The role of uterine artery embolisation in the management of symptomatic fibroids is established but not always readily available. What are the factors behind this?
Uterine fibroids or leiomyomata are the most common tumours of the female reproductive system1
cent depending on age/menstrual status and race2 .
. The overall incidence is approximated at between 20 -70 per . Whilst fibroids are benign and
asymptomatic in the majority, they can cause debilitating symptoms, including heavy and painful periods, and pressure symptoms3,4
Pharmacological management is usually the first line treatment with anti-inflammatory hormone therapy or gonadotrophin releasing hormone agonists5
. Depending on
the type of fibroid and individual patient circumstances, more invasive techniques such as uterine artery embolisation, or surgical options including myomectomy or hysterectomy, may be considered.
UTERINE ARTERY EMBOLISATION – WHERE WE ARE NOW Uterine artery embolisation is an interventional radiological technique involving selective cannulation of both the left and right uterine arteries in turn, and embolisation, usually using particles. This technique was first reported as an alternative to surgical treatment in 1991 by Ravina et al followed by a series by the same group in 19956,7
A prospective fibroid registry from the USA, whilst voluntary and without a control cohort, provided useful data on a large number (n=3160) of fibroid embolisations. Similarly, the UK HOPEFUL12
study involves large numbers (n=1108), but is a
retrospective comparison of UAE with hysterectomy in a matched cohort. Despite all the above variations, the results are more or less comparable across the range of variably powered and designed studies. In summary, UAE is comparable to hysterectomy with regard to quality of life (QoL); the hospital stay and recovery time is shorter with UAE; and the cost-effectiveness at one year favours UAE. On the other hand, symptom control following UAE does not match hysterectomy, with approximately 10 per cent of UAE patients needing a second procedure for symptom control.
Based on current literature at the time, in 2000 the joint working party of the Royal College of Radiologists and the Royal College of Obstetricians and Gynaecologists issued recommendations on the use of uterine artery embolisation in the management of fibroids. These were updated in June 2009 13
. The National Institute of Health and
Clinical Excellence (NICE) has also issued full guidance to the NHS in England, Wales and Scotland on UAE, which was updated just at the end of last year14 figures in the NICE guidelines for the management of heavy menstrual bleeding15
. In addition, UAE .
WHY ARE MORE HYSTERECTOMIES BEING DONE? Hysterectomies are the most common major gynaecological surgery worldwide. Although the numbers of hysterectomies for fibroids have decreased as compared to a decade ago, there are more hysterectomies being done worldwide as compared to all other non-pharmacological techniques.
. Over the last 15 years,
more than 100,000 procedures have been performed in Europe and the USA, with a number of these being part of registries and randomised controlled trials (RCTs).
were hysterectomy8,9
Initial evidence was from single centre cohorts, but were followed by at least four multicentre RCTs published between 2003 and 20088-11 , myomectomy10
and either11 also used in these four RCTs. . The comparison arms . Different primary end points were
In 2005/2006, there were 38,631 hysterectomies performed in NHS hospitals in England & Wales16
constituted the majority of these benign conditions.
The patient The majority of patients who consider non-pharmacological treatment for symptomatic fibroids are older and are likely to have completed their family. Therefore, in this patient group, persistent symptom resolution is more a priority than retention of the uterus. Also, the process of investigation, initial medical management with hormones and/or gonadotrophin releasing hormone (GnRH) analogues, delays resolution. These patients
patients need to Consider uae as safe and effiCient
and approximately 30 per cent of these for benign disease. Fibroids
59 2011
IMAGING & ONCOLOGY
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