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\begin{document}

\title{Uterine artery embolization (UAE) compared with myomectomy for the
management of uterine fibroids: a systematic review and meta-analysis}



\author[1]{Emily Williams}%
\author[2]{Stephen Walker}%
\author[3]{Siobhan Quenby}%
\author[2]{Joshua Odendaal}%
\affil[1]{University of Warwick}%
\affil[2]{University of Warwick Warwick Medical School}%
\affil[3]{Warwick Medical School}%


\vspace{-1em}



  
  \date{May 29, 2024}


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\selectlanguage{english}
\begin{abstract}
Background Uterine artery embolization (UAE) and myomectomy are
uterus-sparing treatments for uterine fibroids. Each carries a different
risk and efficacy profile. Despite this there is a lack of direct
comparison between the two techniques making treatment choice decisions
difficult. Objectives To compare the therapeutic efficacy and
complications of UAE versus myomectomy. Search strategy A systematic
search of The Cochrane Library, Medline, and EMBASE databases was
conducted using a pre-defined search strategy. The review was
prospectively registered on PROSPERO (CRD42021259347). Selection
Criteria All randomised controlled trials and cohort studies published
between January 1995 and August 2021 directly comparing UAE and
myomectomy were included. Data Collection and Analysis Meta-synthesis of
raw data was performed using Review Manager 5.4.1 from the Cochrane
Collaboration. A pooled estimate of efficacy was established using a
fixed-effect model. Main results 8 studies were identified. UAE was
associated with lower complication rates (OR 0.56; 95\% CI 0.40-0.79),
increased improvement in bleeding (OR 1.61 95\% CI 1.07-2.43) and a
shorter total recovery time (7.72 days versus 36.63 days). Whilst
myomectomy was associated with a higher post-procedure quality of life
(mean difference -10.56; 95\% CI -15.34 - -5.79) and lower
re-intervention rate (OR 5.16; 95\% CI 2.41-11.04). No significant
difference in procedural failure rate was seen (OR 0.67; 95\% CI
0.30-1.50). Given concerns with UAE and future fertility limited
post-procedure fertility outcomes were identified. Conclusions: Given
differences in efficacy profiles a personalised approach to treatment
discussions should be maintained. Funding: None Keywords: Uterine artery
embolization, myomectomy, uterine fibroid%
\end{abstract}%



\sloppy


Word count for abstract: 245 Word count for main text: 3284 (excludes
abstracts, in-text references, tables, graphs, figures,
acknowledgements, reference list and appendices)

Co-authors: Emily Williams, BSc. University of Warwick Medical School.
Email: Emily.williams.1@warwick.ac.uk. 07446983225. (Corresponding
author)

Stephen Walker, BSc. University of Warwick Medical School. Email:
stephen.g.walker@warwick.ac.uk

Siobhan Quenby, MD FRCOG. Email: s.quenby@warwick.ac.uk Tommy's National
Centre for Miscarriage Research, University Hospitals Coventry \&
Warwickshire, Coventry CV2 2DX, United Kingdom.

Joshua Odendaal, MBBS BSc(Hons) MRCOG. Email:
joshua.odendaal@warwick.ac.uk Division of Biomedical Sciences, Clinical
Sciences Research Laboratories, Warwick Medical School, University of
Warwick, Coventry CV2 2DX, United Kingdom.

\textbf{Shortened title:} UAE vs myomectomy for uterine
fibroids\textbf{Tweetable abstract:} Myomectomy is associated with
improved quality of life compared to greater symptomatic control with
UAE.

\emph{Abstract}

\textbf{Background}

Uterine artery embolization (UAE) and myomectomy are uterus-sparing
treatments for uterine fibroids. Each carries a different risk and
efficacy profile. Despite this there is a lack of direct comparison
between the two techniques making treatment choice decisions difficult.

\textbf{Objectives}

To compare the therapeutic efficacy and complications of UAE versus
myomectomy.

\textbf{Search strategy}

A systematic search of The Cochrane Library, Medline, and EMBASE
databases was conducted using a pre-defined search strategy. The review
was prospectively registered on PROSPERO (CRD42021259347).

