Uterine artery embolization for the management of uterine fibroids

PICHON RIVIERE, A.; AUGUSTOVSKI, F.; ALCARAZ, A.; BARDACH, A.; FERRANTE, D.; GARCIA MARTI, S.; GLUJOVSKY, D.; LOPEZ, A.; REGUEIRO, A.

Documentos de Evaluación de Tecnologías Sanitarias

IECS

Año: 2006 p. 1 - 30

1668-2793

The purpose of this report is to assess the usefulness of uterine artery embolization in women with uterine fibroids.A search was carried out on the main literature databases (MEDLINE, Cochrane, DARE, NHS EED), on the Internet's general search engines, health technology assessment agencies and health sponsors using the following keywords: "Embolization, Therapeutic"[MeSH] AND "Leiomyoma"[MeSH]; 'fibroid' and 'uterine artery embolization' were also searched. Priority was given to including systematic reviews, randomized controlled trials (RCT), health technology assessments and financial assessments, clinical practice guidelines and coverage policies from other health systems.One RCT compared the use of uterine artery embolization (UAE) versus hysterectomy in women with uterine myomatosis presenting symptoms of metrorrhagia, with myomas smaller than 10 cm and with no future pregnancy expectations. 88% of the cases achieved obstruction of both uterine arteries. 86% of the cases with UAE improved (56% menses normalization; 14% metrorrhagia reduction and 17% with amenorrhea) after 6-months of follow-up. The size of the dominant myoma was reduced by 46% (CI 95%, 27%-66%). Hospital stay was significantly shorter (1.7 days versus 5.8 days, p<0.05). No differences are described when it comes to complications: emergency consultation, readmissions or other complications. In 2004, another RCT recruited 177 premenopausal women with indication for hysterectomy due to uterine myomatosis. One group who underwent UAE was compared against another one who underwent hysterectomy (most of them were transabdominal). 88.9% achieved bilateral obstruction of uterine arteries. Surgical time (79 minutes versus 95.4 minutes) and blood loss (31 ml versus 436 ml) were significantly lower in women under UAE. The same applied to hospital stay (2 days versus 5.1 days). During hospitalization, both groups showed no difference in the incidence of major or minor complications. The group of patients who underwent UAE had a higher frequency of readmissions (most commonly because of fever and pain), although in almost all the cases this was during a period of time when patients who underwent hysterectomy were still in hospital. Even so, hospitalization was shorter in the UAE group.The British technology assessment agency (NICE) states that, in a systematic review they conducted in March, 2004, mean reduction of myomas was between 40% and 75% with the use of UAE. Beyond tumor reduction, between 62% and 95% of women showed symptom improvement after follow-ups not longer than 6 months. Pregnancies were reported after this procedure; however, the rate of women willing to become pregnant and who actually got pregnant is unknown. The American College of Gynecologists and Obstetricians (ACOG) considers that this technology, when conducted by experienced professionals, improves symptoms related to menstrual discharge and the occupying pelvic mass. It also states that even though risks for complications are low, it can sometimes lead to hysterectomy and death. Also, it mentions the scarce evidence available on the effects embolization might have in women willing to keep their fertility. Consequently, in these cases, it should be considered a technology under investigation and is contraindicated. The Society of Obstetricians and Gynaecologists of Canada (SOGC) states that UAE should be considered in women with symptomatic uterine fibroids who require surgical treatment and who, when fertility is to be preserved, patients should be alerted that there is limited evidence about that. The NICE reports that the technology is safe enough and that it offers benefits in short-term symptoms. However, it says that more evidence is required to establish its scope at longer term and to determine its effects on fertility.