Uterine Artery Embolization Versus Myomectomy for Symptomatic Uterine Fibroids

A Cochrane review [Abstract] 1 included 7 studies with a total of 793 subjects. As compared to surgery (hysterectomy or myomectomy), uterine artery embolization (UAE) reduced length of the procedure, hospital stay, and time to resumption of routine activities. Patient satisfaction was similar in both UAE and surgery groups (OR 0.90; 95% CI 0.45 to 1.80; 2 trials, n=295 women, I²=0%, moderate quality evidence). UAE was associated with a higher rate of minor post procedural complications and higher unscheduled visits, but there was no difference in major complications within 1 or 5 years. The rate of further surgical interventions was higher with UAE compared to surgery (within 2 years: OR 3.72; 95% CI 2.28 to 6.04; 6 trials, n=732 women, I²=45%, moderate quality evidence). There was a higher proportion of completely asymptomatic women after myomectomy than after UAE, but the difference was not significant.

A longitudinal retrospective cohort study 2 included 35 631 women with myomectomy (n=13 804; 8 018 abdominal, 941 hysteroscopic, and 4 845 laparoscopic), endometrial ablation (EA, n=17 198), and UAE (n=4 629). Myomectomy had the lowest 12-month reintervention rate (4.2%), followed by UAE (7.0%), then EA (12.4%; both p < 0.001 relative of myomectomy). Estimates of 5-year reintervention rates were 19% for myomectomy (17%, 28%, and 20% for abdominal, hysteroscopic, and laparoscopic, respectively), 33% for EA, and 24% for UAE. EA and UAE had adjusted hazard ratios of 2.63 (95% CI, 2.44 to 2.83) and 1.56 (95% CI, 1.42 to 1.72). Prior anemia, bleeding, pelvic inflammatory disease, and abdominal and pelvic pain increased the hazard of reintervention.

In a Dutch trial all patients with symptomatic uterine fibroids were 1:1 randomly assigned to UAE or hysterectomy. Eventually 81 UAE and 75 hysterectomy were performed. A study 3 assessed the 10-year postintervention outcomes in 131/156 subjects by questionnaires. 5 patients underwent secondary hysterectomy. Generic health-related quality of life remained stable, without differences between both groups. The were no significant difference in urogenital distress inventory, the defecation distress inventory, or in satisfaction between the groups.

A trial 4 assessing the cost-effectiveness of UAE and myomectomy for women with symptomatic uterine fibroids wishing to avoid hysterectomy included 254 women. Over a 2-year time horizon, UAE was associated with higher mean costs (difference £645, 95% CI -1381 to 2580) and lower QALYs (difference -0.09, 95% CI -0.11 to -0.04) when compared with myomectomy. Similar results were observed over the 4-year time horizon. Over 2 years, UAE was associated with higher costs and lower QALYs.

References

• Gupta JK, Sinha A, Lumsden MA et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev 2014;(12):CD005073. [PubMed]
• Davis MR, Soliman AM, Castelli-Haley J et al. Reintervention Rates After Myomectomy, Endometrial Ablation, and Uterine Artery Embolization for Patients with Uterine Fibroids. J Womens Health (Larchmt) 2018;27(10):1204-1214. [PubMed]
• de Bruijn AM, Ankum WM, Reekers JA et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol 2016;215(6):745.e1-745.e12. [PubMed]
• Rana D, Wu O, Cheed V et al. Uterine artery embolisation or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: a cost-utility analysis of the FEMME trial. BJOG 2021;128(11):1793-1802. [PubMed]