Minimally Invasive Therapy. 2014;23:361–365
ORIGINAL ARTICLE
Combined myomectomy and uterine artery embolization
BRUCE MCLUCAS1 & WILLIAM D. VOORHEES III2 1
Department of Obstetrics and Gynecology, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA, and 2Med Institute, Inc., West Lafayette, IN, USA
Abstract Objective: To evaluate the safety and efficacy of uterine artery embolization combined with endoscopic myomectomy. Material and methods: We conducted a retrospective chart review of patients (n = 125) who underwent myomectomy concurrent with embolization within one month. We assessed two groups: 1) uterine artery embolization followed by hysteroscopic myomectomy and 2) uterine artery embolization followed by laparoscopic myomectomy. Results: Following the combination procedures, 72% of the surveyed women reported symptom improvement. With the combined procedures, 92.5% of patients experienced reduction in myoma diameter and 87.5% of patients had decreased uterine size after an average of 4.70 months post subsequent procedure. The amount of decrease in the uterine volume (p = 0.39) and fibroid size (p = 0.23) were not significant between the two endoscopic myomectomy groups. Conclusions: Combining myomectomy with uterine artery embolization is a safe and effective procedure in treating symptoms and reducing myoma and uterine volumes.
Key words: Embolization, hysteroscopic, laparoscopic, myomata, myomectomy
Introduction In most cases, uterine artery embolization (UAE) is a stand-alone procedure, effectively treating myomata with a low rate of complications and good long-term results (1,2). Embolization offers physicians and their patients several advantages compared to myomectomy alone. Advantages offered include decreased blood loss, decreased chance for fluid overload in hysteroscopic myomectomy (HM), and removal of potentially larger myomas. However, there are some cases where UAE alone may not be sufficient in treating patients. A combination procedure is considered (3) in the following circumstances: Large peduncuated subsersosal myoma may be considered a contraindication for UAE alone because of risks including necrosis, torsion at the stalk and separating from the uterus (4,5). Pedunculated submucous myomas are at risk of vaginal prolapse, and some authors consider UAE alone to be contraindicated in such
cases (6-8). Large myomata, a uterus extending to or above the umbilicus, may not shrink enough to give symptom relief after UAE (9,10). Studies have shown that combining UAE with myomectomy for selected patients may allow technical ease in removing myomas. The literature has revealed less blood loss during myomectomy procedures. With UAE prior to myomectomy, studies have shown that complications are less likely to occur (3,5). Furthermore, after UAE, with or without myomectomy, patients experience the high likelihood of no recurrence of myomata compared to myomectomy without embolization (11-13). We offered myomectomy in combination with UAE to selected patients where UAE alone would likely be inadequate for resolution of myoma symptoms. For patients with pedunculated submucous myomas, hysteroscopic myomectomy (HM) was scheduled after UAE to decrease the risk of prolapse (14). For patients with pedunculated subserosal
Correspondence: B. McLucas, 450 Roxbury Dr. Ste. 275, Beverly Hills, CA 90210, USA. Tel: +1 310 208 2442. Fax: +1 310 208 2621. E-mail: [email protected] ISSN 1364-5706 print/ISSN 1365-2931 online 2014 Informa Healthcare DOI: 10.3109/13645706.2014.939589
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myomas, laparoscopic myomectomy (LM) was performed following UAE to reduce the risk of necrosis, adhesion formation, and torsion (15,16). Does combining the two procedures, UAE and myomectomy, instead of myomectomy alone increase morbidity? Prior case reports (17,18) have indicated no additional morbidity combining myomectomy and UAE. Yet, no larger scale study has been undertaken. We report our results in such a large group of patients.
assessed. Follow-up data such as uterine, fibroid size, and a symptom improvement survey were also collected approximately three to six months post combination procedure. Statistical comparisons were made using JMP version 9.02 (SAS Institute, Cary, NC, USA). Statistical significance was determined with p value < 0.05.
