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Uterine artery embolization for the treatment of uterine fibroids
Abstract
Uterine leiomyomata are a frequent finding in a gynecologist’s practice. Until recently, options for management have been limited. A relatively new procedure is gaining popularity as another option for a select group of patients. The treatment of choice for definitive management remains hysterectomy. However, uterine artery embolization (UAE) can be considered in certain women. We discuss the indications, benefits, risks, and potential complications of UAE. We review recent literature including results and complication rates. A proposed protocol is introduced for patient selection, preoperative assessment, and postprocedural follow-up. A coordinated effort is recommended, including incorporating a multiteam approach with the interventional radiologist, pain management service, and gynecologist. A brief technical review of the procedure is included. (Primary Care Update Ob/Gyns 2001;8:232–239
Uterine fibroids (leiomyomas or benign tumors of the smooth muscle) represent the most common form of benign mesenchymal disease of the female genital tract. Clinical studies report an incidence of 25–30% of the female population of childbearing age, with higher prevalence after 40 years and in black women [1].
Uterine leiomyomas are benign tumors that arise from myometrial smooth muscle cells. They are present in 20–25% of women of reproductive age. These benign tumors are generally firm, well circumscribed and composed of smooth muscle cells in an interdigitating pattern separated by fibrous connective tissue. Fibroids are more common in black women, and on an average, 50% of all laparotomies for a pelvic pathology are performed for myomas. If asymptomatic, they can generally be managed expectantly, but 75% do have symptoms. and Up to one third of patients experience abnormal uterine bleeding and/or abdominal or pelvic pain.3 They have also been associated with both impaired fertility and poor obstetric outcome. The incidence of malignancy is small, and has been reported to be 0.29% in a study of 33,000 pathology specimens.1 Patients presenting with infertility and with abnormal uterine bleeding have a higher incidence of uterine fibroids. Possible symptoms of uterine fibroids include bleeding, pressure, pelvic pain, recurrent pregnancy loss, bladder or bowel symptoms, and infertility. Generally, uterine myomas arise from a single smooth muscle cell clone, which proliferates beyond normal control mechanisms. Surgical treatment options include laparotomy with myomectomy, hysteroscopic myoma resection, or laparoscopic myomectomy. More recently, treatment of submucosal myomas has been managed almost exclusively by operative hysteroscopy. The purpose of this manuscript is to briefly discuss symptoms and diagnosis but to primarily focus on treatment.
To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas.
Medline literature review, cross-reference of published data, and review of selected meeting abstracts.
Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas.
Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.
Results from clinical series indicate that uterine artery embolization (UAE) improves pelvic symptoms and excessive uterine bleeding that are caused by uterine leiomyomata. Randomized controlled trials have not been conducted to provide data on the long-term efficacy and risks of UAE compared with conventional surgical options. Even without controlled studies, demand for this procedure has increased rapidly. UAE may be considered an alternative to hysterectomy, or perhaps myomectomy in well-selected cases. Posttreatment hospitalization and recovery tend to be shorter after UAE compared with hysterectomy. UAE should not be recommended routinely for women who desire future fertility. Collaborative efforts between gynecologists and interventional radiologists are necessary to optimize the safety and efficacy of UAE.
To determine whether uterine artery embolization (UAE) prior to myomectomy is more effective than myomectomy alone.
The study included 15 consecutive infertile women with uterine fibroids > 10 cm (Group I) that underwent UAE with spherical particles using a microcatheter technique and a unilateral femoral approach between March 2005 and January 2007. The day after embolization all cases underwent myomectomy since the protocol for large fibroids in our hospital is myomectomy only. The control group was composed of 15 patients who underwent myomectomy only (Group II). Group II was established based on fibroid size (14 +/- 3 cm). Operating time, estimated blood loss and transfusion, complications, and hospital stay were calculated by retrospective chart reviews, and comparisons were made between the groups with Student's t-test.
Mean operating time was 138 min in Group I and 240 minutes in Group II (P < 0.01). Mean estimated blood loss was 250 ml in Group I and 690 ml in Group II (P < 0.01). There was no need for transfusion in Group I, while transfusion was needed in 2 cases (13%) in Group II. Mean hospital stay in Group I was 5 days versus 8 days in Group II. Complications, including subsequent hysterectomy, were seen in 2 cases and bowel-bladder injuries in 1 case in Group II (a total of 20%), while no complications were observed in Group I. One of the cases in Group I later conceived and gave birth to a healthy child.
UAE prior to myomectomy is more effective than myomectomy alone.
To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function.
The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test.
Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses.
The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.
