|Figure 1. A nonselective arteriogram of the pelvis demonstrating the torturous and dilated appearance of uterine arteries supplying a hypervascular uterine fibroid.|
Uterine fibroids are the most common tumor occurring in the female reproductive system. These benign tumors of the muscular wall of the uterus are seen in 20-25% of all women, and are estimated to occur in 40% of menstruating females greater than age 50.1 Most fibroids do not cause symptoms. However, many patients with fibroids will experience abnormal uterine bleeding, pelvic pain, abdominal distension, and bladder compression with frequent urination.2
A patient with uterine fibroids experiencing one or more of these symptoms is typically faced with treatment options including hysterectomy and, more recently, myomectomy. A hysterectomy is the definitive cure for fibroids since the entire uterus is removed, while a myomectomy is the removal of the fibroid(s) while the uterus is kept intact. Almost 40% of all hysterectomies are performed in patients who have benign gynecologic disease, with the majority of those due to fibroids.1 Recently, several reports in the mass media have highlighted both the numbers of hysterectomies performed in the United States and their potential for complications. The less-invasive techniques available to gynecologists performing hysterectomies today, including transvaginal and laparoscopic approaches for these operations, have led to reductions in hospital stays, recovery periods, and complication rates.3 Despite these facts, however, the search continues for new, minimally invasive techniques that are able to successfully address the symptoms associated with uterine fibroids while at the same time preserving the uterus and reducing the need for open surgery.
UTERINE FIBROID EMBOLIZATION
|Figure 2. Image taken after a catheter has been placed selectively in the left uterine artery.|
The use of uterine artery embolization as a treatment for uterine fibroids is a new application for a minimally invasive technique that has been proven effective for a variety of clinical applications. Embolization, in general, is a technique used to occlude arterial or venous blood flow throughout the body, most often to treat life-threatening bleeding or bleeding that is unresponsive to other therapy. The procedure causes thrombosis within an abnormal or injured vessel, which ultimately stops flow to the region supplied by that particular vessel.
The uterine fibroid embolization procedure begins with femoral artery catheterization and placement of that catheter into the pelvic arterial circulation. Contrast injections are then performed through the catheter in order to localize the right and left uterine arteries. Once these arteries are identified, they are directly catheterized under fluoroscopic guidance, and embolic material is injected into the vessel to induce an arterial occlusion. While a variety of materials can be used as an embolic agent, the most commonly used agents for uterine fibroid embolization include polyvinyl alcohol (PVA) particles and biosphere embospheres, both of which are currently being investigated to determine their safety and efficacy specifically for the fibroid embolization procedure. On average, this procedure takes 35-75 minutes to complete.
Uterine fibroid embolization was first utilized in Europe by Ravina et al, in order to reduce operative blood loss during a surgical myomectomy.4 Since then, his published experience in 88 patients demonstrated improvement in abnormal bleeding in 89% of the patients and a 69% reduction in the volume of the dominant fibroids.5 Recently, the same group has presented their findings in 243 patients, with follow-up ranging from 6 months to 7 years, citing an 83% rate of improvement in abnormal bleeding after embolization.6
|Figure 3. Image taken after a catheter has been placed selectively in the right uterine artery.|
Goodwin et al was the first in the United States to publish his experience with uterine fibroid embolization.7 Since that initial article, Goodwin and others have published data on their success with this procedure.8-13 They have shown an 81-96% symptomatic improvement rate for both abnormal bleeding and bulk-related symptoms including pain, abdominal distension, and increased urinary frequency. In addition, volume reductions in both the uterus and dominant fibroids of 42.8-48% and 48.8-78%, respectively, have been demonstrated. Finally, quality of life improves in most patients undergoing this procedure,14 with many patients stating that they would either choose or consider choosing embolization again if an additional procedure was required in the future.15
The significant potential complications associated with uterine fibroid embolization include uterine infection, uterine ischemic injury, early onset of menopause, and pulmonary embolism.16 Infection after embolization is uncommon and can often be successfully treated with antibiotics. More serious cases may require a hysterectomy for treatment.7 One case of an infection resulting in multi-organ failure and death has been reported after uterine fibroid embolization.17 Ischemic injury due to lack of oxygen to the uterus is quite rare but can result in persistent pelvic pain and can potentially require a hysterectomy for relief.12 The early onset of menopause is also a possible complication of this procedure. Because of the existence of collateral pathways between the uterine and ovarian arteries, it is possible for the embolic materials injected into a uterine artery during this procedure to enter the ovarian arterial circulation, which can result in thrombosis of the ovarian artery and ovarian infarction. The early onset of menopause can occur in as many as 14% of patients undergoing the embolization procedure, with the majority of these cases seen in patients older than 45 years of age.18
|Figure 4. Once the arteries are embolized, they are no longer visualized angiographically.|
Based on the above data and experience, uterine fibroid embolization is being used with increasing frequency as a nonsurgical treatment for symptomatic uterine fibroids. After the uterine fibroid embolization procedure, patients typically experience symptoms including pelvic pain, nausea, vomiting, fever, and general malaise.8,12,15,19 This is known as the postembolization syndrome. Inter-
