Bruce McLucas

UTERINE ARTERY EMBOLIZATION FOR THE TREATMENT OF UTERINE LEIOMYOMATA MIDTERM RESULTS

INTRODUCTION The authors review their midterm experience with uterine artery embolization for the treatment of uterine fibroids. MATERIALS AND METHODS Sixty patients were referred for permanent polyvinyl alcohol (PVA) foam particle uterine artery embolization during an 18-month period. Detailed clinical follow-up and ultrasound follow-up were obtained. RESULTS Bleeding was a presenting symptom in 56 patients and pain was a presenting symptom in 47 patients. All patients underwent a technically successful embolization. One of the patients underwent unilateral embolization. Fifty-nine patients underwent bilateral embolization. Of all patients undergoing bilateral embolization, at last follow-up (mean, 16.3 months), 81% had their uterus and had moderate or better improvement in their symptoms. Ninety-two percent of these patients also had reductions in uterine and dominant fibroid volumes. Overall, the mean uterine and dominant fibroid volume reduction were 42.8% and 48.8%, respectively (mean follow-up, 10.2 months). One infectious complication that necessitated hysterectomy occurred. CONCLUSION Uterine artery embolization for the treatment of uterine fibroids is a minimally invasive technique with low complication rates and very good clinical efficacy.

Uterine artery embolization: An underused method of controlling pelvic hemorrhage

Transcatheter arterial embolization has recently emerged as a highly effective percutaneous technique for controlling acute and chronic genital bleeding in a wide variety of obstetric and gynecologic disorders. Benefits for the patient and health care system have included low complication rates, avoidance of surgical risks, fertility preservation, and shorter hospitalizations. In this article the current indications for pelvic embolotherapy, types of embolotherapy, technical considerations, immediate success rates, causes of failure, complications, and outcome expectations are discussed. Our comprehensive literature review and clinical experience suggest that embolization should be used before surgical treatment of nonmalignant pelvic bleeding in many clinical settings, including postpartum, postcesarean, and postoperative bleeding. It is our strong belief that this form of therapy is underused, and the primary purpose of this article is to emphasize its developing role as a highly effective, relatively noninvasive method of treating genital bleeding.

Preliminary experience with uterine artery embolization for uterine fibroids

PURPOSE To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for fibroid-related vaginal bleeding and pelvic pain refractory to hormonal therapy and myomectomy. MATERIALS AND METHODS Eleven patients (aged 27-55 years; mean, 44.2 years; none desiring future pregnancy) with refractory vaginal bleeding and/or chronic pelvic pain related to uterine leiomyomata underwent uterine artery embolization with use of polyvinyl alcohol (PVA) particles. Clinical improvement was assessed by detailed questionnaire at 2-9 months (mean, 5.8 months) after the procedure. Sonographic measurements of the uterus and dominant masses were obtained before and at 2 months after the procedure. RESULTS All 11 patients underwent technically successful embolization. Eight of nine women who completed the follow-up questionnaire reported noticeable symptomatic improvement, including three women with complete resolution of symptoms. One woman (the only patient undergoing unilateral embolization) exhibited no clinical response. Another patient developed endometritis and pyometra 3 weeks after the procedure, necessitating hysterectomy. Large reductions in uterine volume (average, 40%) and dominant fibroid size (average, 60%-65%) were sonographically demonstrated. CONCLUSION Uterine artery embolization represents a promising new method of treating fibroid-related menorrhagia and pelvic pain. Further investigation will be required to assess clinical response and durability, identify appropriate candidates, and define the optimal angiographic technique and PVA particle size.

