iprs000157
10.3205/iprs000157
urn:nbn:de:0183-iprs0001579
Review Article
Can uterine artery embolization be an alternative to plastic and reconstructive uterus operation by minimally invasive surgery?
Kann die Uterusarterienembolisation eine Alternative zur plastischen und rekonstruktiven Gebärmutteroperation durch minimalinvasive Chirurgie sein?
Cezar
Cezar
Cristina
C
University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
author
Torres de la Roche
Torres de la Roche
Luz Angela
LA
University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
author
Hennefründ
Hennefründ
Jörg
J
Tagesklinik Oldenburg, Germany
author
Verhoeven
Verhoeven
Hugo Christian
HC
Private Center for Endocrinology, Preventive Medicine, Reproductive Medicine and Gynecology, Dusseldorf, Germany
author
Devassy
Devassy
Rajesh
R
MD
University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Georgstrasse 12, 26121 Oldenburg, Germany, Phone: + 49 441 229 1500University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
rajeshdevassy@gmail.com
author
De Wilde
De Wilde
Rudy Leon
RL
University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
author
Working Group on Minimally Invasive Therapy in Benign Disease of the Uterine Wall (European Society of Gynecological Endoscopy, ESGE)
Working Group on Minimally Invasive Therapy in Benign Disease of the Uterine Wall (European Society of Gynecological Endoscopy, ESGE)
author
German Medical Science GMS Publishing House
Düsseldorf
610
uterine artery embolization
myoma
complications
gynaecologic surgical procedures
haemostatic techniques
Uterusarterienembolisation
Myom
Komplikationen
gynäkologische chirurgische Eingriffe
hämostatische Techniken
2021060920210610
engl
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung).
2193-8091
10
GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW
GMS Interdiscip Plast Reconstr Surg DGPW
07
20210610Labelling as corresponding author has been added.
Einleitung: Die plastische und rekonstruktive minimal-invasive Chirurgie hat sich als Goldstandard in der Myomektomie etabliert. Therapieversagen führt schließlich zu weiteren chirurgischen Eingriffen oder zur Hysterektomie: Chirurgen und Patientinnen sollten sich der Risiken und des Nutzens bewusst sein. Wir führten eine systematische Übersichtsarbeit durch, um die Evidenz zu den therapeutischen Indikationen und unerwünschten Ereignissen im Zusammenhang mit der Uterusarterienembolisation zu analysieren und damit zu bewerten, ob diese Methode eine valide Therapiealternative darstellen könnte. Methoden: In Übereinstimmung mit dem PRISMA Leitfaden recherchierten wir die medizinische Literatur in den Datenbanken PubMed, Cochrane Library, UpToDate, Amboss und Medline. Klinische Studien, Reviews und Case Reports, die zwischen Januar 2010 und Juni 2020 in Englisch veröffentlicht wurden, waren einbezogen.Ergebnisse: Von den 838 bei der ersten Suche identifizierten Arbeiten wurden 44 Artikel eingeschlossen. In Bezug auf Uterusmyome berichteten drei Originalarbeiten und ein Cochrane-Review über die Vorteile des Verfahrens als Alternative zur Operation, auch bei großen und riesigen Myomen. Darüber hinaus wurde in mehreren Studien der Einsatz der Embolisation bei postpartalen Blutungen diskutiert, um die Rate der Hysterektomie zu senken, nachdem andere hämostatische Methoden wegen des potentiellen Risikos einer abnormalen Plazentation in einer zukünftigen Schwangerschaft ausgeschöpft waren. Das Verfahren kann auch erfolgreich als prophylaktische Methode bei verschiedenen geburtshilflichen Eingriffen eingesetzt werden. Schlussfolgerungen: Die Anwendung der Embolisation bei verschiedenen uterinen Pathologien ist ein minimal-invasives Verfahren als Alternative zur Operation, insbesondere bei Frauen, die ihren Uterus erhalten möchten. Die damit verbundenen Komplikationen sind beschrieben und können durch eine stringente Indikationsstellung des Verfahrens vermieden werden. Mehr Evidenz bezüglich der Fertilität nach UAE, des prophylaktischen Einsatzes des Verfahrens bei geburtshilflichen Blutungen oder bei Adenomyose ist erforderlich.
