[Septic sacroiliitis: early diagnosis due to specific physical examination]. / Septische sacroiliitis.

BACKGROUND: Septic sacroiliitis is an uncommon disease which represents approximately 1-4% of all joint infections, therefore it is difficult to make the right diagnosis and to start early treatment. CASE REPORT: A 18 year old woman was admitted to the emergency room with a fever and pain in the left gluteal region. The patient was considered healthy and had no risk factors for septic arthritis. Edema and a small abscess was found in and around the left sacroiliac joint on pelvic MRI. The patient had positive blood cultures with Staphylococcus Aureus. Antibiotic treatment was initiated and lasted 7 weeks. She recovered completely and had no remaining complaints. CONCLUSION: Physical exam and clinical suspicion are important to consider the diagnosis of septic sacroiliitis. In addition a MRI of the pelvic is the best radiographic exam to conform the diagnosis.

Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial.

BACKGROUND: Since 1995 uterine artery embolization has been described as an alternative for hysterectomy in patients with symptomatic fibroids. Many studies including several randomized controlled trials established uterine artery embolization as a valuable treatment. These randomized controlled trials reported outcomes in terms of health-related quality of life, clinical outcomes, efficacy, and cost-effectiveness after 1, 2, and 5 years of follow-up. OBJECTIVE: The purpose of this study was to compare clinical outcome and health-related quality of life 10 years after uterine artery embolization or hysterectomy in the treatment of heavy menstrual bleeding caused by uterine fibroids in a randomized controlled trial. STUDY DESIGN: In all, 28 Dutch hospitals recruited patients with symptomatic uterine fibroids who were eligible for hysterectomy. Patients were 1:1 randomly assigned to uterine artery embolization or hysterectomy. The outcomes assessed at 10 years postintervention were reintervention rates, health-related quality of life, and patient satisfaction, which were obtained through validated questionnaires. Study outcomes were analyzed according to original treatment assignment (intention to treat). RESULTS: A total of 177 patients were randomized from 2002 through 2004. Eventually 81 uterine artery embolization and 75 hysterectomy patients underwent the allocated treatment shortly after randomization. The remaining patients withdrew from the trial. The 10-year questionnaire was mailed when the last included patient had been treated 10 years earlier. The mean duration of follow-up was 133 months (SD 8.58) accompanied by a mean age of 57 years (SD 4.53). Questionnaires were received from 131 of 156 patients (84%). Ten years after treatment, 5 patients underwent secondary hysterectomy resulting in a total of 28 of 81 (35%) (24/77 [31%] after successful uterine artery embolization). Secondary hysterectomies were performed for persisting symptoms in all cases but 1 (for prolapse). After the initial treatment health-related quality of life improved significantly. After 10 years, generic health-related quality of life remained stable, without differences between both groups. The urogenital distress inventory and the defecation distress inventory showed a decrease in both groups, probably related to increasing age, without significant differences between study arms. Satisfaction in both groups remained comparable. The majority of patients declared being (very) satisfied about the received treatment: 78% of the uterine artery embolization group vs 87% in the hysterectomy group. CONCLUSION: In about two thirds of uterine artery embolization-treated patients with symptomatic uterine fibroids a hysterectomy can be avoided. Health-related quality of life 10 years after uterine artery embolization or hysterectomy remained comparably stable. Uterine artery embolization is a well-documented and less invasive alternative to hysterectomy for symptomatic uterine fibroids on which eligible patients should be counseled.

Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial.

OBJECTIVE: The purpose of this study was to compare clinical outcome and health related quality of life (HRQOL) 5 years after uterine artery embolization (UAE) or hysterectomy in the treatment of menorrhagia caused by uterine fibroids. STUDY DESIGN: Patients with symptomatic uterine fibroids who were eligible for hysterectomy were assigned randomly 1:1 to hysterectomy or UAE. Endpoints after 5 years were reintervention rates, menorrhagia, and HRQOL measures that were assessed by validated questionnaires. RESULTS: Patients were assigned randomly to UAE (n = 88) or hysterectomy (n = 89). Five years after treatment 23 of 81 UAE patients (28.4%) had undergone a hysterectomy because of insufficient improvement of complaints (24.7% after successful UAE). HRQOL measures improved significantly and remained stable until the 5-year follow-up evaluation, with no differences between the groups. UAE had a positive effect both on urinary and defecation function. CONCLUSION: UAE is a well-established alternative to hysterectomy about which patients should be counseled.

Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial.