Results Material and methods A retrospective chart review of patients was performed in a private practice setting in Los Angeles. The same physician performed UAE for all patients. The technique is as follows: Under local anesthetic and conscious sedation, a small incision was made in the right groin for catheter insertion in the femoral artery. Polyvinyl alcohol particles (PVA) of 500 microns or larger were injected into the vessels to block blood supply to the myoma. Patients were observed overnight in many cases. Patients were informed of any potential risks associated with UAE in combination with myomectomy. No institutional review board (IRB) approval was sought because the risks and benefits of combination procedures as well as individual procedures were well known to these patients. All patients gave written and verbal consent for complications including but not limited to conversion to hysterectomy, failure of UAE, early menopause, and possible complications during or after pregnancy. Patients who were candidates for traditional myomectomies were offered the combination procedure and notified of the risks and benefits. Those who consented to the combination procedure were included into the study. Inclusion criteria comprised of patients who had one of two types of myomectomies following UAE: Hysteroscopic (UAE-HM) or laparoscopic (UAE-LM) myomectomy concurrent with embolization. Women were offered UAE-HM to reduce their risk of necrosis. UAE-LM was offered to patients to reduce their risk of infarction. Added morbidity was defined as an increase in postoperative hospital stay, blood transfusion, or other associated complications from myomectomy alone. If symptoms persisted or no reduction in myoma diameter existed, we considered reintervention procedures such as repeat UAE, myomectomy, or hysterectomy, depending on the patient’s needs. Appropriate type of concurrent myomectomy procedure was assessed using physical examination, patient history, and imaging prior to embolization (MRI or ultrasound). Measurements of estimated blood loss, infection, fluoroscopy times, and hospital stay were
During the study period, 1999 to 2013, the total number of patients who underwent embolization was 1671. Of those patients, 126 women (7.54% of total) had a scheduled myomectomy within one month following UAE. These 125 patients are the subject of this study. Most patients reported having bulk symptoms such as pain, pelvic pressure, and excessive bleeding. The mean age of patients at the time of myomectomy was 41.7 years (range 26–54). One hundred fourteen of the patients had UAE and myomectomy treatments on the same day. Of the women who had same day surgery 41.6% (n = 52) had UAE-HM and 49.2% (n = 62) had UAE-LM. Table I shows detailed measurements for all patients in the study. Fifty-six women (44.8%, 56/125) received UAEHM for treatment of submucous myoma. Sixty-nine patients (55.2%, 69/125) underwent UAE-LM for excision of pedunculated subserous myoma. All patients had at least two myomas. For the UAEHM group, an average of 21.42 ± 36.26 g (range 1.0–221 g) of myoma tissue was removed. In the
Table I. Average measurements in total patients in study group. Outcome measurement
Average measurements for total number of patients in study
Uterine volume pre combined procedures (cm3)
521.62
Uterine volume post combined procedures (cm3)
325.29
Myoma diameter pre combined procedures (cm)
6.64
Myoma diameter post combined procedures (cm)
4.52
Myoma tissue removed (g)
80.28
Total fluoroscopy time (min)
16.45
Hospital stay (days) Blood loss (mL) Time between UAE and myomectomy (days)
1.29 13.36 0.68
Combined myomectomy and UAE
363
Table II. Comparison of average measurements between the two different myomectomy combination procedures by analysis of variance. Outcome measure 3
Uterine volume (cm )
UAE-HM (n = 56)
UAE-LM (n = 69)
520.9 ± 436.3
522.2 ± 436.6
6.09 ± 2.34
7.10 ± 2.84
Uterine volume decrease (%)
25.95 ± 8.44
39.70 ± 6.14
Myoma diameter decrease (%)
34.03 ± 5.30
24.49 ± 4.02
p = 0.23
Myoma tissue removed (g)
21.27 ± 40.45
120.09 ± 187.90
p = 0.0002*
Myoma diameter (cm)
Hospital stay (days) Blood loss (mL)
1.4 ± 0.9 10.36 ± 1.9
UAE-LM group, average weight of tissue removed was 120.09 ± 189.90 g (range 2.20–776 g). All patients experienced a uterine volume and myoma reduction of 40.0% and 31.5%, respectively after an average of 4.70 months post combination procedures. Of the surveys that were collected post combined procedures, 72% reported symptom improvement, 92.5% had a reduction in myoma diameter and 87.5% of patients had decreased uterine volume. Reduction in myoma diameter and uterine volume were verified with MRI or pelvic ultrasound. Although patients in both groups showed a reduction in myoma diameter (p = 0.23) and uterine volume (p = 0.39), the differences between the UAE-HM and UAE-LM groups were not significant. In addition, both UAE-HM and UAE-LM groups had blood loss (p > 0.05) and hospital stay (p > 0.05) that were not statistically significant between the two groups. Table II shows a detailed comparison with p-values of the average measurements for patients in each of the two groups, UAE-HM, UAE-LM. All women who received combined UAE and myomectomy experienced no complications, such as conversion to hysterectomy, blood transfusions, or infection. A total of seven patients were admitted due to fever or pain from post embolization. Of these patients, four complained of fever between two to six days post UAE, and three patients complained of uncontrolled pain one day following embolization. None of these patients experienced an infection, and their admissions were likely secondary to the UAE procedure. Patients who were admitted likely experienced symptoms that they would have experienced from UAE alone. Eleven of the 125 patients underwent a second procedure post UAE combined with myomectomy.
