HHE Radiology and imaging supplement 2018 | Page 21

myomectomy have been the traditional ‘gold
standard’ definitive therapies for symptomatic
fibroids. However, not all women wish to have
a surgery and might like to consider non-surgical
alternatives such as medical management or
radiological interventions.
Over the last few decades, new medical and
minimally invasive treatments have become
available for symptomatic uterine fibroids. The
choice of treatment needs to be individualised
depending on underlying symptoms, fibroid
size and location, impact on fertility, history
of previous treatments and the possible need
for repeat interventions.
Radiological interventions
Over the last two decades, uterine arter y
embolisation (UAE) and magnetic resonance
imaging-focused high intensity ultrasound
(MRgFUS) are two modalities that have emerged
as viable alternatives to surgical treatments for
uterine fibroids.
UAE
UAE involves the placement of an angiographic
catheter into the uterine arteries via a common
femoral artery approach and injection of embolic
particles, such as polyvinyl alcohol particles,
until the flow becomes sluggish in both uterine
arteries. The fibroids shrink as a result of
ischaemic necrosis but blood supply to the uterus
is preserved via collateral vessels. Because the
technique aims to achieve fibroid shrinkage
rather than removal, it is less effective in the
case of large fibroids associated with pressure
symptoms. Most patients experience moderate
to severe ischaemic pain up to 12 hours after the
procedure, which then gradually decreases over
the next 12 hours. Patients can usually return to
normal activities within one to two weeks. Main
complications of UAE include ‘post embolisation
syndrome’ (fever, nausea, vomiting and pain),
vaginal expulsion of an infarcted fibroid
(approximately 10% of cases) and intrauterine
infection (<1% of procedures). 3,4 Other concerns
associated with UAE are its effects on the
reproductive system. The use of the procedure
needs to be balanced against the possible loss of
ovarian reserve with scarce data on pregnancy
outcomes. It has been suggested that UAE could
reduce blood flow to the normal uterine tissue
and ovaries resulting in reduced ovarian reserve,
impaired placentation and increased risks of
miscarriage/post-partum haemorrhage. 3
Although the rates of induction of premature
ovarian insufficiency following UAE remain very
infrequent, there are concerns about subclinical
diminution of ovarian functional reserve. Data
from randomised trials and prospective case
series suggest that degradation of ovarian function
may occur after UAE, and is concentrated in
women older than 45 years, with little evidence
of impact in women younger than 40 years of age. 5
The choice
of treatment
needs to be
individualised
depending on
underlying
symptoms,
fibroid size
and location,
impact on
fertility, history
of previous
treatments and
the possible
need for repeat
interventions
Evidence
A Cochrane review assessed the benefits and
risks of UAE versus other medical or surgical
interventions for symptomatic uterine fibroids. 6
Seven randomised controlled trials (RCTs)
including 793 women were included in this
review. Three trials compared UAE with
21
HHE 2018 | hospitalhealthcare.com
abdominal hysterectomy, two trials compared
UAE with myomectomy, and two trials
compared UAE with either type of surgery (53
hysterectomies and 62 myomectomies). Patient
satisfaction rates were up to 41% lower or up to
48% higher with UAE compared with surgery
within 24 months of having the procedure (odds
ratio (OR) 0.94; 95% confidence interval (CI)
0.59–1.48; six trials, 640 women, moderate quality
evidence). Findings were also inconclusive at five
years of follow-up (OR 0.90; 95% CI 0.45–1.80, two
trials, 295 women, moderate quality evidence).
There was some indication that UAE may be
associated with less favourable fertility outcomes
than myomectomy, but it was very low quality
evidence from a subgroup of a single study and
should be regarded with extreme caution (live
birth: OR 0.26; 95% CI 0.08–0.84; pregnancy: OR
0.29; 95% CI 0.10–0.85, one study, 66 women). 6
Similarly, for several safety outcomes there
was evidence of a substantially higher risk of
adverse events in either arm or of no difference
between the groups. This applied to intra-
procedural complications (OR 0.91; 95% CI
0.42–1.97, four trials, 452 women, low quality
evidence), major complications within one year
(OR 0.65; 95% CI 0.33–1.26, five trials, 611 women,
moderate quality evidence) and major
complications within five years (OR 0.56; CI
0.27–1.18, two trials, 268 women). However, the
rate of minor complications within one year was
higher in the UAE group (OR 1.99; CI 1.41–2.81,
six trials, 735 women, I(2)=0%, moderate quality
evidence) and two trials found a higher minor
complication rate in the UAE group at up to five
years (OR 2.93; CI 1.73–4.93, two trials, 268
women). 6
UAE was associated with a higher rate of
further surgical interventions (re-interventions
within two years: OR 3.72; 95% CI 2.28–6.04, six
trials, 732 women, moderate quality evidence;
within five years: OR 5.79; 95% CI 2.65–12.65,
two trials, 289 women). The evidence suggested
that women in the UAE group were less likely
to require a blood transfusion than women
receiving surgery (OR 0.07; 95% CI 0.01–0.52, two
trials, 277 women). UAE was also associated with
a shorter procedural time (two studies), shorter
length of hospital stay (seven studies) and faster
resumption of usual activities (six studies) in all
studies that measured these outcomes. 6
The authors concluded that patient satisfaction
rates at up to two years following UAE versus
surgery (myomectomy or hysterectomy) were not
different. Findings at five-year follow-up were
similarly inconclusive. There was very low quality
evidence to suggest that myomectomy may be
associated with better fertility outcomes than
UAE. There was no clear evidence of a difference
between UAE and surgery in the risk of major
complications, but UAE was associated with
a higher rate of minor complications and an
increased likelihood of requiring surgical
intervention within two to five years of the
initial procedure. This increase in the surgical
re-intervention rate may balance out any initial
cost advantage of UAE. 6
UAE is an option for women with symptomatic
fibroids, who are not planning a pregnancy in the
future and wish to avoid surgery or have a high
risk of surgical or anaesthetic complications.