\textbf{Selection Criteria}

All randomised controlled trials and cohort studies published between
January 1995 and August 2021 directly comparing UAE and myomectomy were
included.

\textbf{Data Collection and Analysis}

Meta-synthesis of raw data was performed using Review Manager 5.4.1 from
the Cochrane Collaboration. A pooled estimate of efficacy was
established using a fixed-effect model.

\textbf{Main results}

8 studies were identified. UAE was associated with lower complication
rates (OR 0.56; 95\% CI 0.40-0.79), increased improvement in bleeding
(OR 1.61 95\% CI 1.07-2.43) and a shorter total recovery time (7.72 days
versus 36.63 days). Whilst myomectomy was associated with a higher
post-procedure quality of life (mean difference -10.56; 95\% CI -15.34 -
-5.79) and lower re-intervention rate (OR 5.16; 95\% CI 2.41-11.04). No
significant difference in procedural failure rate was seen (OR 0.67;
95\% CI 0.30-1.50). Given concerns with UAE and future fertility limited
post-procedure fertility outcomes were identified.

\textbf{Conclusions:} Given differences in efficacy profiles a
personalised approach to treatment discussions should be maintained.

\textbf{Funding:} None

\textbf{Keywords:} Uterine artery embolization, myomectomy, uterine
fibroid

Main text

\emph{Funding}

None.

