The future of percutaneous Uterine fibroid embolisationThe Mater HospitalMultifaculty/ multidisciplinary professional development20th march 2015Breakfast lectureBy Dr. Henry Wanga Interventional Radiologist

Who gets fibroids?Incidence increase with age 20% of women in their 20’s 40% of women in their 40’s 50% at autopsyGenetic predispositionAfrican-American women 3 to 9 timesRisk of sarcoma is 0.04% to 0.13%

Introduction Hysterectomy is one of the most common operation done in

the developed worldIn USA, it is second only to caesarian section in women in

the reproductive age groupRoy Gordon in UCSF in 2OO7 stated that more than one

third of US women will have undergone hysterectomy at the age of 60 years

Anatomy of fibroidsSubserosal- grow outwards, possibly pedunculated,

differential diagnosis, gives pressure rather than bleedingIntramural – most common ; gives rise to bleeding, pressure

symptomsSub mucosal fibroids- are the least common, may cause

bleeding and if pedunculated they lead to extrusion

MRI imaging of the uterus showing Myoma MRI scanogram axial setting

MRI Female pelvisCoronal view ,left Sagittal view ,right

Are we ready?Raise the flag of UAE now!

Pelvic embolisation in Obstetrics and GynecologyPost partum/caesarian section –birth canal laceration,

placenta, retained products atony or ruptureEctopicPost surgicalCancerArterio-venous malformation

Indications Heavy bleedingPain and pressure on back/abdomenUrinary frequency and or obstructionConstipationDysparauniaBody habitusInfertilityRecurrent pregnancy loss

American College of Obstetrics and Gynecology(ACOG) Criteria for Hysterectomy

1. asymptomatic leiomyoma >12 weeks/ patient concernsProfuse bleeding with clots. flooding> 8days , anemiaPelvic discomfortDistended abdomenBack painsBladder symptoms

Patient selectionPatient preference; UFEUterus-sparingRapid recoveryAversion to surgery

Patient selectionConsider alternate procedurePatients with – small pedunculated fibroids with narrow attachment; may

slough into endo cavityPedunculated serosal fibroids >10cm, particularly with narrow

attachmentAre easily removed at myomectomyShrink more slowly post-UFEMay detachProne to adhesionsUterus greater than 24 weeksReproductive ambitions/ this position has since changed.

fibroidMultiple mural and subserosal fibroid

MRI; fibroidPosterior fibroid pressing on bladder

Bulky uterusSubmucosal fibroid

What are the absolute contraindications for a Uterine Fibroid Embolisation?Asymptomatic fibroid disease, leiomyosarcoma of the uterus and pregnancy are absolute contraindications and will be worked up as part of the consultation process. Relative contraindications include allergies to iodinated contrast and infection, but these can be premedicated or treated prior to undergoing the procedure.

UFE Clinical outcomesSummary of published results:Improvement in menorrhagia- Mean: 88% -range 79% to 98%Improvement in pain/pressure-mean; 71%-range 64-98% improvedLeiomyoma volume reductionMean 20% at two monthsMean 60% at 12.2 months

Prospective follow up 200 patientsSpies Obs/Gynae Nov 2005 Patients 200Follow up 182(91%)Improved 73% N.B 18were lost to follow upFailed or recurred 36(20%)Hysterectomy 25 (13%)Myomectomy 8(4.4%)Repeat embolisation 3(1.6%)Note 4 hysterectomies were unrelated to UFE3 deaths un related to UFE

UFE-Fertility+PregnancyDo fibroids cause infertilityDoes myomectomy help?Can one conceive after UFEIs outcome normal for age etc?Is fetal growth retarded?

 What are the adverse effects of a Uterine Fibroid Embolisation?Post embolisation syndrome is common in the immediate post procedure period. It is usually managed within the hospital before discharge. Patients will be discharged with a management plan and medications. Post embolisation syndrome is a triad of pelvic pain, low grade fever and nausea and is thought to be due to ischemia/infarction of the fibroids.

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Infection of the infarcted fibroid is the complication that needs to be watched for and the patient adequately informed about. It is uncommon (less than 2%) and the patient will usually get antibiotics during the procedure and for 5-10 days after the procedure. However, the exact mechanism for infection is not clear and it is also unclear whether antibiotics will reduce the risk. Classically it occurs 4-6 weeks post embolisation, in a previously well patient who then develops fever, sweats and/ or pelvic pain. It is important that the patient see the interventional radiologist as soon as possible. Hysterectomy may be required in those patients not responding to other forms of management.The period is often disrupted for a number of cycles post procedure. If the period has not returned after 3 cycles then the concern is one of permanent amenorrhea and consultation to a gynecologist should be performed either through yourself or usually the radiologist.

Recommendations Increase public awareness as to the fact that the service is readily

available at The MaterReady to answer questionsIntroduce once monthly a gynae/counseling/ interventional

radiology joint clinicProvide easy access to the highest standard of uterine fibroid

embolisation, post procedure management and long term follow up

Consumables to be readily availableTrain nursing, imaging and anesthetic assistant teams to motivate,

stimulate and harness desired skills by themCarry out regular users audits

Customer satisfactionJN after years of fighting back frustration, he became fertile

INTRODUCTION TO IR PHILOSOPHY From inability to let well alone, from too much zeal for the

new and contempt for what is old: from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases and from making the cure of the disease more grievous and the endurance thereof, GOOD LORD, DELIVER US!

Sir Robert Hutchinson, BMJ, March12, 1953, p671

ENDTHANK YOU VERY MUCH FOR YOUR LOVE OF THE

ART OF MEDICINETOGETHER WE ACHIEVE MORESTAY ON COURSE, ESPECIALLY IF YOU FEEL

FRUSTRATED AND DISCOURAGEDSWEAT,SWEET, SUCCESS