What are the treatment options for a patient with two large uterine fibroids, considering uterine artery embolization (UAE) and Acessa (laparoscopic radiofrequency ablation)?

Counseling on UAE vs Acessa for Two Large Fibroids

For a patient with two large fibroids, uterine artery embolization (UAE) is the preferred option over Acessa radiofrequency ablation, as UAE has substantially more robust evidence demonstrating efficacy for large and multiple fibroids, with clinical success rates of 81-100% and proven long-term outcomes. 1

Why UAE is Preferred for Large Fibroids

Evidence Base and Efficacy

• UAE has extensive published evidence including randomized controlled trials and large registries with over 3,000 patients, demonstrating 95% symptomatic relief at 12 months 1
• The procedure achieves median fibroid volume reductions of 42% and uterine volume reductions of 35% by 3 months, with continued improvement over time 1
• Patients with large fibroid burdens (dominant fibroid >10 cm or uterine volume >700 cm³) show clinical results equivalent to those with smaller fibroids, with mean volume reduction of 44% at 48 months follow-up 2
• Symptom improvement includes: menorrhagia (83%), dysmenorrhea (77%), and urinary frequency (86%) 1

Long-Term Durability

• At 5 years, UAE maintains >50% average decrease in fibroid size 1, 3
• Reintervention rates are 28% at 5 years and 35% at 10 years 1, 3
• During 3-year follow-up, only 14.4% of patients required additional procedures (9.8% repeat UAE, 2.8% myomectomy, 1.8% hysterectomy) 1

Acessa Radiofrequency Ablation: Limited Evidence

The provided evidence contains no guideline recommendations or substantial research data on Acessa (laparoscopic radiofrequency ablation) for uterine fibroids. This absence from major ACR guidelines 1 is significant, as these comprehensive 2018 and 2024 guidelines extensively review fibroid treatment options but do not include radiofrequency ablation as a recommended modality.

Practical Considerations for UAE

Pre-Procedure Requirements

• Full gynecologic workup including Pap smear and endometrial biopsy if menometrorrhagia present 1
• Cross-sectional imaging, preferably MRI, to confirm diagnosis and exclude other pathology 1
• Exclude absolute contraindications: viable pregnancy and active pelvic inflammatory disease 1

Procedure Details

• Performed under conscious sedation via femoral or radial arterial approach 1
• Both uterine arteries embolized using particulate embolic agents 1
• Mean hospital stay is 1.3 nights 4
• Mean recovery time is 13.1 days (median 10 days) 4

Complications and Side Effects

• Major complications occur in <3% of patients 1
• Up to 10% may require readmission for pain control 1
• Post-embolization syndrome (flu-like symptoms with pain, nausea, fevers) is common but self-limited 1
• Age-dependent amenorrhea risk: <2-3% for women <45 years, up to 20% for women >45 years 1

Important Caveats

• Cervical fibroids and >1 submucosal fibroid are associated with higher treatment failure rates 1
• Patients <40 years have higher long-term failure rates (23% at 10 years) due to collateral vessel recruitment 1
• Follow-up MRI at 3-6 months recommended to assess fibroid infarction and exclude leiomyosarcoma 1

Comparison to Other Modalities

UAE vs Myomectomy

• At 4 years, UAE shows equivalent quality of life scores and reintervention rates compared to myomectomy 1
• UAE has lower rates of new fibroid formation than myomectomy 1
• UAE associated with decreased blood transfusion risk and shorter hospital stays 1

UAE vs MRgFUS

• UAE demonstrates significantly greater symptom improvement and lower reintervention rates (13% vs 30% at 2 years) compared to MR-guided focused ultrasound 1
• UAE has shorter procedure time (2.3 hours vs 6.75 hours) 1

Fertility Considerations

If the patient desires future fertility, counsel that pregnancy is possible after UAE but outcomes are uncertain 1. The evidence shows:

• Successful pregnancies have been reported after UAE 5
• Women may be at increased risk for malpresentation, preterm birth, cesarean delivery, and postpartum hemorrhage 5
• The role of UAE in women wishing to conceive remains unclear based on current evidence 6

Bottom Line Algorithm

For two large fibroids in a patient not desiring fertility:

1. Proceed with UAE as first-line uterine-sparing treatment 1
2. Expect >80% symptom relief with low complication rates 1
3. Plan for 1-2 night hospital stay and 2-week recovery 4

For patients desiring fertility:

1. Consider myomectomy (laparoscopic or open) as preferred option 1
2. UAE remains an option but counsel on uncertain pregnancy outcomes 5, 6

Acessa should not be recommended given the absence of supporting evidence in major guidelines and the robust data supporting UAE for large, multiple fibroids.