Interventional embolization, surgery and high intensity focused ultrasound for the treatment of uterine fibroids: a network meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

LI Weihao ¹ , GUO You ² , LIN Yisheng ² , WANG Xiaodong ² , LIU Qiong ² ,  WANG Fangjun ²

1. The First Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Guangzhou 510405, P.R.China;
2. Department of Interventional Radiology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou 510405, P.R.China;

Corresponding author：

WANG Fangjun, Email: wfjok@163.com

Keywords：

Uterine fibroids; Uterine artery embolization; Surgery; High intensity focused ultrasound; Network meta-analysis

DOI：

10.7507/1672-2531.201908097

Video：

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Objectives To systematically review the safety and effectiveness of uterine artery embolization (UAE), surgery and high intensity focused ultrasound (HIFU) in the treatment of uterine fibroids.Methods PubMed, EMbase, The Cochrane Library, Web of Science, WanFang Data and CNKI databases were electronically searched to collect relevant studies on comparing the safety and effectiveness of UAE, surgery and HIFU in the treatment of uterine fibroids from January 2000 to August 2019. Two reviewers independently screened the literature, extracted the data and evaluated the risk of bias of included studies, network meta-analysis was performed by ADDIS 1.16.8 software and Stata 14.0 software.Results A total of 11 trials (22 references) involving 3469 patients were included. Compared with surgery, UAE and HIFU patients had higher quality of life (1-year follow-up) improvement, and UAE was higher than HIFU. Network meta-analysis showed that patients treated with HIFU had the lowest incidence of major complications within 1 year, followed by UAE, and surgery. Patients treated with HIFU and UAE had shorter hospitalization and quicker recovery time than surgery. The rate of further intervention after surgery treatment might be lower than that of UAE and HIFU.Conclusions UAE has the highest quality of life improvement (1-year follow-up) for uterine fibroids. HIFU and UAE are safer with shorter hospital stays and quicker recovery time compared with surgery. However, both UAE and HIFU have the risk of re-treatment. However, limited by the number and quality of included studies, the above conclusions are needed to be verified by more high-quality studies.

Citation： LI Weihao, GUO You, LIN Yisheng, WANG Xiaodong, LIU Qiong, WANG Fangjun. Interventional embolization, surgery and high intensity focused ultrasound for the treatment of uterine fibroids: a network meta-analysis. Chinese Journal of Evidence-Based Medicine, 2020, 20(4): 458-465. doi: 10.7507/1672-2531.201908097 Copy

