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Treatment of Intrauterine and Large Pedunculated Subserosal Leiomyomata with Sequential Uterine Artery Embolization and Myomectomy
Treatment of Intrauterine and Large Pedunculated Subserosal Leiomyomata with Sequential Uterine Artery Embolization and Myomectomy Ben E. Paxton, BA, Judy M. Lee, MD, MPH, and Hyun S. Kim, MD
Successful clinical outcomes were obtained after a combined therapy of uterine artery embolization (UAE) and subsequent myomectomy for gigantic subserosal leiomyoma exceeding 1,000 cm3 in volume on a short stalk and multiple intrauterine leiomyomata in young patients who desired fertility and uterine preservation. UAE effectively treated symptomatic multiple intramural and submucosal leiomyomata for menorrhagia symptoms, which also facilitated uncomplicated subsequent myomectomy with devascularized gigantic leiomyoma for the treatment of bulk symptoms. J Vasc Interv Radiol 2006; 17:1947–1950 Abbreviation:
UAE ⫽ uterine artery embolization
UTERINE artery embolization (UAE) for symptomatic uterine leiomyomata has shown excellent short-term clinical efficacy and minimal complications (1). However, large pedunculated subserosal leiomyomas have been generally recognized as a relative contraindication for UAE because of the potential risk and complications from torsion at the stalk, ischemic necrosis, and separation from the uterus (2,3); therefore, these tumors are subject to surgical treatments, often consisting of hysterectomy. Although the safety of UAE for subserosal leiomyomata with stalk diameters of 2 cm or
From The Russell H. Morgan Department of Radiology and Radiological Science (B.P., H.S.K.) and Department of Obstetrics and Gynecology (J.M.L.), Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, Maryland 21287-4010. Received March 8, 2006; revision requested June 26; final revision received September 7; and accepted October 2. Address correspondence to H.S.K.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2006 DOI: 10.1097/01.RVI.0000250889.92043.A8
larger was recently suggested in a retrospective study (3) of 12 patients with leiomyomas with a mean maximum diameter of 8.3 cm and a mean volume of 279 cm3 before UAE, safety and efficacy of UAE for large subserosal leiomyomas with diameters larger than 10 cm and/or volumes greater than 1,000 cm3 on a short stalk are not well established. Patients with large subserosal leiomyomas and multiple intrauterine leiomyomas who desire preservation of the uterus present a unique challenge for clinicians. We describe two cases of successful clinical outcome after combined therapy of UAE and myomectomy for gigantic pedunculated subserosal leiomyoma exceeding 1,000 cm 3 in volume on a short stalk and multiple intrauterine leiomyomata.
CASE REPORTS According to our institutional guidelines, institutional review board approval was not required for this report. A 42-year-old black woman, gravida 2 para 1, presented with main
symptoms of significant menorrhagia, cramping, and clotting. The patient also reported mass-effect symptoms including frequent urination, nocturia, dyspareunia, bloating, fullness, and weight gain. A clinical examination found the uterus size to be about 24 weeks. The baseline transformed symptom severity score was 81.25. Magnetic resonance (MR) imaging demonstrated a markedly enlarged pedunculated leiomyoma with a maximum dimension of 17 cm in a subserosal location and multiple intramural and submucosal leiomyomata (Fig 1). The volume of the pedunculated subserosal leiomyoma was estimated at 1,334 cm3 according to the formula of a prolate ellipse: length ⫻ width ⫻ depth ⫻ 0.5233. There were several intramural and submucosal leiomyomas ranging in size from 4 cm to 6 cm. The patient desired treatment that would ensure uterine preservation. UAE and myomectomy were planned. The patient underwent bilateral UAE with 22 mL of 500- to 700-m tris-acryl gelatin microspheres (Embosphere; BioSphere Medical, Rockland, MA) and a 3-F microcatheter (Fig 2). The endpoints of embolization were
1947
1948
•
Sequential UAE and Myomectomy for Large Subserosal Leiomyomata
December 2006
JVIR
20-cm pedunculated subserosal leiomyoma with a short stalk with an estimated volume of 1,392 cm3 and multiple intramural and submucosal leiomyomata. Fifteen weeks after uncomplicated recovery after UAE, a myomectomy was performed on the pedunculated subserosal leiomyoma. During the procedure, the patient lost 300 mL of blood, but no blood transfusion was required. The patient had complete resolution of all of symptoms after the treatments and has remained asymptomatic for 3 years. No additional treatment for leiomyoma was required.
