Symptomatic uterine fibroids account for 41.7% of hysterectomies in the United States and can cause symptoms such as prolonged or heavy menstrual bleeding, bulk symptoms, and pelvic pain.1, 2, 3 Definitive treatment is hysterectomy, performed via laparotomy or minimally invasive route such as laparoscopic, robotic-assisted, or vaginal approaches. It can either be total with removal of the uterine body and cervix, or subtotal where the cervix is left intact. Minimally invasive hysterectomy (MIH) is associated with reduced blood loss, shorter hospitalization, decreased operative times, faster recovery, and decreased infection risk when compared to abdominal hysterectomy.4, 5, 6, 7, 8 The American College of Obstetricians and Gynecologists recommends minimally invasive routes whenever feasible.1 However, uterine size, number and location of fibroids, surgical history, and surgeon experience make MIH for symptomatic uterine fibroids technically challenging, and may lead to conversion to or planned open hysterectomy. This scoping review examines staged pre-hysterectomy uterine artery embolization (SUAE) as a strategy to decrease blood loss, transfusion needs, and facilitate MIH completion for patients with symptomatic uterine fibroids.

Uterine artery embolization (UAE), introduced in 1995, is an interventional radiologic procedure used to manage fibroids in patients seeking uterine preservation.9,10 Embolic particles are delivered to the uterine arteries via the femoral artery to achieve near stasis flow while maintaining arterial patency.11 While major gynecological societies provide limited recommendations regarding specific fibroid types, UAE is generally considered a safe and effective treatment option.12

UAE may offer additional benefits when combined with surgical intervention for fibroids. Russ et. al reported that preoperative UAE, performed 24 hours to 19 day before planned open myomectomy, significantly reduced intraoperative blood loss >500mL and transfusion requirements compared with historical controls.3 Accordingly, SUAE for symptomatic uterine fibroids may provide similar clinical and economic advantages. This review summarizes the available literature and represents, to our knowledge, the first synthesis on this topic.

The initial objective of this project was to conduct a systematic review with meta-analysis and cost analysis to evaluate the relationship between SUAE and outcomes. However, the literature consisted primarily of case reports, case series, and one cross-sectional study. Consequently, a scoping review was undertaken using the five-stage framework by Arksey and O’Malley13 to summarize existing knowledge and identify its impact. Given the limited literature, this review is exploratory in nature.

This scoping review followed five stages: 1) defining research questions; 2) identifying relevant studies; 3) selecting studies; 4) charting data; and 5) collating, summarizing, and reporting results. Scoping reviews resemble systematic reviews given the methodological rigor and transparency, however instead of answering a specific clinical question through hypotheses, it instead summarizes existing literature on a topic. Given the lack of data on this topic, a scoping review can provide clinically relevant information about this intervention.

Stage 1: Determining our Research Questions

Our research questions were:

RQ1: What empirical evidence exists regarding SUAE for symptomatic uterine fibroids?

RQ2: Does SUAE reduce surgical blood loss?

RQ3: Does SUAE reduce the need for blood transfusion?

RQ4: Does SUAE facilitate completion of MIH