Discussion This study suggests combining UAE with myomectomy as a viable option for selected women in whom
p = 0.39
1.2 ± 0.7 15.8 ± 24.8
UAE or endoscopic myomectomy alone could be associated with high risk of clinical failure. There is no added hospital stay, blood loss, and a reduced risk of recurrence. The UAE-HM and UAE-LM groups both experienced similar reductions in both the uterine volume and myoma size following the combination procedure. Thus, this suggests that the combination procedure can obtain successful results for more than one type of myomectomy combined with UAE. For women who undergo myomectomy, there is an increased chance of recurrence as well as a risk of conversion to hysterectomy (17). Our study has shown that there are less complications and recurrence of myomas. In our previous study, reduction in uterine volume and myoma diameter seen in UAE alone provided similar results compared to this study. In our previous study, there was a 42.8% reduction in uterine volume and a 48.8% decrease in myoma diameter for UAE alone (19). Although these percentages were slightly larger than the ones seen in our cohort, the measurements were reported at an average of 10.2 months post UAE. Our study had a decrease of 40.0% in uterine volume and a 31.5% reduction in myoma diameter after only an average of 4.70 months post combined procedures. With increased intervals in follow-up time, we expect the percentage reduction to be much larger. UAE prior to myomectomy is a valid procedure for reducing blood loss, complications, and easing the removal of myomas due to a bloodless field (17). Our study reported the average blood loss for the UAE-HM group to be 10.4 mL as opposed to a blood loss ranging from 80–93 mL reported in the literature for patients who underwent HM alone (20). This indicates reduced blood loss as a benefit from the combined procedure. For the UAEHM group, removal of significantly reduced myoma volume and ease of uterine suturing may decrease the possibility of conversion to hysterectomy (21). The avascular state of the uterus promotes easier removal of myomas and lowers risk for complications. (13). This combination procedure may also decrease
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hospital stay, as many potential postoperative complications may be avoided (17). For the UAE-LM group, decreased blood loss to the uterus allows for laparoscopic removal of larger myomas (22). This study found that UAE-LM reduces the risk of blood loss with patients having a blood loss of 15.88 mL. A series of studies reported an estimated blood loss for LM alone ranging from 84–240 mL (22-25), which appears larger than UAE-LM. Rather than undergoing myomectomy alone and having the risk of recurrence, the combination procedure offers patients reduced blood loss, reduced risk of recurrence, and a minimally invasive surgery. The average amount of myoma tissue (120.09 g) removed was significantly larger (p = 0.0002) than the amount removed by UAEHM (21.27 g). Furthermore, compared to other studies, this seems to be greater than the average specimens removed by LM (87.2 g) alone (26). For selective patients, LM is the preferred method for myomectomy because of shorter hospital stays, reduced postoperative pain, and a decreased risk of adhesions (22). Indeed, we found the average hospital stay to be 1.2 days for the UAE-LM group, which is also similar to hospital stay for UAE-HM and for UAE alone (27). Other studies have reported hospital stay ranging from 2.1–3.5 days (22,23,28) for patients with LM alone. Shorter hospital stays also lower medical cost for patients (13). The average cost for UAE varies, however, is definitely less than the cost for hospitalization after hysterectomy (29-31). It should be noted that with the combination procedure, no blood transfusion is needed and there is a lower risk of complication that may cause a longer hospital stay (17). There are some limitations to this study. Since this was a retrospective chart review, there may have been some selection bias. Some charts from the earlier years of this study contain data that are no longer accessible In addition, there was no control study conducted to have a group of patients with UAE alone during the same time period as the study. With comparisons made to other studies, there may have been some operative differences. For future studies, a study comparing our own myomectomy only patients with patients undergoing the combination procedure should be investigated. More efforts are needed for follow-ups with these patients to have more accurate reports of any post-operative complications. Additional investigation is needed to determine the recurrence rate of combining UAE with myomectomy.
