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#Grand Rounds

What Uterine-Sparing Treatment for Fibroids Has the Best Outcomes?

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BACKGROUND:

  • Interventions to remove fibroids but retain the uterus include
    • Uterine artery embolization (UAE)
    • Radiofrequency ablation (RFA)
    • (Laparoscopic) ligation and cryoablation
    • High-intensity focused ultrasound (HIFU)
  • Sandberg et al. (Fertility and Sterility, 2018) compared the efficacy of uterine-sparing treatment options for fibroids

METHODS:

  • Systematic review and meta-analysis
  • Participants: Women with uterine fibroids undergoing a uterine-sparing intervention
  • Primary outcomes
    • Reintervention risk after uterine-sparing treatment for fibroids after 12, 36, and 60 months
    • Quality of life outcomes, based on validated questionnaires (scale 0 to 100)
      • Severity Symptom Score (SSS): Score decreases with improvement
      • Health-Related Quality of Life questionnaire (HRQL): Score increases with improvement
    • The first group of procedures used an abdominal approach
      • Myomectomy (abdominal, laparoscopic and robotic combined)
      • Uterine artery embolization (UAE)
      • Artery ligation
      • High-intensity focused ultrasound (HIFU)
      • Laparoscopic radiofrequency ablation (RFA)
      • Cryoablation
    • The second group of procedures used a hysteroscopic approach, used for intracavitary fibroids
      • Hysteroscopic myomectomy
      • Hysteroscopic RFA

Results:

  • The analyses included 85 articles, totaling 17,789 women
  • 87% of women had abdominal approach and 12.2% had a hysteroscopic approach
  • Reintervention risk after 12 months
    • Varied from 0.3% (laparoscopic RFA, 95% CI 0–1.6%) up to 15% (cryoablation, 1 study)
  • Reintervention risk after 36 months
    • Varied from 1.2% (myomectomy, 95% CI 0–5.2%, 4 studies) to 34.7% (HIFU, 95% CI 27.3%–42.4%, 4 studies)
  • Reintervention risk after 60 months was
    • Myomectomy: 12.2% (95% CI 5.2%–21.2%)
    • UAE: 14.4% (95% CI 9.8%–19.6%)
    • HIFU: 53.9% (95% CI 47.2%–60.4%)
    • 7% (95% CI 4.8%–9.5%) for hysteroscopic myomectomy
  • No studies were available at 60 months for artery ligation, laparoscopic RFA, and cryoablation
  • Quality of life improved after treatment for all options
  • The HIFU procedure had the least favorable outcomes
  • Subanalysis for hysterectomy as reintervention
    • At 36 months, hysterectomy reintervention varied from 0.6% (myomectomy) to 8.1% (laparoscopic RFA)
    • at 60 months, hysterectomy reintervention was as follows
      • Myomectomy: 7%
      • UAE: 9.4%
      • HIFU 22.2%

Conclusions:

  • Reintervention was greatest for HIFU to treat fibroids
  • The authors point out that
    • Population selection may be an issue in the HIFU studies
    • Although HIFU is FDA approved since 2004 and morbidity is low, more study may be warranted, especially long-term outcomes
    • Hysterectomy reintervention following UAE was <10%
    • Available evidence did not allow for adjustments based on infertility as an indication for treatment

Learn More – Primary Sources

Reintervention risk and quality of life outcomes after uterine-sparing interventions for fibroids: a systematic review and meta-analysis

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Related ObG Topics:

High-Intensity Ultrasound for Fibroids – What are the Pregnancy Outcomes?
Are Fibroids Associated with Miscarriage?
Ulipristal Acetate: A New Treatment for Symptomatic Uterine Fibroids?
Uterine Artery Embolization or Focused Ultrasound for Uterine Fibroids?

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