\emph{Introduction}Uterine fibroids are benign tumours of the uterine
muscle, and are the most common type of tumour amongst women of
reproductive age\textsuperscript{{[}1{]}}. Symptomatic uterine fibroids
are a common and significant health problem affecting as many as 1 in 3
women in the UK, and have a lifetime prevalence of around
30\%\textsuperscript{{[}2{]}}. Fibroids can cause severe symptoms such
as menorrhagia, pelvic pressure, pain, and also impact upon the mental
health and sexual functioning of those who have them. Fibroids can also
cause infertility. In cases like these, treatment is often required to
improve symptoms\textsuperscript{{[}3{]}} . Two common
uterine-conserving treatments for uterine fibroids are UAE and
myomectomy. UAE is a comparatively newer technique and is limited to
tertiary centres with the appropriate expertise. The British Medical
Journal (BMJ) recommends both UAE and myomectomy as first-line
treatments for fibroids where uterine preservation is desired. According
to this algorithm, UAE is only recommended for those not desiring future
fertility\textsuperscript{{[}4{]}}. Other studies such as Vercellini et
al., 1998\textsuperscript{{[}5{]}} also favour myomectomy for fertility
preservation. However, in 2013, the Royal College of Obstetricians and
Gynaecologists (RCOG) stated that there is no robust evidence comparing
the two for fertility and pregnancy outcomes\textsuperscript{{[}6{]}} .
There are a few randomised controlled trials (RCTs) comparing UAE with
hysterectomy\textsuperscript{{[}7, 8, 9, 10, 11{]}}. There are some
recent systematic reviews that compare UAE with surgical treatment as a
whole\textsuperscript{{[}12, 13{]}} , however it is hard to assess the
differences between UAE and myomectomy specifically where generic
`surgery' headings are used. At the time the current RCOG guidance was
created for fibroids, only two RCTs had been undertaken that directly
compared UAE and myomectomy \textsuperscript{{[}14, 15{]}}, since then
another RCT has been published, the FEMME 2020
trial\textsuperscript{{[}16{]}}. The decision between UAE and myomectomy
can have a significant effect on the quality of life of those who suffer
with uterine fibroids, including symptom control, fatigue, and feeling
of general health. This study aims to review and meta-analyse the data
to assess whether there are any significant differences in outcomes
which may help guide future management
algorithms.~\emph{Methods~}\textbf{Core outcome sets}No core outcome
sets were used in this study.\textbf{Patient and public involvement}No
patients or public were involved in this study.\textbf{Data sources}The
protocol for this systematic review was developed in line with PRISMA-P
guidance\textsuperscript{{[}17{]}} and prospectively registered on the
Prospero database (Reference number CRD42021259347). Ethical approval
was not required to undertake this review.~ A systematic search of The
Cochrane Library, Medline, and EMBASE databases was conducted using a
pre-defined search strategy (Appendix S1) to gather all studies
comparing UAE versus myomectomy in patients with symptomatic uterine
fibroids.~\textbf{Study Selection}Articles were screened by two
independent reviewers. Any discrepancies were resolved by consensus.
Articles were included if they were published in a peer-reviewed
journal, published in English from 1995 onwards, and were comparing UAE
with myomectomy as treatment for women with symptomatic fibroids. Papers
were excluded if they were abstracts, letters, opinion pieces or
reviews. RCTs, cohort studies, and case-controlled studies were
included. A citation search of the selected articles was performed to
identify any further relevant studies.~\textbf{Data extraction}Data from
each paper was entered into a bespoke designed data extraction table.
This included data such as the type and size of fibroid, as well as
patient demographic data. Outcome data was extracted which included:
Technical failure, re-intervention rates, haemorrhage, infection, length
of stay in hospital, mental health/mood, sexual functioning, resolution
of symptoms~, improvement in menorrhagia, post-procedural quality of
life score, time taken to return to normal activities, number of
patients who had complications\textbf{Assessment of Study
Quality/Bias}The papers were assessed for risk of~ bias using the
Newcastle-Ottawa scale (NOS) for cohort
studies\textsuperscript{{[}18{]}} and Cochrane RoB2 tool for RCTs
\textsuperscript{{[}19{]}} . The NOS compares across three domains:
selection, comparability, and exposure. The Cochrane RoB2 tool assesses
for bias across six domains: randomisation, assignment to an
intervention, adherence to an intervention, missing outcome data,
measurement of the outcome, and selection of reported
result.~\textbf{Data analysis~}Dichotomous data were presented as odds
ratio with 95\% confidence intervals (CIs) and continuous outcome
measures by weighted mean differences and 95\% CIs. Meta-synthesis of
raw data was performed using Review Manager 5.4.1 from the Cochrane
Collaboration\textsuperscript{{[}20{]}}.~ Weighted mean scores were
undertaken for `length of stay in hospital' and `time taken to return to
activities' as these were continuous outcomes for which both papers gave
no information on CIs. The I\textsuperscript{2} test was used to test
for heterogeneity between studies and sensitivity analyses were
undertaken for results which gave an I\textsuperscript{2} of over
50\%.\emph{Results}An electronic search of The Cochrane Library,
Medline, and EMBASE databases was conducted on August
21\textsuperscript{st} 2021. This produced 485 results, 180 from
Medline, 253 from Embase, and 52 from The Cochrane Library.~(Table S1)
There were 15 papers included for full-text review and four were removed
as they did not report myomectomy data separately from
hysterectomy\textsuperscript{{[}8, 10, 11, 21{]}}, one was removed as it
was a sub-analysis of the REST trial that focused on imaging
outcomes\textsuperscript{{[}22{]}}, and four papers were removed as they
were systematic reviews \textsuperscript{{[}12, 23, 24, 25{]}}. Two more
papers were added from citation reviews \textsuperscript{{[}26, 27{]}}.
In total there were eight studies included in this meta-analysis and
systematic review. There were five cohort studies\textsuperscript{{[}26,
27, 28, 29, 30{]}} and three RCTs\textsuperscript{{[}14, 15, 16{]}}. The
characteristics of the included studies are shown in Table 1. Bias
assessments are shown in Appendices S2 and S3. Three of the cohort
studies were undertaken at a single institution\textsuperscript{{[}26,
27, 30{]}} and two were undertaken as multi-centre studies
\textsuperscript{{[}28, 29{]}} . There were a total of 625 women in the
cohort, and 489 in the myomectomy cohort.~ Inclusion criteria were
similar across the eight studies, with all of them requiring symptomatic
uterine fibroids. Siskin et al., 2006; Mara et al., 2007 and Goodwin et
al., 2006 all specified maximum FSH levels for their participants, to
ensure that they were not already menopausal at the time of the study.
Manyonda et al., 2012 also specified that only pre-menopausal women were
to be included. However, Razavi et al., 2003 specified that for
inclusion in the study the women must be seeking symptomatic relief, not
seeking treatment for fertility problems.~ All of the studies reported
key demographic data such as age of the participants. For two of the
papers \textsuperscript{{[}14, 15{]}} it was possible to perform
comparison, and there was found to be no significant difference in age
between the UAE and myomectomy cohorts {[}OR=-0.76, 95\% CI (-1.99,
0.47){]} (Appendix S4). There were 12 outcomes that were deemed
comparable between the papers, five of these were related to technical
aspects of the procedure, such as infections and need to re-intervene at
a later date. The remaining seven were related to the quality of life of
the women in the respective studies, such as mental health and sexual
functioning. These are outlined below.