PURPOSE: To investigate whether uterine artery embolization (UAE) is a cost-effective alternative to hysterectomy for patients with symptomatic uterine fibroids, the authors performed an economic evaluation alongside the multicenter randomized EMMY (EMbolization versus hysterectoMY) trial. MATERIALS AND METHODS: Between February 2002 and February 2004, 177 patients were randomized to undergo UAE (n = 88) or hysterectomy (n = 89) and followed up until 24 months after initial treatment allocation. Conditional on the equivalence of clinical outcome, a cost minimization analysis was performed according to the intention to treat principle. Costs included health care costs inside and outside the hospital as well as costs related to absence from work (societal perspective). Cumulative standardized costs were estimated as volumes multiplied with prices. The nonparametric bootstrap method was used to quantify differences in mean (95% confidence interval [CI]) costs between the strategies. RESULTS: In total, 81 patients underwent UAE and 75 underwent hysterectomy. In the UAE group, 19 patients (23%) underwent secondary hysterectomies. The mean total costs per patient in the UAE group were significantly lower than those in the hysterectomy group ($11,626 vs $18,563; mean difference, -$6,936 [-37%], 95% CI: -$9,548, $4,281). The direct medical in-hospital costs were significantly lower in the UAE group: $6,688 vs $8,313 (mean difference, -$1,624 [-20%], 95% CI: -$2,605, -$586). Direct medical out-of-hospital and direct nonmedical costs were low in both groups (mean cost difference, $156 in favor of hysterectomy). The costs related to absence from work differed significantly between the treatment strategies in favor of UAE (mean difference, -$5,453; 95% CI: -$7,718, -$3,107). The costs of absence from work accounted for 79% of the difference in total costs. CONCLUSIONS: The 24-month cumulative cost of UAE is lower than that of hysterectomy. From a societal economic perspective, UAE is the superior treatment strategy in women with symptomatic uterine fibroids.

Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) Trial.

PURPOSE: To prospectively evaluate health-related quality of life (HRQOL) outcomes for uterine artery embolization (UAE) and hysterectomy up to 24 months after the intervention in terms of mental and physical health, urinary and defecatory function, and overall patient satisfaction. MATERIALS AND METHODS: Ethics committee approval and informed consent were obtained for the Embolisation versus Hysterectomy Trial. Women (n = 177) with uterine fibroids and heavy menstrual bleeding who were scheduled to undergo hysterectomy were randomly assigned to undergo UAE (n = 88) or hysterectomy (n = 89). HRQOL was measured six times during a 24-month follow-up period with the following validated questionnaires: Medical Outcome Study Short Form 36 (SF-36) mental component summary (MCS) and physical component summary (PCS), Health Utilities Index Mark 3, EuroQol 5D, urogenital distress inventory (UDI), incontinence impact questionnaire, and defecation distress inventory (DDI). Satisfaction was assessed with a seven-point Likert scale. Repeated measurement analysis was performed for between-group analysis. Paired t tests were performed for within-group analysis. Satisfaction was analyzed with the Fisher exact test. RESULTS: The SF-36 MCS and PCS, Health Utilities Index Mark 3, EuroQol 5D, and UDI scores were improved significantly in both groups at 6 months and afterward (P < .05). The DDI score was improved significantly in only the UAE group at 6 months and afterward (P < .05). No differences between groups were observed, with the exception of PCS scores at 6-week follow-up: Patients in the UAE group had significantly better scores than did patients in the hysterectomy group (P < .001). Improvement in PCS score at 24-month follow-up was significantly higher for patients who were employed at baseline (P = .035). At 24-month follow-up, patients in the hysterectomy group were significantly more satisfied than those in the UAE group (P = .02). CONCLUSION: Both UAE and hysterectomy improved HRQOL. No differences were observed between groups regarding HRQOL at 24-month follow-up. On the basis of HRQOL results, the authors determined that UAE is a good alternative to hysterectomy.

MR reproducibility in the assessment of uterine fibroids for patients scheduled for uterine artery embolization.

Magnetic resonance imaging (MRI) is increasingly applied in the evaluation of uterine fibroids. However, little is known about the reproducibility of MRI in the assessment of uterine fibroids. This study evaluates the inter- and intraobserver variation in the assessment of the uterine fibroids and concomitant adenomyosis in women scheduled for uterine artery embolization (UAE). Forty patients (mean age: 44.5 years) with symptomatic uterine fibroids who were scheduled for UAE underwent T(1)- and T(2)-weighted MRI. To study inter- and intraobserver agreement 40 MR images were evaluated independently by two observers and reevaluated by both observers 4 months later. Inter- and intraobserver agreement was calculated using Cohen's kappa statistic and intraclass correlation coefficient for categorical and continuous variables, respectively. Inter-observer agreement for uterine volumes (kappa = 0.99, p < 0.0001), dominant fibroid volumes (kappa = 0.98, p

Sexuality and body image after uterine artery embolization and hysterectomy in the treatment of uterine fibroids: a randomized comparison.

