Uterine Fibroid Embolization T a y l o r H a n d l e y - MS IVTexas Tech University School of Medicine
Uterine Leiomyomata (Fibroids)Benign smooth muscle tumors of the uterus Roughly 50% of women afflicted with fibroids by menopausal ageBlack 2x > White/Asian womenMost commonly in 35-49 y/o womenOne-half of women with fibroids have significant symptomsSymptoms include: menometrorrhagia, pelvic pain, pelvic fullness, abdominal distension, urinary urgency, constipation, bowel obstruction, hydronephrosis
Uterine FibroidsBecause fibroids are estrogen-dependent, they usually resolve following menopauseResponsible for over 200,000 hysterectomies annuallyOther current treatment options include myomectomy, electrocautery coagulation (myolysis), hormonal therapy, and UFE
Shortcomings of Current TreatmentCurrent surgical options (hysterectomy, myomectomy, myolysis) all require general anesthesia Associated with significant hospital stays and recovery timesMyomectomy is less invasive but has recurrence rate of 10% per year for 5 years following the procedureHormonal therapy relatively as effective as an adjunctive treatment, but fibroids quickly recur following hormone cessation
Uterine Fibroid Embolization (UFE)Proven to be a very effective alternative for some women with symptomatic uterine fibroidsLess invasive procedure involving:Conscious sedation versus general anesthesiaShorter hospital stays More rapid recovery time, less morbidity/fewer complicationsComparative clinical trials discussed later
History of UFEFibroids (hypervascular benign tumors) were noted to spontaneously infarct and subsequently undergo involution/volume reductionUFE with iatrogenic infarction thought to achieve the same resultSelective embolization of uterine arteries has been used since 1970s for gynecologic malignancies and hemorrhage-control in pelvic traumaRavina et al. first used polyvinyl alcohol (PVA) in UFE reported in 1994 (France) with excellent results
Other Uses of EmbolotherapyControl of abnormal uterine bleeding due to GYN malignancies, ectopic pregnancies, post-partum hemorrhageReduction of tumor vascularity prior to surgical excision (renal cell CA, spinal tumors)Palliative treatment of end-stage CA patients (e.g. abdominal pain from inoperable liver tumors, etc.)
Types of Fibroids
Massive pedunculated submucosal fibroid (gross specimen following hysterectomy)
Submucosal FibroidsAssoc. with heavy and prolonged menstrual periods, freq. miscarriagesMay prolapse into the cervixIntramural FibroidsAssociated with mass-related sxs such as abdominal distention or urinary frequency (bladder compression)Subserosal FibroidsFrequently pedunculatedMay grow into the uterine ligamentsFrequent mass sxs
Presenting Fibroid SymptomsAbnormal uterine bleedingEspecially true of submucosal fibroids just deep to endometriumPelvic painFrom intramural degeneration or torsion of intramural fibroidPelvic pressureAbdominal distensionGenitourinary dysfunctionUrinary frequency due to bladder compressionHydronephrosis due to ureteral obstructionInfertilityPedal edema, constipation, intestinal obstruction
Pre-procedure EvaluationEssential to have a thorough gynecologic evaluation, must rule out endometrial hyperplasia and malignancyPap smear within 6 months of procedure Endometrial biopsy (in pts presenting with menorrhagia) within 12 monthsSerum B-hCG to rule out pregnancyCurrent Ultrasound or MRI to document size/location of fibroid/sIf pt on hormonal therapy (GnRH agonist), must withhold agent for 12 weeks prior to procedure
The Ideal Patient for UFEPre-menopausal pt not desiring fertility Post-menopausal pt with failure of spontaneous regressionPt has failed medical managementFibroid is of moderate size (3-7cm)Absolute contraindication to surgery (including pt preference)
Poor Candidates for UFEPt with minimal sxs, or sxs easily controlled w/ medical mgmtPt desires fertility, amenable to myomectomyPrimary complaint of spontaneous ABIsolated pedunculated submucosal fibroidPt requires other pelvic surgery
ContraindicationsAbsolutePregnancyKnown/suspected pelvic infection or bacteremiaRelativeCoagulopathy, renal failure, contrast allergyPeripheral vascular occlusive diseasePt currently on hormonal therapy (e.g. Lupron)
Imaging of FibroidsUltrasound Effective at excluding other uterine pathology, documentation of size/locationResults dependent on pts body habitus, operator skillMRIPreferred imaging modalityExcellent documentation of exact size, location, and internal characteristics of fibroidMizukami et al. report possible prognostic significance of T2-weighted images: better outcome in pts whose fibroids have intermediate/high signal intensityBest method of excluding adenomyosisExcellent in documenting volume reduction after embolizationFibroids usually show decreased signal intensity in T1 and T2 images after embolization
Axial T1-weighted image
Describe the type and location of the fibroidSagittal T2-weighted MRI
3cm Intramural Fibroid in the Posterior, Lower Uterine Segment
45 y/o female with abdominal distention : Incidentally-found calcified uterine fibroid
UFE : Procedural BasicsConscious sedation is used +/- Foley catheter, prophylactic Abx (Cefazolin 1 gm IV)Femoral artery accessed with 4-5 Fr catheterFlush catheter advanced to abdominal aorta and pelvic angiogram performed. Important to identify not only the uterine arteries, but also other collateral supplies to the myomatous uterus (e.g. ovarian aa., lumbar aa.)