Technical failure

Technical failure did not significantly differ between groups
{[}OR=0.67, 95\% CI (0.30, 1.50){]} (Figure 1, A). Five papers commented
on rates of failure \textsuperscript{{[}14, 15, 26, 27, 29{]}} however
Narayan et al., 2010 gave their results as an adjusted OR and this could
not be meta-analysed with the other data. None of the studies gave a
specific definition for `technical failure' however they did give
examples of what was considered to be a failed procedure. In this
review, the need for conversion for hysterectomy mid-procedure, and any
repeat surgery to correct immediate complications were also considered
under this outcome.\textbf{}2. Re-intervention rates Re-intervention
rates varied significantly between groups {[}OR=5.16, 95\% CI (2.41,
11.04){]} (Figure 1, B), with myomectomy having lower rates of
re-intervention post-procedurally compared with UAE. Four studies
reported on this \textsuperscript{{[}14, 15, 27, 30{]}}. One study,
Razavi et al., 2003, did show lower re-intervention rates in its UAE
cohort, with there being five out of 62 patients in the UAE cohort, and
four out of 40 in the myomectomy cohort.~ Manyonda et al., 2012 found
that there was unsuspected adenomyosis in three of the six patients who
underwent a hysterectomy at re-intervention in the UAE group, which
offers a potential explanation for the need for re-intervention in these
cases.~ 3. Haemorrhage There was a significantly lower rate of
haemorrhage in the UAE cohorts compared with the myomectomy ones
{[}OR=0.22, 95\% CI (0.06, 0.77){]} (Figure 1, C), this was demonstrated
in all three studies that commented on this outcome.~ 4. Infection

Infection rates did vary significantly between UAE and myomectomy
cohorts {[}OR=0.20, 95\% CI (0.06, 0.72){]} (Figure 1, D), with the data
favouring the UAE group.~

5. Length of stay in hospital~ A weighted mean was calculated for the
number of days spent in hospital for both the UAE and myomectomy cohorts
across the five studies which recorded this in their study (Figure 2,
K). It was found that the UAE group had a mean number of 1.28 days
(range 0-2.5) in hospital, whereas the myomectomy group had a mean
number of 3.49 days (range 2.5-6) in hospital.~~\textbf{}6. Mental
health/mood

Changes in mental health/mood post-procedurally did not vary
significantly between UAE and Myomectomy {[}OR=-0.13, 95\% CI (-5.3,
5.04){]} (Figure 2, F) This data included two studies reporting their
results at 6 months post-op and at 12 months. \textsuperscript{{[}14,
29{]}}).

