Uterine Artery Embolization in Tanzania: A Procedure with Major Public Health Implications

Uterine Artery Embolization in Tanzania: A Procedure with Major Public Health Implications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Uterine Artery Embolization in Tanzania: A Procedure with Major Public Health Implications Balowa Musa, Jared Mark Alswang, Rose Di Ioia, Lydia Grubic, Azza Naif, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2801136/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment. Methods From June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania’s first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests. Results During the study period, 92.1% (n = 35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n = 3/38) for adenomyosis. 97.3% (n = 37/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p < 0.01). 100% of patients reported satisfaction with outcomes. Among the nine patients with follow-up imaging, there was a mean volumetric decrease of 35.5% (p = 0.109). Conclusions UAE for fibroids and adenomyosis can be performed with high technical success and low complication rates in a low-resource setting like Tanzania, resulting in significant symptom relief for patients. Building capacity for UAE has major public health implications not only for fibroids and adenomyosis, but can help address the region’s leading cause of maternal mortality, postpartum hemorrhage. Uterine artery embolization uterine fibroids adenomyosis postpartum hemorrhage interventional radiology uterine fibroid embolization reproductive health sub-Saharan Africa Tanzania Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Plain Language Summary Interventional radiology (IR), a specialty that uses image guidance to perform minimally invasive lifesaving and -changing procedures, plays an integral role in modern healthcare delivery. However, access to IR in low-resource settings is severely limited and therefore the many benefits that the specialty brings to the field of reproductive health does not reach the majority of patients in sub-Saharan Africa. An IR procedure with particular promise in the region is uterine artery embolization – a procedure in which an interventional radiologist traverses the blood vessels through a pinhole to strategically stop disadvantageous blood flow to regions of the uterus in order to treat conditions such as uterine fibroids, adenomyosis, and postpartum hemorrhage. In this study, we reviewed the outcomes of 38 uterine artery embolization procedures performed by Tanzania’s first IR service and training program. The goal of this study was to assess whether uterine artery embolization, a well-established procedure in high-income countries, could be performed safely and effectively to treat uterine fibroids and adenomyosis in a novel setting, where the specialty of IR is still in its infancy. We followed patients for at least six-months following the procedure to assess their response to the treatment. 100% of patients reported satisfaction with symptom relief. Self-reported severity scores for abnormal uterine bleeding, pain, and bulk symptoms improved significantly at follow-up. Among patients that had repeat imaging, the volume of their fibroids decreased by 35.5%. There was one minor complication observed, which resolved fully with conservative management. In summary, uterine artery embolization procedures were performed on par with international standards, highlighting its potential role as a minimally invasive and long-term cost-effective alternative to treat a variety of reproductive health conditions in sub-Saharan Africa. Background Promoting maternal and reproductive health is a long-standing priority in the field of global health. While impressive strides have been made advancing the field in the last two decades [ 1 – 4 ], potential contributions from various specialties have been under-utilized. Interventional radiology (IR) is a noteworthy example. In high-income countries, IR plays a significant role in maternal and reproductive health with a wide range of procedures at their disposal to treat conditions ranging from obstructive uropathy from cervical cancer to pelvic congestion syndrome [ 5 ]. One such high-yield IR procedure with significant potential to make a global impact in the field is uterine artery embolization (UAE), commonly used to manage uterine fibroids, adenomyosis, and postpartum hemorrhage. Uterine fibroids or leiomyomas, the most common benign neoplasm in women, are highly endemic within sub-Saharan Africa (SSA) and constitute a considerable burden on its female population [ 6 , 7 ]. This very common condition can have significant negative impact on patients’ lives with many affected women experiencing menorrhagia, menometrorrhagia, dysmenorrhea, pelvic pain, dyspareunia, infertility, and/or bulk symptoms [ 8 ]. With stark racial disparities in the incidence of uterine fibroids, and black women far more likely to harbor them, estimated at 70–80% in their lifetime, and be symptomatic, their management in SSA should be considered a public health priority [ 6 , 9 ]. Unfortunately, when medical management fails, the only available treatment option in most of the region remains to be hysterectomy, with myomectomy only available in a few specialized centers [ 10 , 11 ]. UAE, a safe and effective alternative to surgery, has been routinely performed for decades in high-income countries [ 12 – 14 ]. This minimally invasive procedure involves the controlled injection of an embolic agent into the uterine arteries under fluoroscopic-guidance by an interventional radiologist, thus compromising its blood flow, leading to an immediate cessation of bleeding and regression in size and associated symptoms over the following weeks [ 15 ]. Until recently, there was no IR training program in East Africa, accounting for low UAE accessibility for its population. This changed in 2018 with the establishment of Tanzania’s first IR service and training program at Muhimbili National Hospital (MNH), Tanzania’s national referral center [ 16 ]. Elective UAEs for symptomatic fibroids and adenomyosis have since become readily integrated into clinical practice and emergent UAE for the management of postpartum hemorrhage (PPH), the leading cause of maternal morbidity and mortality in SSA [ 17 ], will be offered starting April 2023 with the opening of MNH’s new angiography suite. This retrospective study assesses the safety and effectiveness of UAE as a first-line non-medical therapy for symptomatic fibroids and adenomyosis at MNH and serves as a proof-of-concept for wider adoption of this procedure in the region as a treatment option for symptomatic uterine fibroids, adenomyosis, and PPH going forward. Methods A single-center, retrospective, observational cohort study was conducted at a large tertiary hospital in Tanzania on all patients who underwent UAE for the management of symptomatic uterine fibroids and adenomyosis from June 2019 to July 2022. Throughout the study period, IR faculty from North America and Europe traveled to Tanzania on a monthly basis to provide hands-on teaching for Tanzanian IR fellows. All UAEs were performed by Tanzanian IR fellows as primary operators under the supervision of local or visiting IR faculty [ 16 ]. Ethical clearance (MNH/IRB/EXT/2022/008) was obtained and all patients provided informed consent for enrollment into the study. Patients with symptomatic uterine fibroids or adenomyosis not responsive to medical management were considered for UAE. Exclusion criteria for UAE included viable pregnancy, active uterine infection, malignancy of the uterus, and pedunculated subserosal fibroids [ 18 , 19 ]. Preprocedural workup included detailed medical history, contrast-enhanced Magnetic Resonance Imaging (MRI), routine pre-procedural hematologic evaluation, urine pregnancy test, and pap smear. UAEs were performed following standard international practice guidelines [ 20 , 21 ]. Pre-procedural, procedural, and follow-up data were collected and stored in a Research Electronic Data Capture (REDCap) database (REDCap 8.7.1 - ©2021 Vanderbilt University). Contrast-enhanced pelvic MRI was performed pre-procedure and at six-month follow-up, and the maximum diameter and calculated volume of the dominant fibroid were recorded. Fibroid volume was calculated using the ellipsoid formula (length x width x height) x 0.52 [ 22 ]. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines [ 23 ]. Symptom severity was assessed pre-procedure and six-months post-procedure by telephone interview in the following categories: abnormal uterine bleeding (including irregular menstruation, menometrorrhagia, and menorrhagia), pain (including dysmenorrhea, abdominal pain, back pain, and pelvic pain), and bulk symptoms (including pressure, pelvic fullness, urinary incontinence, bloating, urinary frequency, and constipation), all scored on a 1–10 self-reported likert-type scale (1 = least severe, 10 = most severe). Descriptive analysis was performed and numerical variables were summarized by mean and standard deviation and categorical variables by frequency. Paired t-tests were used to compare pre- and post-procedure dominant fibroid size and symptom severity. Statistical analysis was completed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, Washington, United States). Results From June 2019 to July 2022, 38 patients who underwent uterine artery embolizations were included in this study: 92.1% (n = 35/38) for symptomatic uterine fibroids and 7.9% (n = 3/38) for adenomyosis. The mean age of the study population was 41.6 years (range: 28 to 52 years). Referral data was collected from 89.5% (n = 34/38) of patients. The majority of women (n = 20/34; 58.8%) presented as referrals from the MNH Obstetrics and Gynecology Department, 38.2% (n = 13/34) were self-referred, and 2.9% (n = 1/34) were referred by friends and family. Payment information was available from 94.7% (n = 36/38): 52.8% (n = 19/36) self-paid and 47.2% (n = 17/36) had their procedures covered by insurance (Table 1 ). Presenting symptoms within the patient population included abnormal uterine bleeding, bulk symptoms, pain, infertility, and anemia (Table 2 ). Variable Characteristics Frequency Percent Table 1 Demographic characteristics of the study population n= 37 Age 18–29 1 2.7 30–39 14 37.8 > 40 22 59.5 n = 36 Language Swahili 33 91.7 English 3 8.3 n = 35 Region Dar Es Salaam 29 82.9 Arusha 2 5.7 Pwani 2 5.7 Zanzibar Mjini Magharibi 1 2.9 Mtwara 1 2.9 n = 36 Religion Christian 30 83.3 Muslim 6 16.6 n = 36 Payment method Self 18 50.0 Insurance 17 47.2 Family/friends 1 2.8 Table 2 | Presenting symptoms and diagnoses of the study population Variable Characteristic Frequency n = 38 Percent Presenting Symptoms Abnormal uterine bleeding a 31 81.6 Bulk Symptoms b 13 34.2 Pain c 13 34.2 Infertility d 4 10.5 Anemia 4 10.5 Uterine fibroids 35 92.1 Principal Diagnosis Adenomyosis 3 7.9 a Includes irregular menstruation, menometrorrhagia, and menorrhagia b Includes pressure, pelvic fullness, urinary incontinence, bloating, urinary frequency, constipation c Includes dysmenorrhea, dysmenorrhagia, abdominal pain, pelvic pain, lower back pain, and pain included in same category d Includes spontaneous miscarriages and infertility Overall, 97.3% (n=37/38) of procedures were technically successful. There was no major complication and one minor complication (SIR Class A): post-embolization syndrome, which was managed conservatively with no long-term sequelae (Table 3). Table 3 | Technical success and adverse events from uterine artery embolization in the study population Variable Characteristic Frequency n = 38 Percent Technical success Yes 37 97.4 No 1 2.6 Complications No 37 97.4 Yes* 1 2.6 *SIR class A, no therapy, no consequence. Self-reported symptom-severity scores at six-months post-procedure decreased significantly in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p < 0.001) (Fig. 1 ). 100% (n = 38/38) reported satisfaction with their symptom control. Pre-procedural dominant uterine fibroid volume and diameter were available for 52.6% (n = 20/38) of the study population with an average volume and maximum diameter of 155.6 cm 3 and 7.0 cm, respectively. Of those patients, six-month follow-up imaging was available from 45.0% (n = 9/20) of patients. On follow-up imaging, the average volume and diameter of the dominant fibroid decreased to 97.5 cm 3 (-35.5%; p = 0.109) and 6.2 cm (-11.4%; p = 0.07), respectively (Figs. 2 and 3 ). Discussion Scope and Impact Black women bear the brunt of the fibroid burden globally, having a significantly higher prevalence [ 24 ] and earlier onset [ 25 ] compared to other racial groups. While research on the subject in SSA is severely limited, the impact of uterine fibroids is believed to be significant based on the racial composition of the region [ 6 ]. In a comprehensive scoping review on uterine fibroids in SSA, only five studies reported on the prevalence, each demonstrating significant variance across studies and populations [ 26 ]. Given the limited knowledge regarding fibroids in SSA, yet presumed high incidence and impact on the population, fibroids are a “silent epidemic” in the region. As such, there has been minimal progress in improving patient outcomes in SSA in recent years. This is largely due to the limited treatment options available in the region, with hysterectomy and less commonly myomectomy typically being the only accessible options. While hysterectomy and myomectomy are effective treatment options, associated postoperative complications are not uncommon and include hemorrhage, infection, thromboembolic disease, adhesive disease, and organ damage [ 10 , 27 , 28 ]. In contrast, UAE presents an appealing alternative that may better align with patient preferences given its minimally invasive and uterine-preserving nature. While lamentably the vast majority of women in SSA currently do not have access to UAE, this study demonstrates that a UAE program is possible to implement in the region with our findings validating successful integration of UAE into clinical practice for the treatment of symptomatic fibroids and adenomyosis in Tanzania. Outcomes The treatment of symptomatic fibroids with UAE is supported by strong evidence in the literature [ 29 , 30 ]. Studies have repeatedly validated the safety and effectiveness of this procedure, demonstrating symptom control non-inferior to surgery, fewer major complications, and shorter hospitalization stays and recovery times [ 30 , 31 ]. Our experiences with UAE in Tanzania reflect the findings of prior studies. Adverse events and technical success rates in this study were on par with international standards at 2.6% and 97.3% compared to 4.4% and 95%, respectively [ 21 , 30 ]. The mean volumetric response in this study (35.5%) was generally lower than previously reported [ 32 ]. However, the overall significance of this metric is controversial [ 32 ] and less than a quarter of patients in this study had both pre- and post-procedural imaging available for calculation. In contrast, patient satisfaction and symptom relief are considered the most important outcomes after UAE [ 32 ]. Patients in our cohort achieved adequate symptom control, including a significant reduction of self-reported symptom severity scores in all categories, as well as 100% reported satisfaction in symptom improvement. With high rates of technical and symptomatic success, and minimal complications observed in this study, it is evident that uterine artery embolization can safely and effectively be performed in a resource-limited setting. As such, improving access to this procedure in SSA should be prioritized as an evidence-based means to address the region’s high-burden of symptomatic fibroids. Uterine Fibroid Embolization Awareness Offering minimally invasive treatment options for symptomatic fibroids has far-reaching implications in a population at increased risk. In shared decision making with their treating physician, patients of different age groups, regions and religious beliefs are now afforded the opportunity to undergo UAE with qualified, locally-trained interventional radiologists in Tanzania. However, to date only a small fraction of women in the region that could potentially benefit from UAE, have been able to access the procedure. Therefore, Igboeli et. al. proposes increased education and awareness as a means to bring attention to and address this public health crisis [ 6 ]. This includes improving knowledge of the different treatment options among clinicians and patients alike. Fostering shared-decision making based on enhanced mutual understanding of the condition and