Quality improvement guidelines for uterine artery embolization: an evolution in patient selection.

During the past 20 years, the efforts made to critically evaluate uterine artery embolization (UAE) have resulted in the almost universal acceptance of this procedure as an effective treatment option for patients with symptomatic leiomyomata. In time, questions have been raised regarding the applicability of UAE to defined subsets of patients, including those with adenomyosis, pedunculated fibroids, or a desire for future fertility. These questions are the result of dated reports in the medical literature that, unfortunately, even today, have caused these patients to be denied access to UAE or to not even have UAE included in a discussion on potential treatment options with their physician. The revised Quality Improvement Guidelines for UAE by Dariushnia et al (1) highlight these areas and turn to recent research that supports a change in the management recommendations that can be made for these particular patients (1). We can all appreciate that the initial impressions formed by physicians when learning about new, innovative procedures are difficult to change. The information presented by Dariushnia et al (1) should once again serve as a reminder that the conclusions of case reports and small case series should be acknowledged but held in reserve until larger, better designed studies support or refute those initial conclusions. This certainly seems to be the case with UAE performed in patients with pedunculated fibroids or adenomyosis. The initial sense that patients with adenomyosis are at a significantly increased risk for treatment failure after UAE (2) has not been borne out as larger studies and analyses have been performed. Similarly, an early case report raised concerns about treating pedunculated subserosal fibroids with UAE for fear that the fibroid may detach from the uterus and require surgery for removal (3). This too has not been validated in more recent studies, and, instead, patients with pedunculated subserosal fibroids have been