Uterine Fibroid Embolization
James B. Spies
Uterine fibroid embolization (UFE) was first reported in 1995 and rapidly became accepted into practice around the world. There has been extensive study of the outcomes from embolization of fibroids, including several randomized trials comparing UFE to surgery, with two reporting long-term outcomes (1,2). Recently, an American College of Obstetricians and Gynecologist Practice Bulletin on Alternatives to Hysterectomy in the Management of Leiomyomas (3) indicated that there were good and consistent data (Level A) to state “based on long- and short-term outcomes, uterine artery embolization is a safe and effective option
for appropriately selected women who wish to retain their uteri.” This finding was confirmed in a recent systematic review by the Cochrane Collaborative (4).
for appropriately selected women who wish to retain their uteri.” This finding was confirmed in a recent systematic review by the Cochrane Collaborative (4).
Indications
1. Heavy menstrual bleeding
a. Fibroids typically cause heavy menstrual bleeding without interperiod bleeding. The exception is submucosal fibroids, which may, in addition, cause interperiod bleeding and metrorrhagia. In nearly all cases, fibroids must be deep within the uterus distorting the endometrial cavity to cause heavy bleeding. If only serosal fibroids or small intramural fibroids are present and there is heavy menstrual bleeding, consider other possible causes prior to proceeding with embolization.
2. Pelvic pressure
a. The most common bulk-related symptoms are pressure, heaviness, or bloating. These symptoms typically are worse around the time of the menstrual period. They respond well to UFE. It is important to remember that some perimenstrual bloating is normal, which will likely persist despite a successful UFE.
3. Pelvic pain
a. Fibroids usually cause menstrual cramps or low-grade aching pain. Less frequently, they may cause shooting or severe pain. When severe pain is the predominant symptom, it is important to consider other causes of female pelvic pain such as endometriosis. Also, patients often will experience pain or tenderness over one particular fibroid. If the fibroids are mostly on one side of the pelvis and the patient has pain on the other, consider other causes.
4. Urinary urgency, frequency, incontinence, retention, and hydronephrosis
a. Uterine fibroids commonly compress the urinary bladder causing urgency and frequency, which respond well to embolization. Urinary incontinence is less common, and in women who have had prior vaginal deliveries, the incontinence may be of multifactorial origin. Hydronephrosis may be caused by a substantially enlarged fibroid uterus and usually resolves after UFE. However, a followup renal sonogram is needed 3 to 6 months after treatment to ensure resolution.
Contraindications
Absolute
1. Pregnancy
2. Suspected leiomyosarcoma or endometrial, cervical, or ovarian malignancy
a. Preoperative embolization is occasionally requested prior to surgical resection of a suspected malignancy and this is an acceptable use of embolization, but UFE should never be considered as a sole therapy for a suspected leiomyosarcoma.
Relative
Many of these relative contraindications are circumstances that can be managed with additional care and should not exclude the use of embolization.
1. Coagulopathy or requirement for continuous anticoagulation
a. Similar and greater risks of bleeding are present with surgery. The risks can be reduced or eliminated with the use of an arterial closure device at the puncture site.
2. Renal insufficiency
a. Contrast use should be limited and the patient should be well-hydrated prior to the procedure.
3. Prior severe allergic reaction to iodinated contrast material
a. Corticosteroid premedication can ameliorate this risk. It is important that appropriate drugs and equipment be immediately available and that there be secure intravenous (IV) access. Anesthesia support may be helpful.
4. Desire for pregnancy within 2 years.
a. Although patients can become pregnant and carry pregnancies to term, the relative likelihood of that occurring after UFE may be less than with myomectomy, at least within the first 2 years after treatment (5). However, those with prior fibroid or uterine surgery and those who are poor surgical risk or who have declined surgery can be considered for embolization, with a clear understanding that reproductive outcomes are uncertain.
Preprocedure Preparation
1. Preprocedure history, physical examination, and consultation with an interventional radiologist
a. Gynecologic examination by a gynecologist within 1 year
b. Assessment of uterine size (by weeks of pregnancy) helpful during abdominal examination
2. Imaging evaluation
a. Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging assessment because it allows accurate assessment of fibroid number, size, and location as well as detection of adenomyosis.
b. Transabdominal and transvaginal ultrasound examination of good quality may be a suitable substitute for an MRI in a resource-limited practice environment.
3. Laboratory evaluation
a. Current Pap smear, which should be normal
b. Endometrial biopsy when menstrual bleeding is markedly prolonged or when there is intermittent bleeding between cycles. A useful rule of thumb is biopsy for menstrual periods that are routinely longer than 10 days or when there is bleeding more frequent than every 21 days.
c. Complete blood count, serum electrolytes (including serum creatinine), and a urine or serum pregnancy test in those at risk of pregnancy before the procedure. Given the importance of excluding pregnancy, we obtain a urine pregnancy test in all premenopausal women.
d. Coagulation panel only in patients suspected of having a coagulopathy
4. Patient preparation
a. Patient should have nothing by mouth except normal medications with a sip of water for at least 6 hours prior to the procedure.
b. Most interventionalists place a Foley catheter in the bladder prior to the procedure. This is for patient comfort and to keep bladder empty, which will reduce fluoroscopic dose.
c. The patient should have the anticipated postprocedure recovery explained to them and they should be instructed on the use of the patient-controlled analgesia (PCA) pump for IV narcotics.
d. Many interventionalists give a single dose of prophylactic antibiotics such as cefazolin 1 g IV, although there is no evidence that this has any impact on infection rates postprocedure.
e. The medications needed for postprocedure management should be prepared and ready to administer immediately at the end of the procedure.
f. An IV line should be placed and the patient should be hydrated. One approach is to infuse 500 mL of normal saline over the 2 hours just before and during the procedure, with the rate reduced to 125 mL per hour thereafter.
g. Patient is sedated with fentanyl and midazolam at the beginning of the procedure, with continuous monitoring by a nurse trained in sedation.
Procedure
1. Uterine artery catheterization
a. Either unilateral or bilateral femoral puncture can be used, with a 4 Fr. or 5 Fr. sheath typically used at each puncture site.
b. The advantage of a bilateral puncture is that the angiographic imaging of the uterine arteries can be done simultaneously and, if an assistant is available, the embolization of both uterine arteries can also be done simultaneously, both of which may result in a reduction in overall radiation dose.
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