Bilateral uterine artery embolisation was performed to treat eight women with symptomatic large fibroids requiring treatment. Uterine volume was quantitatively assessed by magnetic resonance imaging. Both uterine arteries were occluded effectively in all women, and the procedure was well tolerated, with a 24–36 hour admission for pain relief. The level of pain experienced was variable, but well controlled. Some women experienced intermittent vaginal discharge and pain following the procedure. Improvement of symptoms occurred in six of the seven women and the eighth woman conceived. There were no significant complications. At three months four women had a uterine volume of < 350 cm3. Embolisation appears to be a good alternative to surgery, but longer follow up is required to evaluate the long term effects and to determine those patients for whom the procedure is suitable.
Purpose:
To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for fibroid-related vaginal bleeding and pelvic pain refractory to hormonal therapy and myomectomy.
Materials and methods:
Eleven patients (aged 27-55 years; mean, 44.2 years; none desiring future pregnancy) with refractory vaginal bleeding and/or chronic pelvic pain related to uterine leiomyomata underwent uterine artery embolization with use of polyvinyl alcohol (PVA) particles. Clinical improvement was assessed by detailed questionnaire at 2-9 months (mean, 5.8 months) after the procedure. Sonographic measurements of the uterus and dominant masses were obtained before and at 2 months after the procedure.
Results:
All 11 patients underwent technically successful embolization. Eight of nine women who completed the follow-up questionnaire reported noticeable symptomatic improvement, including three women with complete resolution of symptoms. One woman (the only patient undergoing unilateral embolization) exhibited no clinical response. Another patient developed endometritis and pyometra 3 weeks after the procedure, necessitating hysterectomy. Large reductions in uterine volume (average, 40%) and dominant fibroid size (average, 60%-65%) were sonographically demonstrated.
Conclusion:
Uterine artery embolization represents a promising new method of treating fibroid-related menorrhagia and pelvic pain. Further investigation will be required to assess clinical response and durability, identify appropriate candidates, and define the optimal angiographic technique and PVA particle size.
Bilateral uterine artery embolisation was performed to treat eight women with symptomatic large fibroids requiring treatment. Uterine volume was quantitatively assessed by magnetic resonance imaging. Both uterine arteries were occluded effectively in all women, and the procedure was well tolerated, with a 24-36 hour admission for pain relief. The level of pain experienced was variable, but well controlled. Some women experienced intermittent vaginal discharge and pain following the procedure. Improvement of symptoms occurred in six of the seven women and the eighth woman conceived. There were no significant complications. At three months four women had a uterine volume of < 350 cm3. Embolisation appears to be a good alternative to surgery, but longer follow up is required to evaluate the long term effects and to determine those patients for whom the procedure is suitable.
Surgical ligation of the hypogastric arteries for control of intractable pelvic hemorrhage is a well established procedure. Indications for ligation for treatment of life-threatening hemorrhage include bleeding from malignancy, pelvic trauma, vascular malformation, iatrogenic injury to major vessels, and postpartum hemorrhage. Due to the rapid collateral flow development in the pelvis, persistent bleeding may be difficult to control. Further ligation, suturing, tight packing, or a more extensive surgical approach have all been suggested. Recent experience suggests that selective transarterial embolization may be a more effective means of therapy than surgery. This paper reports successful hemostasis of massive postpartum pelvic hemorrhage by transcatheter embolization of absorbable gelatin sponge for bleeding which continued despite bilateral surgical internal iliac artery ligation, total abdominal hysterectomy, and vaginal packing. The internal iliac ligation actually complicated the embolization by limiting accessibility of vessels to embolization. To our knowledge neither arterial embolization following bilateral internal iliac artery ligation nor its use in the postpartum setting have been previously reported.
Haemorrhage, probably related to hypervascularisation, is the commonest complication of uterine myomata and is difficult to treat. 16 patients, aged 34-48 years, with symptomatic uterine myomata, for which a major surgical procedure was planned after failure of medical treatment, were treated by selective free-flow arterial embolisation of the myomata with Ivalon particles. With a mean follow-up of 20 months (range 11-48) in the responders, symptoms resolved in 11 patients; menstrual cycles returned to normal in ten of these. Three patients had partial improvement. Two failures required surgery. In 14 cases embolisation caused pelvic pain, which required analgesia in all.
Intrauterine infusion of saline solution during transvaginal ultrasonography enhances visualization of the endometrium. We compared the accuracy and pain rating of saline infusion sonography with those of flexible office hysteroscopy.
The uterine cavities of 130 patients with abnormal bleeding were evaluated by two physicians in an office setting. Findings of endometrial polyps, submucous myomas, synechiae, endometrial hyperplasia, or cancer were recorded independently and subsequently compared. Patients rated their pain after each procedure.
Both procedures were performed in 113 of 130 patients. With saline infusion sonography pathologic findings were identified in 61 patients (54%). For all findings combined, sensitivity was 0.96 and specificity was 0.88, compared with hysteroscopy. The results of saline infusion sonography and hysteroscopy did not differ significantly (p = 0.18). The former was less painful for patients than hysteroscopy (p < 0.0001).
