Uterine Embolization Research Articles

7954 Patient Experiences with a Multidisciplinary Fibroid Program

<h3>Study Objective</h3> Examine patient experience with fibroid management options before and after consultation at a multidisciplinary fibroid center. <h3>Design</h3> Prospective survey-based descriptive study. <h3>Setting</h3> Multidisciplinary (minimally invasive gynecology and interventional radiology) fibroid center New York, NY. <h3>Patients or Participants</h3> Patients who presented for initial consultation with our fibroid program from July 2021 through January 2022. <h3>Interventions</h3> Patients were offered same day office consultations with a minimally invasive gynecologic surgeon followed by a telemedicine visit with an interventional radiologist within 3 weeks of consult request. Collaborative discussions were held between providers regarding patient care. Patients were asked to complete the survey following both appointments. Data was collected regarding patient demographics, prior evaluation of fibroids, knowledge about treatment options, and overall experience. <h3>Measurements and Main Results</h3> A total of 102 patients completed the survey (response rate 77%). A majority (55.9%) had known about their fibroids for at least two years. Most patients sought out the fibroid program for a 2^nd (28.4%), 3^rd(22.5%) or 4^th (7.8%) opinion. Notably, 35.3% of patients who had previously been seen by a gynecologist were not offered treatment. Of those who had been offered treatment, 24.5% were counseled on medical management with oral contraceptives, 28.4% on surgical options and 5.9% on uterine artery embolization. Nearly all patients (86.3%) endorsed that they would not have sought two separate consultations had it not been for the program. Patients were overall satisfied with their experience; with 95.1% reporting they were more knowledgeable about their options and none reporting the consults created more confusion for them. <h3>Conclusion</h3> Many patients with symptomatic uterine fibroids presenting for additional opinions have not been comprehensively counseled on fibroid management options. A collaborative approach to fibroid management helps to better educate patients about their treatment options, provides an opportunity to be thoroughly counseled by the specialists performing either surgical or interventional procedures, and increases patient satisfaction.

8407 Interstitial Ectopic Pregnancy: A Case Series with Practical Tips for Surgical Management

<h3>Study Objective</h3> To review current treatment options for interstitial ectopic pregnancy (IP), with a focus on surgical treatments. To review outcomes of three surgically managed cases of IP. To demonstrate practical tips for success in laparoscopic management of IP. <h3>Design</h3> A case series presenting three cases of surgically managed IP with guided explanation of surgical intervention using video. <h3>Setting</h3> Academic affiliated community hospital. <h3>Patients or Participants</h3> The 3 cases of IP evaluated and treated over the past year were included in the study. <h3>Interventions</h3> Two patients underwent laparoscopic cornual resection of IP and one patient underwent emergent abdominal repair of ruptured IP. <h3>Measurements and Main Results</h3> Estimated blood loss (EBL) for laparoscopic management of 6-week IP with preoperative uterine artery embolization (UAE) was 20ml; length of post operative length of stay (LOS) was 1 day. EBL for 13-week IP without embolization was 50 ml, post op LOS was 0 days. EBL for ruptured IP repaired via open approach was 1000ml including hemoperitoneum, post operative LOS was 2 days. Beta hCG was trended once per week post operatively for all patients. Both patients undergoing laparoscopic resection had negative HCG by week 4. The patient with ruptured IP had negative hCG by week 8; however, she did not complete testing between week 5-7; at 4 weeks her hCG was 17. <h3>Conclusion</h3> IP is sometimes a difficult diagnosis to make; a high index of suspicion is necessary. Laparoscopic surgery for IP is achievable using similar techniques as laparoscopic myomectomy for limiting perioperative blood loss and repair of the myometrial defect; Ultrasonic scalpel, vasopressin, delayed absorbable barbed suture. IP can often be treated laparoscopically, however laparotomy may be necessary in unstable patients with advanced gestation. Further investigation is necessary to determine the best practice for surgical management of IP.

