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.

The Focused Ultrasound Myoma Outcome Study (FUMOS); a retrospective cohort study on long-term outcomes of MR-HIFU therapy.

OBJECTIVES: Since 2004, uterine fibroids have been treated with MR-HIFU, but there are persevering doubts on long-term efficacy to date. In the Focused Ultrasound Myoma Outcome Study (FUMOS), we evaluated long-term outcomes after MR-HIFU therapy, primarily to assess the reintervention rate. METHODS: Data was retrospectively collected from 123 patients treated with MR-HIFU at our hospital from 2010 to 2017. Follow-up duration and baseline (MRI) characteristics were retrieved from medical records. Treatment failures, adverse events, and the nonperfused volume percentage (NPV%) were determined. Patients received a questionnaire about reinterventions, recovery time, satisfaction, and pregnancy outcomes. Restrictive treatment protocols were compared with unrestrictive (aiming for complete ablation) treatments. Subgroups were analyzed based on the achieved NPV < 50 or ≥ 50%. RESULTS: Treatment failures occurred in 12.1% and the number of adverse events was 13.7%. Implementation of an unrestrictive treatment protocol significantly (p = 0.006) increased the mean NPV% from 37.4% [24.3-53.0] to 57.4% [33.5-76.5]. At 63.5 ± 29.0 months follow-up, the overall reintervention rate was 33.3% (n = 87). All reinterventions were performed within 34 months follow-up, but within 21 months in the unrestrictive group. The reintervention rate significantly (p = 0.002) decreased from 48.8% in the restrictive group (n = 43; follow-up 87.5 ± 7.3 months) to 18.2% in the unrestrictive group (n = 44; follow-up 40.0 ± 22.1 months). The median recovery time was 2.0 [1.0-7.0] days. Treatment satisfaction rate was 72.4% and 4/11 women completed family planning after MR-HIFU. CONCLUSIONS: The unrestrictive treatment protocol significantly increased the NPV%. Unrestrictive MR-HIFU treatments led to acceptable reintervention rates comparable to other reimbursed uterine-sparing treatments, and no reinterventions were reported beyond 21 months follow-up. KEY POINTS: • All reinterventions were performed within 34 months follow-up, but in the unrestrictive treatment protocol group, no reinterventions were reported beyond 21 months follow-up. • The NPV% was negatively associated with the risk of reintervention; thus, operators should aim for complete ablation during MR-guided HIFU therapy of uterine fibroids. • Unrestrictive treatments have led to acceptable reintervention rates after MR-guided HIFU therapy compared to other reimbursed uterine-sparing treatments.

A Prospective Intervention Trial on Tailored Radiofrequency Ablation of Uterine Myomas.

Background and Objective: Investigating the use of radiofrequency myolysis (RFM) for the treatment of fibroids through less invasive access by combining transvaginal ultrasound, hysteroscopy and laparoscopy. Materials and Methods: Fifty-four premenopausal women with 106 symptomatic uterine myomas. Patients underwent RFM in three ways: Vaginal Ultrasound-guided RFM (VU-RFM), Laparoscopic RFM (L-RFM) and Hysteroscopic-RFM (H-RFM). The mean patient age was 43 years; 52 symptomatic uterine myomas were subserosal, 44 intramural and 10 submucosal. The outcomes evaluated at 1 and 12 months after RFM were myoma size (volume-diameter), "Uterine Fibroid Symptom and Quality of Life (UFS-QOL)" questionnaire and a 10-point Visual Analogue Scale (VAS). The therapy was completed with a single ablation in all patients, no complication was registered. The average number of fibroids treated per intervention was two with the use of different accesses: 64/106 VU-RFMs (60.4%), 32/106 L-RFMs (30.2%) and 10/106 H-RFMs (9.4%). Results: Volume and diameter of fibroids were significantly reduced by, respectively, 51.3% and 20.1% in the first 30 days post-intervention (p < 0.001) up to a maximum of 73.5% and 37.1% after the second follow-up visit at 12 months (p < 0.001). A similar trend was shown in terms of disability with a progressive and significant reduction of symptoms (menorrhagia, dysmenorrhea, dyspareunia and pollakiuria) demonstrated by percentage variation of UFS-QOL Symptom Severity and VAS scores to -74.3% and -45.3% as well as -84.9% and -74.3%, respectively, at 1 and 12 months after RFM (p < 0.001). An overall improvement in the quality of life was also demonstrated by a significant increase in the UFS-QOL total score of +38.2% in the first 30 days post-intervention up to +44.9% after the second follow-up visit at 12 months (p < 0.001). The overall average surgery time of the RFM for each patient was 48 minutes, and the time to treat each fibroid by Vaginal Ultrasound-guided RFM (23 min) was found to be significantly less than those of laparoscopy or hysteroscopy (respectively 35 and 34 min) (p < 0.05). An electromagnetic virtual needle tracking system (VNTS) was successfully tested during the RFM procedures, and real-time contrast-enhanced ultrasound (CEUS) has proven to be effective in determining the duration of myolysis through the identification of eventual residual areas of enhancement within the fibroids. Conclusion: Radiofrequency can be considered a minimally invasive and safe procedure for the treatment of uterine myomas through the customization and possible combination of transvaginal, laparoscopic or hysteroscopic accesses. The standardization of the ablation technique with pre-intervention biopsy and new technologies such as VNTS and CEUS spares healthy uterine tissue and may change the future management of symptomatic uterine fibroids.