Uterine fibroid embolization: nonsurgical treatment for symptomatic fibroids

BACKGROUND Earlier studies demonstrated the efficacy of uterine fibroid embolization (UFE). We seek to demonstrate the success of the procedure in a community hospital setting, and we attempt to identify patients likely not to benefit from embolization, if possible, before the procedure. STUDY DESIGN The study followed all women treated with UFE for menorrhagia or postmenopausal bleeding at a community hospital between 1997 and 1999. Relief of symptoms, ultrasound changes, and complications were documented. Six months after the procedure, analysis was performed on ultrasound and interview data from patients who underwent UFE. A smaller number of patients has been followed for 12 months and were available for the analysis. We examined characteristics of patients and procedures performed in an attempt to identify likely failures of treatment. We calculated complication and failure rates based on the entire group of patients. RESULTS From 183 patients who applied for UFE, 16 were excluded because ofpathologic conditions found during preembolization evaluation; 167 women had an embolization, 163 were successfully embolized bilaterally, and 4 were embolized unilaterally because of technical failure. Eighty-eight percent of the patients (147 of 167 patients) reported an improvement or stabilization of symptoms 6 months after UFE. Forty-six patients followed for 12 months experienced myoma shrinkage of 37% (a significant shrinkage over 6 months, p < 0.001), and total uterine volume decreased 52%. Analysis of shrinkage data revealed no demographic or procedure variable associated with shrinkage. Six patients underwent hysterectomy (3.5%) after embolization, one as a result of postprocedure infection. Pain in the first 24 hours postprocedure affected almost all patients. Five percent of the patients passed submucous myomata after UFE; all these patients at risk were identified at preembolization hysteroscopy. Four patients experienced premature menopause after embolization early in the study. There were three criteria for failure, of which a patient had to meet only one: hysterectomy, < 10% shrinkage ofmyoma 6 months after UFE, or worsening symptoms after UFE. No variables of age or size of the uterus could be shown to predict failure. Patients who had undergone earlier pelvic surgery were more likely to fail UFE (p = 0.012). CONCLUSIONS Uterine fibroid embolization, an alternative treatment for myomas, offering low morbidity, can be performed in a community hospital setting. Eighty-eight percent of patients reported improvement or stabilization of symptoms. Total uterine volume decreased an average of 49% at 6 months after embolization. Shrinkage was unaffected by the size of the uterus, myoma, or patient characteristic before UFE. Longterm followup study reveals a significant continuing shrinkage of total uterine volume and myomata at 12 months. There has been no regrowth of fibroids. Earlier surgery was a factor predicting failure of UFE in our series. The risks to future fertility were small.

Pregnancy following uterine fibroid embolization

Objective: This paper seeks to evaluate the ability to deliver term pregnancies following uterine fibroid embolization, and to identify impediments to pregnancy in the embolization procedure. Study design: Four physicians performed embolization procedures at various facilities. Patients were asked if fertility was an issue prior to embolization. We measured follicle‐stimulating hormone levels before and after embolization. Clinical follow‐up, six months following embolization was obtained by interview. Patients were questioned regarding attempts to conceive, menstrual history, and subsequent pregnancy. Main outcome measures: Complications were calculated upon the entire patient population, whether or not fertility was identified as a goal. Fertility risks from embolization were identified. We measured radiation exposure in a random consecutive group of 50 women undergoing embolization. All patients who conceived were asked the details of the pregnancy. Results: Four hundred women underwent uterine fibroid embolization between 1996 and 1999. One hundred and thirty nine patients stated a desire for fertility after embolization. Of these, 52 were <40 years old. Seventeen pregnancies have been reported in 14 women. Five spontaneous abortions were observed. Ten women have had normal term deliveries and two women are currently pregnant. No perfusion problems, either during the pregnancy or labor, were reported. The average radiation dosage calculated for 50 women undergoing embolization was 14 rads. Four women under 45 years old suffered premature menopause (10/1000). Two women underwent hysterectomy as a complication of embolization (5/1000). Conclusion: The risks of infertility following embolization, premature menopause, and hysterectomy are small, as is the radiation exposure during embolization. These risks compare favorably with those associated with myomectomy. Fertility rates appear similar to patients undergoing myomectomy. No problems, either during pregnancy or delivery, have been observed after embolization. The course of pregnancy and delivery was normal after embolization with no maternal or fetal complications reported. These findings confirm results from other centers. Desire for future pregnancy is not a contraindication to fibroid embolization.

Diagnosis, imaging and anatomical classification of uterine fibroids

Uterine leiomyomata, commonly referred to as fibroids, are often accompanied by symptoms common to many other pelvic conditions. The correct identification of myomata and the exclusion of other diseases, especially malignancies, are imperative when evaluating therapy options. A confident diagnosis of myomata may be aided by several imaging modalities. The selection of an imaging technique should include an evaluation of both the benefits and the costs associated with the procedure. Imaging can provide information regarding precise myomata location, which may, in turn, dictate treatment options. Myomata may be classified based upon position within the uterus, and may be further described by phase of degeneration. With the increasing popularity of uterine-conserving therapy, accurate diagnosis of myomata becomes even more important.

