Discussion: ‘Uterine artery embolization vs surgery’ by van der Kooij et al




In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed:


van der Kooij SM, Bipat S, Hehenkemp WJK, et al. Uterine artery embolization vs surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis. Am J Obstet Gynecol 2011;205:317.e1-18.


Discussion Questions





  • Did the review address a relevant clinical question?



  • How was the validity of the included studies appraised?



  • What were the overall results of the metaanalysis?



  • How is heterogeneity measured and interpreted?



  • What are fixed and random effect models?



  • What do the findings say about UAE?





Introduction


Uterine artery embolization (UAE) was introduced in the mid-1990s as a new minimally-invasive treatment for symptomatic fibroids. Since that time, results from randomized controlled trials have demonstrated that when assessed against traditional surgical alternatives like myomectomy and hysterectomy, UAE may provide short-term benefits, including reduced length of stay and earlier resumption of daily activities; complications and satisfaction are similar. Yet, use of UAE remains low in comparison to surgical management, perhaps due to a lack of long-term comparative data. A new systematic review by van der Kooij et al addresses this specific question by evaluating short- and long-term outcomes for UAE and surgery.




See related article, page 317




For a summary and analysis of this discussion, see page 389



David Chelmow, MD and George A. Macones, MD, MSCE, Associate Editor




Study Design


Chelmow: Did the review address a relevant, focused, clinical question?


Discussants: The authors addressed an important clinical question: how does UAE compare to surgical management of symptomatic uterine fibroids by either total abdominal hysterectomy or abdominal myomectomy? Symptomatic uterine fibroids may affect 25% or more of women, so information guiding optimal management is extremely important. We need information on the relative risks and benefits of UAE compared to other accepted treatments so that we can appropriately counsel patients. The authors performed a structured review, which included long-term significant outcomes relevant to patients and providers choosing between treatments. These included patient satisfaction and re-intervention rates.


Chelmow: Were the criteria used to select articles for inclusion appropriate?


Discussants: The authors searched the usual appropriate databases (Cochrane Central Register of Controlled Trials, Medline, Embase, and the metaRegister of Controlled Clinical Trials). Their time frame, September 1995 to November 2010, corresponded to the development of UAE, and they chose search terms that were both adequately specific and comprehensive. The authors also searched citation lists of relevant publications in an attempt to find additional qualified studies. They did not search conference proceedings, and although recent ones are usually available through the registries and databases, it is possible that studies available only in abstract form from early in the time frame might have been missed.


Chelmow: Is it unlikely that important relevant studies were missed ?


Discussants: The authors used appropriate search terms and generally-accepted search strategies for relevant papers. In addition, they searched a comprehensive international registry of controlled trials and bibliographies of relevant studies and review articles. It is unlikely that they missed any published studies. One concern is always publication bias, where negative studies are less likely to be published. Here, the goal is to introduce a new less-invasive technology by showing it to be equivalent to older more invasive procedures. Interestingly, here negative studies are actually of interest.


Chelmow: How was the validity of the included studies appraised?


Discussants: Study validity was assessed with the Delphi criteria. The authors stated that some papers were excluded after reading but did not state why. It is not clear if some of these exclusions were for failure to meet quality criteria. In general, the studies met typical quality criteria, except for a single study that did not analyze according to an intention-to-treat design.


Chelmow: Were assessments of studies reproducible?


Discussants: The assessments were performed by 2 reviewers—independently and then collaboratively—using well-described objective selection criteria.

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Jun 4, 2017 | Posted by in GYNECOLOGY | Comments Off on Discussion: ‘Uterine artery embolization vs surgery’ by van der Kooij et al

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