Minimally Invasive Therapy.

2014;23:361365

ORIGINAL ARTICLE

Combined myomectomy and uterine artery embolization

BRUCE MCLUCAS1 & WILLIAM D. VOORHEES III2

1
Department of Obstetrics and Gynecology, University of California, Los Angeles David Geffen School of Medicine,
Los Angeles, CA, USA, and 2Med Institute, Inc., West Lafayette, IN, USA

Abstract
Objective: To evaluate the safety and efcacy of uterine artery embolization combined with endoscopic myomectomy.
Material and methods: We conducted a retrospective chart review of patients (n = 125) who underwent myomectomy
concurrent with embolization within one month. We assessed two groups: 1) uterine artery embolization followed by
hysteroscopic myomectomy and 2) uterine artery embolization followed by laparoscopic myomectomy. Results: Following
the combination procedures, 72% of the surveyed women reported symptom improvement. With the combined procedures,
92.5% of patients experienced reduction in myoma diameter and 87.5% of patients had decreased uterine size after an
average of 4.70 months post subsequent procedure. The amount of decrease in the uterine volume (p = 0.39) and broid size
(p = 0.23) were not signicant between the two endoscopic myomectomy groups. Conclusions: Combining myomectomy
with uterine artery embolization is a safe and effective procedure in treating symptoms and reducing myoma and uterine
volumes.

Key words: Embolization, hysteroscopic, laparoscopic, myomata, myomectomy

Introduction cases (6-8). Large myomata, a uterus extending to or

In most cases, uterine artery embolization (UAE) is a
stand-alone procedure, effectively treating myomata
with a low rate of complications and good long-term
results (1,2). Embolization offers physicians and their
patients several advantages compared to myomec-
tomy alone. Advantages offered include decreased
blood loss, decreased chance for uid overload in
hysteroscopic myomectomy (HM), and removal of
potentially larger myomas. However, there are some
cases where UAE alone may not be sufcient in
treating patients. A combination procedure is consid-
ered (3) in the following circumstances: Large ped-
uncuated subsersosal myoma may be considered a
contraindication for UAE alone because of risks
including necrosis, torsion at the stalk and separating
from the uterus (4,5). Pedunculated submucous myo-
mas are at risk of vaginal prolapse, and some authors
consider UAE alone to be contraindicated in such
above the umbilicus, may not shrink enough to give
symptom relief after UAE (9,10).
Studies have shown that combining UAE with
myomectomy for selected patients may allow techni-
cal ease in removing myomas. The literature has
revealed less blood loss during myomectomy proce-
dures. With UAE prior to myomectomy, studies have
shown that complications are less likely to occur (3,5).
Furthermore, after UAE, with or without myomec-
tomy, patients experience the high likelihood of no
recurrence of myomata compared to myomectomy
without embolization (11-13).
We offered myomectomy in combination with
UAE to selected patients where UAE alone would
likely be inadequate for resolution of myoma symp-
toms. For patients with pedunculated submucous
myomas, hysteroscopic myomectomy (HM) was
scheduled after UAE to decrease the risk of prolapse
(14). For patients with pedunculated subserosal

Correspondence: B. McLucas, 450 Roxbury Dr. Ste. 275, Beverly Hills, CA 90210, USA. Tel: +1 310 208 2442. Fax: +1 310 208 2621.
E-mail: mclucas@ucla.edu