Pregnancy after uterine artery embolization using Gelfoam™.

We present a case study of a patient who underwent uterine artery embolization (UAE) using Gelfoam™ (Pfizer, New York, NY, USA) and had a subsequent pregnancy. Our patient, a 38-year-old female (4 Gravida/2 Para), underwent UAE for treatment of symptomatic myoma in September 2005. At the patient's seven-month post procedure visit, she experienced a 43.9% volume reduction in uterine size and 74.5% reduction in volume of the largest fibroid and relief of bulk symptoms and menorrhagia. The patient had a term delivery of healthy twin infants 15 months post embolization.

[LAPAROSCOPIC MYOMECTOMY AFTER ULIPRISTAL ACFTATF TRFATMFMT.]

Uterine myoma is the most common benign uterine tumor in women of reproductive age and occurs in 20-25 % of the worldwide population. Heavy menstrual bleeding, pelvic pressure and pain and reproductive disfunction are common symptoms that impair women's health and quality of live. No currently approved medical treatment is able to completely eliminate fibroids. Until recently, gonadotropin-releasing hormone agonist were the only available drugs for preoperative treatment of fibroids. Since February 2012, ulipristal acetate (UPA) is also approved in Europe for preoperative fibroid treatment. One-third from them need adjuvant surgical treatment.

Combined myomectomy and uterine artery embolization.

UNLABELLED: Objective: To evaluate the safety and efficacy of uterine artery embolization combined with endoscopic myomectomy. MATERIAL AND METHODS: We conducted a retrospective chart review of patients (n = 125) who underwent myomectomy concurrent with embolization within one month. We assessed two groups: 1) uterine artery embolization followed by hysteroscopic myomectomy and 2) uterine artery embolization followed by laparoscopic myomectomy. RESULTS: Following the combination procedures, 72% of the surveyed women reported symptom improvement. With the combined procedures, 92.5% of patients experienced reduction in myoma diameter and 87.5% of patients had decreased uterine size after an average of 4.70 months post subsequent procedure. The amount of decrease in the uterine volume (p = 0.39) and fibroid size (p = 0.23) were not significant between the two endoscopic myomectomy groups. CONCLUSIONS: Combining myomectomy with uterine artery embolization is a safe and effective procedure in treating symptoms and reducing myoma and uterine volumes.

Is uterine artery embolization for patients with large myomas safe and effective? A retrospective comparative study in 323 patients.

