“Current evidence shows uterine artery embolization (UAE) is a safe and effective option to treat giant fibroids,” Oliver Llewellyn (Royal Infirmary of Edinburgh, Edinburgh, UK), Neeral Patel, and Mohamad Hamady (Imperial College NHS Trust, London, UK) et al conclude in Cardiovascular and Interventional Radiology (CVIR). They recommend that “patients should be selected, counselled, and managed accordingly” in order to benefit from this minimally invasive therapy and limit the “relatively higher risk of complications and reinterventions when compared with non-giant fibroids.”
Evidence supporting UAE for giant fibroids—defined as having a diameter of at least 10cm, and/ or with a uterine volume equal to or greater than 700cc—is sparse, according to Llewellyn and co-authors. They therefore performed a systemic review and meta-analysis of UAE outcomes for symptomatic giant versus non-giant fibroids to try and consolidate existing knowledge.
“This systematic review and meta-analysis of the current available data on the treatment of giant fibroids with UAE indicates there are several key factors required for the successful management of this unique cohort of patients,” Llewellyn tells Interventional News. “This includes close collaboration between gynaecology and interventional radiology colleagues, as well as careful follow-up in the post-procedure period.”
Primary outcome measures of the study were fibroid size, uterine volume reduction, procedure time, length of hospital stay, patent symptom improvement, reintervention rate, and complication rate. Following a systematic literature review, the authors extracted data from four relevant retrospective cohort studies, including a sum of 843 patients in their analysis. Of these, 163 (19.34%) had giant fibroids, and 676 (80.19%) had non-giant fibroids.
The main findings were:
- UAE resulted in uterine volume reduction in both groups: patients with giant fibroids, 38.6%±16.2; non-giant fibroids, 37.5%±18.7. The difference between the groups was not significant.
- Two studies indicated a statistically significant, but not clinically significant longer operative time for giant fibroids than non-giant fibroids (49±13.3 minutes versus 44.9±12.7 minutes, respectively, in one study, and 55.3±15.8 minutes versus 46.6±14.3 minutes; MD: 5.58 minutes; CI: 2.58–8.57; p=0.0003).
- There was a statistically significant but not clinically significant longer hospital stay for the giant fibroid group, as reported in two studies (p=0.01).
- Individually, included studies showed good overall patient satisfaction with the procedure, as well as effective postoperative symptom improvement, but meta-analysis was not possible.
- All studies reported a higher reintervention rate when embolizing giant fibroids (odds ratio [OR]: 3.57; 95% CI: 1.7–7.49; p=0.0008).
- Pooling analysis of all four studies found no significant difference in total postoperative complication rate associated with embolization of giant versus non-giant fibroids (OR: 1.45; 95% CI: 0.94–2.24; p=0.09).
- The rate of major complications was relatively higher in the giant fibroid cohort (OR: 4.71; 95% CI:1.51–14.64; p=0.007).
Commenting on the reported major complication rate following embolization of giant fibroids, Llewellyn et al write: “Broadly, of the seven major complications within the giant fibroid group, three related to fibroid expulsion requiring reintervention/ endocavitatory transformation, three related to uterine infection, and one patient suffered sexual dysfunction post-UAE.” Complications can be minimised with meticulous post-procedure follow-up for women undergoing UAE for giant fibroids and dedicated management pathways for patients who present with uterine infection may expedite treatment in this patient group, subsequently reducing the requirement for emergency surgery.
Elaborating on the clinical implications of this research, Llewellyn says to this newspaper: “The results from this meta-analysis will allow interventional radiology clinicians to fully discuss the risk profile with patients in the clinic setting, allowing a fully informed decision to be made. Further work in this patient population includes a comparison with current surgical techniques such as myomectomy and hysterectomy, as well as standardising patient outcome measures for UAE, which will allow patient centred data to be pooled and compared, as has been achieved with the International Prostate Symptom Score (IPSS) for prostate artery embolization.”
While the study investigators conclude that UAE is safe and effective in the treatment of uterine fibroids of various sizes, they highlight “the heterogeneous methods used by included studies in assessing symptom severity and quality of life pre- and post-UAE”. None of the included papers used a validated measure such as the uterine fibroid symptom and health-related quality of life (UFS-QoL) questionnaire. Instead, each publication utilised their own local questionnaires, which Llewellyn and co-authors say “prevented direct comparison between studies”, missing a valuable opportunity to pool patient related outcome measures for UAE.