Saline infusion sonography is an accurate and well-tolerated method to evaluate abnormal uterine bleeding, compared with hysteroscopy.
To determine the long-term effects of uterine embolotherapy with gelatin sponge pledgets on menses and fertility.
Between June 1990 and December 1995, 17 women (aged 20-44 years) with obstetric hemorrhage underwent selective gelatin sponge pledget embolization of uterine vessels. Gynecologic information in the 12 women who did not undergo hysterectomy was obtained by means of direct communication or from the patients' physicians.
In 11 (92%) of the 12 women, normal menses resumed within 2-5 months of the procedure. There were no complications related to embolotherapy. The follow-up period was 1-6 years. All three patients who desired to conceive had full-term, healthy newborns. The only patient who is amenorrheic is currently receiving medroxyprogesterone acetate; her ultimate menstrual and fertility status cannot yet be determined.
Selective embolization of the uterine vessels with gelatin sponge pledgets is a safe and effective method of managing pregnancy-related hemorrhage. Our results suggest that women who undergo this procedure can expect to have a return of normal menses with no adverse effect on fertility.
To determine the effectiveness of uterine arterial embolization as a primary therapy in the management of symptomatic leiomyomas.
Uterine arterial embolization was performed in 53 patients (age range, 33-58 years) with menorrhagia, bulk-related symptoms (frequency of urination, sensation of pressure, sensation of mass), or both, due to leiomyomas. The effectiveness of this therapy in the control of symptoms and the patients' acceptance of the treatment were measured by means of the information from patient interviews 3 months after the procedure.
Fifty-two (98%) of the 53 patients had technically successful procedures and were interviewed 3 months after embolization. Forty-six (88%) of these patients reported marked improvement in their abnormal bleeding. Twenty-nine (94%) of the 31 patients with bulk-related symptoms reported marked improvement in these symptoms. Follow-up ultrasonographic examinations showed a mean 46% reduction in uterine volume. Forty-one patients interviewed (79%) would choose this procedure again, eight (15%) would consider choosing this procedure again, and only three (6%) would choose another treatment option.
Uterine arterial embolization is an effective therapy in the management of symptomatic leiomyomas and may prove to be a valuable alternative to myomectomy, hysterectomy, or other surgical procedures. Further investigation is warranted.
Uterine artery embolisation is a new technique for the treatment of uterine fibroids. We report a death after this procedure.
Objective:
To treat uterine myomas with embolization, to look for pregnancy-induced myoma recurrences, and to assess pregnancy course and outcome after embolization.
Design:
Observational clinical study.
Setting:
University of Paris VII hospital.
Patient(s):
Nine women had embolization for symptomatic myoma, with 12 pregnancies observed.
Intervention(s):
Embolizations were highly selective and performed bilaterally through the uterine arteries with polyvinyl alcohol.
Main outcome measure(s):
Pregnant women were evaluated by physical and sonographic examinations.
Result(s):
Before embolization, the mean uterine volume was 450 cm(3), and in six patients polymyomas were present. The median age at embolization was 40 years; the median delay before pregnancy was 9 months; and the median age at first pregnancy outcome was 41 years. Five early miscarriages occurred. The seven other pregnancies were uneventful, although three premature births and one case of late toxemia occurred unrelated to previous embolization. Three women delivered vaginally and four by cesarean section. Neither myoma recurrence nor abnormality in uterine function was observed.
Conclusion(s):
The results of this first series of 12 pregnancies after myoma embolization are promising. If these preliminary results are confirmed, embolization could be a major breakthrough in the management of myoma and could replace conventional medical and surgical treatments.
To report a case of transient ovarian failure shortly after arterial embolization for treatment of uterine fibroids, followed by recovery of ovarian function.
Case report.
A university-based hospital.
A 49-year-old woman with menorrhagia and anemia secondary to uterine fibroids and refractory to medical management. The follicle-stimulating hormone (FSH) level on cycle day 3 before the procedure was 8.2 mIU/mL.
Bilateral uterine artery embolization for treatment of menorrhagia.
Serum FSH level.
The patient developed amenorrhea and hot flashes 3 months after uterine artery embolization. Her serum FSH level at that time was 140.1 mIU/mL. Four months later, uterine bleeding resumed; her serum FSH level was 2.1 mIU/mL.
Uterine artery embolization may hasten ovarian failure. This procedure should be reserved for women who have completed their child-bearing or are poor candidates for myomectomy. Patients should be counseled appropriately about the risk of possible ovarian failure.
Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.
Transient ovarian failure
- Amato
Application of particulate arterial embolization in the treatment of uterine fibromyomata
- Ravina
Uterine arterial embolization for the management of leiomyomas
- Worthington-Kirsch
Obstetric embolotherapy
- Stancato-Pasik