- Email: [email protected]
Uterine artery embolisation in women with symptomatic adenomyosis
Presse Med. 2019; 48: 435–439
Dossier thématique
Update
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Uterine artery embolisation in women with symptomatic adenomyosis Paul N.M. Lohle 1, David Higué 2, Denis Herbreteau 3
Disponible sur internet le : 27 April 2019
1. Tilburg university, department of radiology, St. Elisabeth Ziekenhuis, 5022 GC Tilburg, The Netherlands 2. CHU, hôpital de la Côte Basque, service d'imagerie, pôle de gynécologieobstétrique-reproduction, 64109 Bayonne Cedex, France 3. CHRU, hopital Bretonneau pôle imagerie, neuro-radiologie-IRM-Scanner, 2, boulevard Tonnelle, 37044 Tours cedex 9, France
Correspondance : Denis Herbreteau, Université François Rabelais, CHRU, hopital Bretonneau pôle imagerie, neuro-radiologie-IRM-Scanner, 2, boulevard Tonnelle, 37044 Tours cedex 9, France. [email protected]
Summary Adenomyosis is frequently called the "forgotten'' diagnosis, because of its non-characteristic clinical appearance. Similar to fibroid symptoms, adenomyosis may be the cause of disabling symptoms such as heavy menstrual bleeding, in particular pain (abdominal-, pelvic-, low back- and menstrual pain), with or without bulk related symptoms and fertility issues in premenopausal women. The current literature demonstrates durable symptom improvement in patients with adenomyosis following uterine artery embolisation. It is no longer justified to withhold women the option of uterine artery embolisation for symptomatic adenomyosis with or without fibroids.
Résumé Embolisation de l'artère utérine chez les femmes ayant une adenomyose symptomatique Son aspect clinique, souvent non caractéristique, explique que l'adénomyose soit souvent appelée « le diagnostic oublié ». Tout comme les fibromes, il peut être à l'origine de symptômes invalidants: saignements menstruels abondants, douleurs intenses abdominales, pelviennes, lombaires et menstruelles, avec ou sans signes généraux, mais surtout de problèmes de fertilité chez les femmes non ménopausées. L'embolisation de l'artère utérine permet une amélioration notable de tous ces symptômes ; elle est parfaitement justifiée en cas d'adénomyose symptomatique, avec ou sans fibromes.
tome 48 > n84 > April 2019 https://doi.org/10.1016/j.lpm.2019.03.013 © 2019 Published by Elsevier Masson SAS.
exhibits ectopic non-neoplastic endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium [1]. The exact prevalence of adenomyosis is unknown, but
435
A
denomyosis, associated with heavy menstrual bleeding, is a benign invasion of endometrium into the myometrium that results in a diffusely enlarged uterus that microscopically
Update
PNM. Lohle, PNM. Higué, D. Herbreteau
estimated to be 5–8% and up to 40–70% [1–3]. This range may be explained by the different study designs, the random testing described in studies, the lack of a gold standard for identifying adenomyosis and the use of different TVUS-, MRI- and pathologic anatomical criteria for adenomyosis. Adenomyosis causing symptoms is estimated to be in about 2/3 of women. Of women with clinical manifestations of adenomyosis, about one-fifth are under 40, but the vast majority are between 40 and 50 years [4– 6]. The clinical diagnosis of adenomyosis is at times difficult, since the presenting symptoms overlap with common uterine disorders such as uterine fibroids. Adenomyosis is frequently called the "forgotten'' diagnosis, because of its non-characteristic clinical appearance. Similar to fibroid symptoms, adenomyosis may be the cause of disabling symptoms such as heavy menstrual bleeding, in particular pain (abdominal-, pelvic-, low back- and menstrual pain), with or without bulk related symptoms and fertility issues in premenopausal women.
TVUS and MR imaging to diagnose adenomyosis The first-line imaging technique, in women with suspected adenomyosis, is usually transvaginal ultrasound (TVUS), which is inexpensive and readily available. Particularly useful in both doubtful TVUS cases and in providing a complete evaluation of the disease with its panoramic views is magnetic resonance
imaging (MRI). The MR images (T2-weighted and T1-weighted with contrast) provide the thickness of the junction zone, which can be measured reliably; a thickness over 12 mm is by definition a sign to diagnose adenomyosis (figure 1). The occurrence of high signal intensity foci within the myometrium of the uterus forms an additional, but not a obligatory criterion. MRI can label adenomyosis as focal or diffuse and can be repeated in time to assess the effect of treatment. In daily practice and from personal experience, MRI is less operator dependent and therefore very useful and often better compared to TVUS, in detecting adenomyosis and to determine the vascularisation, and thus the infarction grade after embolization. The combination of both modalities in daily practice provides the best accuracy of 90% [7,8].