ISSN 1364-5706 print/ISSN 1365-2931 online  2014 Informa Healthcare

DOI: 10.3109/13645706.2014.939589
362 B. McLucas & W. D. Voorhees
myomas, laparoscopic myomectomy (LM) was per-
formed following UAE to reduce the risk of necrosis,
adhesion formation, and torsion (15,16).
Does combining the two procedures, UAE and
myomectomy, instead of myomectomy alone increase
morbidity? Prior case reports (17,18) have indicated
no additional morbidity combining myomectomy and
UAE. Yet, no larger scale study has been undertaken.
We report our results in such a large group of patients.
Material and methods
A retrospective chart review of patients was performed
in a private practice setting in Los Angeles. The same
physician performed UAE for all patients. The
technique is as follows: Under local anesthetic and
conscious sedation, a small incision was made in the
right groin for catheter insertion in the femoral artery.
Polyvinyl alcohol particles (PVA) of 500 microns or
larger were injected into the vessels to block blood
supply to the myoma. Patients were observed over-
night in many cases. Patients were informed of
any potential risks associated with UAE in combina-
tion with myomectomy. No institutional review board
(IRB) approval was sought because the risks and
benets of combination procedures as well as indi-
vidual procedures were well known to these patients.
All patients gave written and verbal consent for com-
plications including but not limited to conversion to
hysterectomy, failure of UAE, early menopause, and
possible complications during or after pregnancy.
Patients who were candidates for traditional
myomectomies were offered the combination proce-
dure and notied of the risks and benets. Those
who consented to the combination procedure were
included into the study. Inclusion criteria comprised
of patients who had one of two types of myomecto-
mies following UAE: Hysteroscopic (UAE-HM) or
laparoscopic (UAE-LM) myomectomy concurrent
with embolization. Women were offered UAE-HM
to reduce their risk of necrosis. UAE-LM was offered
to patients to reduce their risk of infarction.
Added morbidity was dened as an increase in
postoperative hospital stay, blood transfusion, or
other associated complications from myomectomy
alone. If symptoms persisted or no reduction in
myoma diameter existed, we considered reinterven-
tion procedures such as repeat UAE, myomectomy,
or hysterectomy, depending on the patients needs.
Appropriate type of concurrent myomectomy proce-
dure was assessed using physical examination, patient
history, and imaging prior to embolization (MRI or
ultrasound). Measurements of estimated blood loss,
infection, uoroscopy times, and hospital stay were
assessed. Follow-up data such as uterine, broid size,
and a symptom improvement survey were also
collected approximately three to six months post
combination procedure.
Statistical comparisons were made using JMP
version 9.02 (SAS Institute, Cary, NC, USA).
Statistical signicance was determined with p value
< 0.05.
Results
During the study period, 1999 to 2013, the total
number of patients who underwent embolization
was 1671. Of those patients, 126 women (7.54% of
total) had a scheduled myomectomy within one
month following UAE. These 125 patients are the
subject of this study. Most patients reported having
bulk symptoms such as pain, pelvic pressure, and
excessive bleeding. The mean age of patients at the
time of myomectomy was 41.7 years (range 2654).
One hundred fourteen of the patients had UAE and
myomectomy treatments on the same day. Of the
women who had same day surgery 41.6% (n = 52)
had UAE-HM and 49.2% (n = 62) had UAE-LM.
Table I shows detailed measurements for all patients
in the study.
Fifty-six women (44.8%, 56/125) received UAE-
HM for treatment of submucous myoma. Sixty-nine
patients (55.2%, 69/125) underwent UAE-LM for
excision of pedunculated subserous myoma. All
patients had at least two myomas. For the UAE-
HM group, an average of 21.42 36.26 g (range
1.0221 g) of myoma tissue was removed. In the
Table I. Average measurements in total patients in study group.
Average measurements for
Outcome measurement total number of patients in study
Uterine volume pre 521.62
combined procedures (cm3)
Uterine volume post 325.29
combined procedures (cm3)
Myoma diameter pre 6.64
combined procedures (cm)
Myoma diameter post 4.52
combined procedures (cm)
Myoma tissue removed (g) 80.28
Total uoroscopy time (min) 16.45
Hospital stay (days) 1.29
Blood loss (mL) 13.36
Time between UAE and 0.68
myomectomy (days)