DISCUSSION
Figure 1. Sagittal T2-weighted MR image before UAE and myomectomy demonstrates a markedly enlarged subserosal leiomyoma (open arrows) attached to the uterus by a short stalk (closed arrow). Note additional multiple intrauterine leiomyomas.
occlusion of the perileiomyoma plexus of known leiomyomata, stasis of flow in the distal part of the uterine artery, and reduced flow in the proximal part of the main uterine artery. Ten days after the UAE procedure, a transabdominal myomectomy was performed on the gigantic pedunculated leiomyoma, which weighed 2,700 g on pathologic examination (Fig 3). During the procedure, the patient lost 500 mL of blood and received one unit of packed red blood
cells. Shortly after the treatments, the patient had complete resolution of all her symptoms, as demonstrated by the transformed symptom severity score of zero at 6-month follow-up. The patient has remained asymptomatic for 3 years and has not required additional treatment for leiomyoma. A 41-year-old black woman, gravida 1 para 0, with symptoms of significant menorrhagia, was also treated with the same method for a gigantic
The current report describes two cases of complementary UAE and myomectomy with successful clinical outcome for the treatment of gigantic subserosal leiomyomata and multiple intrauterine leiomyomata. Effective treatment of intramural and submucosal leiomyomata with UAE avoids surgical treatment of intrauterine leiomyomata. Transfusion, fever, ileus, infection, urinary retention, bladder injury, and peritoneal adhesions with adverse effects on fertility have been reported as possible periprocedural or postprocedural complications of myomectomy (4 –7). Increased complications with greater numbers of leiomyomata removed have also been reported (8). Limiting operations on the leiomyoma outside of the uterus with less extensive resection and less reconstructive surgery on the uterus may decrease the risks from such complications. Successful UAE may also avoid the need for gonadotropin-releasing hormone agonists such as leuprolide acetate (Lupron; TPA Pharmaceuticals, Lake Forest, IL) before myomectomy. Leiomyoma recurrence rates as high as 62% on ultrasound imaging at 5 years have been reported after myomectomy (9,10). In comparison with transabdominal myomectomies, greater recurrence rates after laparoscopic myomectomy have been reported (11,12). Repeat surgery rates for symptomatic recurrent leiomyoma as high as 35% at a mean of 84 months of follow-up have also been reported (13). Such recurrence is caused at least in part by incomplete resection of leiomyomata during the initial myomectomies. Complete resection of leiomyomas is technically more difficult for intramural or submucosal leiomyo-
Volume 17
Number 12
Paxton et al
Figure 2. Angiography of the left uterine artery demonstrates a hypertrophic uterine artery supplying the markedly enlarged subserosal leiomyoma (arrows).
mata rather than subserosal leiomyomata. UAE can aid by treating intramural and submucosal leiomyomata that show enhancement with intravenous contrast medium on MR imaging, suggesting the potential for growth.