Acknowledgements The authors would like to acknowledge Katherine Chua, Stephanie Elliott, and Calvin Dunn for
their contribution to this research and manuscript preparation. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Walker WJ, Barton-Smith P. Long-term follow up of uterine artery embolisation–an effective alternative in the treatment of fibroids. BJOG. 2006;113:464–8. 2. Spies JB, Cornell C, Worthington-Kirsch R, Lipman JC, Benenati JF. Long-term outcome from uterine fibroid embolization with tris-acryl gelatin microspheres: results of a multicenter study. J Vasc Interv Radiol. 2007;18:203–7. 3. Malartic C, Morel O, Fargeaudou Y, Le Dref O, Fazel A, Barranger E, et al. Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience. Eur J Radiol. 2012;81:1–5. 4. Paxton BE, Lee JM, Kim HS. Treatment of intrauterine and large pedunculated subserosal leiomyomata with sequential uterine artery embolization and myomectomy. J Vasc Interv Radiol. 2006;17:1947–50. 5. Goldman KN, Hirshfeld-Cytron JE, Pavone ME, Thomas AP, Vogelzang RL, Milad MP. Uterine artery embolization immediately preceding laparoscopic myomectomy. Int J Gynaecol Obstet. 2012;116:105–8. 6. Levy BS. Modern management of uterine fibroids. Acta Obstet Gynecol Scand. 2008;87:812–23. 7. Lupattelli T, Basile A, Garaci FG, Simonetti G. Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status. Eur J Radiol. 2005;54:136–47. 8. Rajan DK, Margau R, Kroll RR, Simonis ME, Tan KT, Jaskolka JD, et al. Clinical utility of ultrasound versus magnetic resonance imaging for deciding to proceed with uterine artery embolization for presumed symptomatic fibroids. Clin Radiol. 2011;66:57–62. 9. Bajekal N, Li TC. Fibroids, infertility and pregnancy wastage. Hum Reprod Update. 2000;6:614–20. 10. Somigliana E, Vercellini P, Daguati R, Pasin R, De Giorgi O, Crosignani PG. Fibroids and female reproduction: a critical analysis of the evidence. Hum Reprod Update. 2007;13: 465–76. 11. Ngeh N, Belli AM, Morgan R, Manyonda I. Pre-myomectomy uterine artery embolisation minimises operative blood loss. BJOG. 2004;111:1139–40. 12. Serradilla LN, Gámez-Rios MA, Nicolás C, Rámon y Cajal L. Embolization before surgery of a large pedunculated submucosal myoma prolapsed into the vagina. Acta Obstet Gynecol Scand. 2011;90:554–5. 13. Butori N, Tixier H, Filipuzzi L, Mutamba W, Guiu B, Cercueil JP, et al. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids. Eur J Radiol. 2011;79:1–6. 14. van der Kooij SM, Ankum WM, Hehenkamp WJ. Review of nonsurgical/minimally invasive treatments for uterine fibroids. Curr Opin Obstet Gynecol. 2012;24:368–75. 15. Al-Fozan H, Tulandi T. Factors affecting early surgical intervention after uterine artery embolization. Obstet Gynecol Surv. 2002;57:810–15.
Combined myomectomy and UAE 16. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol. 2005;184:399–402. 17. Dumousset E, Chabrot P, Rabishong B, Mazet N, Nasser S, Darcha C, et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol. 2008;31:514–20. 18. Kahn V, Pelage JP, Marret H. [Uterine artery embolization for myomas treatment]. Presse Med. 2013;42:1127–32. 19. Goodwin SC, McLucas B, Lee M, Chen G, Perrella R, Vedantham S, et al. Uterine artery embolization for the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol. 1999;10:1159–65. 20. Magos AL, Baumann R, Lockwood GM, Turnbul AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet. 1991;337:1074–8. 21. Tixier H, Loffroy R, Filipuzzi L, Grevoul J, Mutamba W, Cercueil JP, et al. [Uterine artery embolization with resorbable material prior to myomectomy]. J Radiol. 2008;89:1925–9. 22. Madhuri TK, Kamran W, Walker W, Butler-Manuel S. Synchronous uterine artery embolization and laparoscopic myomectomy for massive uterine leiomyomas. JSLS. 2010;14:120–2. 23. Seinera P, Arisio R, Decko A, Farina C, Crana F. Laparoscopic myomectomy: indications, surgical technique and complications. Hum Reprod. 1997;12:1927–30. 24. Stringer NH, Walker JC, Meyer PM. Comparison of 49 laparoscopic myomectomies with 49 open myomectomies. J Am Assoc Gynecol Laparosc. 1997;4:457–64.
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25. Advincula AP, Xu X, Goudeau S, Ransom SB. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14:698–705. 26. Takeuchi H, Kuwatsuru R. The indications, surgical techniques, and limitations of laparoscopic myomectomy. JSLS. 2003;7:89–95. 27. McLucas B, Adler L. Uterine fibroid embolization compared with myomectomy. Int J Gynaecol Obstet. 2001; 74:297–9. 28. Darai E, Dechaud H, Benifla JL, Renolleau C, Panel P, Madelenat P. Fertility after laparoscopic myomectomy: preliminary results. Hum Reprod. 1997;12:1931–4. 29. Volkers NA, Hehenkamp WJK, Smit P, Ankum WM, Reekers JA, Birnie E. Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. J Vasc Interv Radiol. 2008;19:1007–16; quiz 1017. 30. Pourrat X.J, Fourquet F, Guerif F, Viratelle N, Herbreteau D, Marret H. Medico-economic approach to the management of uterine myomas: a 6-month costeffectiveness study of pelvic embolization versus vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2003; 111:59–64. 31. Subramanian S, Spies JB. Uterine artery embolization for leiomyomata: resource use and cost estimation. J Vasc Interv Radiol. 2001;12:571–4.
