Eduardo Zlotnik

Embolização de mioma uterino em mulheres portadoras de miomas volumosos

PURPOSE to evaluate the effectiveness of uterine fibroid embolization (UFE) in patients with giant fibroids, with regard to both clinical outcomes and size reduction. METHODS twenty-six patients with a mean age of 36.5 years, carrying symptomatic fibroids with a volume over 1,000 cm³, were referred for UFE. All patients had indication for percutaneous treatment. The procedures were performed under epidural anesthesia and sedation, using an institutional protocol. By unilateral femoral access, selective catheterization of uterine arteries and infusion of calibrated microspheres through microcatheter were carried out. Clinical evaluation was performed by means of regular outpatient gynecology consultation. All patients underwent magnetic resonance imaging (MRI) before the procedure and 15 patients underwent control MRI after 6 months. RESULTS technical success was 100%. There was no complication related to the procedures. Mean uterine volume of the 15 patients studied was 1,401 cm³ before embolization (min 1,045 cm³, max 2,137 cm³) and 799 cm³ after 6 months (525 cm³ min, max. 1,604 cm³), resulting in a total reduction of 42.9%. Clinical improvement was observed in 25 of 26 patients. One woman with uterine volume of 1,098 cm³ who developed necrosis and partial fibroid expulsion underwent myomectomy. Another patient was submitted to myomectomy six months after the procedure because she wanted to become pregnant, despite partial fibroid size reduction. One patient with a uterine volume of 2,201 cm³ required a second intervention to achieve an adequate angiographic result. No patient underwent hysterectomy. On average, 9.2 microsphere syringes were used per patient. CONCLUSION embolization of giant uterine fibroids is a feasible procedure with acceptable clinical and radiological outcomes. It can be considered an option for patients who desire to preserve the uterus, and it may serve as adjuvant therapy for high-risk myomectomy.OBJETIVO: avaliar a eficacia da embolizacao de mioma uterino (EMUT) em pacientes com miomas volumosos no que diz respeito tanto a evolucao clinica quanto a reducao do tamanho dos mesmos. METODOS: vinte e seis pacientes com media etaria de 36,5 anos, portadoras de miomas uterinos sintomaticos com volume acima de 1.000 cm3, foram submetidas a EMUT. Todas possuiam indicacao para tratamento percutâneo. Os procedimentos foram realizados sob anestesia epidural e sedacao, empregando-se protocolo institucional de analgesia. Apos puncao femoral unilateral, foi realizado o cateterismo seletivo das arterias uterinas e infusao de microesferas calibradas por meio de microcateter. A avaliacao clinica pos-procedimento foi realizada em ambulatorio de ginecologia segundo o protocolo de atendimento. Todas as pacientes tinham ressonância nuclear magnetica (RNM) antes do procedimento e 15 pacientes RNM de controle apos 6 meses. RESULTADOS: o sucesso tecnico foi de 100%. Nao houve complicacao relacionada aos procedimentos. A media de volume uterino das 15 pacientes foi 1.401 cm3 antes da embolizacao (min. 1.045 cm3, max. 2.137 cm3) e, apos 6 meses 799 cm3 (min. 525 cm3, max. 1.604 cm3), constituindo uma reducao media de 42,9%. A melhora clinica foi constatada em 25 das 26 pacientes. Uma paciente com utero de 1.098 cm3 apresentou necrose e expulsao parcial do mioma, sendo submetida a miomectomia. Outra paciente foi submetida a miomectomia apos seis meses devido ao desejo de gravidez, apesar da reducao parcial do volume dos miomas. Uma paciente com volume uterino de 2.201 cm3 necessitou de segunda intervencao para alcancar um resultado adequado. Nenhuma paciente foi submetida a histerectomia. Foram utilizadas em media 9,2 seringas de microesferas por paciente. CONCLUSAO: a embolizacao de miomas uterinos de grande volume e um procedimento factivel, com aceitaveis resultados clinico e radiologico. Pode ser considerada uma opcao para as pacientes que desejam a preservacao uterina e tambem servir como terapeutica adjuvante a miomectomia de alto risco.