For women who desire conservation of the uterus, uncertainty exists about myomectomy because surgical conversion from intended myomectomy to hysterectomy has been reported in 2.6% of cases (14). In addition, several case reports of uterine
•
1949
rupture during pregnancy after myomectomy have been published (15). UAE treatment for symptomatic leiomyomas affords a high probability of uterus conservation, given that only three of 2,729 patients in the recently completed Fibroid Registry (1) underwent hysterectomies within 30 days after UAE procedures. UAE may also assist subsequent myomectomy for the treatment of intrauterine leiomyomata, leaving surgery to be performed only on subserosal leiomyomata and avoiding extensive surgical resection and repair. This may help lessen the perioperative blood loss and requirements for transfusions. Ginsburg et al (16) reported significantly increased blood loss during myomectomy of uteri with volumes greater than 600 mL, increased total weight of leiomyomata removed, and lengthy operating time. It is worth noting that the patients in our report with leiomyomata volumes of more than 1,000 cm3 lost only 500 mL and 300 mL of blood during their myomectomies, with one unit of packed red blood cells transfused in one case. Despite the recent report by Katsumori et al (3) that suggested the safety of UAE of pedunculated subserosal leiomyomata in 12 patients, the mean maximum diameter of subserosal leiomyomas in that report was 8.3 cm, with a mean pretreatment leiomyoma volume 279 cm3 smaller than the subserosal leiomyomas we describe in our report. Repeat intervention rates with recurrent symptoms after UAE have also been described to be as high as 25% over the course of a 5-year follow-up (17). Although successful outcomes after UAE of large leiomyomas has been reported (18), large leiomyoma size and increased number of leiomyomas have been suggested as predictors of recurrence after UAE (19). Continued growth of pedunculated subserosal leiomyomas after UAE has also been reported (20). Therefore, the safety and efficacy of UAE of large subserosal leiomyomas remain debatable, and the issues warrant further investigation. In conclusion, we report successful clinical outcomes after combined UAE and myomectomy for gigantic subserosal leiomyomas and multiple intrauterine leiomyomas. The combined therapy may provide optimal clinical
1950
•
Sequential UAE and Myomectomy for Large Subserosal Leiomyomata
10. 11.
12.
13.
14.
15. Figure 3. Intraoperative photograph shows the pedunculated subserosal leiomyoma during myomectomy. Note short stalk attaching the leiomyoma to the uterus (arrow).
results by minimizing complications associated with either treatment alone and maximizing the benefits of each respective treatment modality. References 1. Worthington-Kirsch R, Spies JB, Myers ER, et al. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol 2005; 106:52–59. 2. Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2004; 15:115–120. 3. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol 2005; 184:399–402. 4. Roth TM, Gustilo-Ashby T, Barber MD, et al. Effects of race and clinical fac-
5.
6.
7.
8. 9.
tors on short-term outcomes of abdominal myomectomy. Obstet Gynecol 2003; 101:881–884. Iverson RE Jr, Chelmow D, Strohbehn K, et al. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415–419. West S, Ruiz R, Parker WH. Abdominal myomectomy in women with very large uterine size. Fertil Steril 2006; 85: 36–39. Fauconnier A, Dubuisson JB, Ancel PY, et al. Prognostic factors of reproductive outcome after myomectomy in infertile patients. Hum Reprod 2000; 15: 1751–1757. Matchar DB, Myers ER, Barber MW. Management of uterine fibroids. Evid Rep Technol Assess (Summ) 2001:1–6. Fedele L, Parazzini F, Luchini L, et al.
16.
17.
18.
19.
20.
December 2006
JVIR
Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Hum Reprod 1995; 10:1795– 1796. Hanafi M. Predictors of leiomyoma recurrence after myomectomy. Obstet Gynecol 2005; 105:877–881. Fauconnier A, Chapron C, Babaki-Fard K, et al. Recurrence of leiomyomata after myomectomy. Hum Reprod Update 2000; 6:595–602. Dubuisso JB, Fauconnier A, BabakiFard K, et al. Laparoscopic myomectomy: a current view. Hum Reprod Update 2000; 6:588–594. Stewart EA, Faur AV, Wise LA, et al. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstet Gynecol 2002; 99: 426–432. Subramanian S, Clark MA, Isaacson K. Outcome and resource use associated with myomectomy. Obstet Gynecol 2001; 98:583–587. Milad MP, Sankpal RS. Laparoscopic approaches to uterine leiomyomas. Clin Obstet Gynecol 2001; 44:401–411. Ginsburg ES, Benson CB, Garfield JM, et al. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 1993; 60:956–962. Spies JB, Bruno J, Czeyda-Pommersheim F, et al. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol 2005; 106:933– 939. Katsumori T, Nakajima K, Mihara T. Is a large fibroid a high-risk factor for uterine artery embolization? AJR Am J Roentgenol 2003; 181:1309–1314. Marret H, Cottier JP, Alonso AM, et al. Predictive factors for fibroids recurrence after uterine artery embolisation. Br J Obstet Gynaecol 2005; 112:461–465. Stringer NH, DeWhite A, Park J, et al. Laparoscopic myomectomy after failure of uterine artery embolization. J Am Assoc Gynecol Laparosc 2001; 8:583–586.
