Pre-myomectomy uterine artery embolisation minimises operative blood loss
Dr I. Manyonda, Department of Obstetrics and Gynaecology, St George's Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK.
Women with massive fibroids (extending beyond the level of the umbilicus) are conventionally offered a hysterectomy, rather than myomectomy, which is considered too technically challenging, with risks of excessive haemorrhage. Some women desire fertility, or may simply wish to preserve their uterus. Uterine artery embolisation is a relatively new treatment for fibroids, and complication rates are thought to be high with massive fibroids. We have performed uterine artery embolisation immediately prior to myomectomy, and found a reduction in blood loss. Uterine artery embolisation may be a useful adjunct to surgery in women with massive fibroids or for whom uterine artery embolisation alone is considered inadequate primary treatment, those with previous myomectomy where surgery might be complicated by extensive adhesions, in Jehovah's Witnesses and in other women who refuse blood transfusion.
Uterine fibroids are the most common tumour in women of reproductive years.1 They were the most common indication for hysterectomy in England in 1998/1999,2 costing the NHS in excess of £70m per year. Fibroids therefore have a major health and cost implication. Myomectomy preserves the uterus, but the risk of intra-operative haemorrhage and technical challenges associated with massive and/or multiple fibroids often result in women being offered a hysterectomy instead. Patients undergoing myomectomy are required to sign consent for hysterectomy, causing considerable consternation and anxiety for the woman wishing to preserve her uterus. Approaches to minimise blood loss at myomectomy include uterine artery compression with Bonney's clamps or tourniquets, or the use of vasoconstrictor agents, but these techniques are limited by access or short half-life. Transcatheter arterial embolisation could overcome both limitations, affording the surgeon a relatively dry field. Indeed, uterine artery embolisation is now an established, but as yet to be evaluated, treatment for fibroids in its own right.3 We have evaluated its potential role in minimising blood loss during myomectomy.
Patients and results
Between January and December 2001, we selected from our myomectomy waiting list five women with massive (extending to the level of the umbilicus or beyond) and/or multiple fibroids to undergo pre-myomectomy uterine artery embolisation. These were women we considered to be at risk of hysterectomy due to potential excessive operative blood loss. All uterine artery embolisation procedures were performed by the same Interventional Radiologists (A-MB and RM), and all the myomectomies were performed by the same surgeon (ITM). Data from these five women were compared with that obtained from historical controls—14 unselected women who underwent myomectomy by the same surgeon between January 1999 and December 2000. Thus, the women were comparable in so far as the operations were performed within a two-year period by the same surgeon, but those who underwent uterine artery embolisation were selected on the basis of anticipated difficulties with the operation.
No difficulties were encountered in shelling out the fibroids following embolisation, which contrasts with difficulties encountered following GnRH analogue therapy pre-operatively, which induces fibrosis, destroys tissue planes and renders fibroid enucleation difficult.
The number of fibroids in the embolised group ranged from 1 to 7 (median 2) per patient and fibroid volume ranged from 6 to 956 mL (median 605 mL). The corresponding figures in the historical group were 1 to 14 (median 3) and 8 to 1080 mL (median 335.5 mL). Blood loss was estimated by routine swab weighing and measurement of volume loss. Estimated blood loss ranged from 100 to 400 mL (median 100 mL) per patient in the embolised group, compared with 180–2700 mL (median 350 mL) in the historical group (P= 0.026). None of the embolised patients required a blood transfusion, while three women in the non-embolised group were each transfused four, five and six units. The woman in the embolised group with the largest fibroid volume (three fibroids, volume 956 cm3) had a blood loss of 100 mL. The woman with the largest number of fibroids (seven) had a blood loss of 400 mL. In the control group, there were two patients with estimated blood loss of greater than 1000 mL. One had 6 fibroids with individual volumes of up to 110 cm3, while the other had 14 fibroids with a volume range of 225–857 cm3.
Only one out of the five (20%) embolised patients developed post-operative pyrexia, and only this one patient required antibiotics. In the non-embolised group, 8 (57%) developed pyrexia and 5 out of 14 (36%) required antibiotics. Duration of operation and length of hospital stay were similar. Gonadotrophin hormone and oestradiol levels measured at least three months post-operatively were normal in all patients.
Our preliminary experience suggests that pre-myomectomy uterine artery embolisation provides the gynaecological surgeon with a relatively dry field to perform a myomectomy where the fibroids are large and/or multiple, and where the risk of excessive blood loss, and therefore hysterectomy, is considered very high. This suggests that many women who might otherwise be condemned to undergo a hysterectomy can now be offered the chance to retain their uterus. Pre-myomectomy uterine artery embolisation appears to be associated with less incidence of pyrexia, blood transfusion and no negative clinical sequelae compared with historical controls. However, our study was not a prospective randomised comparison, and no firm conclusions could be drawn from a comparison of the two groups.
Although more than 20,000 uterine artery embolisation procedures have now been performed worldwide as the primary treatment for uterine fibroids, uterine artery embolisation has yet to be formally evaluated against conventional therapies. This is especially so for massive fibroids, where post-uterine artery embolisation complications are thought to be higher, and include chronic vaginal discharge, fibroid extrusion and serious infectious complications3 necessitating hysterectomy.4 Most studies report that amenorrhoea complicates 1% of procedures,3 although a more recent study found a higher figure of 7%.5 Clearly, where uterine artery embolisation is performed pre-myomectomy, some of the potential complications are eliminated, although the risk of amenorrhoea would persist. While uterine artery embolisation adds to the cost of a myomectomy, this has to be weighed against the costs of blood transfusion and/or prolonged hospital stay from pyrexia due to haematomas, and of course, the benefits to the woman of being able to have a myomectomy where she might otherwise have been offered a hysterectomy.
Pre-myomectomy uterine artery embolisation reduces operative blood loss and may therefore be a useful adjunct to surgery in a select group of women in whom the risk of hysterectomy is considered to be high. This includes women with massive fibroids or for whom uterine artery embolisation alone is considered inadequate primary treatment, those with previous myomectomy where surgery might be complicated by extensive adhesions, and in Jehovah's Witnesses and other women who refuse blood transfusion. We do not advocate pre-myomectomy uterine artery embolisation for all women undergoing myomectomy, and we recognise that further research utilising randomisation of patients is needed to accurately define the place of pre-myomectomy uterine artery embolisation.
All authors initiated the project and searched, extracted, analysed and participated in discussing the results and writing the article. ITM is the guarantor.