PelvicArteriogram 1345678229101112Identify theseArteries!
PelvicArteriogram 13456782291011121- Abdominal Aorta2- Lumbar aa.3- R Common Iliac A.4- LCIA5- R Ext Iliac Art6- R Int Iliac Art (Hypogastric)7- LIIA8- LEIA9- Anterior Division, L Hypogastric A.10 Posterior Division L Hypogastric A.11- Iliolumbar A.12- Superior Gluteal A13- Median Sacral A
The uterine arteries are identified and selectively catheterized
The R. Uterine Artery arising from the anterior division of the Int.Iliac Artery. Its terminal branches, the spiral arteries, appear dilated, tortuous, and laterally displaced in the presence of fibroids.121- Catheter tip positioned in Ant. Div. of R Hypogastric A.2- Origin of R. Uterine A.
Selective Injection of Uterine ArteriesNote the uterine artery supplying the hypervascular benign tumor
5) An embolic agent (PVA or Embospheres) of appropriate diameter is injected into the uterine arteries to induce thrombosis. Bilateral embolization of uterine arteries is essential.
6) Embolization should be continued until there is sluggish flow in the uterine artery with elimination of the fibroid blush
7) Post-embolization pelvic angiography should be performed to document arterial occlusionPre-embolizationPost - embolization
The Post-Embolization SyndromeAffects most patients and lasts 2-7 days after procedurePelvic pain / cramping (usually peaks at 12-24 hrs post-embo)Nausea/vomitingLow-grade feverGeneral malaise
Post-Embolization ManagementHave PCA pump available immediately following procedure for pain controlMost facilities admit pt for one night for pain controlOutpatient protocols involve:Opioid analgesics (Oxycodone 10-20mg q12 hr)NSAIDs (Celebrex 100mg q12 hr x 7 days, followed by Ibuprofen)Antinausea medication (prochlorperazine)
Patient FollowupPatient should follow-up with PCP within 1 monthFollow-up imaging should occur at 3, 6, and 12 months after the procedure to document results
Potential ComplicationsPremature menopause 2-5%Expulsion of fibroid < 2%Sepsis < 1%Emergent hysterectomy < 1%Death < 1%
Clinical Results of UFESpies et al. (2001) followed 200 UFE pts with written questionnaires and follow-up imagingImproved bleeding sxs in 90% of pts at 12 monthsAlso significant improvement in mass sxs, and patient satisfactionThe stability of symptom improvement did not change over the follow-up time of 2 yearsMean fibroid volume reduction of 44% over 3 months and 58% over 12 monthsSpies et al. 2001. Uterine artery embolization for leiomyomata. Obstetrics & Gynecology. 98(1):29-34.
Al-Fozan et al. (2002) compared inpatient hospital costs for 545 women with uterine fibroids treated with either myomectomy, total abdominal hysterectomy, vaginal hysterectomy or UFEUFE assoc with the shortest hospital stayIn-hospital cost of UFE was the leastUFE cost $1,007 (Canadian)Vaginal hysterectomy cost $1,515Abdominal myomectomy $1,781Abdominal hysterectomy $1,933
Al-Fozan et al. 2002. Cost analysis of myomectomy, hysterectomy, and uterine artery embolization. American Journal of Obstetrics and Gynecology. 187(5):1401-1404.
Spies et al. (2002) analyzed baseline variables of 200 pts to determine if they influenced clinical success of UFESmaller baseline leiomyoma size and submucosal location are more likely to result in a positive imaging outcomeThere are limited associations b/w other baseline variables and symptom change or imaging outcomeSpies et al. 2002. Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome. Radiology. 222:45-52.
Smith et al. (2004) studied 64 women to evaluate changes in fibroid-specific symptom severity and health-related quality of life after UFE.Questionnaires given to women undergoing UFE mean of 32 months after procedureSymptom severity scores decreased by a mean of 32%HRQOL scores inc