1.	Hartmann KE, Birnbaum H, Ben-Hamadi R, et al. Annual costs associated with diagnosis of uterine leiomyomata. Obstet Gynecol, 2006, 108(4): 930-937.
2.	Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update, 2016, 22(6): 665-686.
3.	Spies JB, Spector A, Roth AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol, 2002, 100(5 Pt 1): 873-880.
4.	Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005, 5: 13.
5.	Wells G, Shea B, O'connell D, et al. The Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
6.	曾宪涛, 张超, 杜亮. 应用 ADDIS 软件实现网状 Meta 分析. 中国循证医学杂志, 2013, 13(12): 1508-1515.
7.	Pinto I, Chimeno P, Romo A, et al. Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment-a prospective, randomized, and controlled clinical trial. Radiology, 2003, 226(2): 425-431.
8.	Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol, 2005, 193(5): 1618-1629.
9.	Hehenkamp WJ, Volkers NA, Birnie E, et al. Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. Cardiovasc Intervent Radiol, 2006, 29(2): 179-187.
10.	Mara M, Fucikova Z, Maskova J, et al. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol, 2006, 126(2): 226-233.
11.	Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med, 2007, 356(4): 360-370.
12.	Volkers NA, Hehenkamp WJ, Birnie E, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J Obstet Gynecol, 2007, 196(6): 519.e1-11.
13.	Hehenkamp WJ, Volkers NA, Birnie E, et al. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) Trial. Radiology, 2008, 246(3): 823-832.
14.	Mara M, Maskova J, Fucikova Z, et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol, 2008, 31(1): 73-85.
15.	Ruuskanen A, Hippeläinen M, Sipola P, et al. Uterine artery embolisation versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomised prospective clinical trial. Eur Radiol, 2010, 20(10): 2524-2532.
16.	van der Kooij SM, Hehenkamp WJ, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol, 2010, 203(2): 105.e1-e13.
17.	Bouwsma EV, Hesley GK, Woodrum DA, et al. Comparing focused ultrasound and uterine artery embolization for uterine fibroids-rationale and design of the Fibroid Interventions: reducing symptoms today and tomorrow (FIRSTT) trial. Fertil Steril, 2011, 96(3): 704-710.
18.	Moss JG, Cooper KG, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG, 2011, 118(8): 936-944.
19.	Jun F, Yamin L, Xinli X, et al. Uterine artery embolization versus surgery for symptomatic uterine fibroids: a randomized controlled trial and a meta-analysis of the literature. Arch Gynecol Obstet, 2012, 285(5): 1407-1413.
20.	Manyonda IT, Bratby M, Horst JS, et al. Uterine artery embolization versus myomectomy: impact on quality of life--results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. Cardiovasc Intervent Radiol, 2012, 35(3): 530-536.
21.	秦娟. 超声消融子宫肌瘤对机体创伤及肿瘤局部效应安全性研究. 重庆: 重庆医科大学, 2012.
22.	Wang X, Qin J, Chen J, et al. The effect of high-intensity focused ultrasound treatment on immune function in patients with uterine fibroids. Int J Hyperthermia, 2013, 29(3): 225-233.
23.	Wang X, Qin J, Wang L, et al. Effect of high-intensity focused ultrasound on sexual function in the treatment of uterine fibroids: comparison to conventional myomectomy. Arch Gynecol Obstet, 2013, 288(4): 851-858.
24.	AbdElmagied AM, Vaughan LE, Weaver AL, et al. Fibroid interventions: reducing symptoms today and tomorrow: extending generalizability by using a comprehensive cohort design with a randomized controlled trial. Am J Obstet Gynecol, 2016, 215(3): 338.e1-18.
25.	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.e1-12.
26.	Barnard EP, AbdElmagied AM, Vaughan LE, et al. Periprocedural outcomes comparing fibroid embolization and focused ultrasound: a randomized controlled trial and comprehensive cohort analysis. Am J Obstet Gynecol, 2017, 216(5): 500.e1-11.
27.	Chen J, Li Y, Wang Z, et al. Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration study. BJOG, 2018, 125(3): 354-364.
28.	Laughlin-Tommaso S, Barnard EP, AbdElmagied AM, et al. FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery. Am J Obstet Gynecol, 2019, 220(2): 174.e1-13.
29.	Thubert T, Foulot H, Vinchant M, et al. Surgical treatment: Myomectomy and hysterectomy; Endoscopy: a major advancement. Best Pract Res Clin Obstet Gynaecol, 2016, 34: 104-121.
30.	陈春林, 刘萍, 曾北蓝, 等. 子宫动脉栓塞术治疗子宫腺肌病的中远期临床疗效观察. 中华妇产科杂志, 2006, (10): 660-663.
31.	Pisco JM, Duarte M, Bilhim T, et al. Pregnancy after uterine fibroid embolization. Fertil Steril, 2011, 95(3): 1121.e5-8.
32.	Berczi V, Valcseva É, Kozics D, et al. Safety and effectiveness of UFE in fibroids larger than 10 cm. Cardiovasc Intervent Radiol, 2015, 38(5): 1152-1156.
33.	Fennessy FM, Kong CY, Tempany CM, et al. Quality-of-life assessment of fibroid treatment options and outcomes. Radiology, 2011, 259(3): 785-792.
34.	Skehan SJ, Malone DE, Buckley N, et al. Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology. Radiology, 2000, 216(3): 653-659.
35.	许永华, 陈文直. 磁共振引导高强度聚焦超声完全消融子宫肌瘤:可行性、安全性和远期疗效(英文). 介入放射学杂志, 2014, 23(11): 959-968.
36.	Fennessy FM, Tempany CM, McDannold NJ, et al. Uterine leiomyomas: MR imaging-guided focused ultrasound surgery--results of different treatment protocols. Radiology, 2007, 243(3): 885-893.