7. Sexual functioning~ There was no significant difference in sexual
functioning between UAE and myomectomy {[}OR=-6.33, 95\% CI (-12.93,
0.27){]} (Figure 2, G). This data included two studies
\textsuperscript{{[}14, 29{]}}).\textbf{}8. Resolution of symptoms
Resolution of symptoms did not vary significantly between groups
{[}OR=1.72, 95\% CI (0.91, 3.27){]} (Figure 2, H). Three papers reported
on this \textsuperscript{{[}15, 28, 30{]}}. All these papers used
different scoring systems, however, the result had little statistical
heterogeneity (I\textsuperscript{2} 0\%) implying consistency in the
finding.~ 9. Improvement in menorrhagia~ There was a significant
difference in improvement of menorrhagia between UAE and myomectomy
groups {[}OR=1.61, 95\% CI (1.07, 2.43){]} (Figure 2, I). Siskin et
al.,2006 found a reduction in mean menorrhagia bleeding at 6 months of
52.1\% with UAE, and 43.7\% with myomectomy. Razavi et al., 2003 found a
reduction in menorrhagia was 64\% for their myomectomy group and 92\%
for their UAE group.~ 10. Post-procedural quality of life score.
Post-procedural quality of life scores 12 months post-operatively were
significantly higher in the myomectomy cohort in comparison to the UAE
cohort {[}OR=-10.56, 95\% CI (-15.34, -5.79){]} (Figure 2, J). 11. Time
taken to return to normal activities UAE group took a weighted mean of
7.7 days (range 7.5-8) to return to normal activities, whereas the
myomectomy group took 36.6 days (range 36-37) (two studies
\textsuperscript{{[}27, 28{]}} (Figure 2, L)). 12. Complications It was
found that there was a significantly higher rate of complications in the
myomectomy group in comparison to the UAE group {[}OR=0.56, 95\% CI
(0.40, 0.79){]} (Figure 1, E). Five papers provided data on the number
of participants experiencing complications\textsuperscript{{[}14, 15,
27, 28{]}}. `Complications' included events such as infections,
haematomas, post-embolisation syndrome, bowel obstructions, rash,
transfusions, pain, readmissions, and
adhesions.~\emph{Discussion}\textbf{Main findings}Both UAE and
myomectomy are uterine-sparing treatment options for fibroids. UAE
offers a minimally invasive approach, however myomectomy is generally
favoured as first line treatment for fibroids that require further
treatment than hormonal or analgesic
medications\textsuperscript{{[}4{]}}. There are several studies that
compare UAE to all surgical managements of fibroids
\textsuperscript{{[}10, 11, 12, 13, 23, 24, 25{]}} . But very few of
these papers separate results for different surgical techniques, so they
could not be included in this review. A few literature reviews that do
compare UAE and myomectomy do not include more recent RCT data that
would have an impact on the findings. A review by Jun et al., 2012 that
compared UAE with surgical treatments only included one RCT that had
myomectomy data. Since then, there have been two large RCT trials with
more data specifically for UAE versus myomectomy \textsuperscript{{[}14,
16{]}}. Further to this, the 2014 Cochrane review for outcomes of
different treatments for uterine fibroids included only two studies that
compared UAE and myomectomy\textsuperscript{{[}23{]}}. In this review we
included eight studies, which to the best of our knowledge means it is
the largest meta-analysis of UAE versus myomectomy.~ There were no
significant differences found between the UAE and myomectomy groups for
numbers of technical failures, mental health scores, and sexual
functioning. UAE was associated with lower complication rates (OR 0.56;
95\% CI 0.40-0.79), increased improvement in bleeding (OR 1.61 95\% CI
1.07-2.43) and a shorter total recovery time (7.7 days versus 36.6
days). Whilst myomectomy was associated with a higher post-procedure
quality of life (mean difference -10.56; 95\% CI -15.34 - -5.79) and
lower re-intervention rate (OR 5.16; 95\% CI 2.41-11.04). No significant
difference in procedural failure rate was seen (OR 0.67; 95\% CI
0.30-1.50).~ It was expected that UAE is associated with a lower risk of
haemorrhage, infection, stay in hospital, and recovery time. This is
because it is less invasive, and similar results have been reported in
UAE vs surgery meta-analyses \textsuperscript{{[}11, 23{]}}.
Furthermore, `surgery' (including myomectomy) has been associated with a
lower rate of re-interventions \textsuperscript{{[}11, 25{]}}, and
higher post-procedural quality of life score \textsuperscript{{[}21{]}}.
In our review we found that UAE had a lower risk of complications
compared with myomectomy, however, other papers have found that UAE is
associated with higher numbers of complications compared with
`surgery'\textsuperscript{{[}10, 25{]}}. Whereas Jun et al.,2012 found
no difference in complications incidence, and less `major complications'
in UAE cohorts.~These differences are also likely to be explained by
separating out myomectomy from other surgical procedures. The
`improvement in menorrhagia' outcome had high heterogeneity
(I\textsuperscript{2}=71\%). So a sensitivity analysis was undertaken
(Appendix S5) where Razavi et al., 2003's paper was removed, which
improved the heterogeneity. This may be because each author measured the
outcome differently, with Goodwin et al., 2006 and Siskin et al., 2006
measuring a reduction in bleeding score, and Razavi et al., 2003
measured the percentage of patients that had a `successful' reduction in
menorrhagia.~\textbf{Strengths and limitations}The RCTs included within
this study did not blind patients to the intervention, increasing their
risk of bias. However, this is a limitation which was found to be
acceptable given that patients needed to be able to give informed
