Uterine artery embolization versus surgical treatment in patients with symptomatic uterine fibroids: Protocol for a systematic review and meta-analysis of individual participant data.

OBJECTIVE: Uterine fibroids are the most common benign tumours in women of the reproductive age. Symptoms of heavy menstrual bleeding, abdominal discomfort and infertility may seriously affect a woman's quality of life. Uterine artery embolization is a safe and effective alternative treatment to hysterectomy or myomectomy for symptomatic uterine fibroids. Which treatment provides the highest quality of life, least complications, symptom reduction and least chance intervention, has not been established and might depend on strict patient selection. This study aims to identify which specific subgroups benefit most of each treatment by analyzing individual participant data derived from randomized controlled trials of women undergoing embolization or surgical treatment. This study will primarily assess the effectiveness of both treatment groups by evaluating the effect on quality of life of embolization in comparison to surgery on specific patient and fibroid characteristics and the possible need for re-intervention for fibroid-related symptoms. DATA SOURCES: PubMed/MEDLINE, Embase and The Cochrane Library were searched up to August 2020. STUDY ELIGIBILITY CRITERIA: We will collect individual participant data from randomized controlled trials that studied clinical and procedural outcomes of premenopausal women with symptomatic uterine fibroids, who were randomized between uterine artery embolization and surgery. STUDY APPRAISAL AND SYNTHESIS METHODS: Individual participant data from all eligible trials will be sought and analysed according to intention-to-treat principle. Risk of Bias will be done by using version 2 of the Cochrane tool for Risk of Bias in randomized trials. Subgroup analyses to explore the effect of e.g. age, fibroid characteristics and fibroid complaints will be performed, if data is available. This individual patient data meta-analysis will be analysed according to a one-stage model.

Association between magnetic resonance imaging findings of uterine leiomyomas and symptoms demanding treatment.

PURPOSE: To evaluate the association between magnetic resonance imaging (MRI) derived uterine and leiomyoma characteristics and symptoms demanding treatment. MATERIALS AND METHODS: Consecutive patients (n=122; mean age, 47.5 years) with symptomatic leiomyomas participated in a prospective study. The leiomyoma/endometrium relationship, sizes of leiomyomas and uteri, and number and enhancement of leiomyomas were determined by MRI. Submucosal leiomyomas were classified as protruding either ≥50% or <50% into the uterine cavity. RESULTS: Sixty-nine patients (57%) had menorrhagia and pressure symptoms, while 26 (21%) had only menorrhagia and 27 (22%) pressure symptoms alone. Leiomyomas with ≥50% protrusion into the uterine cavity were detected more often in patients with both symptoms or just menorrhagia than in those with pressure symptoms only (18/69 [26%] versus 1/27 [4%], P=0.013; 10/26 [39%] versus 1/27 [4%], P=0.002, respectively). The degree of enhancement of leiomyomas was higher (P=0.005) and leiomyomas were smaller (P=0.002) in patients with menorrhagia than in those with pressure symptoms. Large uterine and leiomyoma measures were associated with increased urinary frequency (P values 0.002-0.032). Urinary stress incontinence, abdominal pain, and pressure on the back were not associated with MRI findings. CONCLUSION: In comparison with pressure symptoms, menorrhagia is associated with smaller uterine and leiomyoma size and with more intense enhancement. While a submucosal leiomyoma largely protruding into the cavity contributes to menorrhagia, significance of a minor submucosal component seems to be unclear. The large leiomyoma and uterine volumes contribute to increased urinary frequency, whereas other mechanisms for urinary stress incontinence and pain symptoms should be considered.

[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 artery embolisation versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomised prospective clinical trial.