PURPOSE: To evaluate the effectiveness, safety, and complications of uterine artery embolization (UAE) in women with large fibroid tumors. MATERIALS AND METHODS: From January 2005 to February 2011, 323 patients underwent UAE for symptomatic uterine leiomyomas without adenomyosis and were included in this study. Patients were divided into two groups: those with a large tumor burden (group 1; n = 63), defined as a dominant tumor with a longest axis of at least 10 cm or a uterine volume of at least 700 cm(3); and the control group (group 2; n = 260). Tumor infarction and volume reduction were calculated based on magnetic resonance imaging findings. Symptom status was assessed with a visual analog scale. Postprocedure complications and repeat interventions were recorded. The data were analyzed with appropriate statistical tests. RESULTS: No significant differences were seen between the two groups in volume reduction of dominant tumors (46.5% in group 1 vs 52.0% in group 2; P = .082) or percentage volume reduction of the uterus (40.7% in group 1 vs 36.3% in group 2; P = .114). Also, no significant differences were seen between the two groups regarding satisfaction scores at immediate or midterm follow-up (P = .524 and P = .497) or in the presence of procedure-related complications (P = .193). CONCLUSIONS: UAE outcomes in large fibroid tumors were comparable to those in smaller tumors, without an increased risk of significant complications. Tumor size may not be a key factor in predicting successful outcomes of UAE.

Myoma expulsion after embolization: case report and literature review.

Uterine artery embolization (UAE) is a very efficient treatment modality for myoma. A rare complication of this procedure is vaginal expulsion of the uterine myoma (expelled myoma) which may occur in 3 to 5% of cases during a period of 3 to 48 months. We report a case of myoma expulsion after embolization, discussing diagnosis and treatment. A literature review was also conducted. A 40-year-old patient sought medical care on 5/2/2021 with intermittent pelvic pain and hypermenorrhagia. Vaginal ultrasound revealed an enlarged uterus (253 cm3) with myomas. The largest intramural myoma measured 7 cm. Uterine artery embolization was performed on 11/11/2021, without any complications. On 12/7/2021, during clinical examination an expelled myoma was observed entirely inside the vaginal canal. A vaginal myomectomy was performed, without any complications. At 15 months after the initial follow-up, the patient is doing well.

[Female with severe multiorgan damage and algetic myoma utery].

Painfull myoma utery in a patient with poor health condition and many disfunctional organs: Diabetes mellitus, Chronic renal insufficiency Gr. III (most probably a result of compression of the ureters causing bilateral hydronephrosis), arterial hypertony, anemia. The authors introduce their therapeutic model and manage to perform successfull operation after stabilizing the patient and intensive postoperative care. They point out the team work and good synchronization between the hospital divisions as crucial for the success of the treatment.

[Obstetric and gynecologic embolizations]. / Obstetriset ja gynekologiset embolisaatiot: synnytyksenjälkeisen verenvuodon tukkimisesta myoomaembolisaatioon.

Postpartum embolization to decrease the maternal mortality rate and postpartum hysterectomies. An interventional radiologist performs the embolization at the obstetrician's request, when conventional means have failed to stop the bleeding. This will efficiently stop the bleeding. Fertility appears to remain normal after embolization. Embolization of uterine arteries is also utilized for the treatment of symptomatic myomas in patients, who do not wish to become pregnant. After the embolization the myomas will gradually shrink within months. The procedure has been found to be safe.

Uterine myoma: a condition amenable to medical therapy?

BACKGROUND: Uterine myomas are the most common benign tumors of the female reproductive tract. Of the different treatment methods available, medical therapy may be a less invasive choice. OBJECTIVE: To review the literature on medical treatments that are available or being developed for women with uterine myomas. METHODS: Literature review of articles pertaining to medical therapeutic strategies of uterine myomas. (Articles were searched by means of a computerized PubMed and Cochrane Library search with the following keywords: uterine myomas, leiomyomata, fibroids, and medical treatment.) RESULTS/CONCLUSION: At present, many drugs are available in routine clinical practice, some of which are under investigation. This review will explore the recent advances in medical treatment for the management of uterine myomas.

[Assessment of different homeostatic methods used in laparoscopic intramural myomectomy].

