Kirsten Hald

Laparoscopic occlusion compared with embolization of uterine vessels: a randomized controlled trial.

OBJECTIVE: To compare clinical outcome 6 months after treatment with bilateral laparoscopic occlusion of the uterine artery versus uterine leiomyoma embolization. METHODS: Sixty-six premenopausal women with symptomatic uterine leiomyomata were randomized to treatment with either laparoscopic occlusion of uterine arteries or uterine leiomyoma embolization. The primary outcome was reduction of blood loss from pretreatment to 6 months postoperatively, measured by a Pictorial Bleeding Assessment Chart. Secondary outcomes included patients’ own assessment of symptom reduction, postoperative pain assessed using visual analog scales, ketobemidone used postoperatively, complications, secondary interventions, and failures. RESULTS: Fifty-eight women were included; 6-month follow-up data were available for 28 participants in each group. The percentage reduction in Pictorial Bleeding Assessment Chart scores did not differ between the treatment groups (52% after uterine leiomyoma embolization and 53% after laparoscopy, P=.96). The study had 52% power to detect a 20% difference on the Pictorial Bleeding Assessment Chart. Fewer participants in the group treated with uterine leiomyoma embolization complained of heavy bleeding after 6 months (4% compared with 21%, P=.044). The postoperative use of ketobemidone was higher after uterine leiomyoma embolization (46 mg compared with 12 mg, P<.001). CONCLUSION: Both laparoscopic occlusion of uterine vessels and embolizaton of uterine leiomyoma improved clinical symptoms in the majority of patients. Participants with the laparoscopic procedure had less postoperative pain but heavier menstrual bleeding 6 months after treatment. A larger study and longer follow-up is necessary before a definite conclusion can be made regarding the most effective treatment. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT 00277680 LEVEL OF EVIDENCE: I

Uterine Artery Embolization versus Laparoscopic Occlusion of Uterine Arteries for Leiomyomas: Long-term Results of a Randomized Comparative Trial

PURPOSE To compare long-term symptom recurrence and 6-month magnetic resonance (MR) imaging results after two different treatments for uterine leiomyomas. MATERIALS AND METHODS Sixty-six women with uterine leiomyomas were randomized to undergo uterine artery embolization (UAE) or laparoscopic bilateral occlusion of uterine arteries. Contrast-enhanced MR imaging was performed before treatment and after 6 months. RESULTS Fifty-eight patients received treatment. Median follow-up time was 48 months (range, 8-73 months). Clinical failure and symptom recurrence occurred in 14 patients after laparoscopy (48%) and in five after UAE (17%; P = .02, log-rank test). Hysterectomy was performed in two patients after UAE (7%) and in eight after laparoscopy (28%; P = .041). Six-month MR imaging results were available for 26 patients treated with UAE and 22 treated with laparoscopy. The mean uterine volume was reduced by 51% (range, 16%-86%) after UAE treatment, compared with 33% (range, 6%-77%) after laparoscopy (P = .001). Complete leiomyoma infarction was seen in all 26 patients in the UAE group and in only five patients in the laparoscopy group (P < .001). Eleven patients experienced symptom recurrence later than 6 months. Uterine volume reduction at 6 months was 24% in this group, compared with 48% in the 37 patients with no recurrence (P = .004). Incomplete infarction of leiomyomas was seen in eight of the 11 cases of recurrence (73%) versus nine of 37 cases without recurrence (24%; P = .009). CONCLUSIONS Recurrence rate was significantly lower after UAE than after laparoscopic treatment. Larger volume reduction and more complete devascularization of leiomyomas were found after UAE treatment and among patients with no recurrence.