Different treatment options for symptomatic adenomyosis Local or systemic medical treatment Women with symptomatic adenomyosis may receive medical treatment, which ranges from local treatment with the release of medications by an intra-uterine device to systemically administered treatment. The Mirena coil, an intra-uterine device releasing progesterone, causes atrophic changes of the endometrium, which reduces the amount of blood loss in these women with symptomatic adenomyosis. Existing medications
Figure 1
436
Sagittal T2-weighted MR image of a patient suffering from very painful heavy menstrual bleedings due to diffuse pure adenomyosis, with thickening of the junctional zone, high intensity lesions and an enlarged uterus
tome 48 > n84 > April 2019
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
Update
Uterine artery embolisation in women with symptomatic adenomyosis
Figure 2 Types of adenomyosis pure and mixed with fibroids with the estimated ratios [17]
Surgical treatment for adenomyosis The usual and preferred surgical approach for women with symptomatic adenomyosis is hysterectomy. When hysterectomy is considered, trans-vaginal access is preferable to trans-abdominal access due to the lower morbidity and shorter hospital stay. Rates of complication after hysterectomy range between 1.5% and 29.3%. Hysterectomy is associated with complications such as blood loss, bowel and general uro-genital injury, pain and infection. The recovery time ranges between 6 and 8 weeks [9–11], and health care-related expenses and lost time at work render hysterectomy an option associated with high costs [12]. In order to avoid these potential surgical difficulties, the less invasive uterine artery embolisation procedure is considered the alternative to solve the patient's and operator's problem. In our uterine artery embolisation practice for symptomatic adenomyosis and fibroids, the ratio between patients treated for symptomatic fibroids versus patients with
tome 48 > n84 > April 2019
pure adenomyosis or fibroids combined with adenomyosis is 7:2:1 (figure 2).
Clinical success Based on the similarity of symptoms of fibroids and adenomyosis and the positive fibroid embolisation results, this intervention has been investigated as an option to treat adenomyosis. The first results of uterine artery embolisation for adenomyosis were disappointing before the year 2000, and therefore considered contraindicated in the past. However, later studies demonstrated encouraging results after embolisation of adenomyosis with significant clinical and symptomatic improvement (figure 3) [13,14]. Embolisation outcomes for adenomyosis are variable and depend on the extent and vascularity of the adenomyosis, the degree of necrosis following embolisation, and the presence and absence of fibroids. Better outcomes have been demonstrated in cases of adenomyosis with lower signal intensity on T2-weighted imaging, focal areas of adenomyosis, and use of smaller particle size for embolization. The longest follow-up report after adenomyosis embolisation demonstrated significant improvement of health-related quality of life and symptom-severity scores at 3 months after embolisation, which remained comparable stable up to 7 years after the intervention. After 7 years of follow-up, in 82% of the embolisation treated patients with symptomatic adenomyosis a
437
for systemic administration include gonadotropin-releasing hormone (GnRH) agonists, which induces menopause by reducing the release of pituitary gonadotropins, lowers the levels of oestrogen, producing atrophy and uterine volume reduction and symptom improvement, since adenomyosis is an oestrogen-dependent disease. If the therapy is stopped, the effect is reversible and symptoms will return.