Introduction: Plastic and reconstructive minimally invasive surgery has been established as gold standard in myomectomy. Therapy failure eventually leads to future surgical interventions or hysterectomy: surgeons and patients should be aware of the risks and benefits. We conducted a systematic review to analyse the evidence on the therapeutic indications and adverse events associated with uterine artery embolization and thereby evaluating if this method could be a valid alternative therapy. Methods: In concordance with PRISMA guidelines, literature research was made in PubMed, Cochrane Library, UpToDate, Amboss and Medline databases. Clinical trials, reviews and case reports published in English between January 2010 and June 2020 were included. Results: 44 articles were included out of 838 papers identified at initial search. Regarding uterine fibroids, three original papers and one <![CDATA[Cochrane</PlainText></TextGroup> review reported the benefits of the procedure as an alternative to surgery, even in large and giant fibroids. Furthermore, several studies discussed the use of embolization for postpartum haemorrhage to decrease rates of hysterectomy after other haemostatic methods were exhausted, because of the potential risk of abnormal placentation in a future pregnancy. The procedure can also be successfully used as prophylactic method in different obstetrical procedures. </Pgraph><Pgraph><Mark1>Conclusions:</Mark1> The use of embolization in different uterine pathologies is a minimally invasive procedure as an alternative to surgery, especially in women who desire to preserve their uterus. Its related complications are described and can be avoided by a stringent indication of the procedure. More evidence regarding fertility after UAE, use of the procedure prophylactically in obstetrical haemorrhage or in adenomyosis is needed.</Pgraph></Abstract>
<TextBlock linked="yes" name="Introduction">
<MainHeadline>Introduction</MainHeadline><Pgraph>Gold standard of care in myomectomy is the plastic and reconstructive minimally invasive uterine surgery <TextLink reference="1"></TextLink>. The benefits of uterine artery embolization (UAE) in the treatment of different uterine pathologies are demonstrated for women desiring organ preservation, being minimally invasive, even in the treatment of giant fibroids <TextLink reference="2"></TextLink>. Since its introduction in 1995 as conservative therapy for fibroids <TextLink reference="3"></TextLink>, the intervention has been developed, being applied for uterine pathologies such as myoma <TextLink reference="4"></TextLink>, postpartum haemorrhage (PPH) <TextLink reference="5"></TextLink>, or as a prophylactic procedure before obstetrical surgery with a high risk of massive bleeding <TextLink reference="6"></TextLink>, adenomyosis <TextLink reference="7"></TextLink>, and uterine vascular malformation <TextLink reference="8"></TextLink>. However complications are possible <TextLink reference="9"></TextLink>, <TextLink reference="10"></TextLink>, which may increase the likelihood of therapy failure eventually leading to future surgical interventions <TextLink reference="11"></TextLink>.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Material and methods">
<MainHeadline>Material and methods</MainHeadline><Pgraph>This review was performed according to the PRISMA guidelines <TextLink reference="12"></TextLink>. In addition to clinical trials, we also analysed several case reports and case series in order to collect as much information as possible regarding the whole spectrum of complications. The research was performed using PubMed, <TextGroup><PlainText>Cochrane Library</PlainText></TextGroup>, <TextGroup><PlainText>UpToDate</PlainText></TextGroup>, <TextGroup><PlainText>Amboss</PlainText></TextGroup> and <TextGroup><PlainText>Medline</PlainText></TextGroup> databases, limited to articles published between January 2010 and June 2020. The search term combination consisted of words and words variations for “uterine artery embolization”, “indications”, “major complications” and “minor complications”. Only articles published in English were selected. Exclusion criteria were: associated pathology as risk factors for venous thrombosis such as postpartum period, bed rest, blood transfusion, pelvic varicose veins and inherited thrombophilia, studies focused on technical aspects, earlier studies – EMMY trial 2006, FIBROID 2005, 2008, REST 2007 and also other minimally invasive procedure such as LUAO (laparoscopic uterine artery occlusion) – MARA 2012 study. Letters and editorials were also excluded. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>Our initial database search identified a total of 838 records (n=178 for indications and n=660 for complications). After the duplicates were removed, 734 records remained and were further screened independently by the first two authors. The screening excluded 418 papers which were irrelevant to the topic of our review, discussing other aspects beside indications and outcomes of UAE. 71 further records were excluded, due to no full text availability. Out of 254 eligible articles, 210 were excluded according to our exclusion criteria: a total of 44 articles were eligible and included in this review (Figure 1 <ImgLink imgNo="1" imgType="figure"/>). </Pgraph><SubHeadline>Indications of UAE</SubHeadline><SubHeadline2>Uterine fibroids</SubHeadline2><Pgraph>Most of the studies included in our review discussed the use of UAE as an important tool in the treatment of myomas. The procedure proved to be an effective therapy for uterine fibroids in women with heavy menstrual bleeding who were resistant to other conservative therapies <TextLink reference="13"></TextLink> and proposed as an alternative myoma therapy in women wishing to preserve fertility. However, the outcomes on fertility are still unclear <TextLink reference="14"></TextLink>. </Pgraph><Pgraph>The procedure can be performed irrespective of the number of fibroids and of their uterine location (submucosal, intramural or subserosal) <TextLink reference="4"></TextLink>. Pedunculated fibroids are a relative contraindication of UAE, due to the risk of degeneration and subsequent infection which may lead to more or less severe complications <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>. </Pgraph><Pgraph>Three original papers REST 2011 <TextLink reference="11"></TextLink>, FUME 2012 <TextLink reference="17"></TextLink>, EMMY 2016 <TextLink reference="18"></TextLink>, and one Cochrane review studied the effects of UAE versus surgery, either myomectomy or hysterectomy, which we included (Table 1 <ImgLink imgNo="1" imgType="table"/>). </Pgraph><Pgraph>The REST 2011 study (Randomised comparison of uterine artery embolization with surgical treatment in patients with symptomatic uterine fibroids) compared the results of UAE versus surgery (myomectomy and hysterectomy) in 157 women with symptomatic fibroids. The study was multicentric, used a randomization 2:1 (106 UAE and <TextGroup><PlainText>51 s</PlainText></TextGroup>urgery) and a long follow-up of 5 years <TextLink reference="11"></TextLink>. The improvement in quality of life was similar in both groups, with most complications occurring in the first 12 months; the authors concluded that the safety profile of UAE is equivalent to that of surgery. Even if the rate of reintervention was higher in the UAE group, it remained an alternative to surgery <TextLink reference="11"></TextLink>. </Pgraph><Pgraph>The FUME 2012 study (Fibroids of the Uterus: Myomectomy versus Embolization) compared the quality of life in patients following UAE or myomectomy performed for uterine fibroids in a prospective cohort <TextLink reference="17"></TextLink>. The outcomes during a follow-up period of 5 years showed similar results regarding significant improvement in quality of life, but myomectomy remained more robust as procedure with fewer reinterventions and complications <TextLink reference="17"></TextLink>. </Pgraph><Pgraph>The EMMY 2016 study (Embolization vs. Hysterectomy) was a multicentric randomized controlled trial conducted between 2002 and 2004 which included 177 patients with symptomatic uterine fibroids who were treated either conservatively, UAE, or operatively by hysterectomy <TextLink reference="18"></TextLink>. The study population was randomized to 81 UAE and <TextGroup><PlainText>75 h</PlainText></TextGroup>ysterectomies with the goal of comparing the outcomes and quality of life 10 years after the procedure <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>. The authors concluded that every woman with symptomatic fibroids could be counselled about UAE as an alternative to hysterectomy, given that in 69% of cases a hysterectomy was avoided, and the satisfaction rates did not differ in both groups <TextLink reference="18"></TextLink>. </Pgraph><Pgraph>According to a Cochrane Review in 2014 <TextLink reference="20"></TextLink>, UAE remains a good alternative for the treatment of uterine fibroids, compared to surgical methods like myomectomy or hysterectomy, as it is associated with a shorter hospital stay and quicker recovery and is also rarely associated with the need of blood transfusion <TextLink reference="20"></TextLink>. However it was observed that UAE was associated with more complications, but a direct correlation to major complications was inconclusive <TextLink reference="20"></TextLink>.