Successful clinical outcomes were obtained after a combined therapy of uterine artery embolization (UAE) and subsequent myomectomy for gigantic subserosal leiomyoma exceeding 1,000 cm3 in volume on a short stalk and multiple intrauterine leiomyomata in young patients who desired fertility and uterine preservation. UAE effectively treated symptomatic multiple intramural and submucosal leiomyomata for menorrhagia symptoms, which also facilitated uncomplicated subsequent myomectomy with devascularized gigantic leiomyoma for the treatment of bulk symptoms. J Vasc Interv Radiol 2006; 17:1947–1950 Abbreviation:
UAE ⫽ uterine artery embolization
UTERINE artery embolization (UAE) for symptomatic uterine leiomyomata has shown excellent short-term clinical efficacy and minimal complications (1). However, large pedunculated subserosal leiomyomas have been generally recognized as a relative contraindication for UAE because of the potential risk and complications from torsion at the stalk, ischemic necrosis, and separation from the uterus (2,3); therefore, these tumors are subject to surgical treatments, often consisting of hysterectomy. Although the safety of UAE for subserosal leiomyomata with stalk diameters of 2 cm or
From The Russell H. Morgan Department of Radiology and Radiological Science (B.P., H.S.K.) and Department of Obstetrics and Gynecology (J.M.L.), Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, Maryland 21287-4010. Received March 8, 2006; revision requested June 26; final revision received September 7; and accepted October 2. Address correspondence to H.S.K.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2006 DOI: 10.1097/01.RVI.0000250889.92043.A8
larger was recently suggested in a retrospective study (3) of 12 patients with leiomyomas with a mean maximum diameter of 8.3 cm and a mean volume of 279 cm3 before UAE, safety and efficacy of UAE for large subserosal leiomyomas with diameters larger than 10 cm and/or volumes greater than 1,000 cm3 on a short stalk are not well established. Patients with large subserosal leiomyomas and multiple intrauterine leiomyomas who desire preservation of the uterus present a unique challenge for clinicians. We describe two cases of successful clinical outcome after combined therapy of UAE and myomectomy for gigantic pedunculated subserosal leiomyoma exceeding 1,000 cm 3 in volume on a short stalk and multiple intrauterine leiomyomata.
CASE REPORTS According to our institutional guidelines, institutional review board approval was not required for this report. A 42-year-old black woman, gravida 2 para 1, presented with main
symptoms of significant menorrhagia, cramping, and clotting. The patient also reported mass-effect symptoms including frequent urination, nocturia, dyspareunia, bloating, fullness, and weight gain. A clinical examination found the uterus size to be about 24 weeks. The baseline transformed symptom severity score was 81.25. Magnetic resonance (MR) imaging demonstrated a markedly enlarged pedunculated leiomyoma with a maximum dimension of 17 cm in a subserosal location and multiple intramural and submucosal leiomyomata (Fig 1). The volume of the pedunculated subserosal leiomyoma was estimated at 1,334 cm3 according to the formula of a prolate ellipse: length ⫻ width ⫻ depth ⫻ 0.5233. There were several intramural and submucosal leiomyomas ranging in size from 4 cm to 6 cm. The patient desired treatment that would ensure uterine preservation. UAE and myomectomy were planned. The patient underwent bilateral UAE with 22 mL of 500- to 700-m tris-acryl gelatin microspheres (Embosphere; BioSphere Medical, Rockland, MA) and a 3-F microcatheter (Fig 2). The endpoints of embolization were
1947
1948
•
Sequential UAE and Myomectomy for Large Subserosal Leiomyomata
December 2006
JVIR
20-cm pedunculated subserosal leiomyoma with a short stalk with an estimated volume of 1,392 cm3 and multiple intramural and submucosal leiomyomata. Fifteen weeks after uncomplicated recovery after UAE, a myomectomy was performed on the pedunculated subserosal leiomyoma. During the procedure, the patient lost 300 mL of blood, but no blood transfusion was required. The patient had complete resolution of all of symptoms after the treatments and has remained asymptomatic for 3 years. No additional treatment for leiomyoma was required.