Update
PNM. Lohle, PNM. Higué, D. Herbreteau
Figure 3 Sagittal T2-weighted (a) and T1+contrast (b) MR images of focal pure adenomyosis in a patient with painful heavy menstrual bleedings. Sagittal contrast enhanced T1-weighted MR image after uterine artery embolisation (c) with 100% infarction of adenomatous tissue and complete relief of symptoms
hysterectomy was avoided [15]. In a recent systematic review and meta-analysis the effect of uterine artery embolisation on symptomatic adenomyosis was evaluated [16]. Four groups were evaluated: short-term (< 12 months) pure adenomyosis and adenomyosis mixed with fibroids, and long-term (> 12 months) pure adenomyosis and adenomyosis mixed with fibroids. The clinical improvement on short term (½ year followup) for adenomyosis pure or mixed with fibroids was 90%, with a hysterectomy rate of 2%. The clinical improvement on long term (2½ year follow-up) for adenomyosis pure or mixed with fibroids was respectively 75% and 85%, with a hysterectomy rate of 7%. Overall, the improvement of symptoms occurred in 84% (882/1056) of patients, with reduction of uterine volumes, decrease in junction zone thickness and increased infarction rates in most patients after uterine artery embolisation. Reported symptom reduction was 4.8% greater in the
short-term combined group and 11.4% greater in the long-term combined group [16].
Conclusion While prospective, randomised trials evaluating the role of embolisation for adenomyosis are warranted, the current literature demonstrates durable symptom improvement in patients with adenomyosis following uterine artery embolisation. It is no longer justified to withhold women the option of uterine artery embolisation for symptomatic adenomyosis with or without fibroids. Disclosure of interest : The Dr Lhole is consultant for Merit Medical, Terumo and Boston Scientific. D. Herbreteau is consultant for Boston scientific.
References [1]
[2]
[3]
[4]
438
[5]
Bird CC, McElin TW, Manalo-Estrella P. The elusive adenomyosis of the uterus-revisited. Am J Obstet Gynecol 1972;112:583–93. Levgur M, Abadi M, Tucker A. Adenomyosis: symptoms, histology and pregnancy terminations. Obstet Gynecol 2000;95:688–91. Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am 1989;16:221– 35. Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2weighted spin-echo and gadoliniumenhanced T1-weighted images. AJR Am J Roentgenol 2004;182:399–404. Bergeron C, Amant F, Ferency A. A pathology and physiopathology of adenomyosis. Best
Res Clin Obstet Gynaecol Pract 2006;20:511–21. [6] Peric H, Fraser IS. The symptomatology of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006;20:547–55. [7] Levgur M. Therapeutic options for adenomyosis: a review. Arch Gynecol Obstet 2007;276:1–15. [8] Mijatovic V, van Waesberghe JH, Schats R, et al. Adenomyose in historisch perspectief met focus op moderne beeldvorming en behandeling. NTOG 2010;123:335–43. [9] Faquhar C, Brosens I. Medical and surgical management of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006;20:603–16. [10] Meyers ER, Steege JF. Risk adjustment for complications of hysterectomy: utility of
routinely collected administrative data. Prim Care Update Ob Gyns 1998;5:202–3. [11] Dembek CJ, Pelletier EM, Isaacson KB, et al. Payer costs in patients undergoing uterine artery embolization, hysterectomy, or myomectomy for treatment of uterine fibroids. J Vasc Interv Radiol 2007;18:1207–13. [12] Volkers NA, Hehenkamp WJ, Smit P, et al. Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. J Vasc Interv Radiol 2008;19:1007–16. [13] Lohle PN, De Vries J, Klazen CA, et al. Uterine artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin
tome 48 > n84 > April 2019
tome 48 > n84 > April 2019
[15] de Bruijn AM, Smink M, Hehenkamp WJK, et al. Uterine artery embolization for symptomatic adenomyosis: 7-year clinical follow-up using UFS-Qol questionnaire. Cardiovasc Intervent Radiol 2017;40:1344–50. [16] de Bruijn AM, Smink M, Lohle PNM, et al. Uterine artery embolization for the treatment of adenomyosis: a systematic review and
meta-analysis. J Vasc Interv Radiol 2017;28:1629–42. [17] Bae SH, Kim MD, Kim GM, et al. Uterine artery embolization for adenomyosis: percentage of necrosis predicts midterm clinical recurrence. J Vasc Interv Radiol 2015;26 (9):1290–6.
Update
microspheres: midterm clinical and MR imaging follow-up. J Vasc Interv Radiol 2007;18:835–41. [14] Liang E, Brown B, Rachinsky M. A clinical audit on the efficacy and safety of uterine artery embolisation for symptomatic adenomyosis: results in 117 women. Aust N Z J Obstet Gynaecol 2018;58:454–9.
