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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Uterine artery embolisation is a new minimally invasive technique used for the treatment of fibroids. Twenty-one women underwent bilateral uterine artery embolisation at our unit, and we assessed the efficacy, morbidity and patient satisfaction with the procedure. Mixed outcomes were found. Reduction in fibroid volume measured by magnetic resonance imaging was impressive, and the majority of women felt their symptoms had improved. One woman achieved a full term pregnancy following the procedure. However, the procedure involved a significant inpatient stay, analgesia requirement, and a slower recovery time than anticipated. One woman died following overwhelming sepsis occurring 10 days after the procedure. Further studies are required to assess the role this technique may play in the management of uterine fibroids.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Uterine fibroids are common benign tumours of the female reproductive tract and are responsible for heavy periods, pelvic pain, urinary symptoms and infertility1,2. They are the indication for nearly 40% of hysterectomies in white women3, and account for around 65% of hysterectomies in Afro-Caribbean women4. There is a trend towards more conservative treatment for benign uterine disease in an attempt to avoid hysterectomy.

Transcatheter arterial embolisation has been established in the management of pelvic haemorrhage secondary to uterine arteriovascular malformation5, postpartum haemorrhage6,7, ectopic pregnancy8, gestational trophoblastic disease9 and malignancy7. Most recently, uterine artery embolisation has been proposed as a potential alternative to surgery for fibroids10–12. Most reports suggest that it is a well tolerated and effective treatment. Its enthusiasts suggest that duration of inpatient care in hospital, cost and morbidity compare favourably to surgical alternatives.

The aim of our study was to assess fibroid embolisation with respect to morbidity, duration of inpatient care in hospital, analgesia requirement, radiological reduction in fibroid volume and patient satisfaction with outcome, using a validated menorrhagia outcomes questionnaire.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Between June 1997 and January 1999, twenty-one women underwent bilateral uterine artery embolisation for fibroids (see Figs. 1 and 2). The approval of the Chelsea and Westminster Hospital ethical committee was received, and all those who participated in the study did so voluntarily, having given their informed consent. Age ranged between 29–52 years (average 40 years). Two-thirds of the women cited heavy periods as their primary problem related to their fibroids, one-third complained primarily of abdominal distension. Magnetic resonance imaging assessment was made before embolisation, and at two and six months following the embolisation13. The type of analgesia required was recorded, as was duration of inpatient stay. Patients were sent a validated menorrhagia outcomes questionnaire following the procedure (range 3–12 months, mean six months after procedure). Non-responders were sent a further copy of the questionnaire one month later. This questionnaire is a scientifically sound measure of outcome assessed from the woman's point of view. It meets standard psychometric criteria for reliability and validity14.

image

Figure 1. (a) Flush aortogram. The left (small arrows) and right (large arrows) uterine arteries, originating from the internal iliac arteries, are demonstrated prior to embolisation. (b) Selective catheterisation of right uterine artery prior to embolisation. The vessel is tortuous, with an extensive collateral blood supply feeding the underlying fibroid.

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image

Figure 2. Selective catheterisation of right uterine artery (a) pre- and (b) post embolisation. Following embolisation, contrast medium is seen to reflux into the internal iliac artery.

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Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

The mean (range) duration of inpatient care in hospital was 2.9 days (1–6). Twelve women required patient controlled analgesia devices [mean (range) 2.25 days (1–3)]. Two women required emergency epidural analgesia 4–8 hours following the procedure and two had epidurals given electively before the procedure. The mean (range) of epidural anaesthesia was 2.5 days (2–4). One woman died following septic shock and multiple organ failure and is excluded from the numerical analysis. No other infections were reported. One woman was readmitted for opioid analgesia control six weeks after the procedure, due to degeneration of her fibroid. Another woman, who had been admitted originally with an 8 cm fundal fibroid, conceived 11 months following embolisation. Serial growth scans were performed at 26 and 34 weeks and fetal growth was normal. Uterine artery blood flow was also noted to be normal. She was delivered by elective caesarean section at 38 weeks of gestation after an uncomplicated pregnancy.

Table 1 shows the reduction in total fibroid volume two and six months after the procedure. The magnetic resonance imaging appearances pre and post-embolisation are shown in Fig. 3. Fourteen women returned completed questionnaires (Table 2). Those who did not return the questionnaire were sent a repeat questionnaire one month later.

Table 1.  Fibroid volume at embolisation, and two and six months after embolisation. Values are given as median (range)
Fibroid volume (mL)Value
At embolisation310 (140–457)
After 2 months209 (57–288)
After 6 months77 (41–164)
image

Figure 3. Sagittal gadolinium enhanced MRI images taken through the uterus (a) pre and (b) two months post embolisation. Following embolisation the multiple fibroids have reduced in size and are of low signal (non-enhancement).