Role of uterine artery Doppler flow in fibroid embolization.

Objective. To determine whether Doppler flow measurements are useful in predicting variables associated with uterine fibroid embolization, including shrinkage of the uterus and myomas, adenomyosis, and uterine fibroid embolization failure. Methods. A group of 227 patients with menorrhagia or postmenopausal bleeding secondary to uterine myomas were evaluated with uterine artery Doppler flow sonography before uterine fibroid embolization. Doppler flow measurements were repeated 6 months after uterine fibroid embolization for 188 of the patients. Data were analyzed for correlations between peak systolic velocity and uterine fibroid embolization patient data, including size and shrinkage of the uterus and myomas, embolization particle size, adenomyosis, and uterine fibroid embolization failure. Results. Initial peak systolic velocity was positively correlated with the size and shrinkage of myomas and uterine volume. Peak systolic velocity was positively correlated with the size and load of embolization particles and was significantly lower (mean, 33.2 cm/s) in patients with adenomyosis than those without adenomyosis (mean, 39.3 cm/s). High peak systolic velocity (>64 cm/s) was a significant predictor of failure. Postembolization peak systolic velocity (mean, 21.85 cm/s) was significantly lower than preembolization peak systolic velocity (mean, 40.33 cm/s) and was not correlated with uterine fibroid embolization variables. Conclusions. Doppler flow measurements can aid in predicting adenomyosis and uterine fibroid embolization failure. Postembolization peak systolic velocity did not show value.

Uterine fibroid embolization compared with myomectomy

Ž . Uterine fibroid embolization UFE was first described in 1995 as a less morbid alternative to myomectomy for the treatment of myoma 1 . Myomectomy is known to have significant rates of morbidity due to transfusion, infection, and other surgical complications 2 . To the best of our knowledge, no study has compared the hospital course for patients undergoing these procedures during the same time period. All patients who underwent either elective myomectomy or uterine artery embolization for the treatment of symptomatic myomata in 1999, were studied at a community hospital. Retrospective chart analysis was performed. Notice was taken of any type of morbidity. Sixteen patients were admitted for elective myŽ . omectomy during 1999 see Table 1 . Different

Predictive factors for success in uterine fibroid embolisation

SummaryA search of patient and procedural variables is performed to better understand the 10% failure rate of uterine fibroid embolisation (UFE) and what factors may contribute to decreased success in UFE Statistical analysis of demographic and procedural factors associated with UFE was performed at two separate centres 300 women were treated in approximately equal numbers for menorrhagia or post-menopausal bleeding at two Los Angeles hospitals, a university centre and a community hospital We did a comparison of success and failure groups by all demographic and procedural variables recorded Both groups were statistically analysed No demographic factors were predictive of success for UFE Both centres had similar success rates The pre-procedural total uterine volume was not associated with failure However, pre-procedural diameter of the largest fibroid >8 5 cm was predicative of failure.

Pregnancy following uterine artery embolization: An update

Abstract Objective: This paper seeks to evaluate the ability to conceive and deliver term pregnancies following uterine artery embolization. Methods: We conducted a retrospective chart review of patients under the age of 40 who indicated a desire for fertility prior to embolization. Patients were questioned regarding attempts to conceive, subsequent pregnancies, and outcomes of those pregnancies. Patients who identified fertility as a desired outcome were studied. All patients who conceived were asked about the details of the pregnancy. Results: Forty-four women under the age of 40 embolized between 1996 and 2010 stated a desire for fertility. Twenty-two of these women have reported 28 pregnancies. Of these pregnancies, 20 live births, three miscarriages, and three instances of premature labor were reported. Seventeen of these pregnancies were delivered by caesarean section and six pregnancies were vaginal deliveries. And one woman is currently pregnant. No perfusion problems, either during pregnancy or labor, were reported. Conclusion: The course of pregnancy and delivery was largely normal after embolization with three cases of premature labor and three miscarriages reported. Forty-eight percent of women who were under 40 and desired pregnancies were able to have successful term pregnancies.