Strategies for reduction of exposure to ionizing radiation in women undergone to uterine fibroid embolization

PURPOSE to determine the dose of ionizing radiation absorbed by the ovaries and the skin of patients undergoing uterine fibroid embolization (UFE), and to suggest a radiologic protocol directed at reducing the risks involved in this procedure. METHODS seventy-three consecutive women (mean age: 27 years) participating in an institutional research protocol, having symptomatic uterine fibroids with indication for minimally invasive treatment, underwent UFE. We estimated the radiation absorbed by the ovaries by means of vaginal dosimeters and the radiation dose absorbed by the skin by means of indirect calculations of radiation absorption. The first 49 patients belonged to the Pre-modification Group, and the last 24, to the Post-modification Group. The second group received a modified protocol of X-ray imaging, with a reduction by half of the frames number per second during arteriography, in an attempt to match the values obtained to those of the literature, and avoiding as much as possible unnecessary exposure to the X-ray beam. RESULTS there were no technical complications in any of the procedures performed. There were no differences in the mean fluoroscopy time or in the mean number of arteriographies between the two groups. We obtained a 57% reduction in the estimated absorbed ovarian dose between groups (29.0 versus 12.3 cGy) and a 30% reduction in the estimated dose absorbed by the skin (403.6 versus 283.8 cGy). CONCLUSIONS a significant reduction in the absorption of radiation in patients undergoing UFE can be achieved by changing the number of frames per second in angiographic series, and by the routine use of radiological protection standards.

Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma

OBJECTIVE: Minimally invasive methods are used as alternatives to treat leiomyomas and include uterine artery embolization, which has emerged as a safe, effective method. This study aims to evaluate the magnetic resonance imaging predictors for a reduction in leiomyoma volume in patients undergoing uterine artery embolization. METHODS: This prospective longitudinal study was performed at a university hospital. We followed 50 symptomatic premenopausal women with uterine leiomyomas who underwent uterine artery embolization. We examined 179 leiomyomas among these patients. Magnetic resonance imaging was performed one month before and six months after uterine artery embolization. Two radiologists who specialized in abdominal imaging independently interpreted the images. Main Outcome Measures: The magnetic resonance imaging parameters were the uterus and leiomyomas volumes, their localizations, contrast perfusion pattern and node-to-muscle ratio. RESULTS: Six months after treatment, the average uterine volume reduction was 38.91%, and the leiomyomas were reduced by 55.23%. When the leiomyomas were submucosal and/or had a higher node-to-muscle ratio in the T2 images, the volume reduction was even greater (greater than 50%). Other parameters showed no association. CONCLUSIONS: We conclude that symptomatic uterine leiomyomas in patients undergoing uterine artery embolization exhibit volume reductions greater than 50% by magnetic resonance imaging when the leiomyomas are submucosal and/or had a high node-to-muscle ratio in the T2 images.

Endovascular surgery in gynecology

Endovascular surgery has presented a high evolution since 1960 with Charles Dotter, who changed the concept of catheter utilization as a mean to diagnose and introduce therapeutic in interventionist vascular environment. The first reports of bleeding control of gastrointestinal and transluminal angioplasty input the development of new techniques for endovascular access, and new materials use, such as microcatheters and embolic agents, become this procedure effective and viable for treatment of several pathologies. The embolization of several organs of human body is a procedure carried out for more than 30 years all over the world showing safety, efficacy and of simple execution. In obstetrics and gynecology, particularly, the first reports refer to pelvic hemorrhage control of varied etiology, including pelvic trauma, bladder and gynecology neoplasia, anteriovenous fistulas and puerperal hemorrhages. The embolization of uterine myoma appears in the 1990s as an alternative for treat of uterine leiomyoma, and a number of studies try to clarify the risks and benefits of this procedure. It is a multidisciplinary technique, with diagnostic and indication performed by gynecologist and the procedure done by interventional vascular radiologist. This review is a critical analysis of interventionist vascular radiologic methods and its main therapeutic indications in gynecology.

Cesarean section and osteosynthesis of lower limb fractures in the same surgical procedure

INTRODUCTION Orthopedic trauma during pregnancy can cause serious complications such as premature birth, stillbirth and maternal morbidities. PRESENTATION OF CASE We report the case of a patient at 38 weeks pregnancy who fractured the left ankle and the right fifth metatarsal after falling. Cesarean section and osteosynthesis were performed in the usual manner in the same surgical procedure. There were no postoperative complications. DISCUSSION Pregnancy and puerperium are associated with a hypercoagulable state. The early mobilization provided by surgical treatment of the fractures reduced the risks of thromboembolic events. CONCLUSION The approach adopted may be used as an example for future procedures done in similar situations.