Management of Hemorrhage during Dilation and Evacuation by Mid-Procedure Laparoscopic Uterine Artery Ligation

<h3>Study Objective</h3> To present a video demonstrating a multidisciplinary technique for managing hemorrhage during a dilation and evacuation (D&E) via intraoperative consult to minimally invasive gynecologic surgery (MIGS) and laparoscopic uterine artery ligation <h3>Design</h3> Case report. <h3>Setting</h3> Operating room at tertiary care center. <h3>Patients or Participants</h3> 37-year-old gravida 5 para 4 at 22 weeks gestation. <h3>Interventions</h3> A video demonstration of a laparoscopic, bilateral uterine artery ligation with pregnancy in situ to control mid-procedure hemorrhage. After initiating the D&E procedure, brisk bleeding was encountering with an estimated blood loss of 1600 mL within minutes. Options for controlling the hemorrhage were limited, as uterotonics or balloon tamponade were not possible with the pregnancy still in situ, and interventional radiology was not available for uterine artery embolization. An urgent, intraoperative consultation to MIGS was placed. A diagnostic laparoscopy was performed to evaluate for placenta accreta, uterine perforation, or other injury. No hemoperitoneum or defect was noted, however given ongoing heavy vaginal bleeding and potential need for a hysterectomy, the decision was made to proceed with uterine artery ligation prior to completion of the D&E procedure. Starting on the left side, the round ligament was incised, and the retroperitoneum was entered. The perirectal space was developed using the horizontal push-spread technique The uterine artery was skeletonized and ligated at its origin with a vascular clip. This was repeated on the contralateral side. Excellent hemostasis was noted, and the D&E was completed under laparoscopic guidance. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Mid-procedure laparoscopic uterine artery ligation is a feasible option for controlling hemorrhage during second trimester dilation and evacuation when more traditional methods are not feasible or unavailable. A multidisciplinary, subspecialty approach to management of gynecologic complications can help optimize safe gynecologic procedures.

8704 Evolving Referral Patterns and Management Following Implementation of a Multidisciplinary Fibroid Center

<h3>Study Objective</h3> Evaluate referral patterns and management of symptomatic fibroids following implementation of a multidisciplinary (minimally invasive gynecologic surgery [MIGS] and interventional radiology [IR]) fibroid center. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Academic medical center in New York, NY. <h3>Patients or Participants</h3> Patients who presented for initial fibroid consultation between January-June 2019 and January-June 2021. Consult providers included general gynecologists (GYN), MIGS, IR and others. <h3>Interventions</h3> In September 2020, our institution established a multidisciplinary fibroid center where patients had same-day consults with both MIGS and IR providers. Data were collected before and after implementation of the program with regards to patient demographics, fibroid characteristics, prior imaging and management, referral patterns, and management after consultation. <h3>Measurements and Main Results</h3> 615 patients met inclusion criteria: 273 patients in 2019 and 342 patients in 2021. Patients seen in 2021 were more likely to have previously tried medical management (30.1% vs 20.2%, p<0.01) and many had no prior treatment (53.2% vs 61.5%, p=0.04). There were more MIGS (65.5% vs 53.1%) and fewer general GYN (19.0% vs 25.6%, p=0.02) consultations in 2021. More patients presented for an additional opinion in 2021 (83.6% vs 67.0%, p<0.01), predominately with MIGS (58.8% vs 37.0%, p<0.01). General GYNs were more likely to refer to MIGS (79.3% vs 73.1%) and IR (16.0% vs 13.0%, p=0.046) in 2021. There was increased utilization of MRI imaging in 2021 among MIGS (66.5% vs 52.4%, p<0.01). Among patients who saw MIGS for consultation in 2021, more underwent uterine artery embolization (UAE) (13.8% vs 6.9%, p=0.04) and fewer underwent diagnostic hysteroscopy/dilation and curettage (11.7% vs 4.5%, p<0.01) within 1 year of consultation. <h3>Conclusion</h3> Many patients with symptomatic fibroids seek specialist opinions regarding their treatment options. A multidisciplinary fibroid management program with coordinated efforts between MIGS and IR allows for comprehensive counseling and may lead to more efficient and timely care and an increase in minimally invasive procedures including UAE.

