V. Uterine fibroid embolization: management of complications

Uterine Artery Embolization for Symptomatic Myomata

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.

Fertility after bilateral uterine artery embolization in a sheep model

OBJECTIVE

To evaluate the impact of bilateral uterine artery embolization (UAE) upon fertility in sheep.

DESIGN

Prospective study.

SETTING

University-based interventional radiology, pathology, and reproductive physiology units.

ANIMAL(S)

Nineteen control ewes, 10 ewes embolized with polyvinyl alcohol particles (PVA group), and 10 ewes embolized with Tris-acryl gelatin microspheres (TGMS group).

INTERVENTION(S)

Bilateral UAE was performed with 600- to 1,000-mum PVA particles or 700- to 900-mum TGMS particles. Animals of three groups were synchronized and naturally inseminated.

MAIN OUTCOME MEASURE(S)

For each ewe, a hormonal follow-up was performed throughout the gestation. Gestation duration, number and weight of newborns, and fertility and gestation rates were recorded.

RESULT(S)

Mean number of estrus before insemination and gestation duration were not different between groups. There were 47 living newborns: 26 control, 9 PVA, and 12 TGMS. Overall birth weight of newborns was 3.7 +/- 0.9 kg for controls, 3.6 +/- 1.1 kg for TGMS, and 2.2 +/- 0.7 kg for PVA (which was statistically significant vs. control). In the PVA group, there was a statistically significant decrease of fertility rate and gestation rate vs. controls, but this was not the case in the TGMS group.

CONCLUSION(S)

Particles of PVA decrease fertility in sheep and lead to intrauterine growth retardation.

[Follow-up in uterine fibroid embolization]

Follow-up controls in patients after uterine fibroid embolization (UFE) should monitor clinical improvement of symptoms, document shrinkage of the fibroids, exclude malignancies and detect and treat potential complications of the intervention.A close cooperation with the referring gynecologist, sufficiently and carefully informing the patient about the routine follow-up procedure, potential complications and their clinical signs are necessary to fulfill this goal.Imaging is usually based on ultrasound imaging but may be supplemented by MRI. There are different complications in the early phase after UFE and in the later postembolization phase.

Clinical improvement and shrinkage of uterine fibroids after thermal ablation by magnetic resonance-guided focused ultrasound surgery

OBJECTIVE

Hysterectomy or myomectomy are the accepted treatments for symptomatic uterine fibroids. Heat ablation of uterine fibroids has been shown to be an effective alternative treatment. The aim of this study was to determine the clinical efficacy of non-invasive thermal ablation by transcutaneous magnetic resonance-guided high-intensity focused ultrasound (MRgFUS) for the treatment of symptomatic uterine fibroids.

METHODS

In this prospective study, MRgFUS ablation of uterine fibroids was performed in 35 symptomatic women scheduled for hysterectomy. Clinical symptoms, patient satisfaction and uterine size were determined at 1 month and 6 months after the procedure.

RESULTS

This outpatient procedure was very well tolerated by all women. Sixty-nine percent (24/35) of the treated patients reported either significant or partial improvement in symptoms. Treated fibroids decreased in volume by 12% and 15% at 1 and 6 months, respectively. Minor transient side-effects were observed in two women. Six women underwent hysterectomy during the follow-up period.

CONCLUSION

This study demonstrates the clinical efficacy of MRgFUS ablation of uterine fibroids. This novel, non-invasive surgical approach may offer an alternative therapy for women with uterine fibroids.

Predictive value of magnetic resonance imaging signal and contrast-enhancement characteristics on post-embolization volume reduction of uterine fibroids

PURPOSE

To assess the magnetic resonance imaging (MRI) signal and contrast-enhancement features of uterine fibroids before and after embolization, and to determine whether or not there are pre-embolization MRI characteristics that predict the volume reduction of fibroids.

MATERIAL AND METHODS

Uterine fibroid embolization (UFE) was carried out in 28 fibroids of 20 patients, all of whom were symptomatic. The patients were prospectively evaluated with T1-weighted, T2-weighted, and gadolinium-enhanced T1 MRI sequences before and 6 months after embolization. The relationship between the characteristics of MRI signal and contrast-enhancement features of fibroids before the procedure and the change in size of the lesions after treatment was investigated.