available management options can effectively optimize patient outcomes and satisfaction. Following the introduction of UAE to the region, this is especially important, as the minimally invasive nature of this approach may better align with patient goals and priorities. Effective collaboration between specialties, as well as with patients themselves, is essential in providing optimal patient care, which has been an exhibited strength in the early experiences of Tanzania’s first UAE program. The hospital’s Department of Obstetrics and Gynecology (OB/GYN) provided most UAE referrals. The remaining patients were either self-referred or presented upon recommendation from relatives who had previously undergone the procedure. This demonstrates a promising trajectory of awareness with observed referral streams from both physicians specialized in the treatment of fibroids and satisfied patients by word-of-mouth. Due to the infancy of interventional radiology in SSA, it is important to continue to raise awareness among local clinicians and patients alike about the many benefits of procedures offered by the specialty [ 33 ]. This is especially important regarding symptomatic uterine fibroids, a condition in which women of color and those belonging to a lower socioeconomic bracket are often underdiagnosed and have a lower likelihood of receiving treatment [ 34 ] – an issue that can be mitigated through increased awareness and education. Clinical Implications UAE is not only an effective treatment for symptomatic fibroids and adenomyosis, but for postpartum hemorrhage as well, a common delivery complication and the leading cause of maternal mortality worldwide [ 35 ]. In SSA, lifetime risk of maternal mortality is estimated at 1 in 36 women [ 35 ], with 30–50% of maternal deaths attributed to PPH [ 36 ]. When conservative management fails, UAE is considered a first-line treatment option for patients and an evidence-based alternative to emergent hysterectomy [ 37 ]. However, given the relative novelty of interventional radiology at MNH, UAEs for PPH have not yet been integrated into clinical practice. Nonetheless, the service’s demonstrated proficiency in treating uterine fibroids and adenomyosis, reflected by high technical, clinical, and radiological success, suggest that the incorporation of UAE into management protocols for PPH would be practical. While the implementation of emergent UAEs for the treatment of PPH will take time in SSA, it will serve to benefit the patient population as it has done in high-income countries. Addressing this devastating and common obstetric emergency will be an important advancement for IR in the region, majorly impacting maternal health outcomes. Developing a UAE program that includes emergent PPH, in tandem to elective fibroids and adenomyosis, has the potential to increase the long-term sustainability and accessibility of the program as a whole. Coverage by insurance and patients’ willingness to pay-out-of-pocket for elective procedures can generate enough revenue to subsidize emergent, life-saving UAEs. Striking a balance financially is important to ensure a self-sustaining operation capable of bridging inequities in health access and outcomes across the spectrum of procedural indications. Limitations While the findings of this study demonstrate a promising proof-of-concept for the establishment of UAE programs in SSA, there are several limitations that should be considered. This is a single-center study and experiences implementing a UAE program may differ across the culturally, geopolitically, and socioeconomically diverse region. Additionally, given the novelty of UAE in Tanzania, the overall sample size of this study is relatively small and the safety and effectiveness of UAE in this setting for indications other than uterine fibroids, including adenomyosis and PPH, cannot be meaningfully interpreted and/or are conjectural. In addition, symptom impact on quality of life was not assessed and the evaluation of symptom severity was not performed using a validated measure. Finally, both baseline and follow-up imaging was only available for a subset of the study population due to MNH not having an established picture archiving and communication system, which introduced selection bias to all radiological analyses. Additional research is needed to further assess the safety and effectiveness of uterine artery embolization for different indications and across different populations and healthcare systems in sub-Saharan Africa. Conclusions Uterine artery embolization is a procedure that well-exemplifies the potential role that IR can play in global health at large. While IR is still a specialty in its infancy in nations such as Tanzania, its rapid trajectory of growth in the region shows promise in how it may impact critical areas in resource-limited settings, including maternal and reproductive health. Less than five years old, the Tanzania IR training program has already produced ten graduates sufficiently trained in UAE, as demonstrated in this study, who have since spread out across Tanzania, as well as to Rwanda and Nigeria. With additional IR training programs launching in neighboring countries, Kenya in 2020 and Rwanda and Uganda in 2023, a domino effect is underway expanding the reach of the specialty in East Africa. Sustaining this growth is essential in order to ensure equitable access to IR services, including UAE. As uterine artery embolization has emerged as a standard of care option to manage symptomatic uterine fibroids and postpartum hemorrhage in high-resource settings, with adequate support and investment, the same is possible in SSA. Abbreviations IR - Interventional Radiology; UAE - Uterine Artery Embolization; SSA - sub-Saharan Africa; MNH - Muhimbili National Hospital; PPH - Postpartum Hemorrhage ; OB/GYN - Obstetrics and Gynecology Declarations Ethics Approval and Consent to Participate: Ethics approval was granted by the Muhimbili National Hospital Institutional Review Board (MNH/IRB/EXT/2022/008). All participating patients provided a written agreement prior to starting data collection. Consent for Publication: All authors approve the manuscript and give their consent for submission and publication. Availability of Data and Materials: Anonymized data not published within this article will be made available by the corresponding author, upon reasonable request. We take full responsibility for the data, analyses, interpretation and research conduct. We have full access to all data and have obtained the rights to publish these results. Competing Interests: The authors involved in this study have no conflicts of interest to report. Funding: This work has received no specific funding. The training program in which this work took place in was supported by the RSNA Research and Education Foundation (#6614). Authors’ Contributions: BM and JA collected the data. LG analyzed and reported the data in the manuscript. JA, LG, RD, BM, and FLG wrote the manuscript. All authors read and approved the final manuscript. References Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL (2010) Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2801136","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":191814173,"identity":"df5851df-0f67-4778-be92-415bed0e8242","order_by":0,"name":"Balowa Musa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBACAwbmBiiT+QCQkJAhQgsjTAtbAkgLDylaeAzAJEEt5uwHGx/z1GxLnN9+5vOrGzUWPAzsh49uwKfFsiex2Zjn2O3EDWdyt1nnHAM6jCct7QZehx1IbJPOYQNqYcjdZpzDBtQiwWOGX8v5h0At/24nzu9/88w45x8xWm4Abcltu53YcCOH+XFuGxFaLGc8bDb+23fbeMONZ2bMuX0SPGyE/GLOn3zw4Yxvt2Xn9yc//pzzrU6On/3wMbxakAGbBJgkVjkIMH8gRfUoGAWjYBSMHAAAYF5NRg4ttmkAAAAASUVORK5CYII=","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Balowa","middleName":"","lastName":"Musa","suffix":""},{"id":191814174,"identity":"25cc35bb-2f8b-43fb-be54-3360e4244bd8","order_by":1,"name":"Jared Mark Alswang","email":"","orcid":"","institution":"Harvard University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jared","middleName":"Mark","lastName":"Alswang","suffix":""},{"id":191814175,"identity":"fad678f0-19f2-4a99-906a-100fab226ad1","order_by":2,"name":"Rose Di Ioia","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rose","middleName":"Di","lastName":"Ioia","suffix":""},{"id":191814176,"identity":"a3a8d68a-657e-4da5-9928-8b22480f0d0c","order_by":3,"name":"Lydia