Uterine Artery Embolization

Uterine Artery Embolization For
Uterine Fibroids & Adenomyosis

Uterine Artery Embolization has many Indications:-

·  Single / multiple Uterine Fibroids.

·  Adenomyosis.

·  Failed myomectomy / recurrence of fibroids after myomectomy

·  High risk patient for surgery like obesity, anaemia, Chronic renal failure etc .

·  Post-partum Hemorrhage

·  Bleeding from Cancer of Cervix & Uterus

·  Pre-operative embolization to reduce bleeding during uterine surgery.

Uterine Fibroids:Their symptoms and Treatment

Q. What are uterine fibroids?

A. Uterine fibroids are noncancerous (benign) growths that develops in the muscular wall of the uterus and these are the most frequent tumors of the female genital tract: 20 to 40% of women of childbearing age have a fibroid. Fibroids range in size from very tiny to the size of an orange or larger. In some cases, they can cause the uterus to grow to the size of a five-month pregnancy or more. Fibroid may be located in various parts of the uterus. There are three primary types of uterine fibroids: 

Subserosal fibroids, which develop in the outer portion of the uterus and expand outward. They typically do not affect women’s menstrual flow, but can become uncomfortable because of their size and the pressure they cause. 

Intramural fibroids, which develop within the uterine wall and expand, making the uterus feel larger than normal. These are the most common fibroids. These can result in heavier menstrual flow and lower abdominal pain or pressure. 

Submucosal fibroids are deep within the uterus, just under the lining of the uterine cavity. These are the least common fibroids, but they often cause symptoms, including very heavy and prolonged periods. 

Q. What are typical symptoms?

A. Depending on location, size and number of fibroids, they may cause:

·  Heavy, prolonged menstrual periods and unusual bleeding, sometime with clots. This might lead to anemia.

·  Lower abdomen, back or leg pain

·  Lower abdomen pressure or heaviness

·  Bladder pressure leading to a constant urge to urinate

·  Pressure on bowel, leading to constipation and bloating

·  Abnormally enlarged abdomen

Q. Who is most likely to have uterine fibroids?

A. Uterine fibroids are very common, although, often they are very small and cause no problem. From 20 to 40 % of women aged 35 and older have uterine fibroids of a significant size. 

Q. How are uterine fibroids diagnosed?

A. Fibroids are usually diagnosed during a gynecologic examination. The presence of fibroids is most often confirmed by a lower abdomen ultrasound. Fibroids can also be confirmed using MRI (magnetic resonance imaging) and computed tomography (CT scan). Appropriate treatment depends on the size and location of the fibroids, as well as the severity of symptoms.

Q. How are uterine fibroids treated?

A. Treatment options for uterine fibroids:

1.      Medical Management.

2.      Minimally Invasive Therapy (Uterine artery or fibroid embolization) and

3.      Surgical Management

1.      Medical Management 

Effective medical therapy is not available for management of fibroids. However hormonal drugs in the form of injections have recently become available which are expensive (GnRH analogue) this hormonal therapy cannot be used for long term basis because of its side effects. Also rapid regrowth of fibroids can occur when therapy is discontinued. 

2. Minimally invasive therapy (Uterine Artery (or fibroid) embolization 

This minimally invasive procedure will be explored further in this brochure. Briefly, an interventional radiologist makes a tiny incision in the groin and passes a small tube called catheter through the artery. When the catheter reaches the uterine artery, the interventional radiologist slowly releases tiny particles, the size of grains of sand, into the vessels. The particles flow to the fibroids and wedge into the vessels and cannot travel to other parts of the body. This blocks the blood flow to the fibroids, causing it to shrink.

Q. What is fibroid embolization?

A. It is a minimally invasive procedure, which means it requires only a tiny nick in the skin. It is performed while the patient is conscious but sedated – drowsy and feeling no pain. 

Fibroid embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures. The interventional radiologist makes a small nick in the skin (less then ¼ of an inch) in the groin and inserts a catheter into an artery. The catheter is guided through the artery to the uterus while the interventional radiologist guide the progress of the procedure using a moving X-ray (fluroscopy). The interventional radiologist injects tiny plastic particles the size of grains of sand into the artery that is supplying blood to the fibroid tumor. This cuts off the blood flow and causes the tumor (or tumors) to shrink. The artery on the other side of the uterus is then treated. 

  Embolization preparation. A tiny angiographic catheter is inserted through a nick in the skin in to an artery and advanced into uterus. A.      Injection. Tiny polyvinyl alcohol particles of 500 um in diameter are wedge in the small arteries, blocking the blood flow to the fibroids.

While embolization to treat uterine fibroids has been performed since 1995, embolization of the uterus is not new. It has been used successfully by interventional radiologist for over 20 years to treat heavy bleeding after childbirth. This procedure is now available at few hospitals. 