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ORIGINAL ARTICLE
Combined myomectomy and uterine artery embolization
BRUCE MCLUCAS1 & WILLIAM D. VOORHEES III2 1
Department of Obstetrics and Gynecology, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA, and 2Med Institute, Inc., West Lafayette, IN, USA
Abstract Objective: To evaluate the safety and efficacy of uterine artery embolization combined with endoscopic myomectomy. Material and methods: We conducted a retrospective chart review of patients (n = 125) who underwent myomectomy concurrent with embolization within one month. We assessed two groups: 1) uterine artery embolization followed by hysteroscopic myomectomy and 2) uterine artery embolization followed by laparoscopic myomectomy. Results: Following the combination procedures, 72% of the surveyed women reported symptom improvement. With the combined procedures, 92.5% of patients experienced reduction in myoma diameter and 87.5% of patients had decreased uterine size after an average of 4.70 months post subsequent procedure. The amount of decrease in the uterine volume (p = 0.39) and fibroid size (p = 0.23) were not significant between the two endoscopic myomectomy groups. Conclusions: Combining myomectomy with uterine artery embolization is a safe and effective procedure in treating symptoms and reducing myoma and uterine volumes.
Key words: Embolization, hysteroscopic, laparoscopic, myomata, myomectomy
Introduction In most cases, uterine artery embolization (UAE) is a stand-alone procedure, effectively treating myomata with a low rate of complications and good long-term results (1,2). Embolization offers physicians and their patients several advantages compared to myomectomy alone. Advantages offered include decreased blood loss, decreased chance for fluid overload in hysteroscopic myomectomy (HM), and removal of potentially larger myomas. However, there are some cases where UAE alone may not be sufficient in treating patients. A combination procedure is considered (3) in the following circumstances: Large peduncuated subsersosal myoma may be considered a contraindication for UAE alone because of risks including necrosis, torsion at the stalk and separating from the uterus (4,5). Pedunculated submucous myomas are at risk of vaginal prolapse, and some authors consider UAE alone to be contraindicated in such
cases (6-8). Large myomata, a uterus extending to or above the umbilicus, may not shrink enough to give symptom relief after UAE (9,10). Studies have shown that combining UAE with myomectomy for selected patients may allow technical ease in removing myomas. The literature has revealed less blood loss during myomectomy procedures. With UAE prior to myomectomy, studies have shown that complications are less likely to occur (3,5). Furthermore, after UAE, with or without myomectomy, patients experience the high likelihood of no recurrence of myomata compared to myomectomy without embolization (11-13). We offered myomectomy in combination with UAE to selected patients where UAE alone would likely be inadequate for resolution of myoma symptoms. For patients with pedunculated submucous myomas, hysteroscopic myomectomy (HM) was scheduled after UAE to decrease the risk of prolapse (14). For patients with pedunculated subserosal
Correspondence: B. McLucas, 450 Roxbury Dr. Ste. 275, Beverly Hills, CA 90210, USA. Tel: +1 310 208 2442. Fax: +1 310 208 2621. E-mail: [email protected] ISSN 1364-5706 print/ISSN 1365-2931 online 2014 Informa Healthcare DOI: 10.3109/13645706.2014.939589
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myomas, laparoscopic myomectomy (LM) was performed following UAE to reduce the risk of necrosis, adhesion formation, and torsion (15,16). Does combining the two procedures, UAE and myomectomy, instead of myomectomy alone increase morbidity? Prior case reports (17,18) have indicated no additional morbidity combining myomectomy and UAE. Yet, no larger scale study has been undertaken. We report our results in such a large group of patients.
assessed. Follow-up data such as uterine, fibroid size, and a symptom improvement survey were also collected approximately three to six months post combination procedure. Statistical comparisons were made using JMP version 9.02 (SAS Institute, Cary, NC, USA). Statistical significance was determined with p value < 0.05.