consent to the procedure. Furthermore, Manyonda et al., 2012 and 2020
had some deviations from the initial randomisation with some patients
receiving a different intervention. Four of the cohort studies were
deemed to have issues with comparability between UAE and myomectomy
groups (Table S1). These included problems such as a large difference in
cohort sizes \textsuperscript{{[}29{]}}, and the presence of potential
confounding variables such as obesity and smoking
\textsuperscript{{[}26{]}}. Siskin 2006 evaluated the gynaecological
histories between the cohorts as well as looking at demographic
information and surgical histories. Overall, there were no papers that
presented a significant risk of bias, and therefore all eight were
included in the data analysis.~ In regards to bias assessment, two of
cohort studies had a low risk of bias (Goodwin et al., 2006 and Siskin
et al., 2006), and three had a medium risk of bias (Narayan et al.,
2010, Broder et al., 2002, and Razavi et al., 2003). One RCT was
determined to have a low risk of bias (Mara et al., 2007), and the other
two were found to have a medium risk (Manyonda et al., 2012 and 2020).
The aspects of bias that were most prevalent in the studies was in the
study selection and availability of follow-up data for all participants.
Although four of the eight papers did use the Uterine Fibroid Symptom
and Quality of Life (UFS-QOL) score\textsuperscript{{[}31{]}{[}14, 16,
28, 29{]}} , to assess quality of life outcomes, most studies reported
their results in different formats, and some papers did not give data
for each outcome on the UFS-QOL scoring framework.~ There were some
outcomes that could not be meta-analysed and this was a limitation of
our study. Two studies did give data for patient satisfaction
\textsuperscript{{[}26, 29{]}} , although Narayan et al., 2010 gave
their results in odds ratio and Broder et al., 2002 gave theirs in
percentages of participants satisfied. This meant it was not possible to
meta-analyse.~ Three papers did report on pain \textsuperscript{{[}27,
28, 29{]}} , Siskin et al., 2006 reported pain scores as a change from
baseline, and Goodwin et al., 2006 reported it as a mean score. Although
both used the UFS-QOL framework they presented their results differently
and because of this they could not be meta-analysed. Razavi et al., 2003
reported on pain as a percentage of patients with resolution of pain.~
There was difficulty in assessing post-procedural complications between
the papers. Some gave complication rates as `early' or
`late'\textsuperscript{{[}15, 28{]}}, whilst others gave `occurrence of
adverse events' \textsuperscript{{[}14, 27{]}} without indication of
when they occurred. Some papers elaborated on specific complications
such as `infection' or `haematoma' \textsuperscript{{[}14, 28{]}} ,
however others just reported how many patients had a `complication', and
gave examples within the text. Because of this, in this review outcomes
were reported both under a generic `complication' heading and specific
ones where possible.\textbf{Interpretation}Mara et al., 2007 and Siskin
et al., 2006 gave data on pregnancies, labours, and miscarriages . With
Mara et al., 2007 also giving data on live birth. They found five births
in the UAE group (out of 26 who tried to conceive) and 19 births in the
Myomectomy group (out of 40 who tried to conceive).~ Some of the papers
noted that they did not include women who wanted to get pregnant in the
UAE cohort due to ethical reasons\textsuperscript{{[}14, 28, 29{]}} .
Therefore, pregnancy and fertility outcomes could not be compared.
Current NHS treatment algorithms for fibroids do suggest that there are
hesitations for use of UAE in those who may wish to become pregnant
\textsuperscript{{[}3,5{]}}. Therefore, this is a key comparator for the
two treatment modalities that needs to be explored further, especially
given that fibroids do largely affect pre-menopausal women. The findings
of this study suggest that guidelines for the treatment of uterine
fibroids should be based upon the individual preferences of the
patients. It would be hard to make a treatment algorithm based on the
findings, as there is no clear `better' treatment. Rather, there are
risks associated with both treatments that need to be balanced with the
goal of reducing symptoms and increasing the quality of life of the
patient.~ There is a hesitancy for use of UAE over myomectomy within
current guidelines that may need to be re-assessed to ensure the best
options are offered to those seeking treatment for uterine fibroids.
Patients should be given the data in a clear format that shows which
outcomes are associated with each treatment option, and healthcare
professionals should aid the patient in this decision using an
appropriate evidence-base. ~\emph{Conclusions}Both UAE and myomectomy
are safe and effective treatment options for uterine fibroids. They both
offer a high rate of technical success, and offer significant
improvement in sexual functioning, mental health, and general quality of
life. However, there is a higher chance of requiring re-interventions if
UAE is chosen. UAE offers lower rates of haemorrhage and infection, and
allows for patients to leave hospital faster, and return to activities
of daily life faster than those who have myomectomy. More research needs
to be undertaken to compare fertility and birth outcomes, as there is a
mixed picture in the literature and few studies have explored these
outcomes. Future research on this topic could potentially benefit from a
standardised method of reporting outcomes, including follow-up times, so
that more accurate comparisons can be made.

