Objective: To help direct the organized and effective implementation of uterine fibroid embolization into clinical practice in Canada.
Options: This document is restricted to the management of uterine fibroid embolization as performed by the radiologists utilizing a trans-femoral artery approach with arteriography followed by vessel embolization.
Outcomes: Uterine fibroid embolization has been evaluated in terms of patient satisfaction, risks of complications, risks in subsequent pregnancy and rate of hysterectomy within a few months of the procedure. As the procedure is relatively new, data on long-term outcomes are not available.
Evidence: Published opinions of experts, supplemented by evidence from clinical trials where appropriate.
Values: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination.
Benefits, harms, and costs: For women presenting with symptomatic uterine fibroids who are candidates for UFE, there is often a benefit to avoiding an abdominal surgery. The risks of the UFE procedure, possible complications, and short- and long-term prognosis must be measured on an individual basis against the well-studied surgical alternatives. Patient preference is an important component of this evaluation. The non-material costs of ongoing symptoms from the fibroids are difficult to measure and use comparatively against the cost of hospitalization and treatment. In evaluating costs of UFE, the calculations should take into consideration the cost of managing occasional complications including subsequent hysterectomy. The cost of myomectomy or hysterectomy will vary largely depending on technique used and length of hospital stay.
Recommendations: 1. Women considering treatment of fibroids should be counselled that while the early results of uterine artery embolization are encouraging, no long-term data exist. (II-2-B) 2. UFE should only be considered for women with symptomatic or problematic fibroids who might otherwise be advised to have surgical treatment. (III-A) 3. UFE as a treatment for fibroids in patients wishing to preserve their fertility should be undertaken with full disclosure to the patient about the limitations of such a procedure and the lack of existing data regarding future fertility and pregnancy outcomes. (III-C) 4. UFE is contraindicated in women who have evidence of current genitourinary infection and/or malignancy. (II-2-B) 5. Women who choose UFE as an alternative to hysterectomy should be counselled regarding the risk of major complications f UFE where hysterectomy may be urgently required and potentially lifesaving. In view of this small but important risk, UFE is relatively contraindicated in women who are unwilling to have a hysterectomy under any circumstances. (III-C) 6. Genitourinary infection is the predominant cause of serious morbidity and mortality. Further research on the utility of prophylactic antibiotic therapy and the value of pretreatment screening for infection is needed. (II-2-B) 7. A gynaecologist who is familiar with UFE should evaluate all patients considered for UFE before the procedure is booked and a consensus on the suitability of the procedure achieved between the gynaecologist and radiologist. (III-C) 8. Only radiologists with specialized embolization experience and techniques should perform UFE. (III-C) 9. The particular responsibilities of both gynaecologist and radiologist should be established prior to treatment and be set out in a relevant hospital protocol. A particular physician must be responsible for the patient at all times. (III-C) 10. A Canadian national registry of numbers, indications, outcomes, complications, and successful pregnancies associated with UFE should be created and jointly administered and funded by the SOGC, CAR, and CIRA. (III-C).