</Pgraph><SubHeadline2>UAE to improve fertility</SubHeadline2><Pgraph>Regarding the use of UAE to improve fertility in women with fibroids, Karlsen et al. <TextLink reference="21"></TextLink> analysed the results of 17 studies including 989 patients. The authors observed that in women receiving UAE the rates of pregnancy were lower and the rates of miscarriage were higher, when compared to those with myomectomy. However, they also discussed the low quality of evidence, indicating the necessity of further studies to elucidate this aspect <TextLink reference="21"></TextLink> (Table 2 <ImgLink imgNo="2" imgType="table"/>). </Pgraph><Pgraph>The effects of UAE on ovarian reserve is a subject of interest for clinicians and the results from different studies seem to indicate a negative influence of the procedure on ovarian reserve, however, the authors underlined the necessity of further studies to verify these outcomes <TextLink reference="8"></TextLink>. The age of the patients plays an important role, with younger women having a decreased risk of ovarian failure after UAE <TextLink reference="22"></TextLink>. Another approach to improve fertility in women with large fibroids could be the combination of UAE followed by myomectomy <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>. </Pgraph><SubHeadline2>UAE in large and very large fibroids </SubHeadline2><Pgraph>Regarding the size of the fibroids to be treated, previous trials have demonstrated a low evidence (level 1) <TextLink reference="2"></TextLink> in the use of UAE as treatment of most fibroid sizes <TextLink reference="11"></TextLink>, <TextLink reference="18"></TextLink>. </Pgraph><Pgraph>The effectiveness and safety of UAE in the treatment of large and very large fibroids have been debated <TextLink reference="2"></TextLink>: we found one retrospective study <TextLink reference="25"></TextLink> and four case reports <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink> (Table 3 <ImgLink imgNo="3" imgType="table"/>) indicating a higher risk of complications such as uterine necrosis and infection, possible leading to sepsis and necessity of hysterectomy, or even life threatening situations due to ischemia of adjacent organs such as toxic megacolon or perforation of transverse colon <TextLink reference="26"></TextLink>. </Pgraph><Pgraph>Regarding the issue of large fibroids, a new report discussed the possibility of the aberrant vascularization of large fibroids from neighbouring abdominal structures, a situation which requires a better consideration of cases to be embolized <TextLink reference="30"></TextLink>. In this report, 24 cases of large fibroids treated between 2008 and 2017 were analysed. In all subjects, arteriography and embolization were performed prior to subsequent myomectomy or total hysterectomy. In three cases the arteriography showed the aberrant vascularization of the large fibroids from omental arteries and gastroepiploic arteries <TextLink reference="30"></TextLink>. However, this kind of complications are rare <TextLink reference="31"></TextLink>, <TextLink reference="30"></TextLink>. Concerning the safety and effectiveness of UAE in fibroids larger than <TextGroup><PlainText>10 cm</PlainText></TextGroup>, Bérczi et al. reported the results of 303 patients underlying no differences observed between fibroids smaller and larger than 10 cm <TextLink reference="29"></TextLink>.</Pgraph><SubHeadline2>UAE prophylactic use in obstetrical procedures and postpartum haemorrhage</SubHeadline2><Pgraph>A further useful indication of UAE is as a prophylactic method before obstetrical procedures with high risk of massive bleeding such as dilatation and curettage associated with uterine ectopic pregnancy (cervical or caesarean scar) <TextLink reference="6"></TextLink>, termination of pregnancy with complete placenta praevia (CPP) <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>, suspected gestational trophoblastic disease, or retained placenta with vascularity <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink> (Table 4 <ImgLink imgNo="4" imgType="table"/>). </Pgraph><Pgraph>Concerning the effects on future pregnancy, different authors reported that UAE might induce endometrial ischemia and necrosis, potentially followed by abnormal placentation, with afterwards affected uteroplacental exchange and possible intrauterine growth restriction <TextLink reference="23"></TextLink>, placenta accrete <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>, placenta increta <TextLink reference="36"></TextLink>, and placenta praevia <TextLink reference="37"></TextLink>. The leading factors which contribute to necrosis are reduced blood flow as well as damage to the endomyometrium <TextLink reference="38"></TextLink>. </Pgraph><Pgraph>Other previous studies and trials have documented that several procedures to control the bleeding such as uterine compression sutures (B-Lynch) or Bakri balloon tamponade have to be taken into consideration by clinicians before proceeding to embolization, as these haemostatic methods seem not to be associated with increased risk of abnormal placentation <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>. </Pgraph><SubHeadline2>UAE for adenomyosis</SubHeadline2><Pgraph>Concerning the use of UAE, a recent review reports a good level of evidence regarding the acceptance and safety of the procedure, but the evidence is low regarding fertility outcomes after the procedure <TextLink reference="7"></TextLink>, <TextLink reference="43"></TextLink>.