Re: Analysis of Presurgical Uterine Artery Embolization (PUAE) for Very Large Uterus Myomatosus; Patient’s Desire to Preserve the Uterus; Case Series and Literature Review

Dear Sir or Madam,

We commend Schnapauff et al. on the publication of this interesting literature review and case series of women who have undergone presurgical uterine artery embolization (PUAE), with the aim of uterine and fertility preservation [1]. However, we feel that this should be against the backdrop of laparoscopic myomectomy as the gold standard for those requiring surgery for fibroids.

Although the authors cite the objectives of uterine sparing and improved fertility, they present a case series with a hysterectomy rate of 5 % despite “hybrid treatment”, which is well above the rates reported for laparoscopic myomectomy in modern literature even with “giant fibroids” over 9 cm [2]. Moreover, even though they report a decreased incidence of blood loss and blood transfusions, they do not present a series that is truly uterine sparing and have not reported on the fertility outcomes of these patients.

In our series of laparoscopic myomectomies [2] in patients with fibroids greater than 9 cm, though there was a significantly greater operating time as well as blood loss, there were no increased rates of blood transfusion, not dissimilar to the values in this study. However, the duration of hospital stay following laparoscopic myomectomy was 1.64 days, compared to 8 – 10 days in the patients presented in this study.

The authors present a series of cases of PUAE, but have not stratified for the type of myomectomy carried out and did not compare with other women who have had myomectomy without embolization or those who have had embolization without myomectomy in their institution, which would have allowed us to draw even more useful conclusions.

We agree with the authors that PUAE is a tool in the armamentarium for the management of uterine fibroids and that women who need to have interventions for their fibroids should go through multidisciplinary team review to ensure that they have the right procedure tailored to their needs, with laparoscopic myomectomy being the gold standard. Where such expertise does not exist or there is a perceived increased risk, embolization prior to surgery may be offered. Women must also be informed that pregnancy after embolization in itself is not without complications [4], and that fertility outcome after “hybrid interventions” remains unknown.

In the 21^st century we should be able to provide evidence-based information to our patients. The previously conducted REST trial comparing uterine artery embolization with surgery found similar satisfaction in both groups, but did not address fertility [3]. As PUAE is feasible, it is time for a multicenter randomized controlled trial comparing women who have undergone PUAE with those who have undergone surgery alone stratifying for age and assessing the long-term fertility outcomes.

• References

• 1 Schnapauff D, Russ M, Kroncke T. et al. Analysis of presurgical uterine artery embolization (PUAE) for very large uterus myomatosus; patient’s desire to preserve the uterus; case series and literature review. ROFO 2018; (epub ahead of print) DOI: 10.1055/s-0044-101555.
• 2 Mallick R, Odejinmi F. Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre. Gynecological surgery 2017; 14: 22
• 3 Homer H, Saridogan E. Pregnancy outcomes after uterine artery embolisation for fibroids. The Obstetrician & Gynaecologist 2009; 11: 265-270
• 4 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: An International Journal of Obstetrics & Gynaecology 2011; 118: 936-944