OBJECTIVE: To explore the safe and effective method of hemostasis in laparoscopic hysteromyomectomy (LM). METHODS: Two hundred and eighty women with symptomatic uterine intramural fibroids undergoing LM were assigned to 4 groups, Group A undergoing fibroid pedicle ligation, Group B injected with 12 IU diluted vasopressin around the myoma, Group C injected with 20 IU oxytocin combined with pedicle ligation, and Group D injected with vasopressin combined with pedicle ligation. The operation time, amount of blood loss, operative complications, bowel deflation, post-operative hemoglobin dropping, and length of hospital stay were compared. RESULTS: The amounts of blood loss of Groups A and C were (171 +/- 146) ml and (184 +/- 140) ml, both significantly higher than those of Groups B and D [(115 +/- 70) ml and (106 +/- 73) ml, both P < 0.01]. The length of hospital stay of Group D was (2.9 +/- 0.5) d, significantly shorter than those of Groups A, B, and C [(3.1 +/- 0.7) d, (3.6 +/- 0.8) d, and (3.3 +/- 0.7) d, all P < 0.05]. The bowel deflation time of Group D was (20 +/- 6) h, significantly shorter than those of the Groups A, B, and C [(26 +/-) h, (25 +/- 7) h, and (25 +/- 8) h respectively, all P < 0.05]. The post-operative hemoglobin dropping of group D was (1.1 +/- 0.9) g/L, significantly less than those of Groups A, B, and C [(1.5 +/- 1.0), (1.4 +/- 0.8), and (1.2 +/- 0.7) g/L respectively, all P < 0.05]. CONCLUSIONS: Vasopressin (12 IU) injection around the myoma is a simple, effective, and safe homeostatic procedure during LM. Pedicle ligation can reduce advanced post-operative bleeding post-operation.

Health Education Using Telephone and WeChat in Treatment of Symptomatic Uterine Myoma with High-Intensity Focused Ultrasound.

BACKGROUND Adopting modern communication methods in traditional healthcare services is a trend of modern medicine. In this study we explored the value of telephone and WeChat in health education on uterine myoma by high-intensity focused ultrasound (HIFU). MATERIAL AND METHODS A total number of 426 patients diagnosed with symptomatic uterine myoma from April 2017 to September 2017 were selected and randomly divided into a routine preoperative education group (175 patients) and a telephone/WeChat preoperative health education group (251 patients). The patients in the routine preoperative education group received routine preoperative education, whereas those in the telephone/WeChat preoperative health education group received telephone/WeChat preoperative health education. Patients were evaluated before and after treatment. RESULTS Compared with the routine preoperative education group, the patients in telephone/WeChat preoperative health education group had less preoperative and postoperative anxiety, less postoperative pain, and higher treatment satisfaction (P<0.05). CONCLUSIONS Health education using telephone and WeChat preoperatively can reduce preoperative and postoperative anxiety, postoperative pain, and early postoperative inflammatory response in patients with uterine myoma, and can improve treatment satisfaction.

Treatment patterns for women with new episodes of uterine myomas in an insured population in the US.

INTRODUCTION: Uterine myomas are the most common benign tumors in reproductive-aged women and a leading reason for gynecologist visits and hysterectomies in the United States. This study examines the treatment patterns of insured women with new episodes of uterine myomas. MATERIALS AND METHODS: We used administrative claims from a proprietary research database to evaluate services (inpatient, outpatient, and prescription claims) incurred from January 1, 2001 to December 31, 2003. We identified women with CPT or ICD-9-CM codes suggestive of myoma and described treatment patterns for all women with a new episode of myoma and those with abnormal bleeding. RESULTS: The primary study group included 35 329 women with new episodes of care and at least three months of data before and after their index date for myoma. Most women (82.9%) had no code for diagnostic testing in the three months before or after the first myoma marker. Of 14 434 women with one year of follow-up, 26.1% had surgery and 24.7% were treated pharmacologically (oral contraceptives, progestins, or gonadotropin-releasing hormone agonists). Over half (55.1%) of women were untreated, including 45% of those with an ICD-9 code that indicated abnormal bleeding. CONCLUSIONS: Women with new myoma episodes rarely had codes for confirmatory diagnostic tests. Many women with myomas go untreated for at least a year. This is true even for those with evidence of abnormal bleeding. Myoma care may be improved through the introduction of new, safe, and effective therapies.

Use of a levonorgestrel-releasing intrauterine device for the symptomatic treatment of uterine myomas.