In this paper the effect of uterine artery embolization (UAE) on sexual functioning and body image is investigated in a randomized comparison to hysterectomy for symptomatic uterine fibroids. The EMbolization versus hysterectoMY (EMMY) trial is a randomized controlled study, conducted at 28 Dutch hospitals. Patients were allocated hysterectomy (n = 89) or UAE (n = 88). Two validated questionnaires (the Sexual Activity Questionnaire [SAQ] and the Body Image Scale [BIS]) were completed by all patients at baseline, 6 weeks, and 6, 12, 18, and 24 months after treatment. Repeated measurements on SAQ scores revealed no differences between the groups. There was a trend toward improved sexual function in both groups at 2 years, although this failed to reach statistical significance except for the dimensions discomfort and habit in the UAE arm. Overall quality of sexual life deteriorated in a minority of cases at all time points, with no significant differences between the groups (at 24 months: UAE, 29.3%, versus hysterectomy, 23.5%; p = 0.32). At 24 months the BIS score had improved in both groups compared to baseline, but the change was only significant in the UAE group (p = 0.009). In conclusion, at 24 months no differences in sexuality and body image were observed between the UAE and the hysterectomy group. On average, both after UAE and hysterectomy sexual functioning and body image scores improved, but significantly so only after UAE.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial.

OBJECTIVE: The purpose of this study was to compare the 2 years' efficiency of uterine artery embolization (UAE) with hysterectomy in the treatment of menorrhagia caused by uterine fibroids in a randomized controlled trial. STUDY DESIGN: Twenty-eight Dutch hospitals recruited patients with uterine fibroids and menorrhagia, who were eligible for hysterectomy. Patients were randomized to UAE or hysterectomy. The primary endpoint was if UAE could avoid a subsequent hysterectomy in at least 75% of cases. Secondary endpoints were changes in pain, bulk-related complaints, and uterine and dominant fibroid volume reduction. RESULTS: One hundred seventy-seven patients were randomized to UAE (n = 88) or hysterectomy (n = 89). Two years after treatment 23.5% of UAE patients had undergone a hysterectomy. There were no significant differences in improvement compared to baseline in pain and bulk-related complaints. Uterine and dominant fibroid volume reduction in UAE patients was 48.2% and 60.5%, respectively. CONCLUSION: UAE is a valuable alternative treatment for symptomatic uterine fibroids. Nevertheless, when patients seek for certainty on the cessation of bleeding problems, a hysterectomy remains the treatment of choice.

Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy.

BACKGROUND: Ovarian failure as a complication of uterine artery embolization (UAE) for symptomatic uterine fibroids has raised concerns about this new treatment modality. METHODS: We investigated the occurrence of ovarian reserve reduction in a randomized trial comparing UAE and hysterectomy by measuring follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH). A total of 177 pre-menopausal women with menorrhagia due to uterine fibroids were included (UAE:n=88; hysterectomy:n=89). FSH and AMH were measured at baseline and at several time-points during the 24 months follow-up period. Follow-up AMH levels were also compared to the expected decrease due to ovarian ageing during the observational period. RESULTS: FSH increased significantly compared to baseline in both groups after 24 months follow-up (within group analysis: UAE:+12.1; P=0.001; hysterectomy:+16.3; P<0.0001). No differences in FSH values between the groups were found (P=0.32). At 24 months after treatment the number of patients with FSH levels>40 IU/l was 14/80 in the UAE group and 17/73 in the hysterectomy group (relative risk=0.75; P=0.37). AMH was measured in 63 patients (UAE: n=30; hysterectomy: n=33). After treatment AMH levels remained significantly decreased during the entire follow-up period only in the UAE group compared to the expected AMH decrease due to ageing. No differences were observed between the groups. CONCLUSIONS: This study shows that both UAE and hysterectomy affect ovarian reserve. This results in older women becoming menopausal after the intervention. Therefore, the application of UAE in women who still wish to conceive should only be considered after appropriate counselling.

Uterine artery embolization in the treatment of symptomatic uterine fibroid tumors (EMMY trial): periprocedural results and complications.