Grubic","email":"","orcid":"","institution":"Marian University College of Osteopathic Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lydia","middleName":"","lastName":"Grubic","suffix":""},{"id":191814177,"identity":"69fca5a1-d3d6-4cce-b303-b936e878c196","order_by":4,"name":"Azza Naif","email":"","orcid":"","institution":"Muhimbili National Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azza","middleName":"","lastName":"Naif","suffix":""},{"id":191814178,"identity":"cf4cd54d-c90a-47a9-baf6-dbc151af5cf6","order_by":5,"name":"Erick Michael Mbuguje","email":"","orcid":"","institution":"Muhimbili National Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Erick","middleName":"Michael","lastName":"Mbuguje","suffix":""},{"id":191814180,"identity":"32260279-e54a-424b-b1eb-441f0701d5b0","order_by":6,"name":"Victoria Vuong","email":"","orcid":"","institution":"University of California San Diego Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Vuong","suffix":""},{"id":191814181,"identity":"ba143d43-006f-4f42-92e1-be9526bc86f6","order_by":7,"name":"Janice Newsome","email":"","orcid":"","institution":"Emory University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janice","middleName":"","lastName":"Newsome","suffix":""},{"id":191814183,"identity":"686e9a24-3ba8-49a7-a9fd-af069859830b","order_by":8,"name":"Vijay Ramalingam","email":"","orcid":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vijay","middleName":"","lastName":"Ramalingam","suffix":""},{"id":191814185,"identity":"5f705498-8299-4995-8e01-aa59d798e403","order_by":9,"name":"Fabian Max Laage Gaupp","email":"","orcid":"","institution":"Yale School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"Max Laage","lastName":"Gaupp","suffix":""}],"badges":[],"createdAt":"2023-04-11 09:44:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2801136/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2801136/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":35962259,"identity":"39893671-4ca8-4593-ab4a-de1fe3956b12","added_by":"auto","created_at":"2023-04-18 21:45:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39990,"visible":true,"origin":"","legend":"\u003cp\u003eMean symptom severity score at baseline and six months post-procedure\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/24a2604adb9d40f0d1abf9e5.png"},{"id":35962260,"identity":"62194109-69cc-4a81-8921-b4ec32222b5e","added_by":"auto","created_at":"2023-04-18 21:45:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37478,"visible":true,"origin":"","legend":"\u003cp\u003eDominant uterine fibroid volume at baseline and six months post-procedure\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/5e7757840406e333de2772ae.png"},{"id":35962258,"identity":"486bf705-82da-4be0-b2a6-7cbc8bd47407","added_by":"auto","created_at":"2023-04-18 21:45:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33477,"visible":true,"origin":"","legend":"\u003cp\u003eDominant uterine fibroid maximum diameter at baseline and six months post-procedure\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/4a9a7da92559460472727c49.png"},{"id":35962537,"identity":"2e6b2901-dddd-4910-9ba6-63fc0c7190f5","added_by":"auto","created_at":"2023-04-18 21:53:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1010490,"visible":true,"origin":"","legend":"\u003cp\u003ePelvic MRI demonstrating a uterine fibroid measuring 12.3 x 7.2 x 11.5 cm (530 cm\u003csup\u003e3\u003c/sup\u003e) pre-procedure (A \u0026amp; B) and 6.8 x 6.0 x 7.6 cm (161 cm\u003csup\u003e3\u003c/sup\u003e) six months post-procedure (C\u0026amp;D). A \u0026amp; C: Sagittal T2-weighted post-gadolinium. B \u0026amp; D: Coronal T1-weighted post-gadolinium.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/22e2eda7e9bcb6bf9608f171.png"},{"id":35962262,"identity":"44994063-dc96-4c9b-b477-4ccdacc70c21","added_by":"auto","created_at":"2023-04-18 21:45:03","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":530328,"visible":true,"origin":"","legend":"\u003cp\u003eSelective left uterine artery digital-subtraction angiograms (30-degree left anterior oblique view) pre-embolization (A) and post-embolization (B). A: demonstrates arterial blush and uterine artery branches linked with the fibroid. B: demonstrates occlusion of flow of the vessel branches feeding the fibroid, absence of arterial blush, and patency of the left uterine artery.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/e559097dc76958736daa1e97.png"},{"id":36173415,"identity":"4ebc4dd7-5052-46ef-84be-266233b59de4","added_by":"auto","created_at":"2023-04-23 08:29:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2089221,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2801136/v1/ff498907-c15b-4787-8ce4-37483e076c98.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Uterine Artery Embolization in Tanzania: A Procedure with Major Public Health Implications","fulltext":[{"header":"Plain Language Summary","content":"\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Interventional radiology (IR), a specialty that uses image guidance to perform minimally invasive lifesaving and -changing procedures, plays an integral role in modern healthcare delivery. However, access to IR in low-resource settings is severely limited and therefore the many benefits that the specialty brings to the field of reproductive health does not reach the majority of patients in sub-Saharan Africa. An IR procedure with particular promise in the region is uterine artery embolization \u0026ndash; a procedure in which an interventional radiologist traverses the blood vessels through a pinhole to strategically stop disadvantageous blood flow to regions of the uterus in order to treat conditions such as uterine fibroids, adenomyosis, and postpartum hemorrhage. In this study, we reviewed the outcomes of 38 uterine artery embolization procedures performed by Tanzania\u0026rsquo;s first IR service and training program. The goal of this study was to assess whether uterine artery embolization, a well-established procedure in high-income countries, could be performed safely and effectively to treat uterine fibroids and adenomyosis in a novel setting, where the specialty of IR is still in its infancy. We followed patients for at least six-months following the procedure to assess their response to the treatment. 100% of patients reported satisfaction with symptom relief. Self-reported severity scores for abnormal uterine bleeding, pain, and bulk symptoms improved significantly at follow-up. Among patients that had repeat imaging, the volume of their fibroids decreased by 35.5%. There was one minor complication observed, which resolved fully with conservative management. In summary, uterine artery embolization procedures were performed on par with international standards, highlighting its potential role as a minimally invasive and long-term cost-effective alternative to treat a variety of reproductive health conditions in sub-Saharan Africa.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003ePromoting maternal and reproductive health is a long-standing priority in the field of global health. While impressive strides have been made advancing the field in the last two decades [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], potential contributions from various specialties have been under-utilized. Interventional radiology (IR) is a noteworthy example. In high-income countries, IR plays a significant role in maternal and reproductive health with a wide range of procedures at their disposal to treat conditions ranging from obstructive uropathy from cervical cancer to pelvic congestion syndrome [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. One such high-yield IR procedure with significant potential to make a global impact in the field is uterine artery embolization (UAE), commonly used to manage uterine fibroids, adenomyosis, and postpartum hemorrhage.