8506 Surgical Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> A case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position with sponge on ring forceps placed in the vagina. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancythrough transvaginal ultrasound and discuss management options in the late 1^st trimester. We show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with low estimated blood loss during laparoscopic total gravid hysterectomy. Final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st TM ultrasound should be considered inpatients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

Healthcare Cost and Utilization of Uterus-Sparing Interventions in Women with Uterine Fibroids: A Retrospective Claims Analysis

<h3>Study Objective</h3> To describe peri-operative costs and healthcare utilization of four uterus-sparing interventions used to treat women with intramural and/or subserosal uterine fibroids. <h3>Design</h3> Retrospective US insurance claims analysis. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> The IBM MarketScan® Commercial Database was queried to identify 37,730 women with no history of gynecology cancer who underwent a uterus sparing procedure for fibroids between 1/2014-7/2021. Of those, 15,557 patients underwent abdominal myomectomy (AM), 11,896 underwent laparoscopic myomectomy (LM), 9,158 underwent uterine artery embolization (UAE), and 270 underwent laparoscopic radiofrequency ablation (LAP-RFA). The mean age was 36.6 for women undergoing AM, 37.4 for LM, 41.2 for LAP-RFA, and 44.7 for UAE. <h3>Interventions</h3> Abdominal and laparoscopic myomectomy, UAE, LAP-RFA. <h3>Measurements and Main Results</h3> Median perioperative costs, defined as patient out-of-pocket cost and insurance payments, were $11,710 (IQR $7,907, $18,762) for LAP-RFA, $13,774 (IQR $9,132, $21,890) for LM, $15,830 (IQR $11,265, $21,915) for AM and $15,877 (IQR $10,398, $24,193) for UAE patients. Eighty-one percent of AM patients required hospital admission post-operatively, compared with 7% of UAE, 6% of LM, and 1% LAP-RFA patients. Less than 10% of patients had an ER visit within 30 days after the procedure (8% for UAE, 6% for all other interventions). The 1-year re-intervention rate of any subsequent procedure (AM, LM, LAP-RFA, UAE, or hysterectomy) was lowest in AM group (3%) followed by LM (8%), LAP-RFA (9%), and UAE (9%). The 2-year re-intervention rate was 5% for AM, 10% for LM (10%), 12% for UAE and 13% for LAP-RFA. <h3>Conclusion</h3> The 3 minimally invasive approaches had similar rates of re-intervention at 2 years (10-13%). AM was associated with the lowest re-intervention rate (5%) but also the highest rate of post-operative admissions. LAP-RFA was associated with the lowest peri-operative cost, and UAE was associated with the highest peri-operative cost. Further studies are needed to assess the cost, effectiveness, and patient satisfaction with each procedure.

8731 Combined Preserving Fertility Treatment of Women with Cervical Pregnancy

Study Objective To evaluate the effectiveness of combined approaches for preserving fertility in patients with cervical/cesarean scar pregnancy. Design Canadian Task Force Level II Study. Setting Operative Gynecology department, National Medical Research Centre for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov, Moscow, Russia. Patients or Participants 105 cases of cervical pregnancy were treated at Operative Gynecology department over the period of 15 years. Interventions 35 of 89 women with cervical pregnancy required combined therapy with preoperative methotrexate chemotherapy and resectoscopy; 3 patients had abdominal hysterectomy. Resectosopy included evacuation of embrio, curettage of the uterine cavity and cervical canal, resectoscopic coagulation of cervical vessels, ligation of the descending branches of the uterine arteries (as needed). In 33 cases with highest blood supply of chorion and its invasion into the cervix, we added bilateral selective uterine artery embolization (SUAE). Parameters for each approach were established. Measurements and Main Results The gestational age ranged from 5 to 10 weeks. Patients with cervical pregnancy received methotrexate at an average of 50 mg/every 48 hours, leucovorin administered at a dose of 6 mg after 28 hours after methotrexate injection. The total dose of administered methotrexate was 200 to 300 mg. Surgical procedure started at decreased level of β-hCG about 4000-7000 IU/l. The blood loss in all cases after SUAE was less than 30 cc. The effectiveness of organ-spearing treatment of cervical pregnancy is 96.63% and 100% in cesarean scar pregnancy. Conclusion The results of our study suggest that resectoscopic removal of embryo preceded by cytostatic therapy with methotrexate and leucovorin allows to preserve fertility in women with early cervical pregnancy. In cases of chorion invasion into the cervix and myometrium SUAE following resectoscopy appears to be a treatment of choice. To evaluate the effectiveness of combined approaches for preserving fertility in patients with cervical/cesarean scar pregnancy. Canadian Task Force Level II Study. Operative Gynecology department, National Medical Research Centre for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov, Moscow, Russia. 105 cases of cervical pregnancy were treated at Operative Gynecology department over the period of 15 years. 35 of 89 women with cervical pregnancy required combined therapy with preoperative methotrexate chemotherapy and resectoscopy; 3 patients had abdominal hysterectomy. Resectosopy included evacuation of embrio, curettage of the uterine cavity and cervical canal, resectoscopic coagulation of cervical vessels, ligation of the descending branches of the uterine arteries (as needed). In 33 cases with highest blood supply of chorion and its invasion into the cervix, we added bilateral selective uterine artery embolization (SUAE). Parameters for each approach were established. The gestational age ranged from 5 to 10 weeks. Patients with cervical pregnancy received methotrexate at an average of 50 mg/every 48 hours, leucovorin administered at a dose of 6 mg after 28 hours after methotrexate injection. The total dose of administered methotrexate was 200 to 300 mg. Surgical procedure started at decreased level of β-hCG about 4000-7000 IU/l. The blood loss in all cases after SUAE was less than 30 cc. The effectiveness of organ-spearing treatment of cervical pregnancy is 96.63% and 100% in cesarean scar pregnancy. The results of our study suggest that resectoscopic removal of embryo preceded by cytostatic therapy with methotrexate and leucovorin allows to preserve fertility in women with early cervical pregnancy.

