Marcos de Lorenzo Messina

Uterine artery embolization for the treatment of uterine leiomyomata

Objectives: To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids. Methods: Twenty‐six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow‐up was performed before the procedure, at 3 months, and 1 year after. Results: All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm3, after 3 months 255 cm3 and after 1 year 202 cm3. The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow‐up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients). Conclusions: UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Safety, efficacy, and prognostic factors in endovascular treatment of pelvic congestion syndrome

To evaluate the safety and effectiveness of transcatheter embolization using coils for treatment of pelvic congestion syndrome (PCS) and to elucidate prognostic factors for clinical success.

Comparative Study of Different Dosages of Goserelin in Size Reduction of Myomatous Uteri

STUDY OBJECTIVE To compare uterine size reduction obtained with three monthly subcutaneous injections of 3.6 mg of goserelin versus a single subcutaneous injection of 10.8 mg. DESIGN Prospective, randomized clinical trial (Canadian Task Force classification I). SETTING Department of Gynecology and Obstetrics at the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. PATIENTS Forty-five premenopausal women with uterine leiomyomas and uterine size greater than 600 cm(3) randomized to one of two groups. INTERVENTION Group A: 23 women received three monthly subcutaneous 3.6-mg doses of goserelin. Group B: 22 women received a single subcutaneous injection of 10.8 mg of goserelin. Follicle-stimulating hormone (FSH), estradiol, and hemoglobin levels were measured monthly. After 3 months, uterine size was determined by transvaginal and/or abdominal ultrasound. MEASUREMENTS AND MAIN RESULTS In group A, mean reduction of uterine size was 43% (426 cm(3)) at the end of treatment. In Group B, mean reduction of uterine size was 54% (494 cm(3)). Serum levels of FSH and estradiol were in postmenopausal range during treatment. Hemoglobin level improvement was equivalent in both groups. CONCLUSION Use of single injection of 10.8 mg of goserelin promoted significantly greater reduction in uterine size than three monthly 3.6-mg injections in patients with voluminous uterine leiomyomas.

Percutaneous embolization of large vulvar vascular malformation.

Vascular malformations are a type of benign vascular tumor that consist of a collection of abnormal blood vessels, which do not follow the normal pattern of development with blood passing from an artery to a vein. Vascular malformations comprise dysplastic plexiform vessels and almost never regress spontaneously [1]. Rapid enlargement of vascular malformations can occur as a result of trauma, hormonal changes, thrombosis, infection, or surgical intervention. They may be complicated by cutaneous ulceration and hemorrhage, limb hypertrophy, or even high-output cardiac failure. Diagnosis of vascular malformations is primarily clinical and is confirmed by ultrasound, color Doppler ultrasound, and magnetic resonance imaging (MRI). Diagnostic angiography is usually performed at the same time as embolization or sclerotherapy. With vascular malformations the therapeutic goal is to obliterate and resect the nidus of the malformation, using embolization followed by resection. Extensive vascular malformations exist for which only palliative embolization is possible [2]. Vascular malformations are often more extensive than can be demonstrated clinically, and tend to recur after embolization. A 42-year-old female (gravida 2) presented for gynecologic evaluation complaining of pelvic pressure. On physical examination she had a large, warm and pulsating vulvar mass (Fig. 1). The patient reported that a vulvar macular lesion was present at birth and had been surgically resected, but

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.

Review of magnetic resonance-guided focused ultrasound in the treatment of uterine fibroids

Uterine leiomyoma is the most frequently occurring solid pelvic tumor in women during the reproductive period. Magnetic resonance-guided high-intensity focused ultrasound is a promising technique for decreasing menorrhagia and dysmenorrhea in symptomatic women. The aim of this study is to review the role of Magnetic resonance-guided high-intensity focused ultrasound in the treatment of uterine fibroids in symptomatic patients. We performed a review of the MEDLINE and Cochrane databases up to April 2016. The analysis and data collection were performed using the following keywords: Leiomyoma, High-Intensity Focused Ultrasound Ablation, Ultrasonography, Magnetic Resonance Imaging, Menorrhagia. Two reviewers independently performed a quality assessment; when there was a disagreement, a third reviewer was consulted. Nineteen studies of Magnetic resonance-guided high-intensity focused ultrasound-treated fibroid patients were selected. The data indicated that tumor size was reduced and that symptoms were improved after treatment. There were few adverse effects, and they were not severe. Some studies have reported that in some cases, additional sessions of Magnetic resonance-guided high-intensity focused ultrasound or other interventions, such as myomectomy, uterine artery embolization or even hysterectomy, were necessary. This review suggests that Magnetic resonance-guided high-intensity focused ultrasound is a safe and effective technique. However, additional evidence from future studies will be required before the technique can be recommended as an alternative treatment for fibroids.

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.

Necrotic fibroid expulsion with intrauterine infection after uterine fibroid embolization.

Since the 1995 publication of the first report on uterine fibroid embolization (UFE), injecting small particles in the uterine arteries has been associated not only with pain but also with such conditions as menorrhagia, dysmenorrhea, infection, and bulkrelated symptoms [1]. Leiomyomas located close to or inside the endometrium have a higher risk of becoming infected after UFE; and because treatment with antibiotics is not always sufficient when infection occurs, a surgical intervention can be needed. A 35-year-old woman, gravida 0, presented with pelvic pressure and vaginal discharge. Although she had undergone myomectomy in 2003, a pelvic ultrasonographic examination showed a dominant intramural leiomyoma 107×85×78 mm in volume 6 months before the UFE. Three months before presenting to the hospital, polyvinyl alcohol particles 500 to 710 μm in diameter (Ivalon; Cook, Bloomington, IN) were used to embolize each uterine artery via the bilateral femoral access approach. Following UFE she developed fever, her pelvic pain increased, and laboratory studies revealed an elevated white blood cell count. A vaginal examination revealed a purulent bloody discharge without cervical dilatation. However, on another visit 5 days later, a fibroid was in the process of being expelled through the cervix. Magnetic resonance imaging showed a dominant submucosal fibroid 102×83×69 mm in volume and a cervical dilatation of 3 cm. Perfusion of the surrounding myometrium was preserved (Fig. 1). After the patient was sedated, her fibroid was removed by twisting its stalk. Expulsion of leiomyomas after UFE has been reported in the literature, and some investigators have suggested that submucosal leiomyomasmaybeassociatedwithan increased risk of infection [2]. Patients may present with symptoms ranging from cramping to pain with or without evidence of infection, and with vaginal discharge and passage of tissue fragments. Surgical evacuation of infarcted fibroid tissue may be necessary in patients who do not respond to supportive treatment, and in those who are not able to pass the fibroid tissue on their own [3]. Submucosal uterine fibroids occasionally prolapse into the vagina and even the vulvar region. If this tissue does not pass spontaneously, dilation and curettage of the uterus might become necessary. The present case demonstrates that the evacuation of a fibroid as large as 130 mm in diameter can occur spontaneously without any complications.