DISCUSSION
Figure 1. Sagittal T2-weighted MR image before UAE and myomectomy demonstrates a markedly enlarged subserosal leiomyoma (open arrows) attached to the uterus by a short stalk (closed arrow). Note additional multiple intrauterine leiomyomas.
occlusion of the perileiomyoma plexus of known leiomyomata, stasis of flow in the distal part of the uterine artery, and reduced flow in the proximal part of the main uterine artery. Ten days after the UAE procedure, a transabdominal myomectomy was performed on the gigantic pedunculated leiomyoma, which weighed 2,700 g on pathologic examination (Fig 3). During the procedure, the patient lost 500 mL of blood and received one unit of packed red blood
cells. Shortly after the treatments, the patient had complete resolution of all her symptoms, as demonstrated by the transformed symptom severity score of zero at 6-month follow-up. The patient has remained asymptomatic for 3 years and has not required additional treatment for leiomyoma. A 41-year-old black woman, gravida 1 para 0, with symptoms of significant menorrhagia, was also treated with the same method for a gigantic
The current report describes two cases of complementary UAE and myomectomy with successful clinical outcome for the treatment of gigantic subserosal leiomyomata and multiple intrauterine leiomyomata. Effective treatment of intramural and submucosal leiomyomata with UAE avoids surgical treatment of intrauterine leiomyomata. Transfusion, fever, ileus, infection, urinary retention, bladder injury, and peritoneal adhesions with adverse effects on fertility have been reported as possible periprocedural or postprocedural complications of myomectomy (4 –7). Increased complications with greater numbers of leiomyomata removed have also been reported (8). Limiting operations on the leiomyoma outside of the uterus with less extensive resection and less reconstructive surgery on the uterus may decrease the risks from such complications. Successful UAE may also avoid the need for gonadotropin-releasing hormone agonists such as leuprolide acetate (Lupron; TPA Pharmaceuticals, Lake Forest, IL) before myomectomy. Leiomyoma recurrence rates as high as 62% on ultrasound imaging at 5 years have been reported after myomectomy (9,10). In comparison with transabdominal myomectomies, greater recurrence rates after laparoscopic myomectomy have been reported (11,12). Repeat surgery rates for symptomatic recurrent leiomyoma as high as 35% at a mean of 84 months of follow-up have also been reported (13). Such recurrence is caused at least in part by incomplete resection of leiomyomata during the initial myomectomies. Complete resection of leiomyomas is technically more difficult for intramural or submucosal leiomyo-
Volume 17
Number 12
Paxton et al
Figure 2. Angiography of the left uterine artery demonstrates a hypertrophic uterine artery supplying the markedly enlarged subserosal leiomyoma (arrows).
mata rather than subserosal leiomyomata. UAE can aid by treating intramural and submucosal leiomyomata that show enhancement with intravenous contrast medium on MR imaging, suggesting the potential for growth.
For women who desire conservation of the uterus, uncertainty exists about myomectomy because surgical conversion from intended myomectomy to hysterectomy has been reported in 2.6% of cases (14). In addition, several case reports of uterine
•
1949
rupture during pregnancy after myomectomy have been published (15). UAE treatment for symptomatic leiomyomas affords a high probability of uterus conservation, given that only three of 2,729 patients in the recently completed Fibroid Registry (1) underwent hysterectomies within 30 days after UAE procedures. UAE may also assist subsequent myomectomy for the treatment of intrauterine leiomyomata, leaving surgery to be performed only on subserosal leiomyomata and avoiding extensive surgical resection and repair. This may help lessen the perioperative blood loss and requirements for transfusions. Ginsburg et al (16) reported significantly increased blood loss during myomectomy of uteri with volumes greater than 600 mL, increased total weight of leiomyomata removed, and lengthy operating time. It is worth noting that the patients in our report with leiomyomata volumes of more than 1,000 cm3 lost only 500 mL and 300 mL of blood during their myomectomies, with one unit of packed red blood cells transfused in one case. Despite the recent report by Katsumori et al (3) that suggested the safety of UAE of pedunculated subserosal leiomyomata in 12 patients, the mean maximum diameter of subserosal leiomyomas in that report was 8.3 cm, with a mean pretreatment leiomyoma volume 279 cm3 smaller than the subserosal leiomyomas we describe in our report. Repeat intervention rates with recurrent symptoms after UAE have also been described to be as high as 25% over the course of a 5-year follow-up (17). Although successful outcomes after UAE of large leiomyomas has been reported (18), large leiomyoma size and increased number of leiomyomas have been suggested as predictors of recurrence after UAE (19). Continued growth of pedunculated subserosal leiomyomas after UAE has also been reported (20). Therefore, the safety and efficacy of UAE of large subserosal leiomyomas remain debatable, and the issues warrant further investigation. In conclusion, we report successful clinical outcomes after combined UAE and myomectomy for gigantic subserosal leiomyomas and multiple intrauterine leiomyomas. The combined therapy may provide optimal clinical
1950
•
Sequential UAE and Myomectomy for Large Subserosal Leiomyomata
10. 11.