Large pyomyoma after an urgent uterine artery embolization (UAE)

Leiomyomas, or fibroids, are a common, benign tumor of the smooth muscle of the uterus, with a cumulative incidence of 70% in white women and 80% in black women by age 50 [1]. Suppurative leiomyoma, also referred to as pyomyoma, is a rare disorder of infarction with subsequent infection of a leiomyoma, which must be distinguished from other degenerative changes [2,3]. Incidence of the disease is unknown but previously estimated under 1% of operated fibroids [3], and there have been approximately 100 cases reported since 1945. The modes of infection are thought to be via direct extension from the uterine cavity, a lymphatic or a vascular route of bacterial seeding [3,4]. Pregnancy, the post-partum period, and uterine instrumentation, including dilatation and curettage (D&amp;C) and C-section, are important risk factors for direct inoculation and account for the majority of pyomyoma cases that were reported [5,6]. Idiopathic pyomyomas also occur, such as in post-menopausal women; risk factors for ischemia, such as hypertension, diabetes, and atherosclerosis, increase the risk of pyomyoma [4,5]. Uterine Artery Embolization (UAE) is increasingly used as a non-invasive treatment for symptomatic fibroids and involves infarction of leiomyomas, which can rarely lead to pyomyoma [7,8]. We present a case of pyomyoma that developed after an urgent uterine artery embolization with a follow-up discussion of the relevant literature.

Evidences in Uterine Artery Embolization: A Radiologist's Primer

AbstractUterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.

Safety and effectiveness of uterine fibroid embolization in patients with scarred uterus.

To evaluate the safety and effectiveness of uterine fibroid embolization (UFE) in patients with a scarred uterus caused by a previous myomectomy or cesarean section. A total of 140 patients who underwent embolization for symptomatic fibroids were included in this retrospective study. The patients were divided into two groups, those with a history of myomectomy and/or cesarean section (scarred uterus group, n=56), and those without surgical history involving the uterus (no-scar group, n=84). Demographics, embolization details, outcomes, and complications were analyzed. The overall clinical success rate was 89.28% in the scarred uterus group and 95.24% in the no-scar group. There was no statistical difference in infarction rate or change in fibroid volume in follow-up magnetic resonance imaging between the groups. There was one major complication in the no-scar group, but there was no statistical difference in complications between the groups. The mean follow-up period was 25.9months. The mean symptom-free time was 27.2months in the scarred uterus group and 21.9months in the no-scar group without a significant difference. There were no statistically significant differences in symptom changes, recurrence, and complication rates between the groups. Recurrence seen on imaging or regrowth was more common in the group with myomectomy history. However, there was no significant difference in symptom recurrence rates. No statistically significant difference in technical and clinical outcomes was observed between the two groups. There was no significant increase in complication rates of UFE in scarred uterus group.