</Pgraph><SubHeadline>Complications of the UAE</SubHeadline><Pgraph>In defining the complications of UAE several criteria and classifications are used <TextLink reference="4"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="23"></TextLink>, <TextLink reference="28"></TextLink>. According to SIR (Society of Interventional Radiology), the complications of UAE can be divided in five grades <TextLink reference="11"></TextLink>, the first two categories being considered as minor and the other three as major complications. </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">No therapy, no consequence.</ListItem><ListItem level="1" levelPosition="2" numString="2.">No therapy, no consequence, but including overnight observation. </ListItem><ListItem level="1" levelPosition="3" numString="3.">Therapy needed, short hospitalization <48 hours.</ListItem><ListItem level="1" levelPosition="4" numString="4.">Major therapy needed, prolonged hospitalisation <TextGroup><PlainText>>48 hours</PlainText></TextGroup>.</ListItem><ListItem level="1" levelPosition="5" numString="5.">Permanent sequelae for the patient <TextLink reference="44"></TextLink>. </ListItem></OrderedList></Pgraph><Pgraph>Depending on the moment of onset, the complications can be divided into acute, subacute and chronic <TextLink reference="4"></TextLink>:</Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">Acute (in the first 24 hours after UAE): such as PES – post embolization syndrome, septic bleeding, pulmonary embolus, vasovagal response <TextLink reference="45"></TextLink>. </ListItem><ListItem level="1" levelPosition="2" numString="2.">Subacute (up to one week) and chronic: urinary retention, local infections such as endometritis or abscesses, amenorrhea, necrosis, fibroid expulsion <TextLink reference="13"></TextLink>. </ListItem></OrderedList></Pgraph><Pgraph>Classifications regarding the intensity of the events:</Pgraph><Pgraph>1. Minor complications <TextLink reference="28"></TextLink> </Pgraph><Pgraph><UnorderedList><ListItem level="1">Post-embolization syndrome (PES) induced by an inflammatory response to the necrotic tissue and characterized by fever, nausea and vomiting, local pain and leukocytosis <TextLink reference="46"></TextLink>.</ListItem><ListItem level="1">Fibroid passage <TextLink reference="47"></TextLink> after UAE with severe menstrual cramping, vaginal discharge, sometimes fibroid expulsion or even severe bleeding <TextLink reference="28"></TextLink>.</ListItem></UnorderedList></Pgraph><Pgraph>2. Major complications <TextLink reference="23"></TextLink> </Pgraph><Pgraph><UnorderedList><ListItem level="1">Events related to technical procedure: iodine allergy, vessel dissection or aneurysm, arterial thrombosis or pulmonary embolism. </ListItem><ListItem level="1">Ischemic necrotic complications which could be limited to genital area or at distance due to the passage of embolizing particles into vessels.</ListItem><ListItem level="1">Infection: puncture site infections, up to severe forms such as provoked endometritis and sepsis. </ListItem><ListItem level="1">Death by large pulmonary embolus or sepsis with multiorgan system failure, due to uterine necrosis. </ListItem></UnorderedList></Pgraph><Pgraph>Another important aspect to be taken into account is the risk of repeated UAE and reintervention. According to the REST trial <TextLink reference="11"></TextLink>, the rates of reinterventions were 13% at 1 year to 32% at 5 years, compared to 2% in organ saving surgery at 1 and 5 years <TextLink reference="47"></TextLink>. </Pgraph><Pgraph>UAE complications’ incidence: </Pgraph><Pgraph><UnorderedList><ListItem level="1">Prolonged vaginal discharge 2–17% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Discharge with fever 4% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">UAE failure 4% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Urinary stress incontinence 3.7%, pressure symptoms 2.8% or menorrhagia 2.6% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Postembolization syndrome 2.86% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Fibroid expulsion 1–10% <TextLink reference="48"></TextLink>, <TextLink reference="49"></TextLink>, <TextLink reference="50"></TextLink>, <TextLink reference="51"></TextLink> ranging up to 50% for submucosal fibroids <TextLink reference="52"></TextLink>. A cervical passage of fibroids can occur even 3 years after the procedure has been done <TextLink reference="53"></TextLink>. The submucosal and intracavitary location of the fibroids is more frequently associated with the expulsion which could lead to a septic complication <TextLink reference="28"></TextLink>. Therefore, preprocedural MR was proposed to localize the myoma and thereby improve the outcomes of the intervention performed on selected patients <TextLink reference="28"></TextLink>. </ListItem><ListItem level="1">Septicaemia 1–3% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Pulmonary embolization <1% or deep vein thrombosis <1% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Rare complications at the urinary bladder as vesical fissure <1% or intra-abdominal abscess <1% <TextLink reference="47"></TextLink> </ListItem><ListItem level="1">Permanent amenorrhoea 0–3% under 45 years and 20–40% in older women <TextLink reference="54"></TextLink> </ListItem><ListItem level="1">Less common complications such as infectious events and even septic reactions due to the material used or injuries of nerves and vessels <TextLink reference="48"></TextLink> </ListItem><ListItem level="1">Patients requiring hysterectomy due to the complications <1% <TextLink reference="48"></TextLink> </ListItem></UnorderedList></Pgraph></TextBlock>
