http://www.scvir.org/clinical/cpg/Qual_Improv_Guidelines_UFE_leiomyomata.pdf

Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic Leiomyomata

OBJECTIVES The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically updated evidence on the management of uterine fibroids, specifically incidence and prevalence of fibroids, treatment outcomes, comparisons of treatment, modifiers of outcomes, and costs. DATA SOURCES We searched MEDLINE(R), Cochrane Collaboration resources, and Embase. REVIEW METHODS We included studies published in English from February 2000 through August 2006. We excluded studies with low sample size (based on study design, cases series < 100 and cohorts < 40) or lack of relevance to uterine fibroids. Of 107 included studies, 3 were good quality, 56 fair, and 48 poor. RESULTS The cumulative incidence by age 50 is 70 percent to 80 percent; black women are more likely to get fibroids at younger ages. Appearance of new fibroids and growth of existing fibroids after treatment are poorly studied. Trials of preoperative medical management indicate that treatment reduces fibroid volume but do not provide sufficient evidence of improvement in important operative outcomes. When women are treated for reasons other than symptom relief, such as when pregnancy is desired, weak evidence supports treating submucous fibroids via hysteroscopy. No well-conducted trials in U.S. populations directly compared treatment options, including the option of expectant management, or followed women to determine whether the intervention met their treatment objectives. Common procedures such as hysterectomy and myomectomy, including choice among types of myomectomy, still cannot be meaningfully compared. Studies comparing uterine artery embolization (UAE) with other procedures reported procedure time and length of stay favoring UAE, but inconsistency of the direction of effect for complications and absence of key information on longer-term outcomes suggest that this evidence base is inadequate to comment on the relative risks and benefits of UAE versus hysterectomy or myomectomy. Costs of fibroid treatment, despite shorter average lengths of stay, are rising. CONCLUSIONS The dearth of high-quality evidence supporting the effectiveness of most interventions for uterine fibroids is remarkable, given how common this problem is. The current state of the literature does not permit definitive conclusions about benefit, harm, or relative costs to help guide women's choices. Significant research gaps include well-conducted trials in U.S. populations that directly compare interventions on short- and, especially, long-term outcomes, studies on therapeutics for medical management, and information on treatment decisions for women who desire a pregnancy.

Management of uterine fibroids: an update of the evidence.

Purpose
To perform an extensive systematic review to examine all the available literature reporting iatrogenic acquired arteriovenous malformation (AVM) induced after diagnostic curettage and to describe a further case of a 34-year-old woman presenting with acute vaginal bleeding due to AVM induced after uterine curettage for termination of pregnancy.

Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review

OBJECTIVE. The purpose of this meta-analysis was to determine the rates of major complications, other associated adverse events, reintervention, and clinical improvement from studies reporting complications of uterine artery embolization (UAE) for the treatment of symptomatic leiomyomas. MATERIALS AND METHODS. PubMed, Medline, Embase, and Cochrane databases were searched for publications on the treatment of leiomyomas by UAE. Data pertaining to study characteristics, numbers of complications, symptomatic improvement, and reinterventions were collected by two readers. Pooled event rates were calculated using a random effects method. RESULTS. Fifty-four study populations met the inclusion criteria, yielding a total of 8159 patients. There were no reported deaths. Major complications occurred at a rate of 2.9% (95% CI, 2.2-3.8%). The rate of hysterectomy for resolution of a complication from UAE was 0.7% (0.5-0.9%), and the rate of readmission was 2.7% (1.9-3.7%). Multiple other specific complications were r...

https://www.ajronline.org/doi/pdfplus/10.2214/AJR.11.8362

Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis.

Study selection Randomised controlled trials that evaluated non-surgical interventions for non-pregnant women with irregular or abnormal cyclic uterine bleeding for three months or more were eligible for inclusion. Studies of women with polycystic ovarian syndrome were included with studies of irregular bleeding as long as the patient baseline and outcome data included information regarding cycle regularity. Studies of women with abnormal uterine bleeding caused by coagulation defects, systemic disease, structural abnormalities, cancer, medication side-effects or infertility (with a primary treatment goal of conception) were excluded. Outcomes of interest included bleeding profile, quality of life, pain, sexual function and patient satisfaction with treatment outcomes. For evidence of harms, observational studies with at least 1,600 participants/records were included.

Primary care management of abnormal uterine bleeding

Purpose: A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids Methods: Technical recommendations included embolization using large microspheres (>500 µm) with no secondary embolization agent Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months Results: Eighty-five women complaining of fibroid-related symptoms entered the study In seven women, a secondary embolization agent was used in addition to microspheres Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively) Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid Eight women were treated by hysterectomy because of treatment failure In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids Conclusion: Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction Confidence in the end-point recommended here may require the experience of several cases

Jean-Michel Tubiana

Papers

FEMIC (Fibromes Embolisés aux MICrosphères calibrées): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study