Clinical Long-term Outcome after Uterine Artery Embolization: Sustained Symptom Control and Improvement of Quality of Life

doi:10.1016/j.jvir.2013.02.018

Journal of Vascular and Interventional Radiology

Volume 24, Issue 6, June 2013, Pages 765-771

https://doi.org/10.1016/j.jvir.2013.02.018 Get rights and content

Abstract

Purpose

To evaluate long-term clinical efficacy of uterine artery embolization (UAE) for uterine fibroids with respect to symptom control and improvement in quality of life.

Materials and Methods

Between October 2000 and October 2007, 380 consecutive women underwent UAE. To determine long-term efficacy, the rate of reinterventions (ie, repeat UAE, hysterectomy, myomectomy) and the clinical response regarding symptoms related to bleeding and bulk were documented. Persistence, worsening, or recurrence of symptoms and reinterventions were classified as treatment failure (TF). The cumulative rate of freedom from TF was determined by Kaplan-Meier analysis. Cox regression was used to identify possible clinical or morphologic predictors of outcome. Secondary outcome measures were changes in disease-specific quality of life and onset of menopause.

Results

Follow-up was available for a median of 5.7 years (range, 3.1–10.1 y) after treatment in 304 of 380 (80%) patients. There were 54 TFs with subsequent reintervention in 46 women. Kaplan-Meier analysis revealed a cumulative TF rate of 23.3% after 10 years. Cox regression demonstrated a significantly higher likelihood of TF in patients<40 years old compared with patients>45 years old (hazard ratio, 2.28; P = .049). Women without TF showed sustained normalization of disease-specific quality of life (P <.001). Cessation of menstruation at a median age of 51 years was reported by 57 (22.8%) of 250 women.

Conclusions

UAE leads to long-term control of fibroid-related symptoms and normalization of quality of life in approximately 75% of patients. Younger women seem to have a higher risk of TF than older women closer to menopause.

Section snippets

Study Setting and Patient Population

Between October 2000 and October 2007, 380 consecutive patients with a median age of 44 years (quartile range [QR], 41–47 y; range, 33–64 y) were enrolled in a prospective clinical study of UAE. Inclusion criteria were symptomatic uterine fibroid disease confirmed clinically (bleeding-related symptoms, such as hypermenorrhea or dysmenorrhea, and bulk-related symptoms, such as feeling of abdominal distention, increased urinary frequency, or constipation) and by magnetic resonance (MR) imaging or

Results

Of 380 patients initially included in the study, 74 (19.5%) patients were lost to follow-up. Two patients were additionally classified as dropouts. One woman died of another cause, and the other underwent hysterectomy for endometrial cancer 6 years after UAE at the age of 51. There were 304 women who completed clinical long-term follow-up after a median of 5.7 years (range, 3.1–10.1 y). The demographic characteristics and baseline clinical presentations and objective disease burden of these

Discussion

Introduced into clinical practice in the late 1990s as an alternative to hysterectomy, UAE has since proved to be an effective, minimally invasive, and low-risk treatment option for women with symptomatic uterine fibroids (3, 7, 15). Available retrospective analyses and prospective randomized trials comparing UAE with established surgical treatments (ie, hysterectomy, myomectomy) followed patients for up to 5 years (7, 16, 17, 18, 19, 20). The results either are in favor of UAE in terms of

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Cited by (40)