OBJECTIVE: To compare uterine artery embolisation (UAE) and hysterectomy for the treatment of leiomyomas at 2-year follow-up in a prospective, randomised, single-centre study. METHODS: Fifty-seven symptomatic patients were randomised to UAE (n = 27) or hysterectomy (n = 30). Complications, recovery, reinterventions and satisfaction with treatment were recorded. Primary endpoint was improvement of symptoms. Analyses were performed by intent-to-treat and per protocol. RESULTS: Two hysterectomy patients (7%) developed major complications. Hospital discharge occurred earlier after UAE than after hysterectomy (p < 0.001). Length of sick leave was longer after hysterectomy than after UAE (p < 0.001). Twenty-two (82%) UAE patients and 28 (93%) hysterectomy patients reported overall relief of symptoms (p = 0.173). In 12/18 (67%) UAE patients menorrhagia was completely resolved or reduced. Improvement of pressure symptoms was reported significantly more by UAE patients than by hysterectomy patients (19/20 [95%] versus 18/26 [69%], respectively; p = 0.029). Five (19%) UAE patients underwent additional interventions due to worsening symptoms. Twenty-four (89%) UAE patients and 29 (97%) hysterectomy patients would have chosen treatment again (p = 0.336). CONCLUSION: UAE gave relief of symptoms (apart from menorrhagia) comparable to hysterectomy with less severe complications, but with an increased rate of secondary interventions. UAE may be the preferable treatment especially for patients with pressure symptoms.

Preinterventional quantitative magnetic resonance imaging predicts uterus and leiomyoma size reduction after uterine artery embolization.

PURPOSE: To investigate the relationship between magnetic resonance imaging (MRI) measures and uterus and leiomyoma size reductions after uterine artery embolization (UAE). MATERIALS AND METHODS: Fifty-two women with leiomyomas underwent selective UAEs. Uterine and dominant leiomyoma sizes were measured with preinterventional MRI and a 6-month follow-up MRI. Four MRI measures of the dominant leiomyoma were recorded: T1 time; T2 time; leiomyoma-to-skeletal muscle T2 SI-ratio; and percentage of contrast enhancement. To evaluate the predictive value of MRI measures we used Spearman rank correlation, area under the receiver operating characteristic (ROC) curve (A(z)), and values for diagnostic performance. RESULTS: Uterus and dominant leiomyoma size reductions were highly variable. Leiomyoma size reductions of >or=75% were accurately predicted with leiomyoma-to-skeletal muscle T2 SI-ratio (ROC curve A(z) = 0.930; 95% confidence interval [CI]: 0.853, 1.000). Leiomyoma size reductions >or=75% were predicted by leiomyoma-to-skeletal muscle T2 SI-ratio >or=3.5 and T1-time >or=750 msec with 100% and 86% sensitivities and 67% and 72% specificities, respectively. Uterus size reduction >or=50% were identified by dominant leiomyoma-to-skeletal muscle T2 SI-ratio >or=2.5. CONCLUSION: Uterus and dominant leiomyoma size reductions after UAE were predicted with preoperative MRI measures of the dominant leiomyoma.

Pain after uterine fibroid embolisation is associated with the severity of myometrial ischaemia on magnetic resonance imaging.

The purpose of the study was to evaluate uterine ischaemia after uterine artery embolisation (UAE) using magnetic resonance imaging and the role of myometrial and fibroid ischaemia in the pathogenesis of post-procedural pain. T1-weighted gradient echo imaging before and after contrast agent was performed on 62 women before and 24 h after UAE. We assessed the severity (mild, moderate, severe) of myometrial ischaemia, and the percentage and volume of ischaemic tissue in myometrium and fibroids. The Verbal Rating Scale was used to assess in-hospital post-procedural pain (1-3 mild, 4-6 moderate, 7-10 severe). Mean maximal pain was 7.7. Myometrial ischaemia was mild, moderate and severe in 29, 23 and 10 patients, respectively. Moderate or severe myometrial ischaemia (p = 0.041), the percentage (p = 0.037) and volume (p = 0.012) of ischaemic tissue in the myometrium, and a large volume of embolic material (p = 0.038) correlated with severe pain. In summary, pain following UAE is common and partly explained by myometrial ischaemia.