\u003c/p\u003e \u003cp\u003eUterine fibroids or leiomyomas, the most common benign neoplasm in women, are highly endemic within sub-Saharan Africa (SSA) and constitute a considerable burden on its female population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This very common condition can have significant negative impact on patients\u0026rsquo; lives with many affected women experiencing menorrhagia, menometrorrhagia, dysmenorrhea, pelvic pain, dyspareunia, infertility, and/or bulk symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. With stark racial disparities in the incidence of uterine fibroids, and black women far more likely to harbor them, estimated at 70\u0026ndash;80% in their lifetime, and be symptomatic, their management in SSA should be considered a public health priority [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnfortunately, when medical management fails, the only available treatment option in most of the region remains to be hysterectomy, with myomectomy only available in a few specialized centers [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. UAE, a safe and effective alternative to surgery, has been routinely performed for decades in high-income countries [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This minimally invasive procedure involves the controlled injection of an embolic agent into the uterine arteries under fluoroscopic-guidance by an interventional radiologist, thus compromising its blood flow, leading to an immediate cessation of bleeding and regression in size and associated symptoms over the following weeks [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUntil recently, there was no IR training program in East Africa, accounting for low UAE accessibility for its population. This changed in 2018 with the establishment of Tanzania\u0026rsquo;s first IR service and training program at Muhimbili National Hospital (MNH), Tanzania\u0026rsquo;s national referral center [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Elective UAEs for symptomatic fibroids and adenomyosis have since become readily integrated into clinical practice and emergent UAE for the management of postpartum hemorrhage (PPH), the leading cause of maternal morbidity and mortality in SSA [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], will be offered starting April 2023 with the opening of MNH\u0026rsquo;s new angiography suite. This retrospective study assesses the safety and effectiveness of UAE as a first-line non-medical therapy for symptomatic fibroids and adenomyosis at MNH and serves as a proof-of-concept for wider adoption of this procedure in the region as a treatment option for symptomatic uterine fibroids, adenomyosis, and PPH going forward.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA single-center, retrospective, observational cohort study was conducted at a large tertiary hospital in Tanzania on all patients who underwent UAE for the management of symptomatic uterine fibroids and adenomyosis from June 2019 to July 2022. Throughout the study period, IR faculty from North America and Europe traveled to Tanzania on a monthly basis to provide hands-on teaching for Tanzanian IR fellows. All UAEs were performed by Tanzanian IR fellows as primary operators under the supervision of local or visiting IR faculty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Ethical clearance (MNH/IRB/EXT/2022/008) was obtained and all patients provided informed consent for enrollment into the study. Patients with symptomatic uterine fibroids or adenomyosis not responsive to medical management were considered for UAE. Exclusion criteria for UAE included viable pregnancy, active uterine infection, malignancy of the uterus, and pedunculated subserosal fibroids [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Preprocedural workup included detailed medical history, contrast-enhanced Magnetic Resonance Imaging (MRI), routine pre-procedural hematologic evaluation, urine pregnancy test, and pap smear. UAEs were performed following standard international practice guidelines [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePre-procedural, procedural, and follow-up data were collected and stored in a Research Electronic Data Capture (REDCap) database (REDCap 8.7.1 - \u0026copy;2021 Vanderbilt University). Contrast-enhanced pelvic MRI was performed pre-procedure and at six-month follow-up, and the maximum diameter and calculated volume of the dominant fibroid were recorded. Fibroid volume was calculated using the ellipsoid formula (length x width x height) x 0.52 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Symptom severity was assessed pre-procedure and six-months post-procedure by telephone interview in the following categories: abnormal uterine bleeding (including irregular menstruation, menometrorrhagia, and menorrhagia), pain (including dysmenorrhea, abdominal pain, back pain, and pelvic pain), and bulk symptoms (including pressure, pelvic fullness, urinary incontinence, bloating, urinary frequency, and constipation), all scored on a 1\u0026ndash;10 self-reported likert-type scale (1\u0026thinsp;=\u0026thinsp;least severe, 10\u0026thinsp;=\u0026thinsp;most severe).\u003c/p\u003e \u003cp\u003eDescriptive analysis was performed and numerical variables were summarized by mean and standard deviation and categorical variables by frequency. Paired t-tests were used to compare pre- and post-procedure dominant fibroid size and symptom severity. Statistical analysis was completed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, Washington, United States).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom June 2019 to July 2022, 38 patients who underwent uterine artery embolizations were included in this study: 92.1% (n\u0026thinsp;=\u0026thinsp;35/38) for symptomatic uterine fibroids and 7.9% (n\u0026thinsp;=\u0026thinsp;3/38) for adenomyosis. The mean age of the study population was 41.6 years (range: 28 to 52 years). Referral data was collected from 89.5% (n\u0026thinsp;=\u0026thinsp;34/38) of patients. The majority of women (n\u0026thinsp;=\u0026thinsp;20/34; 58.8%) presented as referrals from the MNH Obstetrics and Gynecology Department, 38.2% (n\u0026thinsp;=\u0026thinsp;13/34) were self-referred, and 2.9% (n\u0026thinsp;=\u0026thinsp;1/34) were referred by friends and family. Payment information was available from 94.7% (n\u0026thinsp;=\u0026thinsp;36/38): 52.8% (n\u0026thinsp;=\u0026thinsp;19/36) self-paid and 47.2% (n\u0026thinsp;=\u0026thinsp;17/36) had their procedures covered by insurance (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Presenting symptoms within the patient population included abnormal uterine bleeding, bulk symptoms, pain, infertility, and anemia (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics of the study population\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"null\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"null\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"null\"\u003e\u003cstrong\u003e\u003cem\u003en=\u003c/em\u003e37\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"null\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u0026ndash;39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003en\u0026thinsp;=\u003c/span\u003e\u0026thinsp;\u003cstrong\u003e36\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLanguage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSwahili\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e91.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;35\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDar Es Salaam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArusha\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePwani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eZanzibar Mjini Magharibi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMtwara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;36\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003en\u0026thinsp;=\u0026thinsp;36\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePayment method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily/friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 |\u0026nbsp;\u003c/strong\u003ePresenting symptoms and diagnoses of the study population\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Taba\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;38\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresenting Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbnormal uterine bleeding\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBulk Symptoms\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePain\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfertility\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUterine fibroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrincipal Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdenomyosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Includes irregular menstruation, menometrorrhagia, and menorrhagia\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Includes pressure, pelvic fullness, urinary incontinence, bloating, urinary frequency, constipation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e Includes dysmenorrhea, dysmenorrhagia, abdominal pain, pelvic pain, lower back pain, and pain included in same category\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ed\u003c/sup\u003e Includes spontaneous miscarriages and infertility\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eOverall, 97.3% (n=37/38) of procedures were technically successful. There was no major complication and one minor complication (SIR Class A): post-embolization syndrome, which was managed conservatively with no long-term sequelae (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003e\u003cstrong\u003eTable 3 |\u0026nbsp;\u003c/strong\u003eTechnical success and adverse events from uterine artery embolization in the study population\u0026nbsp;\u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;38\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercent\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTechnical success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e97.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e97.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*SIR class A, no therapy, no consequence.\u003c/p\u003e\n\u003cp\u003eSelf-reported symptom-severity scores at six-months post-procedure decreased significantly in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e100% (n\u0026thinsp;=\u0026thinsp;38/38) reported satisfaction with their symptom control. Pre-procedural dominant uterine fibroid volume and diameter were available for 52.6% (n\u0026thinsp;=\u0026thinsp;20/38) of the study population with an average volume and maximum diameter of 155.6 cm\u003csup\u003e3\u003c/sup\u003e and 7.0 cm, respectively. Of those patients, six-month follow-up imaging was available from 45.0% (n\u0026thinsp;=\u0026thinsp;9/20) of patients. On follow-up imaging, the average volume and diameter of the dominant fibroid decreased to 97.5 cm\u003csup\u003e3\u003c/sup\u003e (-35.5%; p\u0026thinsp;=\u0026thinsp;0.109) and 6.2 cm (-11.4%; p\u0026thinsp;=\u0026thinsp;0.07), respectively (Figs. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eScope and Impact\u003c/h2\u003e \u003cp\u003eBlack women bear the brunt of the fibroid burden globally, having a significantly higher prevalence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and earlier onset [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] compared to other racial groups. While research on the subject in SSA is severely limited, the impact of uterine fibroids is believed to be significant based on the racial composition of the region [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a comprehensive scoping review on uterine fibroids in SSA, only five studies reported on the prevalence, each demonstrating significant variance across studies and populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Given the limited knowledge regarding fibroids in SSA, yet presumed high incidence and impact on the population, fibroids are a \u0026ldquo;silent epidemic\u0026rdquo; in the region.\u003c/p\u003e \u003cp\u003eAs such, there has been minimal progress in improving patient outcomes in SSA in recent years. This is largely due to the limited treatment options available in the region, with hysterectomy and less commonly myomectomy typically being the only accessible options. While hysterectomy and myomectomy are effective treatment options, associated postoperative complications are not uncommon and include hemorrhage, infection, thromboembolic disease, adhesive disease, and organ damage [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In contrast, UAE presents an appealing alternative that may better align with patient preferences given its minimally invasive and uterine-preserving nature. While lamentably the vast majority of women in SSA currently do not have access to UAE, this study demonstrates that a UAE program is possible to implement in the region with our findings validating successful integration of UAE into clinical practice for the treatment of symptomatic fibroids and adenomyosis in Tanzania.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe treatment of symptomatic fibroids with UAE is supported by strong evidence in the literature [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Studies have repeatedly validated the safety and effectiveness of this procedure, demonstrating symptom control non-inferior to surgery, fewer major complications, and shorter hospitalization stays and recovery times [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Our experiences with UAE in Tanzania reflect the findings of prior studies. Adverse events and technical success rates in this study were on par with international standards at 2.6% and 97.3% compared to 4.4% and 95%, respectively [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The mean volumetric response in this study (35.5%) was generally lower than previously reported [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, the overall significance of this metric is controversial [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and less than a quarter of patients in this study had both pre- and post-procedural imaging available for calculation. In contrast, patient satisfaction and symptom relief are considered the most important outcomes after UAE [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Patients in our cohort achieved adequate symptom control, including a significant reduction of self-reported symptom severity scores in all categories, as well as 100% reported satisfaction in symptom improvement. With high rates of technical and symptomatic success, and minimal complications observed in this study, it is evident that uterine artery embolization can safely and effectively be performed in a resource-limited setting. As such, improving access to this procedure in SSA should be prioritized as an evidence-based means to address the region\u0026rsquo;s high-burden of symptomatic fibroids.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eUterine Fibroid Embolization Awareness\u003c/h2\u003e \u003cp\u003eOffering minimally invasive treatment options for symptomatic fibroids has far-reaching implications in a population at increased risk. In shared decision making with their treating physician, patients of different age groups, regions and religious beliefs are now afforded the opportunity to undergo UAE with qualified, locally-trained interventional radiologists in Tanzania. However, to date only a small fraction of women in the region that could potentially benefit from UAE, have been able to access the procedure.\u003c/p\u003e \u003cp\u003eTherefore, Igboeli et. al. proposes increased education and awareness as a means to bring attention to and address this public health crisis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This includes improving knowledge of the different treatment options among clinicians and patients alike. Fostering shared-decision making based on enhanced mutual understanding of the condition and available management options can effectively optimize patient outcomes and satisfaction. Following the introduction of UAE to the region, this is especially important, as the minimally invasive nature of this approach may better align with patient goals and priorities. Effective collaboration between specialties, as well as with patients themselves, is essential in providing optimal patient care, which has been an exhibited strength in the early experiences of Tanzania\u0026rsquo;s first UAE program. The hospital\u0026rsquo;s Department of Obstetrics and Gynecology (OB/GYN) provided most UAE referrals. The remaining patients were either self-referred or presented upon recommendation from relatives who had previously undergone the procedure. This demonstrates a promising trajectory of awareness with observed referral streams from both physicians specialized in the treatment of fibroids