Results Material and methods A retrospective chart review of patients was performed in a private practice setting in Los Angeles. The same physician performed UAE for all patients. The technique is as follows: Under local anesthetic and conscious sedation, a small incision was made in the right groin for catheter insertion in the femoral artery. Polyvinyl alcohol particles (PVA) of 500 microns or larger were injected into the vessels to block blood supply to the myoma. Patients were observed overnight in many cases. Patients were informed of any potential risks associated with UAE in combination with myomectomy. No institutional review board (IRB) approval was sought because the risks and benefits of combination procedures as well as individual procedures were well known to these patients. All patients gave written and verbal consent for complications including but not limited to conversion to hysterectomy, failure of UAE, early menopause, and possible complications during or after pregnancy. Patients who were candidates for traditional myomectomies were offered the combination procedure and notified of the risks and benefits. Those who consented to the combination procedure were included into the study. Inclusion criteria comprised of patients who had one of two types of myomectomies following UAE: Hysteroscopic (UAE-HM) or laparoscopic (UAE-LM) myomectomy concurrent with embolization. Women were offered UAE-HM to reduce their risk of necrosis. UAE-LM was offered to patients to reduce their risk of infarction. Added morbidity was defined as an increase in postoperative hospital stay, blood transfusion, or other associated complications from myomectomy alone. If symptoms persisted or no reduction in myoma diameter existed, we considered reintervention procedures such as repeat UAE, myomectomy, or hysterectomy, depending on the patient’s needs. Appropriate type of concurrent myomectomy procedure was assessed using physical examination, patient history, and imaging prior to embolization (MRI or ultrasound). Measurements of estimated blood loss, infection, fluoroscopy times, and hospital stay were
During the study period, 1999 to 2013, the total number of patients who underwent embolization was 1671. Of those patients, 126 women (7.54% of total) had a scheduled myomectomy within one month following UAE. These 125 patients are the subject of this study. Most patients reported having bulk symptoms such as pain, pelvic pressure, and excessive bleeding. The mean age of patients at the time of myomectomy was 41.7 years (range 26–54). One hundred fourteen of the patients had UAE and myomectomy treatments on the same day. Of the women who had same day surgery 41.6% (n = 52) had UAE-HM and 49.2% (n = 62) had UAE-LM. Table I shows detailed measurements for all patients in the study. Fifty-six women (44.8%, 56/125) received UAEHM for treatment of submucous myoma. Sixty-nine patients (55.2%, 69/125) underwent UAE-LM for excision of pedunculated subserous myoma. All patients had at least two myomas. For the UAEHM group, an average of 21.42 ± 36.26 g (range 1.0–221 g) of myoma tissue was removed. In the
Table I. Average measurements in total patients in study group. Outcome measurement
Average measurements for total number of patients in study
Uterine volume pre combined procedures (cm3)
521.62
Uterine volume post combined procedures (cm3)
325.29
Myoma diameter pre combined procedures (cm)
6.64
Myoma diameter post combined procedures (cm)
4.52
Myoma tissue removed (g)
80.28
Total fluoroscopy time (min)
16.45
Hospital stay (days) Blood loss (mL) Time between UAE and myomectomy (days)
1.29 13.36 0.68
Combined myomectomy and UAE
363
Table II. Comparison of average measurements between the two different myomectomy combination procedures by analysis of variance. Outcome measure 3
Uterine volume (cm )
UAE-HM (n = 56)
UAE-LM (n = 69)
520.9 ± 436.3
522.2 ± 436.6
6.09 ± 2.34
7.10 ± 2.84
Uterine volume decrease (%)
25.95 ± 8.44
39.70 ± 6.14
Myoma diameter decrease (%)
34.03 ± 5.30
24.49 ± 4.02
p = 0.23
Myoma tissue removed (g)
21.27 ± 40.45
120.09 ± 187.90
p = 0.0002*
Myoma diameter (cm)
Hospital stay (days) Blood loss (mL)
1.4 ± 0.9 10.36 ± 1.9
UAE-LM group, average weight of tissue removed was 120.09 ± 189.90 g (range 2.20–776 g). All patients experienced a uterine volume and myoma reduction of 40.0% and 31.5%, respectively after an average of 4.70 months post combination procedures. Of the surveys that were collected post combined procedures, 72% reported symptom improvement, 92.5% had a reduction in myoma diameter and 87.5% of patients had decreased uterine volume. Reduction in myoma diameter and uterine volume were verified with MRI or pelvic ultrasound. Although patients in both groups showed a reduction in myoma diameter (p = 0.23) and uterine volume (p = 0.39), the differences between the UAE-HM and UAE-LM groups were not significant. In addition, both UAE-HM and UAE-LM groups had blood loss (p > 0.05) and hospital stay (p > 0.05) that were not statistically significant between the two groups. Table II shows a detailed comparison with p-values of the average measurements for patients in each of the two groups, UAE-HM, UAE-LM. All women who received combined UAE and myomectomy experienced no complications, such as conversion to hysterectomy, blood transfusions, or infection. A total of seven patients were admitted due to fever or pain from post embolization. Of these patients, four complained of fever between two to six days post UAE, and three patients complained of uncontrolled pain one day following embolization. None of these patients experienced an infection, and their admissions were likely secondary to the UAE procedure. Patients who were admitted likely experienced symptoms that they would have experienced from UAE alone. Eleven of the 125 patients underwent a second procedure post UAE combined with myomectomy.