RESULTS

Before embolization, the mean volume of fibroids was 123 cm3 (8-560 cm3). The decrease rate in fibroid volumes was 44.6% (range 7-70%) 6 months after embolization. Volume reduction was more prominent in fibroids that had a high signal intensity on T2-weighted images and a marked contrast enhancement on T1-weighted images (P < 0.001). However, the volume reduction was insufficient in fibroids with high signal characteristics on pre-contrast T1-weighted images (P < 0.001).

CONCLUSION

MRI is an effective method for revealing size and signal changes of fibroids after embolization. MRI signal characteristics and the contrast-enhancement pattern of fibroids before embolization can predict tumor volume reduction after embolization.

Effectiveness of intra-arterial anesthesia for uterine fibroid embolization using dilute lidocaine

A modified protocol of uterine fibroid embolization (UFE) is proposed for alleviating the postinterventional pain. This randomized and double-blinded clinical trial is to evaluate the effectiveness of intra-arterial infusion of dilute lidocaine for postinterventional pain relief in UFE. Forty-six patients who underwent UFE were randomly grouped equally. In the test group, after the poly(vinyl alcohol) embolization was complete, a dilute lidocaine solution with 40 mg in 6.0 ml, 3.0 ml for each side or 4.0 and 2.0 ml for two sides, was given through the catheter. In the control group, the patients received 6.0 ml of saline solution as a placebo. A simple pain degree classification method for patient self-evaluation was developed. A questionnaire was completed by each patient to record the degree of pain during five periods; these were during the procedure, the first 12 h, the second 12 h, between 24 and 48 h, and between 48 and 72 h. The numbers of patients with the same degree of pain in the five time segments from the two groups were statistically compared. Compared with the control group, the patients in the test group experienced less pain within 48 h after the procedure (p<0.01). The results suggest that this improved UFE protocol is a simple approach to prevent the acute postinterventional pain of UFE.

Ovarian Function after Uterine Artery Embolization and Hysterectomy

STUDY OBJECTIVE

To evaluate the effect of uterine artery embolization (UAE) and hysterectomy on ovarian function.

DESIGN

Prospective case control study (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Eighty-four healthy premenopausal women with symptomatic uterine myoma(s) undergoing UAE or hysterectomy.

INTERVENTION

Patients had blood drawn to measure follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels and underwent transvaginal ultrasound to measure volume of the myoma(s) and uterus on cycle day 3 before the procedures. These measurements were repeated 3 and 6 months after treatment.

MEASUREMENTS AND MAIN RESULTS

The main outcome was the differences in serum FSH, LH, E2, and ultrasound findings before and after UAE or hysterectomy. Of the 68 patients who underwent UAE and 16 who underwent hysterectomy, 48 and 13 respectively, completed 6-month follow-up. The mean age of the patients in the UAE group was 44.9 +/- 3.8 years and 43.7 +/- 5.6 years in the hysterectomy group. There was no significant difference in serum FSH before (8.9 +/- 0.7 IU/L) and 6 months after UAE (9.9 +/- 1.0 lU/L), and between the baseline (10.4 +/- 1.8 lU/L) and 6 months posthysterectomy (7.8 +/- 1.8 lU/L). The uterine volume 6 months after UAE (361 +/- 50 mL) was significantly smaller than before UAE(538 +/- 38mL; p =.005, 95% CI 44-241). Compared with baseline (154 +/- 20 mL), the dominant myoma volume was smaller at 6 months after UAE (97 +/- 16 mL; p <.05, 95% CI 1.57-62).

CONCLUSION

Uterine artery embolization is associated with a significant reduction in myoma and uterine volume. Ovarian function at 6 months, as indicated by day 3 FSH levels, is not affected by UAE or hysterectomy.

Ovarian Protection by Occlusion of Uteroovarian Collateral Vessels before Uterine Fibroid Embolization

In an attempt to decrease the incidence of premature ovarian failure, three patients with prominent ovarian collateral vessels from the uterine artery (UA) underwent collateral vessel embolization before uterine fibroid embolization. UA anatomy and collateral pathways are reviewed.