Acute complications with same-day versus overnight cervical preparation before dilation and evacuation at 14 to 16 weeks

Evaluate if same-day cervical preparation is associated with a clinically acceptable complication rate compared with overnight osmotic dilators for dilation and evacuation (D&E). This retrospective, noninferiority, cohort study compared complication rates for same-day versus overnight cervical preparation with D&E between 14 and 16 weeks gestation. Cervical preparation was achieved with misoprostol, osmotic dilators, or both. Our primary outcome was the acute complication rate, defined as: hemorrhage (≥500 mL); hospitalization or hospital transfer; transfusion; or unplanned procedure occurring within 24 hours of the index procedure. Secondarily we evaluated nonmajor (re-aspiration, suture repair of cervical laceration, uterine tamponade, or emergency department only transfer) and major (transfusion, uterine artery embolization, abdominal surgery, or hospital admission) complications separately. Inverse probability of treatment weighting using the propensity score was used to perform an adjusted analysis, taking into account age, ethnicity, clinic location, insurance, gestational age, gravidity, and prior pregnancy outcomes. We analyzed 1,319 subjects (n=864 same-day, n=455 overnight). Same-day cervical preparation patients were more likely to have Medicaid and a prior vaginal delivery. In both unadjusted and adjusted analyses, acute complication rates for same-day were noninferior to overnight preparation (unadjusted 0.93% vs 1.98%, difference of -1.05%, CI: -2.48% to 0.38%; adjusted difference -0.50%, CI: -1.45 to 0.44%). Only one major complication in the same-day group, a cervical laceration resulting in hemorrhage requiring transfusion, occurred in the entire sample. In this retrospective review, same-day cervical preparation was noninferior to overnight preparation for D&E between 14 and 16 weeks gestation, both with low complication rates. For early second trimester dilation and evacuation, same-day cervical preparation should be considered a safe alternative to overnight cervical preparation.

Spontaneous Expulsion of a Huge Cervical Fibroid After Uterine Artery Embolization Done as a Lifesaving Procedure for Acute Severe Abnormal Uterine Bleeding

Uterine fibroids are a prevalent disease that most commonly affects women of reproductive age group and causes symptoms such as abnormal uterine bleeding that can have a detrimental impact on their quality of life. Being in the reproductive age group, fertility-conserving modalities in the form of hormonal therapy, myomectomy, hysterectomy, and uterine artery embolization (UAE) remain the main treatment options. Uterine artery embolization is one of the treatment options for select cases of fibroid uterus. Here, we present the case of a 36-year-old woman diagnosed with cervical leiomyoma who presented with uncontrollable uterine bleeding, severe anemia, and many failed medical therapies. Although the case did not fit within the usual UAE guidelines, the treatment was done to tide over the crisis as a temporary method to control severe hemorrhage. Bleeding was controlled immediately and the patient was getting prepared for major surgery with the correction of severe anemia. However, seven days after UAE, the fibroid spontaneously expelled itself, resulting in improved symptoms and the avoidance of surgery. The patient is currently symptomless and has improved sexual life, self-esteem, and quality of life.

Saving The Uterus; Our Experience In Uterine Artery Embolization For Acquired Uterine Vascular Abnormalities.

Acquired uterine vascular abnormalities are a rare cause of potentially life threatening bleeding. These include uterine artery pseudoaneurysms (UAP)and acquired arteriovenous malformations. The objective of this study was to describe our experience with the diagnosis of acquired uterine vascular abnormalities and its treatment with uterine preservation. It was a retrospective cohort study. Eight patients were enrolled from the hospital database who presented to our Interventional Radiology department from April 2017 to March 2021 for uterine artery embolisation (UAE) with a history of iatrogenic/acquired uterine vascular abnormalities confirmed on imaging. These included two patients with uterine artery pseudoaneurysm (PA) concurrently with arteriovenous malformation (AVM), one with uterine artery PA and five having uterine AVMs. Embolisation agents used were histoacryl glue, lipiodol, PVA particles, and gelfoam slurry. Medical records, imaging studies, and telephonic contact with patients were assessed for patient presentation, intraprocedural details, and follow up to record treatment success. Statistical analysis was performed using descriptive statistics. Bilateral UAE was performed in six patients, while two patients underwent unilateral UAE. Three of the patients presented with life-threatening bleeds requiring multiple transfusions. Clinical as well as angiographic success was achieved in all patients with immediate control of haemorrhage. No complications were observed during follow-up. Two of the patients were able to conceive normally within one year, though it resulted in a miscarriage. Acquired/iatrogenic uterine vascular abnormalities are a rare but important cause of life-threatening haemorrhage that can be expertly managed and successfully treated using UAE, which is rapid, safe, and minimally invasive, with the added advantage fertility preservation.