Table II. Comparison of average measurements between the two different myomectomy combination procedures by analysis of variance.
Outcome measure UAE-HM (n = 56)
Uterine volume (cm ) 3
520.9 436.3
Myoma diameter (cm) 6.09 2.34
Uterine volume decrease (%) 25.95 8.44
Myoma diameter decrease (%) 34.03 5.30
Myoma tissue removed (g) 21.27 40.45
Hospital stay (days) 1.4 0.9
Blood loss (mL) 10.36 1.9
UAE-LM group, average weight of tissue removed
was 120.09 189.90 g (range 2.20776 g).
All patients experienced a uterine volume and
myoma reduction of 40.0% and 31.5%, respectively
after an average of 4.70 months post combination
procedures. Of the surveys that were collected post
combined procedures, 72% reported symptom
improvement, 92.5% had a reduction in myoma
diameter and 87.5% of patients had decreased uterine
volume. Reduction in myoma diameter and uterine
volume were veried with MRI or pelvic ultrasound.
Although patients in both groups showed a reduction
in myoma diameter (p = 0.23) and uterine volume
(p = 0.39), the differences between the UAE-HM and
UAE-LM groups were not signicant. In addition,
both UAE-HM and UAE-LM groups had blood loss
(p > 0.05) and hospital stay (p > 0.05) that were not
statistically signicant between the two groups.
Table II shows a detailed comparison with p-values
of the average measurements for patients in each of
the two groups, UAE-HM, UAE-LM.
All women who received combined UAE and
myomectomy experienced no complications, such
as conversion to hysterectomy, blood transfusions,
or infection. A total of seven patients were admitted
due to fever or pain from post embolization. Of these
patients, four complained of fever between two to six
days post UAE, and three patients complained of
uncontrolled pain one day following embolization.
None of these patients experienced an infection,
and their admissions were likely secondary to the
UAE procedure. Patients who were admitted likely
experienced symptoms that they would have experi-
enced from UAE alone. Eleven of the 125 patients
underwent a second procedure post UAE combined
with myomectomy.
Discussion
This study suggests combining UAE with myomec-
tomy as a viable option for selected women in whom
Combined myomectomy and UAE 363
UAE-LM (n = 69)
522.2 436.6
7.10 2.84
39.70 6.14 p = 0.39
24.49 4.02 p = 0.23
120.09 187.90 p = 0.0002*
1.2 0.7
15.8 24.8
UAE or endoscopic myomectomy alone could be
associated with high risk of clinical failure. There is
no added hospital stay, blood loss, and a reduced risk
of recurrence. The UAE-HM and UAE-LM groups
both experienced similar reductions in both the
uterine volume and myoma size following the com-
bination procedure. Thus, this suggests that the
combination procedure can obtain successful results
for more than one type of myomectomy combined
with UAE. For women who undergo myomectomy,
there is an increased chance of recurrence as well as
a risk of conversion to hysterectomy (17). Our
study has shown that there are less complications
and recurrence of myomas.
In our previous study, reduction in uterine volume
and myoma diameter seen in UAE alone provided
similar results compared to this study. In our previous
study, there was a 42.8% reduction in uterine volume
and a 48.8% decrease in myoma diameter for UAE
alone (19). Although these percentages were slightly
larger than the ones seen in our cohort, the measure-
ments were reported at an average of 10.2 months
post UAE. Our study had a decrease of 40.0% in
uterine volume and a 31.5% reduction in myoma
diameter after only an average of 4.70 months post
combined procedures. With increased intervals in
follow-up time, we expect the percentage reduction
to be much larger. UAE prior to myomectomy is a
valid procedure for reducing blood loss, complica-
tions, and easing the removal of myomas due to a
bloodless eld (17). Our study reported the average
blood loss for the UAE-HM group to be 10.4 mL as
opposed to a blood loss ranging from 8093 mL
reported in the literature for patients who underwent
HM alone (20). This indicates reduced blood loss as a
benet from the combined procedure. For the UAE-
HM group, removal of signicantly reduced myoma
volume and ease of uterine suturing may decrease the
possibility of conversion to hysterectomy (21). The
avascular state of the uterus promotes easier removal
of myomas and lowers risk for complications. (13).
This combination procedure may also decrease
364 B. McLucas & W. D. Voorhees
hospital stay, as many potential postoperative
complications may be avoided (17).
For the UAE-LM group, decreased blood loss to the
uterus allows for laparoscopic removal of larger myo-
mas (22). This study found that UAE-LM reduces the
risk of blood loss with patients having a blood loss of
15.88 mL. A series of studies reported an estimated
blood loss for LM alone ranging from 84240 mL
(22-25), which appears larger than UAE-LM. Rather
than undergoing myomectomy alone and having the
risk of recurrence, the combination procedure offers
patients reduced blood loss, reduced risk of recurrence,
and a minimally invasive surgery. The average amount
of myoma tissue (120.09 g) removed was signicantly
larger (p = 0.0002) than the amount removed by UAE-
HM (21.27 g). Furthermore, compared to other stud-
ies, this seems to be greater than the average specimens
removed by LM (87.2 g) alone (26). For selective
patients, LM is the preferred method for myomectomy
because of shorter hospital stays, reduced postoperative
pain, and a decreased risk of adhesions (22). Indeed, we
found the average hospital stay to be 1.2 days for the
UAE-LM group, which is also similar to hospital stay
for UAE-HM and for UAE alone (27). Other studies
have reported hospital stay ranging from 2.13.5 days
(22,23,28) for patients with LM alone. Shorter hospital
stays also lower medical cost for patients (13). The
average cost for UAE varies, however, is denitely less
than the cost for hospitalization after hysterectomy
(29-31). It should be noted that with the combination
procedure, no blood transfusion is needed and there is a
lower risk of complication that may cause a longer
hospital stay (17).
There are some limitations to this study. Since this
was a retrospective chart review, there may have been
some selection bias. Some charts from the earlier years
of this study contain data that are no longer accessible
In addition, there was no control study conducted to
have a group of patients with UAE alone during the
same time period as the study. With comparisons
made to other studies, there may have been some
operative differences. For future studies, a study
comparing our own myomectomy only patients with
patients undergoing the combination procedure
should be investigated. More efforts are needed for
follow-ups with these patients to have more accurate
reports of any post-operative complications. Addi-
tional investigation is needed to determine the recur-
rence rate of combining UAE with myomectomy.
Acknowledgements
The authors would like to acknowledge Katherine
Chua, Stephanie Elliott, and Calvin Dunn for
their contribution to this research and manuscript
preparation.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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