Alterações endometriais após embolização de leiomiomas uterinos avaliadas por ressonância magnética de alto campo (3 Tesla)

ABSTRACT Objective: To evaluate the endometrial alterations related to embolization of uterine arteries for the treatment of symptomatic uterine leiomyomatosis (pelvic pain and/or uterine bleeding) by means of high-field (3-Tesla) magnetic resonance. Methods: This is a longitudinal and prospective study that included 94 patients with a clinical and imaging diagnosis of symptomatic uterine leiomyomatosis, all of them treated by embolization of the uterine arteries. The patients were submitted to evaluations by high-field magnetic resonance of the pelvis before and 6 months after the procedure. Specific evaluations were made of the endometrium on the T2-weighted sequences, and on the T1-weighted sequences before and after the intravenous dynamic infusion of the paramagnetic contrast. In face of these measures, statistical analyses were performed using Students t test for comparison of the results obtained before and after the procedure. Results: An average increase of 20.9% was noted in the endometrial signal on T2-weighted images obtained after the uterine artery embolization procedure when compared to the pre-procedure evaluation (p=0.0004). In the images obtained with the intravenous infusion of paramagnetic contrast, an average increase of 18.7% was noted in the post-embolization intensity of the endometrial signal, compared to the pre-embolization measure (p<0.035). Conclusion: After embolization of the uterine arteries, there was a significant increase of the endometrial signal on the T2-weighted images and on the post-contrast images, inferring possible edema and increased endometrial flow. Future studies are needed to assess the clinical impact of these findings.OBJECTIVE: To evaluate the endometrial alterations related to embolization of uterine arteries for the treatment of symptomatic uterine leiomyomatosis (pelvic pain and/or uterine bleeding) by means of high-field (3-Tesla) magnetic resonance. METHODS: This is a longitudinal and prospective study that included 94 patients with a clinical and imaging diagnosis of symptomatic uterine leiomyomatosis, all of them treated by embolization of the uterine arteries. The patients were submitted to evaluations by high-field magnetic resonance of the pelvis before and 6 months after the procedure. Specific evaluations were made of the endometrium on the T2-weighted sequences, and on the T1-weighted sequences before and after the intravenous dynamic infusion of the paramagnetic contrast. In face of these measures, statistical analyses were performed using Students t test for comparison of the results obtained before and after the procedure. RESULTS: An average increase of 20.9% was noted in the endometrial signal on T2-weighted images obtained after the uterine artery embolization procedure when compared to the pre-procedure evaluation (p=0.0004). In the images obtained with the intravenous infusion of paramagnetic contrast, an average increase of 18.7% was noted in the post-embolization intensity of the endometrial signal, compared to the pre-embolization measure (p<0.035). CONCLUSION: After embolization of the uterine arteries, there was a significant increase of the endometrial signal on the T2-weighted images and on the post-contrast images, inferring possible edema and increased endometrial flow. Future studies are needed to assess the clinical impact of these findings.

Estimativa de dose ovariana e dose na entrada da pele em procedimentos de embolização de artéria uterina

O objetivo deste estudo foi estimar a dose ovariana e a dose na entrada da pele de pacientes submetidas ao procedimento de embolizacao de mioma uterino (EMUT). Para isso, foram acompanhados 49 procedimentos de EMUT onde foram anotados os parâmetros de aquisicao de imagem para calculo da DEP atraves do rendimento do tubo de raios-X. A estimativa de dose ovariana foi realizada atraves da insercao de uma sonda vaginal contendo 3 pastilhas de TLD. Os valores obtidos foram comparados com resultados de outros autores e verificou-se um valor superior de dose ovariana (28,97 cGy) e DEP (403,57 cGy) neste trabalho. A analise dos resultados permitiu observar que esse resultado foi obtido principalmente devido ao alto numero de series de arteriografia e taxa de frames/segundo empregada. Como resultado dessas observacoes, o protocolo de EMUT foi alterado baixando-se a taxa de frames/seg de 2 para 1. Esforcos no sentido de reduzir o numero de series de arteriografia tambem passaram a fazer parte dos procedimentos seguintes.