PURPOSE: Uterine artery embolization (UAE) is an emerging treatment for symptomatic uterine fibroid tumors. This study was performed to evaluate the periprocedural results of the UAE procedure and identify risk factors for technical failure, fever after UAE, pain, and other complications. MATERIALS AND METHODS: As part of a multicenter, randomized trial to compare UAE versus hysterectomy in patients with symptomatic uterine fibroid tumors, 81 patients underwent UAE. Univariate and multivariate analyses were used to identify predictors for technical failure, postprocedural fever, complications as defined by the Society of Interventional Radiology (SIR), and pain scores. RESULTS: The technical failure rate according to SIR guidelines was 5.3% (95% CI, 2.3%-10.1%). The procedural failure rate was 17.3% (95% CI, 9.8%-27.3%). Bilateral failure occurred in four of 81 patients and unilateral failure occurred in 10 of 81 patients. Technical failure occurred mainly as a result of difficult anatomy (3.7%) or absence of the uterine artery (3.1%). The overall complication rates were 28.4% during the patients' hospital stay and 60.5% for the 6 weeks after discharge. The risk of technical failure was found to increase in the presence of a single fibroid tumor (odds ratio [OR], 6.21; 95% CI, 1.65-23.41; P = .007) and/or a small uterine volume (<500 cm(3); OR, 10.8; 95% CI, 1.25-93.36; P = .03). The amount of embolization material was associated with the onset of fever after UAE (OR, 2.05; 95% CI, 1.09-3.87; P = .027), major complications (OR, 5.68; 95% CI, 2.05-15.75; P = .001), and high pain scores (OR, 1.97; 95% CI, 1.08-3.58; P = .027). CONCLUSIONS: The procedural failure rate for UAE was higher than those reported by others, mainly as a result of difficult anatomy and absence of a uterine artery in some cases. The risk of procedural failure was increased for patients with single fibroid tumors and/or small uterine volumes. A clear dose-effect response was revealed between the amount of embolization material used and the risk for postprocedural fever, major complications, and severe pain.

Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial.

PURPOSE: To evaluate the safety and efficacy of uterine artery embolization (UAE) and hysterectomy for symptomatic uterine fibroids by means of a randomized controlled trial. The present paper analyses short-term outcomes, i.e., pain and return to daily activities. METHODS: Patients were randomized (1:1) to UAE or hysterectomy. Pain was assessed during admission and after discharge, both quantitatively and qualitatively, using a numerical rating scale and questionnaires. Time to return to daily activities was assessed by questionnaire. RESULTS: Seventy-five patients underwent hysterectomy and 81 patients underwent UAE. UAE patients experienced significantly less pain during the first 24 hr after treatment (p = 0.012). Non-white patients had significantly higher pain scores. UAE patients returned significantly sooner to daily activities than hysterectomy patients (for paid work: 28.1 versus 63.4 days; p < 0.001). In conclusion, pain appears to be less after UAE during hospital stay. Return to several daily activities was in favor of UAE in comparison with hysterectomy.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial.

OBJECTIVE: This was a randomized controlled trial to evaluate the safety of uterine artery embolization (UAE) compared with hysterectomy. STUDY DESIGN: Twenty-eight Dutch hospitals recruited 177 patients with symptomatic uterine fibroids and menorrhagia who were eligible for hysterectomy. Patients were randomized to UAE (n = 88) or hysterectomy (n = 89). In this paper we evaluate the peri- and postprocedural complications, length of hospital stay, unscheduled visits, and readmission rates up to 6 weeks' post-intervention. Analysis was by intention to treat. RESULTS: Bilateral UAE failure occurred in 4 patients (4.9%). Major complications occurred in 4.9% (UAE) and 2.7% (hysterectomy) of cases (P = .68). The minor complication rate from discharge until 6 weeks after was significantly higher in the UAE group than in the hysterectomy group (58.0% vs 40.0%; RR 1.45 [1.04-2.02]; P = .024). UAE patients were more often readmitted (11.1% vs 0%; P = .003). Total length of hospital stay was significantly shorter in UAE patients (mean [SD]: 2.5 [2.7] vs 5.1 [1.3], P < .001). CONCLUSION: UAE is a procedure similar to hysterectomy with a low major complication rate and with a reduced length of hospital stay. Higher readmission rates after UAE stress the need for careful postprocedural follow-up.

Myoma expulsion after uterine artery embolization: complication or cure?

A 54-year-old woman had an expulsed myoma 10 weeks after uterine artery embolization. After treatment with antibiotics and a small surgical intervention, she recovered completely without any sign of myomatous disease afterwards. Patients should be informed about the possibility of expulsion. Expulsion of myomas after uterine artery embolization occurs relatively frequently and may be just one of the ways to attain cure.