Q. Which patient can go for fibroid embolization?

A. Ideal Patient for uterine artery embolization.

1.   They have single / multiple fibroids

2.  The fibroids are symptomatic.

3.  There is no cancer (as suggested by pap smear or endometrial biopsy)

Q. What are the benefits of fibroid embolization? (Minimally invasive procedure)

A. The benefits are:

1.      It is performed under Local anesthesia. Not General anesthesia.

2.      Requires only a tiny nick in the skin (No surgical incision of abdomen).

3.      Recovery is shorter than from hysterectomy or open myomectomy. Within 3 days patient can attend the job.

4.      Virtually no adhesion formation has been found. But in surgery adhesions are common.

5.      All fibroids are treated at once, which is not the case with myomectomy.

6.      There has been no observed recurrent growth of treated fibroids in the past 9 years.

7.      Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.

8.      Many women resume light activities in a few days and the majority of women are able to return to normal activities (including exercise) within a week.

9.   If the presenting complaint was excess vaginal bleeding, 87-90% of cases experience resolution within 24 hours.

10. Emotionally, financially and physically – embolization can have an overall advantage over other procedures for the patient, as the uterus is not removed.

Q. How successful is the fibroid embolization procedure?

A. Studies show that 94-98% of women who have the procedure experience significant or total relief of heavy bleeding, pain and other symptoms. The procedure also is effective for multiple fibroids. No regrowth of treated fibroids is observed. 

Q. Are there risks associated with the treatment of fibroid tumors?

A. Fibroid embolization is considered a safe alternative to hysterectomy and myomectomy. 

There are some associated risks, as there are with almost any medical procedure. Most women experience moderate pain, nausea and fever. These symptoms can be controlled with antibiotics and pain medication. Less then 1% of the patient need myomectomy or hysterectomy to complete the removal of a persisting fibroid. 

Myomectomy and hysterectomy also carry risks, including infection, bleeding leads to blood transfusion. Patients who undergo myomectomy may develop adhesions causing tissue and organs in abdomen to fuse together, which can lead to other problems. In addition, the recovery time is much longer for abdominal myomectomy, generally one to two months. 
3. (Surgical option) Myomectomy Myomectomy is a surgical procedure that removes visible fibroids from the uterine wall. Myomectomy, like uterine artery embolization for fibroids, leaves the uterus in place and may, therefore, preserve the women’s ability to have children. There are several way to perform myomectomy, including hysteroscopic myomectomy, laparoscopic myomectomy and open abdominal myomectomy: 

     Hysteroscopic Myomectomy: It is used only for fibroids that are just under the lining of the uterus and that protrude into the uterine cavity (submucosal fibroid). There is no need for surgical incision. The doctor inserts a flexible scope (hysteroscope) into the uterus through the vagina and cervix and removes the fibroids using surgical tools fitted to the scope. Usually this procedure is performed while the patient is under anesthesia and not conscious. The hospital stay is about 2 days, the postoperative recovery period of two weeks, needs general anesthesia, some time causes bleeding which may need blood transfusion and chances of infection are also there. Removal of big size fibroid is difficult which may need 2-3 sittings. 

     Laparoscopic Myomectomy: Laparoscopic myomectomy may be used if the fibroid is on the outer wall of the uterus. Small incisions are made on the abdomen and then a probe is inserted with a tiny camera attached and another probe fitted with surgical instruments, into the abdominal cavity and tumor is removed piecemeal. It is performed while the patient is under general anesthesia and not conscious. The average recovery time is about two weeks. Some time cause bleeding which may need blood transfusion and chances of infection may also be there. 

     Abdominal Myomectomy: This is an open abdominal surgery to remove fibroids. It needs 2-3 incision on abdomen. Once the fibroids are removed, the uterus is stitched and closed. The patient is given general anesthesia and not conscious for this procedure, the hospital stay is 4-5 days and postoperative recovery period is six weeks. Some times procedure causes bleeding which may need blood transfusion, adhesions may cause problem. Regrowth rate of fibroids is high. 

While myomectomy is frequently successful in controlling symptoms, it is not successful in case of multiple fibroids.. In addition, fibroids may grow back several months/ years after myomectomy 

Hysterectomy. 

In hysterectomy (Vaginal or Abdominal), the uterus is removed by an open surgical procedure. This operation is considered a major surgery and is performed while the patient is under general anesthesia. It requires four to five days of hospitalization and the average recovery period is about six weeks. 

Hysterectomy is the most common current therapy for women who have fibroid. It is typically performed in women who have completed their childbearing years or who understand that after the procedure, they cannot become pregnant. 

This blog-page was created to answer frequently asked questions about uterine fibroids. The page contains general information about this common condition, as well details about procedures performed by interventional radiologists to treat uterine fibroids. 

For more in-depth information on fibroids embolization contact muleypradeep@hotmail.com or call at mobile +91-98104 92778. 

Dr. Pradeep Muley M.D.
Head & Senior Consultant Interventional Radiologist

Fortis Hospital, vasant Kunj, New Delhi, INDIA
Fellow, Neurointerventional Radiology, John’s Hopkins Medical Institutions, USA
Visiting Associate, Neurointerventional Radiology, Iowa University, USA
Fellow Interventional Radiology, Singapore General Hospital, Singapore
Lecturer Vascular & Interventional Radiology, KEM Hospital, Mumbai.
Neuroradiology, AIIMS, New Delhi.

Mobile 098104 92778 or E-mail at muleypradeep@hotmail.com
Website http://www.indianinterventionalradiology.in/