Erosion of calcified uterine leiomyoma into the urinary bladder: A case report

Introduction: Uterine leiomyomas are benign smooth muscle tumors that affect approximately 70–80% of women worldwide. Erosion of leiomyomas into surrounding tissues is a rare complication. We present a case of a postmenopausal female with uterine leiomyoma eroding into the urinary bladder. Case Report: A 55-year-old, postmenopausal female with history of uterine fibroids previously treated with uterine artery embolization presented with recurrent bladder stones, hematuria, and pelvic pain. Pelvic magnetic resonance imaging described a 4.3 cm heterogenous mass involving the ventral uterine fundus and bladder dome concerning for malignancy. She underwent robotic-assisted total laparoscopic hysterectomy, right salpingo-oophorectomy, left salpingectomy, and partial bladder cystectomy. Pathology was significant for benign calcified leiomyoma and benign calcifications within the bladder mucosa. Conclusion: Erosion of leiomyoma through the bladder mucosa is rare complication but should be considered in the differential diagnosis for patients presenting with hypercalciuria and recurrent bladder stones in the setting of uterine fibroids previously treated with uterine artery embolization.

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A Systematic Review and Meta-Analysis of the Efficacy of Uterine Artery Embolization in the Treatment of Endometriosis.

Objective To compare the efficacy of uterine artery embolization (UAE) with traditional methods for treating endometriosis. Methods The randomized controlled trials of uterine artery embolization and other medical treatments for endometriosis in PubMed, Embase, Web of Science, Cochrane Library, China Journal Full-Text Database, Wanfang Database, VIP Database, and China Biomedical Literature Database were retrieved by computer. The search time was up to June 2022. The quality of articles was evaluated by Cochrane ROB 2.0, and meta-analysis was performed by Stata15.1 software. Results 7 studies were finally included. Meta-analysis showed that the serum CA125 level after uterine artery embolization was significantly lower than that in the control group (SMD = −0.85, 95%CI (−1.12, −0.59)], and the postoperative visual analogue scale (VAS) of dysmenorrhea was significantly lower than that in the control group (SMD = −1.86, 95%CI (−2.21, −1.50)) There was no significant difference in the effective rate, FSH level, E2 level, and LH level between the two groups. Conclusion UAE can effectively reduce the VAS score of dysmenorrhea and serum CA125 level for treating endometriosis. However, due to the limitation of the quality of included articles, more large sample size and high quality RCTs are needed to provide stronger evidence-based medicine evidence for clinical practice.

Risk Factors Associated with Clinical Failure of Uterine Artery Embolization for Postpartum Hemorrhage

PurposeTo identify risk factors for clinical failure of uterine artery embolization (UAE) for postpartum hemorrhage (PPH), with particular attention to the uterine artery diameter. Materials and MethodsThis retrospective study included 47 patients who underwent UAE for PPH between January 1, 2010, and January 31, 2021. Technical success was defined as the completion of embolization of the arteries thought to be the cause of the bleeding. Clinical success was defined as no recurrent bleeding or need for additional therapeutic interventions. Univariate and multivariate analyses were performed to examine the risk factors associated with clinical failure of UAE. ResultsOf the 47 patients, 6 had recurrent bleeding. Of the 6 patients, 4 underwent hysterectomy, and 2 underwent repeat embolization. The clinical success rate was 87.2% (41/47), with no major adverse events such as uterine infarction or death. In univariate analysis, there were slight differences in multiparity (P = .115) and placental abruption (P = .128) and a significant difference in the findings of a narrow uterine artery on digital subtraction angiography (DSA) (P = .005). In multivariate analysis, only a narrow uterine artery on DSA was a significant factor (odds ratio, 18.5; 95% confidence interval, 2.5–134.8; P = .004). ConclusionsA narrow uterine artery on DSA was a risk factor for clinically unsuccessful UAE for PPH. It may be prudent to conclude the procedure only after it is ensured that vasospasm has been relieved.