Discussion This study suggests combining UAE with myomectomy as a viable option for selected women in whom
p = 0.39
1.2 ± 0.7 15.8 ± 24.8
UAE or endoscopic myomectomy alone could be associated with high risk of clinical failure. There is no added hospital stay, blood loss, and a reduced risk of recurrence. The UAE-HM and UAE-LM groups both experienced similar reductions in both the uterine volume and myoma size following the combination procedure. Thus, this suggests that the combination procedure can obtain successful results for more than one type of myomectomy combined with UAE. For women who undergo myomectomy, there is an increased chance of recurrence as well as a risk of conversion to hysterectomy (17). Our study has shown that there are less complications and recurrence of myomas. In our previous study, reduction in uterine volume and myoma diameter seen in UAE alone provided similar results compared to this study. In our previous study, there was a 42.8% reduction in uterine volume and a 48.8% decrease in myoma diameter for UAE alone (19). Although these percentages were slightly larger than the ones seen in our cohort, the measurements were reported at an average of 10.2 months post UAE. Our study had a decrease of 40.0% in uterine volume and a 31.5% reduction in myoma diameter after only an average of 4.70 months post combined procedures. With increased intervals in follow-up time, we expect the percentage reduction to be much larger. UAE prior to myomectomy is a valid procedure for reducing blood loss, complications, and easing the removal of myomas due to a bloodless field (17). Our study reported the average blood loss for the UAE-HM group to be 10.4 mL as opposed to a blood loss ranging from 80–93 mL reported in the literature for patients who underwent HM alone (20). This indicates reduced blood loss as a benefit from the combined procedure. For the UAEHM group, removal of significantly reduced myoma volume and ease of uterine suturing may decrease the possibility of conversion to hysterectomy (21). The avascular state of the uterus promotes easier removal of myomas and lowers risk for complications. (13). This combination procedure may also decrease
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hospital stay, as many potential postoperative complications may be avoided (17). For the UAE-LM group, decreased blood loss to the uterus allows for laparoscopic removal of larger myomas (22). This study found that UAE-LM reduces the risk of blood loss with patients having a blood loss of 15.88 mL. A series of studies reported an estimated blood loss for LM alone ranging from 84–240 mL (22-25), which appears larger than UAE-LM. Rather than undergoing myomectomy alone and having the risk of recurrence, the combination procedure offers patients reduced blood loss, reduced risk of recurrence, and a minimally invasive surgery. The average amount of myoma tissue (120.09 g) removed was significantly larger (p = 0.0002) than the amount removed by UAEHM (21.27 g). Furthermore, compared to other studies, this seems to be greater than the average specimens removed by LM (87.2 g) alone (26). For selective patients, LM is the preferred method for myomectomy because of shorter hospital stays, reduced postoperative pain, and a decreased risk of adhesions (22). Indeed, we found the average hospital stay to be 1.2 days for the UAE-LM group, which is also similar to hospital stay for UAE-HM and for UAE alone (27). Other studies have reported hospital stay ranging from 2.1–3.5 days (22,23,28) for patients with LM alone. Shorter hospital stays also lower medical cost for patients (13). The average cost for UAE varies, however, is definitely less than the cost for hospitalization after hysterectomy (29-31). It should be noted that with the combination procedure, no blood transfusion is needed and there is a lower risk of complication that may cause a longer hospital stay (17). There are some limitations to this study. Since this was a retrospective chart review, there may have been some selection bias. Some charts from the earlier years of this study contain data that are no longer accessible In addition, there was no control study conducted to have a group of patients with UAE alone during the same time period as the study. With comparisons made to other studies, there may have been some operative differences. For future studies, a study comparing our own myomectomy only patients with patients undergoing the combination procedure should be investigated. More efforts are needed for follow-ups with these patients to have more accurate reports of any post-operative complications. Additional investigation is needed to determine the recurrence rate of combining UAE with myomectomy.