12.
13.
14.
15. Figure 3. Intraoperative photograph shows the pedunculated subserosal leiomyoma during myomectomy. Note short stalk attaching the leiomyoma to the uterus (arrow).
results by minimizing complications associated with either treatment alone and maximizing the benefits of each respective treatment modality. References 1. Worthington-Kirsch R, Spies JB, Myers ER, et al. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol 2005; 106:52–59. 2. Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2004; 15:115–120. 3. Katsumori T, Akazawa K, Mihara T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol 2005; 184:399–402. 4. Roth TM, Gustilo-Ashby T, Barber MD, et al. Effects of race and clinical fac-
5.
6.
7.
8. 9.
tors on short-term outcomes of abdominal myomectomy. Obstet Gynecol 2003; 101:881–884. Iverson RE Jr, Chelmow D, Strohbehn K, et al. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415–419. West S, Ruiz R, Parker WH. Abdominal myomectomy in women with very large uterine size. Fertil Steril 2006; 85: 36–39. Fauconnier A, Dubuisson JB, Ancel PY, et al. Prognostic factors of reproductive outcome after myomectomy in infertile patients. Hum Reprod 2000; 15: 1751–1757. Matchar DB, Myers ER, Barber MW. Management of uterine fibroids. Evid Rep Technol Assess (Summ) 2001:1–6. Fedele L, Parazzini F, Luchini L, et al.
16.
17.
18.
19.
20.
December 2006
JVIR
Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Hum Reprod 1995; 10:1795– 1796. Hanafi M. Predictors of leiomyoma recurrence after myomectomy. Obstet Gynecol 2005; 105:877–881. Fauconnier A, Chapron C, Babaki-Fard K, et al. Recurrence of leiomyomata after myomectomy. Hum Reprod Update 2000; 6:595–602. Dubuisso JB, Fauconnier A, BabakiFard K, et al. Laparoscopic myomectomy: a current view. Hum Reprod Update 2000; 6:588–594. Stewart EA, Faur AV, Wise LA, et al. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstet Gynecol 2002; 99: 426–432. Subramanian S, Clark MA, Isaacson K. Outcome and resource use associated with myomectomy. Obstet Gynecol 2001; 98:583–587. Milad MP, Sankpal RS. Laparoscopic approaches to uterine leiomyomas. Clin Obstet Gynecol 2001; 44:401–411. Ginsburg ES, Benson CB, Garfield JM, et al. The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 1993; 60:956–962. Spies JB, Bruno J, Czeyda-Pommersheim F, et al. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol 2005; 106:933– 939. Katsumori T, Nakajima K, Mihara T. Is a large fibroid a high-risk factor for uterine artery embolization? AJR Am J Roentgenol 2003; 181:1309–1314. Marret H, Cottier JP, Alonso AM, et al. Predictive factors for fibroids recurrence after uterine artery embolisation. Br J Obstet Gynaecol 2005; 112:461–465. Stringer NH, DeWhite A, Park J, et al. Laparoscopic myomectomy after failure of uterine artery embolization. J Am Assoc Gynecol Laparosc 2001; 8:583–586.