Volumetric ablation of uterine fibroids using Sonalleve high-intensity focused ultrasound in a 3 Tesla scanner – first clinical assessment

Abstract Introduction: The purpose of this study was to evaluate the feasibility and safety of the Sonalleve high-intensity focused ultrasound (HIFU; Philips Healthcare, Vantaa, Finland) system in ablating uterine fibroids in a 3T magnet. Material and methods: Seven women were included in this study. Treatment was performed according to the manufacturers recommendation. Technical data describing the HIFU procedures were collected. On MR images at baseline, immediately and 30 days after ablation, we evaluated the volumes of the uterus, the dominant fibroid and the ablation zone. The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire was used to assess potential clinical response. Results: The procedure was technically feasible in all patients. The median number of sonications performed during each procedure was 20 (range 2–27) per patient, the maximum temperature in all sonication cells was about 68°C. The median procedure time was 156 minutes (range 95–164). The non-perfused volume after treatment ranged from 1 to 27 ml and was unchanged or decreased in all but one patient at 30 days follow-up. There were no major adverse events. Discussion: In our 3T magnet the system was able to heat tissue and induce areas of non-enhancement within uterine fibroids without major complications. Clinical benefit remains to be proven.

Treatment of Uterine Myomas with Transvaginal Uterine Artery Occlusion: Possibilities and Limitations

The objective of this pilot study was to evaluate the feasibility of a transvaginal clamp prototype used for temporary uterine artery occlusion as a treatment for myomas. In particular, we aimed to evaluate technical aspects of successful occlusion with angiography and magnetic resonance imaging (MRI) and to evaluate possible ureter occlusion with pyelography. Ten premenopausal women aged 34 to 37 years with menorrhagia and myomas were treated with a temporary uterine artery occlusion for 6 hours. Five patients did not complete the clamping procedure because of unsuccessful clamping. While the clamp was in position, angiographic examination of the uterine arteries and pyelography were performed in 8 of the patients. The clamps occluded both uterine arteries in 4 patients and 1 side in another 2. Two procedures occluded the ureter unilaterally. MRI with contrast was done before, the day after, and 3 months after the procedure. Three of 5 patients who completed the clamp treatment had reduced or no contrast enhancement at MRI afterward. Clinical effects were obtained in 3 patients. Difficulties with application of the vaginal clamp were related to initial learning and size of the myomas. Our initial experience shows that the treatment is feasible in some patients with symptomatic myomas. However, improvement of the technique and equipment is needed. Care with regard to the ureters is required during further studies aimed at evaluating this approach.

Shortened cervix in the subsequent pregnancy after embolization for postpartum cervical hemorrhage

Introduction. Rupture of a branch of uterine artery during delivery often leads to a massive postpartum hemorrhage that can be successfully treated using uterine artery embolization. Case Report. A 33-year-old woman had a cesarean section at term followed by a secondary postpartum hemorrhage due to a ruptured cervicovaginal branch terminating in a large, partially thrombosed hematoma of the cervix. She was given selective uterine artery embolization, and she was discharged to home in stable condition on the third day after embolization. In the forthcoming pregnancy a shortened cervix was a risk of threatened premature delivery from 26 weeks of gestation onwards. Conclusion. Superselective unilateral embolization of a thrombosed hematoma in the cervix might prevent extensive iatrogenic trauma of the cervix, which allows preservation of reproductive function.

Effect of Uterine Manipulation on the Relation of the Ureter and the Uterine Vessels

Intervention: We present the laparoscopic surgery techniques. We reviewed the literature and summarized the criteria for endoscopic surgery. Measurements and Main Results: There have been only five references reporting 14 cases were successfully managed under laparoscopy; and four references reporting 52 cases were treated by hysteroscopy. Conclusion: Endoscopic surgery for cesarean scar pregnancy is safe and effective for a skilled endoscopist. But for type I cesarean scar pregnancy, hysteroscopy is more suitable; laparoscopy is recommended for type II. Type I was defined as gestational tissue implanted in the scar growing towards the cervicoisthmic space and type II was defined as a pregnancy mass that protruded from the uterus and grew towards the abdominal cavity.