascial supracervical hysterectomy for symptomatic fibroid treatment: differences in post-operative quality-of-life measures

Objective

Prospective comparison of laparoscopic uterine artery occlusion plus myomectomy (LUAO + M) with classic intrafascial supracervical hysterectomy (CISH) for symptomatic fibroid treatment, regarding differences in post-operative quality-of-life measures.

Study design

Three hundred and thirty-two women with symptomatic fibroids who met the inclusion criteria were prospectively randomized into two treatment groups. The study group consisted of 158 women treated with LUAO + M. The control group contained 174 women treated with CISH. Quality of life was measured before surgery and at 2- and 24-month follow-up visits with the World Health Organization Quality of Life-BREF (WHOQOL-BREF), 4-domain questionnaire adapted for Chinese-speaking patients.

Results

By age, education, operation time, operative blood loss, and pre-operative WHOQOL-BREF 4-domain and overall scores, both groups were statistically equivalent, demonstrating that the randomization process worked. At 24 months, overall scores were improved for both the study group and control group patients (P < 0.01). At 2 months post-surgery, physical domain and social relationship domain scores were statistically higher in the study group than the control group patients (P < 0.01). By 24 months, the study group patients’ overall scores were statistically higher than the control group scores (P < 0.01) because of greater improvements in the physical, psychological, and social relationship domain scores. Only in the environmental domain were the study group and the control group scores statistically equivalent. At 24-month follow-up, the study group patients had a fibroid recurrence rate of only 2.53%-low by historical standards.

Conclusion

At 24-month follow-up, overall WHOQOL-BREF scores were statistically improved for the study group and control group patients. At the same statistical level, however, women in the study group had greater overall improvement than women in the control group because of higher scores in three of the four questionnaire domains. Women treated with LUAO + M have a very low fibroid recurrence rate at 24 months.     

Laparoscopic occlusion of uterine vessels for the treatment of symptomatic fibroids: Initial experience and comparison to uterine artery embolization

OBJECTIVE: Our purpose was to evaluate the effects of laparoscopic occlusion of uterine vessels in treating symptomatic fibroids and compare with embolization of the uterine arteries. STUDY DESIGN: We studied 46 premenopausal women, aged 43 (34-51) years with symptomatic uterine fibroids, undergoing radiologic embolization (n=24) and laparoscopy closure of the uterine arteries (n=22). RESULTS: The laparoscopic technique reduced picture blood assessment score after 6 months by 50% from an initial value of 345 (+/-288). Uterus volume was reduced by 37% (+/-18%), and the dominant fibroid was reduced by 36% (+/-31%). Postoperative pain and use of pain relief differed significantly, requiring more pain medication after embolization: ketobemidon 38 mg compared with 16 mg in the laparoscopic group (P=.008). Specific complications to the laparoscopic technique were temporary damage to the obturator nerve in three patients. CONCLUSION: Laparoscopic occlusion of uterine vessels is a promising new method for treating fibroid-related symptoms, with less postoperative pain than embolization and comparable effects on symptoms.     

The effects of RU 486 and leuprolide acetate on uterine artery blood flow in the fibroid uterus: A prospective,randomized study

OBJECTIVE: Our purpose was to examine the effects of RU 486 and leuprolide acetate on uterine artery blood flow and uterine volume. STUDY DESIGN: Patients were randomly assigned to group A (eight patients) receiving 25 mg of RU 486 daily for 3 months or group B (six patients) receiving 3.75 mg of leuprolide acetate monthly for 3 months. Uterine artery blood flow change was determined by resistive index by means of vaginal color Doppler ultrasonography. Uterine volume was measured before and during the study with abdominal ultrasonography. RESULTS: Both groups showed an increase in resistive index. Patients receiving RU 486 had uterine artery blood flow decreased by 40%, and those receiving leuprolide acetate had a 21% decrease. We noted a sigificant decrease in uterine volume compared with pretreatment in both groups at 3 months. There was no significant decrease between groups. CONCLUSION: Both RU 486 (25 mg daily) and leuprolide acetate (3.75 mg monthly) are effective in decreasing blood flow to the uterus (increasing resistive index) and decreasing uterine volume at 3 months. A significant decrease in uterine artery blood flow may provide a mechanism for the decrease in uterine size and the decrease in uterine blood loss at the time of surgery. (AM J Obstet Gynecol 1994;170:1623-8.)     

Efficacy of different types of treatment in FIGO stage IB2 cervical cancer in Korea: results of a multicenter retrospective Korean study (KGOG-1005)

The purpose of this study is to review FIGO stage IB2 cervical cancers in Korea for the past 10 years, and evaluate the most frequently employed and appropriate management strategy, and also assess the survival benefits of neoadjuvant chemotherapy (NAC). This is a retrospective chart review of 727 FIGO stage IB2 patients from 1995 to 2005. Six hundred ninety-two patients were enrolled, and all dates on which the patients died were double checked through the "National Registry of Death Statistics" of the Korea National Statistical Office. Management strategies were divided into five groups according to the primary treatment modality. The most frequently employed primary treatment modality for stage IB2 cervical cancer in Korea during the past 10 years was radical hysterectomy (RH). The next was NAC, followed by radiotherapy (RT) and/or extrafascial hysterectomy, concurrent chemoradiotherapy (CCRT) and/or extrafascial hysterectomy, in descending order. The surgery group showed the best results, with an 89% 5-year disease-free survival rate. However, there was no statistical difference between the surgery, NAC, and CCRT groups. For FIGO stage IB2 cervical cancer during the past 10 years in Korea, RH and adjuvant RT or CCRT was the most frequently employed treatment strategy. As a primary modality, RH, NAC, and CCRT showed similar survival rates. However, RH demonstrated the best survival rate among the above treatment strategies.