ventional radiologists around the world have developed a variety of different strategies to manage these symptoms in an attempt to maximize patient comfort during the recovery period. These strategies include a variety of medications administered by oral, intravenous (with or without patient-controlled analgesia), and epidural routes.8,12,20 Many of these regimens include an overnight stay in the hospital to allow practitioners to aggressively manage the symptoms experienced during the postembolization recovery period.15
As we developed our embolization practice, we recognized that both patient preference and economic pressures within health care were driving a shift toward ambulatory surgical procedures. It was, therefore, our goal to empower our patients to participate in the decision-making process concerning where they wish to recover: at home or in the hospital. To accommodate those patients desiring the comfort that home recovery potentially allows, we worked to develop a medication regimen that would enable uterine fibroid embolization to be performed as an outpatient procedure.12
The philosophy that we utilized in designing this regimen involved the combined use of opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the symptoms described above. It has been shown that the efficacy of any medication regimen designed for pain relief is often enhanced by the additive effect of two analgesics. Regimens consisting of NSAIDs alone have been shown to be inadequate for pain relief during and immediately after many surgical procedures.21 When given in combination with opioid analgesics, however, NSAIDs have been shown to effectively provide postoperative pain relief and reduce the dosage of opioid analgesics at the same time.22,23
In our initial regimen, we utilized ketorolac tromethamine as our NSAID due to its potent analgesic and moderate anti-inflammatory activity.24 During the procedure, ketorolac is administered intravenously after each uterine artery is embolized in order to allow time for peak analgesia to be achieved early in the recovery period, when patients typically start experiencing pelvic pain. Upon discharge from the hospital, ketorolac, or a newer NSAID such as celecoxib, can be continued orally. If ketorolac is used, it should be stopped within 5 days since with prolonged postoperative administration (>5 days), transient decreases in renal function as well as cases of acute renal failure have been demonstrated.25,26 If additional pain medications are required at that time, we recommend the use of over-the-counter ibuprofen.
Opioid analgesics also play a prominent role in our postprocedure medication regimen, as they exert their primary effects on the central nervous system and organs containing smooth muscle.27,28 In the immediate postprocedure recovery period, intravenous meperidine is used for pain relief. Upon discharge from the hospital, this can be converted to oral meperidine followed by hydrocodone bitartrate and acetaminophen after 24 hours (in order to reduce the strength of the opioid analgesic). Alternatively, oxycodone hydrochloride can be used in sustained release form with the goal of decreasing the complexity of the regimen and reducing the overall medication requirements during the recovery period.
Controlling Side Effects
The side effects inherent to many oral pain medication regimens include nausea, vomiting, and constipation. Nausea and vomiting are uncomfortable for a patient and can contribute to dehydration and an inability to take orally administered medications. The nausea experienced by patients undergoing the uterine artery embolization procedure is due both to the effects of the embolization procedure (fibroid infarction and transient uterine ischemia) and to the effects of the prescribed opioid analgesics.29 Our regimen consists of the administration of a prochlorperazine suppository prior to the initiation of the procedure due to its effectiveness in reducing postoperative nausea and vomiting.30 Rectal administration is preferred so that it can be administered at home, even during episodes of nausea. Constipation, a well-known side effect of opioid analgesics, can be addressed with the use of laxatives.
Patient education is the final, but arguably the most critical component of the pain control regimen that we have established.31 During the initial consultation with a prospective patient, the expected symptoms during the postembolization recovery period are covered in detail, as is our regimen for pain control. This discussion is repeated on the morning of the procedure to ensure that patients have realistic expectations for their recovery period. When these patients have adequate education and appropriate expectations, the expectations often exceed reality and patient satisfaction with management during the recovery period increases.31
Once discharged, patients are recommended to observe bed rest with only limited activity on the day of the procedure. The next day, patients may move on to limited activity around their home. Normal activity is permitted 2 days after the procedure. After 2 days, individual tolerance for activity and the requirement for pain medication are the best indicators of what a patient can and cannot do. Most of our patients have been able to return to work 6-10 days after the procedure.
We have studied this protocol in order to determine its success at addressing the most common symptoms experienced by patients after the uterine fibroid embolization procedure. Most recently, we evaluated 73 consecutive patients undergoing the embolization procedure.32 Utilizing the regimen described above, 71 of 73 patients were discharged within 8 hours of the procedure; two patients required overnight observation. Two patients required additional pain medication during the first 2 days of the postprocedure recovery period with one of these patients ultimately requiring admission to the hospital; 69 of 73 patients were ultimately satisfied with the decision for home discharge.
