Endovascular and Surgical Treatments for Fibroids

Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective

Clinical question
What are the outcomes of a population-level analysis of surgical and endovascular interventions for symptomatic uterine leiomyomas in the outpatient setting?

Take away point
Uterine Artery Embolization (UAE) may be an underutilized and a lower cost alternative than surgical interventions. Future research should focus on the role of UAE and fertility preservation.

Reference
Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective. Wang, C.. et al. Journal of Vascular and Interventional Radiology, Volume 31, Issue 10, 1552-1559.

Click here for abstract

Study design
Retrospective review using the Healthcare Cost and Utilization Project (HCUP) databases of patients treated in the outpatient setting for symptomatic leiomyomas in California and Florida.

Funding source
No funding

Setting
Hospital-owned and non-hospital owned outpatient settings in California and Florida

Summary

The three main treatments for symptomatic leiomyomas include: hysterectomy, myomectomy and uterine artery embolization. Surgical intervention, whether definitive treatment with hysterectomy or fertility-preserving myomectomy, are the most common interventions for leiomyoma treatment. Uterine artery embolization has also been established as an effective minimally invasive treatment option, though is used less frequently. Given the lack of information regarding the utilization of these procedures, this paper addresses the association between different treatment options and various patient characteristics.

Data was gathered from the Healthcare Cost and Utilization Project (HCUP) database for all outpatient hospital encounters for symptomatic uterine leiomyomata in California (2005-2011) and Florida (2005-2014) (n=227,489). These states were chosen as they have large populations, socioeconomic diversity, geographic distribution and a mixture of urban and rural populations. They analyzed patient characteristics and common comorbidities including: age, ethnicity, hypertension, diabetes, renal insufficiency, obesity, smoking, chronic obstructive pulmonary disease, and congestive heart failure. They also noted the hospital stay duration and costs.

Of the total 227,489 patients with uterine leiomyomata, nearly 40% (n=90,800) underwent an intervention. Hysterectomy was the most common intervention (73%), followed by myomectomy (19%) and UAE (8%). Over time the proportion of patients receiving a hysterectomy increased—and laparoscopic (versus open) hysterectomy accounted for the greatest proportion. Given hysterectomy is a definitive treatment, it was later performed in 4.1% of those who underwent myomectomy and 3.5% of patients who underwent UAE. Patients who underwent myomectomy were younger and had fewer comorbidities than those who underwent hysterectomy or UAE. Those receiving UAE instead of myomectomy or hysterectomy were older and more likely to have congestive heart failure, renal failure, and hypertension. UAE is performed more frequently in those with comorbidities, as it is often safer to avoid general anesthesia or an invasive surgery. The hospital stay duration varied between the groups with hysterectomy having a significantly greater length of stay (0.5 d; range 0-3 d). No difference between length of stay was seen between myomectomy (0.2 d; range 0-3 d) and UAE (0.3 d; range 0-3 d). Hysterectomy and myomectomy were also significantly higher in cost than UAE ($5,409 and $6,318 vs $3,772, respectively).

Previous research has demonstrated lower cost, shorter hospital length of stay and faster return to activities in UAE compared to invasive surgical interventions. Despite these findings UAE is not utilized as frequently. Given the large portion of child-bearing aged women undergoing myomectomy, the authors argue a part of this difference may be due to the lack of definitive research regarding fertility preservation.

Commentary

This study helps underscore many differences between endovascular and surgical treatments for symptomatic leiomyomas. It also helps support existing findings in research, while shedding light on new areas such as patient comorbidities and prevalence of particular interventions. Although this is a retrospective review, the large and diverse sample size helps give the study power. The study notes that UAE is more cost effective, has a shorter recovery time and is generally regarded as safer for those with significant comorbidities. However, given the lack of definitive research on fertility, it is often not performed in women of childbearing age. Further research into UAE and fertility may help broaden its use if it is found to be a fertility-preserving alternative. Lastly, the article mentions that the cost for the intervention was based on the initial encounter and did not include any subsequent treatments. They discuss that the subsequent treatments have a long time interval between them and that repeat intervention rate is low. Clarity into the specific numbers would help strengthen the cost differences between the interventions. Overall, this study helps shed light on the current interventions, patient populations and future challenges of the treatment of symptomatic leiomyomas.

Post Author
Marissa Stumbras, MD
Interventional Radiology Resident, PGY2
Oregon Health & Science University
@MarissaStumbras