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
439
Uterine artery embolisation in women with symptomatic adenomyosis
Dossier thématique
Update
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Uterine artery embolisation in women with symptomatic adenomyosis Paul N.M. Lohle 1, David Higué 2, Denis Herbreteau 3
Disponible sur internet le : 27 April 2019
1. Tilburg university, department of radiology, St. Elisabeth Ziekenhuis, 5022 GC Tilburg, The Netherlands 2. CHU, hôpital de la Côte Basque, service d'imagerie, pôle de gynécologieobstétrique-reproduction, 64109 Bayonne Cedex, France 3. CHRU, hopital Bretonneau pôle imagerie, neuro-radiologie-IRM-Scanner, 2, boulevard Tonnelle, 37044 Tours cedex 9, France
Correspondance : Denis Herbreteau, Université François Rabelais, CHRU, hopital Bretonneau pôle imagerie, neuro-radiologie-IRM-Scanner, 2, boulevard Tonnelle, 37044 Tours cedex 9, France. [email protected]
Summary Adenomyosis is frequently called the "forgotten'' diagnosis, because of its non-characteristic clinical appearance. Similar to fibroid symptoms, adenomyosis may be the cause of disabling symptoms such as heavy menstrual bleeding, in particular pain (abdominal-, pelvic-, low back- and menstrual pain), with or without bulk related symptoms and fertility issues in premenopausal women. The current literature demonstrates durable symptom improvement in patients with adenomyosis following uterine artery embolisation. It is no longer justified to withhold women the option of uterine artery embolisation for symptomatic adenomyosis with or without fibroids.
Résumé Embolisation de l'artère utérine chez les femmes ayant une adenomyose symptomatique Son aspect clinique, souvent non caractéristique, explique que l'adénomyose soit souvent appelée « le diagnostic oublié ». Tout comme les fibromes, il peut être à l'origine de symptômes invalidants: saignements menstruels abondants, douleurs intenses abdominales, pelviennes, lombaires et menstruelles, avec ou sans signes généraux, mais surtout de problèmes de fertilité chez les femmes non ménopausées. L'embolisation de l'artère utérine permet une amélioration notable de tous ces symptômes ; elle est parfaitement justifiée en cas d'adénomyose symptomatique, avec ou sans fibromes.
tome 48 > n84 > April 2019 https://doi.org/10.1016/j.lpm.2019.03.013 © 2019 Published by Elsevier Masson SAS.
exhibits ectopic non-neoplastic endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium [1]. The exact prevalence of adenomyosis is unknown, but
435
A
denomyosis, associated with heavy menstrual bleeding, is a benign invasion of endometrium into the myometrium that results in a diffusely enlarged uterus that microscopically
Update
PNM. Lohle, PNM. Higué, D. Herbreteau
estimated to be 5–8% and up to 40–70% [1–3]. This range may be explained by the different study designs, the random testing described in studies, the lack of a gold standard for identifying adenomyosis and the use of different TVUS-, MRI- and pathologic anatomical criteria for adenomyosis. Adenomyosis causing symptoms is estimated to be in about 2/3 of women. Of women with clinical manifestations of adenomyosis, about one-fifth are under 40, but the vast majority are between 40 and 50 years [4– 6]. The clinical diagnosis of adenomyosis is at times difficult, since the presenting symptoms overlap with common uterine disorders such as uterine fibroids. Adenomyosis is frequently called the "forgotten'' diagnosis, because of its non-characteristic clinical appearance. Similar to fibroid symptoms, adenomyosis may be the cause of disabling symptoms such as heavy menstrual bleeding, in particular pain (abdominal-, pelvic-, low back- and menstrual pain), with or without bulk related symptoms and fertility issues in premenopausal women.
TVUS and MR imaging to diagnose adenomyosis The first-line imaging technique, in women with suspected adenomyosis, is usually transvaginal ultrasound (TVUS), which is inexpensive and readily available. Particularly useful in both doubtful TVUS cases and in providing a complete evaluation of the disease with its panoramic views is magnetic resonance
imaging (MRI). The MR images (T2-weighted and T1-weighted with contrast) provide the thickness of the junction zone, which can be measured reliably; a thickness over 12 mm is by definition a sign to diagnose adenomyosis (figure 1). The occurrence of high signal intensity foci within the myometrium of the uterus forms an additional, but not a obligatory criterion. MRI can label adenomyosis as focal or diffuse and can be repeated in time to assess the effect of treatment. In daily practice and from personal experience, MRI is less operator dependent and therefore very useful and often better compared to TVUS, in detecting adenomyosis and to determine the vascularisation, and thus the infarction grade after embolization. The combination of both modalities in daily practice provides the best accuracy of 90% [7,8].