and satisfied patients by word-of-mouth. Due to the infancy of interventional radiology in SSA, it is important to continue to raise awareness among local clinicians and patients alike about the many benefits of procedures offered by the specialty [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This is especially important regarding symptomatic uterine fibroids, a condition in which women of color and those belonging to a lower socioeconomic bracket are often underdiagnosed and have a lower likelihood of receiving treatment [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] \u0026ndash; an issue that can be mitigated through increased awareness and education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eUAE is not only an effective treatment for symptomatic fibroids and adenomyosis, but for postpartum hemorrhage as well, a common delivery complication and the leading cause of maternal mortality worldwide [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In SSA, lifetime risk of maternal mortality is estimated at 1 in 36 women [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], with 30\u0026ndash;50% of maternal deaths attributed to PPH [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. When conservative management fails, UAE is considered a first-line treatment option for patients and an evidence-based alternative to emergent hysterectomy [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, given the relative novelty of interventional radiology at MNH, UAEs for PPH have not yet been integrated into clinical practice. Nonetheless, the service\u0026rsquo;s demonstrated proficiency in treating uterine fibroids and adenomyosis, reflected by high technical, clinical, and radiological success, suggest that the incorporation of UAE into management protocols for PPH would be practical. While the implementation of emergent UAEs for the treatment of PPH will take time in SSA, it will serve to benefit the patient population as it has done in high-income countries. Addressing this devastating and common obstetric emergency will be an important advancement for IR in the region, majorly impacting maternal health outcomes.\u003c/p\u003e \u003cp\u003eDeveloping a UAE program that includes emergent PPH, in tandem to elective fibroids and adenomyosis, has the potential to increase the long-term sustainability and accessibility of the program as a whole. Coverage by insurance and patients\u0026rsquo; willingness to pay-out-of-pocket for elective procedures can generate enough revenue to subsidize emergent, life-saving UAEs. Striking a balance financially is important to ensure a self-sustaining operation capable of bridging inequities in health access and outcomes across the spectrum of procedural indications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhile the findings of this study demonstrate a promising proof-of-concept for the establishment of UAE programs in SSA, there are several limitations that should be considered. This is a single-center study and experiences implementing a UAE program may differ across the culturally, geopolitically, and socioeconomically diverse region. Additionally, given the novelty of UAE in Tanzania, the overall sample size of this study is relatively small and the safety and effectiveness of UAE in this setting for indications other than uterine fibroids, including adenomyosis and PPH, cannot be meaningfully interpreted and/or are conjectural. In addition, symptom impact on quality of life was not assessed and the evaluation of symptom severity was not performed using a validated measure. Finally, both baseline and follow-up imaging was only available for a subset of the study population due to MNH not having an established picture archiving and communication system, which introduced selection bias to all radiological analyses. Additional research is needed to further assess the safety and effectiveness of uterine artery embolization for different indications and across different populations and healthcare systems in sub-Saharan Africa.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUterine artery embolization is a procedure that well-exemplifies the potential role that IR can play in global health at large. While IR is still a specialty in its infancy in nations such as Tanzania, its rapid trajectory of growth in the region shows promise in how it may impact critical areas in resource-limited settings, including maternal and reproductive health. Less than five years old, the Tanzania IR training program has already produced ten graduates sufficiently trained in UAE, as demonstrated in this study, who have since spread out across Tanzania, as well as to Rwanda and Nigeria. With additional IR training programs launching in neighboring countries, Kenya in 2020 and Rwanda and Uganda in 2023, a domino effect is underway expanding the reach of the specialty in East Africa. Sustaining this growth is essential in order to ensure equitable access to IR services, including UAE. As uterine artery embolization has emerged as a standard of care option to manage symptomatic uterine fibroids and postpartum hemorrhage in high-resource settings, with adequate support and investment, the same is possible in SSA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIR - Interventional Radiology; UAE - Uterine Artery Embolization; SSA - sub-Saharan Africa; MNH - Muhimbili National Hospital; PPH - Postpartum Hemorrhage ; OB/GYN - Obstetrics and Gynecology\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eEthics approval was granted by the Muhimbili National Hospital Institutional Review Board (MNH/IRB/EXT/2022/008). All participating patients provided a written agreement prior to starting data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eAll authors approve the manuscript and give their consent for submission and publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eAnonymized data not published within this article will be made available by the corresponding author, upon reasonable request. We take full responsibility for the data, analyses, interpretation and research conduct. We have full access to all data and have obtained the rights to publish these results.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors involved in this study have no conflicts of interest to report.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis work has received no specific funding. The training program in which this work took place in was supported by the RSNA Research and Education Foundation (#6614).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBM and JA collected the data. LG analyzed and reported the data in the manuscript. JA, LG, RD, BM, and FLG wrote the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJL (2010) Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 375:1609\u0026ndash;1623\u003c/li\u003e\n\u003cli\u003eLozano R, Wang H, Foreman KJ, et al (2011) Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 378:1139\u0026ndash;1165\u003c/li\u003e\n\u003cli\u003eAwortwi N, Musahara H (2016) Implementation of the Millennium Development Goals: Progresses and Challenges in Some African Countries. OSSREA\u003c/li\u003e\n\u003cli\u003eGaffey MF, Das JK, Bhutta ZA (2015) Millennium Development Goals 4 and 5: Past and future progress. Semin Fetal Neonatal Med 20:285\u0026ndash;292\u003c/li\u003e\n\u003cli\u003eFortier A-S, Milovanovic L (2022) Interventional Radiology in Women\u0026rsquo;s Health. In: Athreya S, Albahhar M (eds) Demystifying Interventional Radiology: A Guide for Medical Students. Springer International Publishing, Cham, pp 167\u0026ndash;191\u003c/li\u003e\n\u003cli\u003eIgboeli P, Walker W, McHugh A, Sultan A, Al-Hendy A (2019) Burden of Uterine Fibroids: An African Perspective, A Call for Action and Opportunity for Intervention. Curr Opin Obstet Gynecol 2:287\u0026ndash;294\u003c/li\u003e\n\u003cli\u003eStewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R (2017) Epidemiology of uterine fibroids: a systematic review. BJOG 124:1501\u0026ndash;1512\u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists\u0026rsquo; Committee on Practice Bulletins-Gynecology (2021) Management of symptomatic uterine leiomyomas: ACOG Practice Bulletin, number 228. Obstet Gynecol 137:e100\u0026ndash;e115\u003c/li\u003e\n\u003cli\u003eEltoukhi HM, Modi