Outcome prediction for symptomatic patients with fibroids who underwent uterine artery embolization
2024, Clinical Imaging
To predict the clinical outcome of symptomatic patients with uterine leiomyomas who underwent uterine artery embolization (UAE), based on clinical and radiological features.
Patients with symptomatic uterine leiomyomas who underwent UAE from March 2010 to September 2019 were consecutively included in this retrospective study. Patients with persistent or recurrent symptoms and those who needed repeated UAE, myomectomy, or hysterectomy following the initial treatment were considered to have a poor outcome after UAE. The total and enhancing volume of the dominant leiomyoma in each location and uterine volume were obtained before and after UAE. Univariate and multivariate Cox proportional hazard analyses were used to evaluate the parameters that could predict poor outcome.
A total of 116 patients (mean age, 45 ± 5 years) were included. Forty-six patients (46/116, 39.7%) showed poor outcome. Cox regression analysis showed higher hazard of poor outcome for younger patients vs. older patients (HR: 0.92, p-value: 0.01), patients with adenomyosis vs. patients without adenomyosis (HR: 2.47, p-value < 0.01), patients with adenomyosis thickness > 2.5 cm before UAE vs. patients without adenomyosis (HR: 4.2, p-value < 0.01) and for patients with intramural fibroid enhancement volume > 440 cm³ compared to patients with no intramural fibroids (p-value: 0.06). Multivariate Cox regression analysis including age, the thickness of adenomyosis, and intramural leiomyoma volume of enhancement before UAE was chosen as the best model to predict the outcome.
Pretreatment clinical and MRI features could identify patients with a higher risk for poor outcome after UAE.
Long-term outcome and pre-interventional predictors for late intervention after uterine fibroid embolization
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
This consideration might be powered by the fact that in this study less than 20 % of patients needed a second intervention lately after UFE for failed treatment. These results are in accordance or even slightly better than published failure rates and reinterventions lately after UFE: Scheurig-Muenkler et al. reported a failure rate of 23.3 % after median 5.7 years of follow-up [2] and Dutton et al. found a 23 % risk of requiring further treatment for fibroids after UFE, with a median of 4.6 years of follow-up [24] and de Bruijn et al. reported a secondary hysterectomy in 31 % of patients after an initial successful uterine artery embolization at a follow-up of 10 years [25]. The secondary objective of the present study is the analysis of potential preinterventional predictors for late treatment failure.
To assess the long-term freedom of surgical conversion after uterine fibroid embolization (UFE) and to define predictors for better clinical outcome. Additionally, the potential of pregnancy after UFE is assessed.
Study design: Single-center retrospective cohort study including 190 patients who underwent UFE between 2001 and 2016. Data were obtained by postal questionnaire including symptom severity, late reintervention rate and post procedural fertility. Patient characteristics were extracted from the patients' electronic medical records. The cumulative rate of freedom from treatment failure was determined by Kaplan-Meier analysis. Cox regression models were used for univariate analyses of the association between patient preinterventional characteristics and late surgical conversion. Secondary outcome measures were patient specific predictors of treatment failure and evaluation of post-procedural fertility.
Long-term follow-up was available for a median of 6.1 years (range 1.2–15.2 y) in 95 out of 190 patients (50 %). Freedom from treatment failure showed a cumulative rate of 72.9 % after 10 years and stable until end of follow-up. A 63.8 % reduction in symptoms and a 23.3% increase in quality of life was found. Significant increase of treatment failure was found in patients with increasing pre-interventional uterine volume (p = 0.0003) or dominant fibroid volume (p = 0.0042); 9 out of 23 patients (39.13 %) with child-bearing wish became pregnant and conceived one or more children after UFE.
UFE is associated with sustained long-term symptom control. Larger size uterus or dominant fibroma are correlated with higher late surgical conversion rate. Last, women can become pregnant and deliver after UFE.
Intraprocedural Superior Hypogastric Nerve Block Allows Same-Day Discharge following Uterine Artery Embolization
2020, Journal of Vascular and Interventional Radiology
In a single-arm, nonrandomized, retrospective case-control study, 39 patients (mean age, 44 y) who underwent elective outpatient uterine artery embolization with the use of superior hypogastric nerve block (SNHB) for pain control over a period of 3 years were identified. Technical success of SNHB was 87%. Of the 34 patients who received SNHB, 97% did not need a patient-controlled analgesia pump. The median opioid requirement for the 17 patients who needed opioid agents was 7.5 morphine milligram equivalents (interquartile range [IQR], 10). The median length of stay was 2.2 hours (IQR, 1.7 h). SHNB offers a safe and effective intervention that significantly reduces pain and the need for opiate agents and allows same-day discharge after uterine artery embolization.
Feasibility of quantitative MR-perfusion imaging to monitor treatment response after uterine artery embolization (UAE) in symptomatic uterus fibroids
2019, Magnetic Resonance Imaging
Citation Excerpt :
This effect is observed not only after embolization but also at follow-up while change in volume at all time points is not significant. Comparing our results to previous studies analyzing tumor volume, we could also reproduce reduction in tumor volume [17,20]. However, significant reduction in tumor volume is only observable in the follow-up exam.