Different treatment options for symptomatic adenomyosis Local or systemic medical treatment Women with symptomatic adenomyosis may receive medical treatment, which ranges from local treatment with the release of medications by an intra-uterine device to systemically administered treatment. The Mirena coil, an intra-uterine device releasing progesterone, causes atrophic changes of the endometrium, which reduces the amount of blood loss in these women with symptomatic adenomyosis. Existing medications
Figure 1
436
Sagittal T2-weighted MR image of a patient suffering from very painful heavy menstrual bleedings due to diffuse pure adenomyosis, with thickening of the junctional zone, high intensity lesions and an enlarged uterus
tome 48 > n84 > April 2019
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
Update
Uterine artery embolisation in women with symptomatic adenomyosis
Figure 2 Types of adenomyosis pure and mixed with fibroids with the estimated ratios [17]
Surgical treatment for adenomyosis The usual and preferred surgical approach for women with symptomatic adenomyosis is hysterectomy. When hysterectomy is considered, trans-vaginal access is preferable to trans-abdominal access due to the lower morbidity and shorter hospital stay. Rates of complication after hysterectomy range between 1.5% and 29.3%. Hysterectomy is associated with complications such as blood loss, bowel and general uro-genital injury, pain and infection. The recovery time ranges between 6 and 8 weeks [9–11], and health care-related expenses and lost time at work render hysterectomy an option associated with high costs [12]. In order to avoid these potential surgical difficulties, the less invasive uterine artery embolisation procedure is considered the alternative to solve the patient's and operator's problem. In our uterine artery embolisation practice for symptomatic adenomyosis and fibroids, the ratio between patients treated for symptomatic fibroids versus patients with
tome 48 > n84 > April 2019
pure adenomyosis or fibroids combined with adenomyosis is 7:2:1 (figure 2).
Clinical success Based on the similarity of symptoms of fibroids and adenomyosis and the positive fibroid embolisation results, this intervention has been investigated as an option to treat adenomyosis. The first results of uterine artery embolisation for adenomyosis were disappointing before the year 2000, and therefore considered contraindicated in the past. However, later studies demonstrated encouraging results after embolisation of adenomyosis with significant clinical and symptomatic improvement (figure 3) [13,14]. Embolisation outcomes for adenomyosis are variable and depend on the extent and vascularity of the adenomyosis, the degree of necrosis following embolisation, and the presence and absence of fibroids. Better outcomes have been demonstrated in cases of adenomyosis with lower signal intensity on T2-weighted imaging, focal areas of adenomyosis, and use of smaller particle size for embolization. The longest follow-up report after adenomyosis embolisation demonstrated significant improvement of health-related quality of life and symptom-severity scores at 3 months after embolisation, which remained comparable stable up to 7 years after the intervention. After 7 years of follow-up, in 82% of the embolisation treated patients with symptomatic adenomyosis a
437
for systemic administration include gonadotropin-releasing hormone (GnRH) agonists, which induces menopause by reducing the release of pituitary gonadotropins, lowers the levels of oestrogen, producing atrophy and uterine volume reduction and symptom improvement, since adenomyosis is an oestrogen-dependent disease. If the therapy is stopped, the effect is reversible and symptoms will return.
Update
PNM. Lohle, PNM. Higué, D. Herbreteau
Figure 3 Sagittal T2-weighted (a) and T1+contrast (b) MR images of focal pure adenomyosis in a patient with painful heavy menstrual bleedings. Sagittal contrast enhanced T1-weighted MR image after uterine artery embolisation (c) with 100% infarction of adenomatous tissue and complete relief of symptoms
hysterectomy was avoided [15]. In a recent systematic review and meta-analysis the effect of uterine artery embolisation on symptomatic adenomyosis was evaluated [16]. Four groups were evaluated: short-term (< 12 months) pure adenomyosis and adenomyosis mixed with fibroids, and long-term (> 12 months) pure adenomyosis and adenomyosis mixed with fibroids. The clinical improvement on short term (½ year followup) for adenomyosis pure or mixed with fibroids was 90%, with a hysterectomy rate of 2%. The clinical improvement on long term (2½ year follow-up) for adenomyosis pure or mixed with fibroids was respectively 75% and 85%, with a hysterectomy rate of 7%. Overall, the improvement of symptoms occurred in 84% (882/1056) of patients, with reduction of uterine volumes, decrease in junction zone thickness and increased infarction rates in most patients after uterine artery embolisation. Reported symptom reduction was 4.8% greater in the
short-term combined group and 11.4% greater in the long-term combined group [16].