\emph{Acknowledgements}

None

\emph{Disclosure of interests} There are no patent ownership, stock
ownership, consultancies, speaker's fees, shares, personal, political,
intellectual or religious interests to disclose

\emph{Contribution to Authorship}

Initial idea: EW

Data extraction, analysis: JO, SW, EW

Manuscript preparation: JO, EW

Manuscript revisions: SQ

Project supervision: SQ, JO

\emph{Ethics approval} No ethical approval was required for this project
as per the NHS Research Ethics Service guidelines.

\emph{Funding}

No funding was received for this project.

\emph{References}

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\emph{Tables and Figures}

\emph{Included in print:}

Table 1: Included Study Characteristics table

Figure 1 : Technical outcomes: Panel A: Technical failure, Panel B:
Re-intervention rates, Panel C: Haemorrhage, Panel D: Infection, Panel
E: Complication rate

Figure 2 : Quality of life outcomes and length of stay: Panel F: Mental
health/mood, Panel G: Sexual functioning, Panel H: Resolution of
symptoms, Panel I: Improvement in menorrhagia,

Panel J: Post-procedural quality of life score, Panel K: Length of stay
in hospital, Panel L: Time taken to return to normal
activities\emph{Supplementary:}

Figure S1: Search terms

Table S1: PRISMA diagram of article selection

Figure S2: Newcastle-Ottawa scores of cohort studies

Figure S3: Cochrane Rob2 scores of RCTs

Figure S4: Age of the participants

Figure S5: Sensitivity analysis, menorrhagia

\emph{Tables (to be provided in Main Document as per file upload
instructions) :}

Table 1: Included Study Characteristics table\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
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Table S1: PRISMA diagram of article selection.

\textbf{Hosted file}

\verb`Figure 1.docx`  available at \url{https://authorea.com/users/492275/articles/575015-uterine-artery-embolization-uae-compared-with-myomectomy-for-the-management-of-uterine-fibroids-a-systematic-review-and-meta-analysis}

\textbf{Hosted file}

\verb`Figure 2.docx`  available at \url{https://authorea.com/users/492275/articles/575015-uterine-artery-embolization-uae-compared-with-myomectomy-for-the-management-of-uterine-fibroids-a-systematic-review-and-meta-analysis}

\textbf{Hosted file}

\verb`study characteristics table.xlsx`  available at \url{https://authorea.com/users/492275/articles/575015-uterine-artery-embolization-uae-compared-with-myomectomy-for-the-management-of-uterine-fibroids-a-systematic-review-and-meta-analysis}

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