OBJECTIVE: To assess the effect of a levonorgestrel-releasing intrauterine device (LNG-IUD) for the treatment of women with uterine myomas with increased bleeding by measuring total uterine volume and by determining patient clinical improvement, uterine artery flow velocity and hemoglobin levels. STUDY DESIGN: Ten patients with a complaint of increased uterine bleeding associated with the presence of uterine myomas were assessed in a descriptive case series and studied before and 6 months after placement of an LNG-IUD. The patients were assessed for intensity of bleeding, uterine volume, Doppler velocimetry of the uterine arteries, hematocrit and hemoglobin. RESULTS: One patient asked to be released from the study 15 days after LNG-IUD insertion, claiming the occurrence of increased bleeding, and 2 patients underwent spontaneous expulsion of the device after 2 and 4 months of follow-up. Of the 7 patients who continued the study, 3 started to present a bleeding pattern of the oligomenorrhea type, and the other 4 experienced amenorrhea. All patients (n = 6) with anemia at the beginning of the study presented normalization of hematocrit and hemoglobin levels after 6 months of treatment (p=0.0003 and p <0.0001, respectively). However, we observed no reduction in uterine volume (p = 0.11) or flow velocity assessed by the uterine artery pulsatility index (right, p=0.17; left, p=0.19) and of the series resistance index (right, p = 0.54; left, p =0.31) using Doppler velocimetry. CONCLUSION: Use of an LNG-IUD may be effective in controlling uterine bleeding secondary to myomatosis even in the absence of reduction of uterine volume.

Pregnancy after embolization of uterine myoma: report of 12 cases.

OBJECTIVE: To treat uterine myomas with embolization, to look for pregnancy-induced myoma recurrences, and to assess pregnancy course and outcome after embolization. DESIGN: Observational clinical study. SETTING: University of Paris VII hospital. PATIENT(S): Nine women had embolization for symptomatic myoma, with 12 pregnancies observed. INTERVENTION(S): Embolizations were highly selective and performed bilaterally through the uterine arteries with polyvinyl alcohol. MAIN OUTCOME MEASURE(S): Pregnant women were evaluated by physical and sonographic examinations. RESULT(S): Before embolization, the mean uterine volume was 450 cm(3), and in six patients polymyomas were present. The median age at embolization was 40 years; the median delay before pregnancy was 9 months; and the median age at first pregnancy outcome was 41 years. Five early miscarriages occurred. The seven other pregnancies were uneventful, although three premature births and one case of late toxemia occurred unrelated to previous embolization. Three women delivered vaginally and four by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed. CONCLUSION(S): The results of this first series of 12 pregnancies after myoma embolization are promising. If these preliminary results are confirmed, embolization could be a major breakthrough in the management of myoma and could replace conventional medical and surgical treatments.

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.

Medico-economic approach to the management of uterine myomas: a 6-month cost-effectiveness study of pelvic embolization versus vaginal hysterectomy.

INTRODUCTION: Uterine artery embolization is a technique that has been recently proposed for the management of uterine myomas an alternative to vaginal hysterectomy. The results provided by the first published studies demonstrate a significant decrease in symptoms in 70-95% of cases. The aim of our study was to compare the cost-effectiveness ratios for pelvic embolization and vaginal hysterectomy looked at from the hospital point of view. MATERIALS AND METHODS: Two populations of patients were randomly selected from women undergoing pelvic embolization or vaginal hysterectomy. We retrospectively measured the cost at 6 months of the two types of procedure (costs of hospitalization, drugs, and complementary examinations) as well as the success of each of them at 6 months. The cost of the techniques themselves were measured prospectively on the basis of four procedures. RESULTS: The cost-effectiveness ratios were 2320 Euros per success (mean cost 2134 Euros per effectiveness 92%) for embolization and 2789 Euros per success (mean cost 2789 Euros per effectiveness 100%) for hysterectomy. DISCUSSION: Pelvic embolization is more cost-effective than vaginal hysterectomy. The integration of the notion of quality of life with the notion of cost should permit a future study to reinforce interest in performing pelvic embolizations in the management of uterine myomas.