<TextBlock linked="yes" name="Discussion">
<MainHeadline>Discussion</MainHeadline><Pgraph>The present paper summarizes the current publications regarding the indications and complications of UAE in different uterine pathologies. Despite the large heterogeneity of the reports and reviews presented, there is a trend to consider UAE as an alternative therapy, as the major complications are rare, sustained by the previous metaanalysis <TextLink reference="10"></TextLink>. Several papers described serious and severe complications especially when UAE was performed in large fibroids <TextLink reference="2"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>; these complications may be avoided by stringent indication of the intervention after preprocedural imaging such as MRI or even CT <TextLink reference="30"></TextLink>, <TextLink reference="47"></TextLink>. </Pgraph><Pgraph>As an approach to treat postpartum haemorrhage, UAE has been used as a prophylactic method in high-risk patients before different abortive procedures to avoid massive bleeding, to decrease rates of hysterectomy <TextLink reference="6"></TextLink>. Because of the risk of subsequent placenta accreta in future pregnancies, clinicians should consider standard methods to stop massive bleeding before proceeding to embolization <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>. Cases should be made on an individual basis and discussed with the patient before establishing a therapeutic plan as shared consent. </Pgraph><Pgraph>The strength of this work is the extensive incorporation of research published since 2010, including case reports and case series up to clinical trials and studies. A limitation of this review is that only articles published in English language were taken into consideration, eventually excluding other relevant articles reported in other languages. In addition, the heterogeneity in the definition of major and minor complications within studies limited the qualitative analysis. </Pgraph><Pgraph>Despite the limitations, the actual trend useful for the clinicians as much as for the patients is to consider UAE as a tool to treat women with different uterine pathologies. UAE showed acceptable clinical outcomes in the treatment of uterine myomata, even in the management of fibroids larger than 10 cm. However, due to the risk of possible complications, imaging such as MR or CT is advised to be performed before the procedure. Complications are possible, so these problems should be discussed with the patient before establishing a therapeutic plan.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Conclusion">
<MainHeadline>Conclusion</MainHeadline><Pgraph>Current data show that UAE is an acceptable procedure to treat different uterine pathologies. However, several trials and studies discuss the high risk of complications and reinterventions, emphasizing the importance of proper selection of women that could benefit from the proce<TextGroup><PlainText>du</PlainText></TextGroup>re. Patients with various symptomatic uterine pathologies can be counselled about the possibility of UAE as an alternative to surgery such as myomectomy or hysterectomy. </Pgraph><Pgraph>Regarding future research, several aspects have to be clarified such as fertility after UAE, the use of the procedure in obstetrical haemorrhage, in adenomyosis, and eventually comparing it with other minimally invasive treatment by means of high frequency ultrasound using newly designed prospective randomized controlled studies.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Notes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph><SubHeadline>Authors’ contributions </SubHeadline><Pgraph>RDW, CC and LATR: conceptualization. CC and LATR: data curation, formal analysis, writing original study report. All authors read, corrected and approved the final manuscript, based on their expertise.</Pgraph><SubHeadline>Acknowledgments </SubHeadline><Pgraph>Jennifer Eidswick for language corrections. </Pgraph></TextBlock>
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<Caption><Pgraph><Mark1>Table 1: Uterine artery embolization (UAE) versus surgery (myomectomy and/or hysterectomy) in the treatment of fibroids</Mark1></Pgraph></Caption>
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