In 25% of women, symptomatic uterus myomas are diagnosed with clinical and functional impairment ranging from abdominal and pelvic pain to dys- and hypermenorrhea, dyspareunia, pollakiuria and infertility. Women undergoing a treatment increasingly prefer nowadays minimal invasive, uterus preserving therapies like uterine artery embolization (UAE) over surgical hysterectomy, nowadays. To emphasize the efficacy of UAE as a uterus preserving treatment with targeted therapy of myomas only, analysis of tissue perfusion pre and post embolization is required. The purpose of this study was to assess treatment response in UAE in females with symptomatic uterus myomas by quantitative magnetic resonance perfusion imaging.
Seven females scheduled for uterus myoma embolization underwent three MRI examinations (pre, post, follow-up) including morphological and dynamic contrast enhanced perfusion imaging at 3 T. To measure tumor volume, regions-of-interest covering the tumor and the uterus were drawn by two readers in consensus. Blood flow, blood volume, and mean transit time were calculated by a pixel-by-pixel deconvolution approach. Kruskal-Wallis/Friedman test was employed to test whether the group medians differ significantly with correction for multiple comparisons using Bonferroni method.
Change of volume could be observed in all patients after embolization but was significantly different only between pre/post and follow-up time point. Measured differences in all perfusion parameters were significant between pre-intervention and post-intervention/follow-up in the myomas, no significant differences could be detected for the uterus tissue.
Our results demonstrate devascularization of symptomatic myomas which correlates with cessation of hypermenorrhea in all treated patients without affecting healthy uterus tissue. Supplementing UAE with perfusion imaging to monitor early treatment response is feasible and might provide valuable information for the follow-up of patients and contribute to providing confidence for the patients in treatment success.
Insufficient Leiomyoma Infarction in Uterine Artery Embolization: Relationship with Tumor Location
2019, Journal of Vascular and Interventional Radiology
To evaluate which leiomyoma location in the uterus predicts insufficient tumor infarction after uterine artery embolization (UAE).
In this single-institution retrospective study, 45 patients (mean age, 43.4 y ± 4.1) underwent UAE for leiomyomas using trisacryl gelatin microspheres alone with “pruned-tree” endpoint performed by qualified interventional radiologists between October 2015 and July 2017. Technical outcomes and complications were assessed. All patients underwent unenhanced and enhanced MR imaging before and after UAE. A total of 476 tumors of ≥ 1 cm observed in all patients were evaluated. Multivariate generalized linear mixed model analysis was performed to investigate relationships between insufficient tumor infarction (< 90%) on contrast-enhanced MR imaging after UAE and baseline factors, including tumor location in the long-axis, front-back, and inner-outer directions and tumor size.
All patients successfully underwent UAE with no major complications. Multivariate analysis revealed that there was a higher likelihood of insufficient infarction of tumors at the cervix (odds ratio [OR] 80.45; 95% confidence interval [CI] 9.97, 649.09; P < .001) and lower body (OR 4.31; 95% CI 2.52, 7.38; P < .001) than at the upper body and of tumors at the front than at the back wall (OR 2.20; 95% CI 1.32, 3.67; P = .002). Tumor size (OR 0.71; 95% CI 0.61, 0.82; P < .001) was a significant factor, whereas tumor location in the inner-outer direction was not.
Insufficient leiomyoma infarction after UAE was more likely to involve tumors at the cervix, lower body, or front wall of the uterus or smaller tumors.
Five-year clinical outcomes of uterine artery embolization for symptomatic leiomyomas: An analysis of risk factors for reintervention
2018, European Journal of Radiology
The objective of this study is to investigate the five-year reintervention rate of uterine artery embolization (UAE) for symptomatic leiomyomas and to identify potential predictive factors of reintervention.
From March 2011 to February 2012, 92 consecutive women (mean age 41.9 years, range 28–55 years) underwent bilateral UAE. Contrast-enhanced magnetic resonance imaging (MRI) was performed at three-month follow-up. After annual follow-up, a survey on clinical outcome and reintervention incidences was performed at five-year follow-up. Potential predictive factors of reintervention were evaluated.
Of the 67 patients, menorrhagia and/or bulk-related symptoms were resolved after UAE in all but one patient (98.5%). At median follow-up of 60 months (range, 5–60 months), reintervention rate was 10.4%, with seven reintervention cases (five myomectomy and two hysterectomy cases). Complete (100%) or near complete (90–99%) infarction rate of the dominant leiomyoma was 96.4% (54 of 56). Independent factors of reintervention on multivariate logistics regression analysis included near complete or partial (<90%) infarction of the dominant leiomyoma (odds ratio [OR] 22.238; 95% confidence interval [CI] 2.405–205.620; p = 0.006), as well as the presence of non-dominant viable leiomyomas (OR 12.134; 95% CI 1.213–121.409; p = 0.034).
UAE provides excellent and sustained symptom improvement of symptomatic leiomyomas with a low reintervention rate at five-year follow-up. In addition to near complete or partial infarction of the dominant leiomyoma on follow-up MRI, the presence of viable non-dominant leiomyomas indicates a higher risk of reintervention.

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: None of the authors have identified a conflict of interest.

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Clinical StudyClinical Long-term Outcome after Uterine Artery Embolization: Sustained Symptom Control and Improvement of Quality of Life

Abstract

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Study Setting and Patient Population

Results

Discussion

Lancet

J Vasc Interv Radiol

Eur J Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Obstet Gynecol

Obstet Gynecol

J Vasc Interv Radiol

Am J Obstet Gynecol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Lancet

Clinical Study
Clinical Long-term Outcome after Uterine Artery Embolization: Sustained Symptom Control and Improvement of Quality of Life