Successful Laparoscopic Surgical Removal of a Caesarean Scar Pregnancy (CSP) Using Temporary Uterine Artery Ligation

To demonstrate a laparoscopic technique to remove a scar pregnancy. Stepwise demonstration of the surgical technique. Santa Croce and Carle Hospital, Cuneo. Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall. Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively.

A rare case of high-grade endometrial stromal sarcoma initially misdiagnosed as a uterine fibroid in a postmenopausal woman

Introduction: High-grade endometrial stromal sarcoma (HG-ESS) is a rare and aggressive malignant neoplasm that has a poor prognosis and accounts for 0.2% of uterine malignancies. There is a lack of available information on HG-ESS due to its high case fatality rate. Due to the poor prognosis associated with HG-ESS, it is important to diagnose HG-ESS in its early stages. Case Report: In this case report, we describe the case of a 63-year-old postmenopausal woman who presented with a pelvic mass and postmenopausal bleeding. The patient’s past history included a fibroid for which the patient underwent a successful uterine fibroid embolization. The patient underwent a pelvic ultrasound and an endometrial biopsy prior to gynecological consult. Both were inconclusive and led to an initial diagnosis of a uterine fibroid. After a gynecological consult and an additional biopsy, pathological examination revealed high-grade neoplastic cells that expressed strong and diffuse nuclear BCL1/Cyclin D1. The pattern of diffuse cyclin D1 expression and negative CD10 was suggestive of the YWHAE-rearranged subtype of HG-ESS. The combined morphologic and immunophenotypic features were consistent with a high-grade endometrial stromal sarcoma with fluorescence in situ hybridization (FISH) positivity for YWHAE gene rearrangement and FISH negativity for BCOR gene rearrangement. The patient underwent a robotic-assisted modified radical hysterectomy, radical pelvic tumor resection, bilateral salpingo-oophorectomy, sentinel pelvic lymph node dissections, and an appendectomy. The resulting surgical pathologic diagnosis was HG-ESS stage 1. Currently, no adjuvant therapy is recommended given negative margins with stage 1 status. Conclusion: High-grade endometrial stromal sarcoma is a rare clinical entity in postmenopausal women which is initially misdiagnosed but should be included in the differential diagnosis of necrotic masses.

Comparison of high-intensity focused ultrasound ablation and uterine artery embolization in the management of cervical pregnancy.

BackgroundCervical pregnancy (CP) is an uncommon type of ectopic pregnancy with a rising risk to life. Currently, there is no universal protocol for the safe and effective management of CP. This study aimed to investigate the clinical efficacy of high-intensity focused ultrasound ablation (HIFU) vs. uterine artery embolization (UAE) in the management of CP to develop a standard for the treatment of CP.MethodsFrom January 2015 to October 2021, 36 patients with CP were diagnosed, treated, and followed up at the Department of Gynecology of Third Xiangya Hospital of Central South University. A total of 11 patients were treated with HIFU followed by suction curettage under hysteroscopic guidance, and 25 patients were treated with UAE followed by suction curettage under hysteroscopic guidance. Medical records and pregnancy outcomes were retrospectively analyzed.ResultsCompared to the UAE group, the HIFU group had a shorter interval time (1.5 ± 0.21 days vs. 2.6 ± 0.26 days), shorter duration of hospitalization (5.5 ± 0.31 days vs. 6.6 ± 0.21 days), shorter recovery time of menstruation (30.6 ± 7.09 days vs. 36.9 ± 5.54 days), fewer adverse reactions (0/11 vs. 9/25), and fewer postoperative complications (1/11 vs. 8/25). There were no significant differences in age, gravidity, parity, abortion, gestational age, cardiac pulsation, admission symptoms, hemoglobin level, largest diameter of the sac/mass, serum human chorionic gonadotropin (hCG) level at admission, hospitalization expenses, hospitalization days, blood loss during curettage, degree of hCG decline, residue after curettage, fertility requirement, and pregnancy outcomes.ConclusionBoth HIFU and UAE are safe and effective in the treatment of patients with CP. Compared to UAE, HIFU treatment for CP is a safer and more effective therapeutic schedule owing to the advantages of being more minimally invasive, shorter interval time, shorter hospitalization days and recovery time of menstruation, fewer adverse reactions, and fewer postoperative complications.