MN, Weston M, Armstrong AY, Stewart EA (2014) The health disparities of uterine fibroid tumors for African American women: a public health issue. Am J Obstet Gynecol 210:194\u0026ndash;199\u003c/li\u003e\n\u003cli\u003eMichael D, Mremi A, Swai P, Shayo BC, Mchome B (2020) Gynecological hysterectomy in Northern Tanzania: a cross- sectional study on the outcomes and correlation between clinical and histological diagnoses. BMC Womens Health 20:122\u003c/li\u003e\n\u003cli\u003eChama CM, Bukar M, Kwari S THE SURGICAL TREATMENT OF SYMPTOMATIC UTERINE FIBROIDS AT THE UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL, MAIDUGURI, NIGERIA. parity 2:3\u003c/li\u003e\n\u003cli\u003eDi Stasi C, Cina A, Rosella F, Paladini A, Amoroso S, Romualdi D, Manfredi R, Colosimo C (2018) Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center. Radiol Med 123:385\u0026ndash;397\u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists (2008) ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol 112:387\u0026ndash;400\u003c/li\u003e\n\u003cli\u003eBulman JC, Ascher SM, Spies JB (2012) Current concepts in uterine fibroid embolization. Radiographics 32:1735\u0026ndash;1750\u003c/li\u003e\n\u003cli\u003eKeung JJ, Spies JB, Caridi TM (2018) Uterine artery embolization: A review of current concepts. Best Pract Res Clin Obstet Gynaecol 46:66\u0026ndash;73\u003c/li\u003e\n\u003cli\u003eGaupp FML, Laage Gaupp FM, Solomon N, et al (2019) Tanzania IR Initiative: Training the First Generation of Interventional Radiologists. Journal of Vascular and Interventional Radiology 30:2036\u0026ndash;2040\u003c/li\u003e\n\u003cli\u003eKhan KS, Wojdyla D, Say L, G\u0026uuml;lmezoglu AM, Van Look PF (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066\u0026ndash;1074\u003c/li\u003e\n\u003cli\u003eAndrews RT, Spies JB, Sacks D, et al (2004) Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 15:115\u0026ndash;120\u003c/li\u003e\n\u003cli\u003evan Overhagen H, Reekers JA (2015) Uterine artery embolization for symptomatic leiomyomata. Cardiovasc Intervent Radiol 38:536\u0026ndash;542\u003c/li\u003e\n\u003cli\u003eDariushnia SR, Nikolic B, Stokes LS, Spies JB, Society of Interventional Radiology Standards of Practice Committee (2014) Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol 25:1737\u0026ndash;1747\u003c/li\u003e\n\u003cli\u003eYoung M, Coffey W, Mikhail LN (2022) Uterine Fibroid Embolization. StatPearls\u003c/li\u003e\n\u003cli\u003eMoshesh M, Peddada SD, Cooper T, Baird D (2014) Intraobserver variability in fibroid size measurements: estimated effects on assessing fibroid growth. J Ultrasound Med 33:1217\u0026ndash;1224\u003c/li\u003e\n\u003cli\u003eKhalilzadeh O, Baerlocher MO, Shyn PB, et al (2017) Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 28:1432\u0026ndash;1437.e3\u003c/li\u003e\n\u003cli\u003eMarsh EE, Ekpo GE, Cardozo ER, Brocks M, Dune T, Cohen LS (2013) Racial differences in fibroid prevalence and ultrasound findings in asymptomatic young women (18\u0026ndash;30 years old): a pilot study. Fertil Steril 99:1951\u0026ndash;1957\u003c/li\u003e\n\u003cli\u003eBaird DD, Dunson DB, Hill MC, Cousins D, Schectman JM (2003) High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 188:100\u0026ndash;107\u003c/li\u003e\n\u003cli\u003eMorhason-Bello IO, Adebamowo CA (2022) Epidemiology of uterine fibroid in black African women: a systematic scoping review. BMJ Open 12:e052053\u003c/li\u003e\n\u003cli\u003eMadueke-Laveaux OS, Elsharoud A, Al-Hendy A (2021) What We Know about the Long-Term Risks of Hysterectomy for Benign Indication\u0026mdash;A Systematic Review. J Clin Med Res 10:5335\u003c/li\u003e\n\u003cli\u003eLoddo A, Djokovic D, Drizi A, De Vree BP, Sedrati A, van Herendael BJ (2022) Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE). Eur J Obstet Gynecol Reprod Biol 268:121\u0026ndash;128\u003c/li\u003e\n\u003cli\u003eSpies JB (2013) Current evidence on uterine embolization for fibroids. Semin Intervent Radiol 30:340\u0026ndash;346\u003c/li\u003e\n\u003cli\u003eFonseca MCM, Castro R, Machado M, Conte T, Girao MJB (2017) Uterine Artery Embolization and Surgical Methods for the Treatment of Symptomatic Uterine Leiomyomas: A Systemic Review and Meta-analysis Followed by Indirect Treatment Comparison. Clinical Therapeutics 39:1438\u0026ndash;1455.e2\u003c/li\u003e\n\u003cli\u003eClements W, Brown N, Buckley B, Rogan C, Kok HK, Liang E (2022) Quality care guidelines for uterine artery embolisation in women with symptomatic uterine fibroids in Australia and New Zealand: According to the AGREE‐II checklist and endorsed by the Interventional Radiology Society of Australasia. Journal of Medical Imaging and Radiation Oncology 66:819\u0026ndash;825\u003c/li\u003e\n\u003cli\u003eCzuczwar P, Woźniak S, Szkodziak P, Woźniakowska E, Paszkowski M, Wrona W, Milart P, Paszkowski T, Popajewski M (2014) Predicting the results of uterine artery embolization: correlation between initial intramural fibroid volume and percentage volume decrease. Prz Menopauzalny 13:247\u0026ndash;252\u003c/li\u003e\n\u003cli\u003eKaur M, Gaupp FL, Rukundo I, Naif AA, Lwakatare F, Mbuguje EM, Asch M (2021) Interventional Radiology Awareness Among Clinicians at Muhimbili National Hospital, Tanzania. Cardiovasc Intervent Radiol 44:658\u0026ndash;661\u003c/li\u003e\n\u003cli\u003eMarsh EE, Al-Hendy A, Kappus D, Galitsky A, Stewart EA, Kerolous M (2018) Burden, prevalence, and treatment of uterine fibroids: A survey of U.s. women. J Womens Health 27:1359\u0026ndash;1367\u003c/li\u003e\n\u003cli\u003eBongaarts J (2016) WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Trends in Maternal Mortality: 1990 to 2015 Geneva: World Health Organization, 2015. Population and Development Review 42:726\u0026ndash;726\u003c/li\u003e\n\u003cli\u003eLancaster L, Barnes RFW, Correia M, Luis E, Boaventura I, Silva P, von Drygalski A (2020) Maternal death and postpartum hemorrhage in sub-Saharan Africa - A pilot study in metropolitan Mozambique. Res Pract Thromb Haemost 4:402\u0026ndash;412\u003c/li\u003e\n\u003cli\u003eChen C, Lee SM, Kim JW, Shin JH (2018) Recent Update of Embolization of Postpartum Hemorrhage. Korean J Radiol 19:585\u0026ndash;596\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Uterine artery embolization, uterine fibroids, adenomyosis, postpartum hemorrhage, interventional radiology, uterine fibroid embolization, reproductive health, sub-Saharan Africa, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-2801136/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2801136/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFrom June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania\u0026rsquo;s first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDuring the study period, 92.1% (n\u0026thinsp;=\u0026thinsp;35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n\u0026thinsp;=\u0026thinsp;3/38) for adenomyosis. 97.3% (n\u0026thinsp;=\u0026thinsp;37/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). 100% of patients reported satisfaction with outcomes. Among the nine patients with follow-up imaging, there was a mean volumetric decrease of 35.5% (p\u0026thinsp;=\u0026thinsp;0.109).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUAE for fibroids and adenomyosis can be performed with high technical success and low complication rates in a low-resource setting like Tanzania, resulting in significant symptom relief for patients. Building capacity for UAE has major public health implications not only for fibroids and adenomyosis, but can help address the region\u0026rsquo;s leading cause of maternal mortality, postpartum hemorrhage.\u003c/p\u003e","manuscriptTitle":"Uterine Artery Embolization in Tanzania: A Procedure with Major Public Health Implications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-18 21:44:58","doi":"10.21203/rs.3.rs-2801136/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2c6af28-db89-4fab-99c5-d59b41293571","owner":[],"postedDate":"April 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-04-23T08:29:13+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-18 21:44:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2801136","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2801136","identity":"rs-2801136","version":["v1"]},"buildId":"ehx78VzkSd0WSzXnipQa-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}