1. Hartmann KE, Birnbaum H, Ben-Hamadi R, et al. Annual costs associated with diagnosis of uterine leiomyomata. Obstet Gynecol, 2006, 108(4): 930-937.
2. Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update, 2016, 22(6): 665-686.
3. Spies JB, Spector A, Roth AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol, 2002, 100(5 Pt 1): 873-880.
4. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005, 5: 13.
5. Wells G, Shea B, O'connell D, et al. The Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
6. 曾宪涛, 张超, 杜亮. 应用 ADDIS 软件实现网状 Meta 分析. 中国循证医学杂志, 2013, 13(12): 1508-1515.
7. Pinto I, Chimeno P, Romo A, et al. Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment-a prospective, randomized, and controlled clinical trial. Radiology, 2003, 226(2): 425-431.
8. Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol, 2005, 193(5): 1618-1629.
9. Hehenkamp WJ, Volkers NA, Birnie E, et al. Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. Cardiovasc Intervent Radiol, 2006, 29(2): 179-187.
10. Mara M, Fucikova Z, Maskova J, et al. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol, 2006, 126(2): 226-233.
11. Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med, 2007, 356(4): 360-370.
12. Volkers NA, Hehenkamp WJ, Birnie E, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J Obstet Gynecol, 2007, 196(6): 519.e1-11.
13. Hehenkamp WJ, Volkers NA, Birnie E, et al. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) Trial. Radiology, 2008, 246(3): 823-832.
14. Mara M, Maskova J, Fucikova Z, et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol, 2008, 31(1): 73-85.
15. Ruuskanen A, Hippeläinen M, Sipola P, et al. Uterine artery embolisation versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomised prospective clinical trial. Eur Radiol, 2010, 20(10): 2524-2532.
16. van der Kooij SM, Hehenkamp WJ, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol, 2010, 203(2): 105.e1-e13.
17. Bouwsma EV, Hesley GK, Woodrum DA, et al. Comparing focused ultrasound and uterine artery embolization for uterine fibroids-rationale and design of the Fibroid Interventions: reducing symptoms today and tomorrow (FIRSTT) trial. Fertil Steril, 2011, 96(3): 704-710.
18. Moss JG, Cooper KG, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG, 2011, 118(8): 936-944.
19. Jun F, Yamin L, Xinli X, et al. Uterine artery embolization versus surgery for symptomatic uterine fibroids: a randomized controlled trial and a meta-analysis of the literature. Arch Gynecol Obstet, 2012, 285(5): 1407-1413.
20. Manyonda IT, Bratby M, Horst JS, et al. Uterine artery embolization versus myomectomy: impact on quality of life--results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. Cardiovasc Intervent Radiol, 2012, 35(3): 530-536.
21. 秦娟. 超声消融子宫肌瘤对机体创伤及肿瘤局部效应安全性研究. 重庆: 重庆医科大学, 2012.
22. Wang X, Qin J, Chen J, et al. The effect of high-intensity focused ultrasound treatment on immune function in patients with uterine fibroids. Int J Hyperthermia, 2013, 29(3): 225-233.
23. Wang X, Qin J, Wang L, et al. Effect of high-intensity focused ultrasound on sexual function in the treatment of uterine fibroids: comparison to conventional myomectomy. Arch Gynecol Obstet, 2013, 288(4): 851-858.
24. AbdElmagied AM, Vaughan LE, Weaver AL, et al. Fibroid interventions: reducing symptoms today and tomorrow: extending generalizability by using a comprehensive cohort design with a randomized controlled trial. Am J Obstet Gynecol, 2016, 215(3): 338.e1-18.
25. 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.e1-12.
26. Barnard EP, AbdElmagied AM, Vaughan LE, et al. Periprocedural outcomes comparing fibroid embolization and focused ultrasound: a randomized controlled trial and comprehensive cohort analysis. Am J Obstet Gynecol, 2017, 216(5): 500.e1-11.
27. Chen J, Li Y, Wang Z, et al. Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration study. BJOG, 2018, 125(3): 354-364.
28. Laughlin-Tommaso S, Barnard EP, AbdElmagied AM, et al. FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery. Am J Obstet Gynecol, 2019, 220(2): 174.e1-13.
29. Thubert T, Foulot H, Vinchant M, et al. Surgical treatment: Myomectomy and hysterectomy; Endoscopy: a major advancement. Best Pract Res Clin Obstet Gynaecol, 2016, 34: 104-121.
30. 陈春林, 刘萍, 曾北蓝, 等. 子宫动脉栓塞术治疗子宫腺肌病的中远期临床疗效观察. 中华妇产科杂志, 2006, (10): 660-663.
31. Pisco JM, Duarte M, Bilhim T, et al. Pregnancy after uterine fibroid embolization. Fertil Steril, 2011, 95(3): 1121.e5-8.
32. Berczi V, Valcseva É, Kozics D, et al. Safety and effectiveness of UFE in fibroids larger than 10 cm. Cardiovasc Intervent Radiol, 2015, 38(5): 1152-1156.
33. Fennessy FM, Kong CY, Tempany CM, et al. Quality-of-life assessment of fibroid treatment options and outcomes. Radiology, 2011, 259(3): 785-792.
34. Skehan SJ, Malone DE, Buckley N, et al. Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology. Radiology, 2000, 216(3): 653-659.
35. 许永华, 陈文直. 磁共振引导高强度聚焦超声完全消融子宫肌瘤:可行性、安全性和远期疗效(英文). 介入放射学杂志, 2014, 23(11): 959-968.
36. Fennessy FM, Tempany CM, McDannold NJ, et al. Uterine leiomyomas: MR imaging-guided focused ultrasound surgery--results of different treatment protocols. Radiology, 2007, 243(3): 885-893.

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