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Table 2.  Women's symptoms following embolisation. Values are given as n or n (%). NA = not available.
QuestionBetterSameWorseTOTAL
Ability to carry out daily activities6 (43)7 (50)1 (7)14
Sex life2 (18)8 (73)1 (9)11(NA = 3)
Tiredness6 (43)6 (43)2 (14)14
Body image7 (50)7 (50)0 (0)14

Of the 13 women whose primary indication for fibroid embolisation was heavy periods, nine returned questionnaires. Symptoms had improved in eight: six were ‘much better’, and two reported being ‘a little better’; one woman reported that she was ‘a little worse’. Of the seven women whose primary indication for fibroid embolisation was abdominal distension, five returned questionnaires: two noted an improvement in symptoms (one ‘much better’, one ‘a little better’), while two women's symptoms were unchanged, and one woman stated her symptoms to be ‘much worse’.

Seven women said they would definitely recommend the procedure to a friend, two said they would probably recommend it, four were not sure, and one probably would not recommend it.

Recovery was faster than expected in two women, about the same as expected in three women, and slower than expected in seven. Two women had no idea how long it would take.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

In our study we have found that most women who underwent fibroid embolisation were satisfied with their clinical outcome. In general, they felt their symptoms had improved in that they were able to carry out daily activities and had improved body image. These findings are based on those women that returned questionnaires, and we acknowledge that the actual satisfaction may in fact have been lower had questionnaires been obtained from the nonresponders.

Most subjective improvement was noted in women with heavy periods as their primary symptom related to their fibroid. Future studies are needed to provide more objective measures of reduced menstrual blood loss following bilateral uterine artery embolisation.

There were no immediate complications related to the procedure itself. The most common adverse effect following embolisation was pain, making an analgesia protocol essential. The pain is thought to be due to the consequent fibroid necrosis following embolisation and is noted in most accounts of embolisation10–12,15. It has been suggested to be dependent on the size of particles used for embolisation, but this is yet to be shown clinically. In some cases, the ischaemic pain necessitated opioid analgesia for up to four days post embolisation. Initially, this was quite an unexpected phenomenon, with most women being told that they would probably be discharged after two days, and back to resuming normal activity between two to four weeks later. More than half of our patients felt that recovery was slower than they had expected. One woman experienced constant cramping pain following the procedure, such that she had to be readmitted six weeks later for further opioid analgesia.

There are very few reports in the literature of significant infection complicating embolisation10. In our series each woman received parenteral prophylactic broad spectrum antibiotics (cefuroxime and metronidazole) at the time of the procedure. One woman developed a urinary tract infection three days after embolisation and was commenced on antibiotics according to culture sensitivity. She recovered well at home, but was readmitted 10 days following fibroid embolisation with sudden, severe abdominal pain. She was found to have overwhelming sepsis and disseminated intravascular coagulation. She was resuscitated initially, and a total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed eight hours later, revealing an infected uterus containing a large necrotic submucous fibroid. She was admitted to the intensive therapy unit, and died 15 days later from a massive haemothorax complicating multi-organ failure16. To date, around 1500 cases have been performed (W. J. Walker, Royal Surrey Hospital, personal communication). Submucous fibroids have been suggested to be more susceptible to infection following the procedure, although no mechanism is postulated and, furthermore, many fibroids contain a submucous element.

More recently, details from another unit have emerged, reporting a further death following uterine artery embolisation (P. Vercellini, Istituto Ostetrico e Ginecologico ‘Luigi Mangiagalli’, Milan, Italy, personal communication). The procedure itself was uneventful, but pulmonary embolism developed twenty hours after the procedure, with increasing dyspnoea, syncope, hypotension, and cardiac arrest. At autopsy, massive pulmonary embolism originating from a pelvic vein thrombosis was identified as the cause of death.

Another concern regarding uterine artery embolisation is the effect it may have on subsequent blood supply to the ovaries and uterus. The effects on subsequent fertility are unclear. There are reports of possible premature ovarian failure11, but there are little long term data available. The abundant pelvic collateral circulation seems to be able to retain functional support to the uterus and indeed in our series, one woman successfully became pregnant nine months after the procedure.

Many women are searching for newer minimally invasive techniques for uterine fibroids. The media plays a significant role in educating women about such treatment modalities and influences clinical practice17, but there is a continual need to evaluate rigorously all new techniques.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Uterine artery embolisation appears to provide successful treatment some women suffering from uterine fibroids. However, it is associated with an appreciable inpatient stay, considerable analgesic requirements, longer recovery period than many patients realise, and potentially fatal complications. Further studies are required to identify which patients will benefit most from this technique, and to evaluate whether uterine artery embolisation does become a useful adjunct to the well established surgical treatments in the management of fibroids.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References