Metanálise seguida de comparação indireta de tratamentos e modelo de custo-efetividade comparando embolização da artéria uterina e os métodos cirúrgicos para o tratamento de leiomiomas uterinos sintomáticos

• Ano de defesa: 2015
• Autor(a) principal: Fonseca, Marcelo Cunio Machado [UNIFESP]
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de São Paulo (UNIFESP)
• Palavras-chave em Português: leiomyoma; uterine artery embolization; hysterectomy; myomectomy uterine; cost - efficiency analysis; metanálise; leiomioma embolização da artéria uterina histerectomia miomectomia uterina; análise de custo-eficiência
• Link de acesso: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=3169264; https://repositorio.unifesp.br/handle/11600/47170

Objectives: Symptomatic uterine leiomyomas (SUL) impacts health, quality of life, and the working ability. Surgery is still the main therapeutic intervention. This study assessed the benefits and risks of uterine artery embolization (UAE) and its costeffectiveness in relation to the surgical interventions in the Brazilian healthcare system (SUS). Methods: We conducted a systematic search for randomised controlled trials of UAE versus any surgical therapy for SUL. We performed a meta-analysis comparing procedural, effectiveness, ovarian failure and patient experience outcomes. To compare the surgical procedures an indirect treatment comparison was performed anchored on the results of direct comparisons with a common control intervention, UAE. To evaluate the relative cost-effectiveness of UAE versus surgical procedures, a decision model simulating a SUL cohort receiving initially UAE or hysterectomy or myomectomy or laparoscopic occlusion of the uterine arteries (LOUA) was constructed from a SUS perspective over 5 years. We used effectiveness data from our meta-analysis and SUS data on resource use. The incremental cost expected for each additional quality adjusted life-year (QALY) gained and each avoided intervention was calculated and presented as the incremental cost-effectiveness ratio. Results: We identified 10 relevant RCTs for the meta-analysis. Length of hospital stay, recovery and the need for transfusions is lower in UAE. UAE have higher number of minor complications and reinterventions until two years after the procedure. Ovarian failure and patients? experiences did not differ between UAE and surgical procedures. In the indirect treatment comparison LOUA presents disadvantage compared to hysterectomy and myomectomy concerning the need for re-intervention within two years after the procedure and the need for re-intervention due to the persistence of symptoms; on the other hand it presents shorter hospital stay than them. Compared to hysterectomy, LOUA presents more re-interventions after two years and up to five years and lower resolution of menorrhagia after the first and second years of the initial procedure. Hysterectomy and myomectomy are equivalent in relation to the all studied outcomes. In the cost-effectiveness analysis, UAE compared to hysterectomy and myomectomy, was not a cost effective alternative, however, UAE is a cost-effective alternative compared to LOUA regarding the number of procedure avoided, but not QALYs. 176 Conclusion: Patients? experiences and ovarian failure appear to be similar among UAE and surgical procedures, whilst UAE offers an advantage with regards to a shorter hospital length of stay, a quicker recovery time and less need for transfusions. Conversely, UAE has a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two years of the initial procedure. Concerning the other studied surgeries LOUA seems to present an increased rate of persistence of symptoms leading to an increased likelihood of requiring surgical procedure, mainly within two years after the initial intervention. Hysterectomy and myomectomy are equivalent in relation to the all studied outcomes although hysterectomy is not a uterus sparing procedure. UAE is not a cost-effective option in relation to hysterectomy and myomectomy in SUS.