Acknowledgements The authors would like to acknowledge Katherine Chua, Stephanie Elliott, and Calvin Dunn for
their contribution to this research and manuscript preparation. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Walker WJ, Barton-Smith P. Long-term follow up of uterine artery embolisation–an effective alternative in the treatment of fibroids. BJOG. 2006;113:464–8. 2. Spies JB, Cornell C, Worthington-Kirsch R, Lipman JC, Benenati JF. Long-term outcome from uterine fibroid embolization with tris-acryl gelatin microspheres: results of a multicenter study. J Vasc Interv Radiol. 2007;18:203–7. 3. Malartic C, Morel O, Fargeaudou Y, Le Dref O, Fazel A, Barranger E, et al. Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience. Eur J Radiol. 2012;81:1–5. 4. Paxton BE, Lee JM, Kim HS. Treatment of intrauterine and large pedunculated subserosal leiomyomata with sequential uterine artery embolization and myomectomy. J Vasc Interv Radiol. 2006;17:1947–50. 5. Goldman KN, Hirshfeld-Cytron JE, Pavone ME, Thomas AP, Vogelzang RL, Milad MP. Uterine artery embolization immediately preceding laparoscopic myomectomy. Int J Gynaecol Obstet. 2012;116:105–8. 6. Levy BS. Modern management of uterine fibroids. Acta Obstet Gynecol Scand. 2008;87:812–23. 7. Lupattelli T, Basile A, Garaci FG, Simonetti G. Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status. Eur J Radiol. 2005;54:136–47. 8. Rajan DK, Margau R, Kroll RR, Simonis ME, Tan KT, Jaskolka JD, et al. Clinical utility of ultrasound versus magnetic resonance imaging for deciding to proceed with uterine artery embolization for presumed symptomatic fibroids. Clin Radiol. 2011;66:57–62. 9. Bajekal N, Li TC. Fibroids, infertility and pregnancy wastage. Hum Reprod Update. 2000;6:614–20. 10. Somigliana E, Vercellini P, Daguati R, Pasin R, De Giorgi O, Crosignani PG. Fibroids and female reproduction: a critical analysis of the evidence. Hum Reprod Update. 2007;13: 465–76. 11. Ngeh N, Belli AM, Morgan R, Manyonda I. Pre-myomectomy uterine artery embolisation minimises operative blood loss. BJOG. 2004;111:1139–40. 12. Serradilla LN, Gámez-Rios MA, Nicolás C, Rámon y Cajal L. Embolization before surgery of a large pedunculated submucosal myoma prolapsed into the vagina. Acta Obstet Gynecol Scand. 2011;90:554–5. 13. Butori N, Tixier H, Filipuzzi L, Mutamba W, Guiu B, Cercueil JP, et al. Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids. Eur J Radiol. 2011;79:1–6. 14. van der Kooij SM, Ankum WM, Hehenkamp WJ. Review of nonsurgical/minimally invasive treatments for uterine fibroids. Curr Opin Obstet Gynecol. 2012;24:368–75. 15. Al-Fozan H, Tulandi T. Factors affecting early surgical intervention after uterine artery embolization. Obstet Gynecol Surv. 2002;57:810–15.
Combined myomectomy and UAE 16. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol. 2005;184:399–402. 17. Dumousset E, Chabrot P, Rabishong B, Mazet N, Nasser S, Darcha C, et al. Preoperative uterine artery embolization (PUAE) before uterine fibroid myomectomy. Cardiovasc Intervent Radiol. 2008;31:514–20. 18. Kahn V, Pelage JP, Marret H. [Uterine artery embolization for myomas treatment]. Presse Med. 2013;42:1127–32. 19. Goodwin SC, McLucas B, Lee M, Chen G, Perrella R, Vedantham S, et al. Uterine artery embolization for the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol. 1999;10:1159–65. 20. Magos AL, Baumann R, Lockwood GM, Turnbul AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet. 1991;337:1074–8. 21. Tixier H, Loffroy R, Filipuzzi L, Grevoul J, Mutamba W, Cercueil JP, et al. [Uterine artery embolization with resorbable material prior to myomectomy]. J Radiol. 2008;89:1925–9. 22. Madhuri TK, Kamran W, Walker W, Butler-Manuel S. Synchronous uterine artery embolization and laparoscopic myomectomy for massive uterine leiomyomas. JSLS. 2010;14:120–2. 23. Seinera P, Arisio R, Decko A, Farina C, Crana F. Laparoscopic myomectomy: indications, surgical technique and complications. Hum Reprod. 1997;12:1927–30. 24. Stringer NH, Walker JC, Meyer PM. Comparison of 49 laparoscopic myomectomies with 49 open myomectomies. J Am Assoc Gynecol Laparosc. 1997;4:457–64.
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25. Advincula AP, Xu X, Goudeau S, Ransom SB. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14:698–705. 26. Takeuchi H, Kuwatsuru R. The indications, surgical techniques, and limitations of laparoscopic myomectomy. JSLS. 2003;7:89–95. 27. McLucas B, Adler L. Uterine fibroid embolization compared with myomectomy. Int J Gynaecol Obstet. 2001; 74:297–9. 28. Darai E, Dechaud H, Benifla JL, Renolleau C, Panel P, Madelenat P. Fertility after laparoscopic myomectomy: preliminary results. Hum Reprod. 1997;12:1931–4. 29. Volkers NA, Hehenkamp WJK, Smit P, Ankum WM, Reekers JA, Birnie E. Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. J Vasc Interv Radiol. 2008;19:1007–16; quiz 1017. 30. Pourrat X.J, Fourquet F, Guerif F, Viratelle N, Herbreteau D, Marret H. Medico-economic approach to the management of uterine myomas: a 6-month costeffectiveness study of pelvic embolization versus vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2003; 111:59–64. 31. Subramanian S, Spies JB. Uterine artery embolization for leiomyomata: resource use and cost estimation. J Vasc Interv Radiol. 2001;12:571–4.
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