Conclusion While prospective, randomised trials evaluating the role of embolisation for adenomyosis are warranted, the current literature demonstrates durable symptom improvement in patients with adenomyosis following uterine artery embolisation. It is no longer justified to withhold women the option of uterine artery embolisation for symptomatic adenomyosis with or without fibroids. Disclosure of interest : The Dr Lhole is consultant for Merit Medical, Terumo and Boston Scientific. D. Herbreteau is consultant for Boston scientific.
References [1]
[2]
[3]
[4]
438
[5]
Bird CC, McElin TW, Manalo-Estrella P. The elusive adenomyosis of the uterus-revisited. Am J Obstet Gynecol 1972;112:583–93. Levgur M, Abadi M, Tucker A. Adenomyosis: symptoms, histology and pregnancy terminations. Obstet Gynecol 2000;95:688–91. Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am 1989;16:221– 35. Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2weighted spin-echo and gadoliniumenhanced T1-weighted images. AJR Am J Roentgenol 2004;182:399–404. Bergeron C, Amant F, Ferency A. A pathology and physiopathology of adenomyosis. Best
Res Clin Obstet Gynaecol Pract 2006;20:511–21. [6] Peric H, Fraser IS. The symptomatology of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006;20:547–55. [7] Levgur M. Therapeutic options for adenomyosis: a review. Arch Gynecol Obstet 2007;276:1–15. [8] Mijatovic V, van Waesberghe JH, Schats R, et al. Adenomyose in historisch perspectief met focus op moderne beeldvorming en behandeling. NTOG 2010;123:335–43. [9] Faquhar C, Brosens I. Medical and surgical management of adenomyosis. Best Pract Res Clin Obstet Gynaecol 2006;20:603–16. [10] Meyers ER, Steege JF. Risk adjustment for complications of hysterectomy: utility of
routinely collected administrative data. Prim Care Update Ob Gyns 1998;5:202–3. [11] Dembek CJ, Pelletier EM, Isaacson KB, et al. Payer costs in patients undergoing uterine artery embolization, hysterectomy, or myomectomy for treatment of uterine fibroids. J Vasc Interv Radiol 2007;18:1207–13. [12] Volkers NA, Hehenkamp WJ, Smit P, et al. Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. J Vasc Interv Radiol 2008;19:1007–16. [13] Lohle PN, De Vries J, Klazen CA, et al. Uterine artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin
tome 48 > n84 > April 2019
tome 48 > n84 > April 2019
[15] de Bruijn AM, Smink M, Hehenkamp WJK, et al. Uterine artery embolization for symptomatic adenomyosis: 7-year clinical follow-up using UFS-Qol questionnaire. Cardiovasc Intervent Radiol 2017;40:1344–50. [16] de Bruijn AM, Smink M, Lohle PNM, et al. Uterine artery embolization for the treatment of adenomyosis: a systematic review and
meta-analysis. J Vasc Interv Radiol 2017;28:1629–42. [17] Bae SH, Kim MD, Kim GM, et al. Uterine artery embolization for adenomyosis: percentage of necrosis predicts midterm clinical recurrence. J Vasc Interv Radiol 2015;26 (9):1290–6.
Update
microspheres: midterm clinical and MR imaging follow-up. J Vasc Interv Radiol 2007;18:835–41. [14] Liang E, Brown B, Rachinsky M. A clinical audit on the efficacy and safety of uterine artery embolisation for symptomatic adenomyosis: results in 117 women. Aust N Z J Obstet Gynaecol 2018;58:454–9.
RADIOLOGIE INTERVENTIONNELLE -- 1 R E PARTIE
439
Uterine artery embolisation in women with symptomatic adenomyosis