Our patient population has accepted the protocol that we have established at our institution and, in general, prefer being discharged to their home environment with medications that control the expected symptoms. At the present time, approximately 75-80% of our patients choose to be discharged within 8 hours of the embolization procedure. An overnight stay is selected by or recommended to our remaining patients because they are experiencing pain they believe will not be or is not being adequately addressed with our medication regimen or because of a home situation that is not conducive to postoperative recovery.
Of course, the safety of performing this procedure on an outpatient basis needs to be demonstrated before becoming a routine part of clinical practice. Both our published and follow-up studies revealed that an emergency department visit or readmission to the hospital is a rare event during the first 2 days following the embolization procedure. In addition, with appropriate education, patient complaints concerning inadequate pain relief are rare. Therefore, the medication regimen offered to these patients, although somewhat complex, effectively managed the expected symptoms during the recovery period. On our part, we acknowledge the complexity of these regimens by supporting our patients with provider availability and a detailed schedule outlining when each medication should be taken.
It is our expectation that differences in pain thresholds and pain tolerance within different patient populations will continue to support the almost routine overnight observation for the management of the postembolization syndrome. However, with a medication regimen designed to address the postembolization syndrome together with adequate patient education, diligent follow-up, provider availability, and home support by family or friends, the decision as to where a patient can or should recover can be made on a case-by-case basis. When this type of protocol is followed, many patients will elect to recover at home and can do so knowing that their comfort and the ultimate success of the embolization procedure will not be compromised.
In recognition of the shift toward ambulatory care seen in surgery, physicians today have been required to develop protocols that adequately provide relief to patients as they recover from minimally invasive surgical procedures in an outpatient setting.1-2 In the case of uterine fibroids, arterial embolization has become an option for patients seeking organ-conserving treatment since it represents a treatment offering both clinical success and low risk for significant complications. A postembolization syndrome, consisting of pain, nausea, vomiting, fever, and general malaise, is often seen after this procedure and is responsible for much of the discomfort associated with it. We believe that by working closely with the patients undergoing this procedure and by developing a medication regimen designed to address the symptoms expected after it is performed, that uterine fibroid embolization can be performed safely and effectively as an outpatient procedure.
EDITOR’S NOTE: The references for this article are posted with the online version of this story at www.imagingeconomics.com.
Gary Siskin, MD, is division director, Institute for Vascular Health and Disease, Albany Medical College, Albany, NY, [email protected]
Kyran Dowling, MD, is associate professor of radiology, Albany Medical College
Eric G. Dolen, MD, is assistant professor of radiology, Albany Medical College
Steven Quarfordt, MD, is assistant professor of radiology, Albany Medical Center
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- Reidy JF, Bradley EA. Uterine artery embolization for fibroid disease. Cardiovasc Intervent Radiol. 1998;21:357-360.
- Meikle SE, Nugent EW, Orleans M. Complications and recovery from laparoscopy assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol. 1997;89:304-311.
- Ravina JH, Bouret JM, Fried D, et al. Value of preoperative embolization of uterine fibroma: report of a multicenter series of 31 cases. Contraception, Fertilitie, Sexualite. 1995;23:45-49.
- Ravina JA, Bouret J, Ciraru-Vigneron N, et al. Recourse to particular arterial embolization in the treatment of some uterine leiomyoma. Bull Acad Natl Med. 1997;181:233-243.
- Ciraru-Vigneron N, Ravina JH, Aymard A, et al. Arterial embolization of uterine myomata: results of a seven-year study at Hospital Lariboisiere. Presented at: Society of Minimally Invasive Therapy Annual Meeting; 1999; Boston.
- Goodwin SC, Vendantham S, McLucas B, et al. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol. 1997;8:517-526.
- Goodwin SC, McLucas B, Lee M, et al. Uterine artery embolization for the treatment of uterine leiomyomata: midterm results. J Vasc Interv Radiol. 1999;10:1159-1165.
- Hutchins FL, Worthington-Kirsch R, Berkowitz RP. Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri: a review of 305 consecutive cases. Presented at: Society of Minimally Invasive Therapy Annual Meeting; 1999; Boston.
- Spies JB, Scialli AR, Jha RC, et al. Initial results from uterine fibroid embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 1999;10:1149-1157.
- Spies JB, Levy EB, Gomez-Jorge J, Wood BJ, Roth AM, Walsh SM. Uterine fibroid embolization: midterm results. J Vasc Interv Radiol. 2000;11(Part 2):169.
- Siskin GP, Stainken BF, Dowling K, Meo P, Ahn J, Dolen EG. Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients. J Vasc Interv Radiol. 2000;11:305-311.
- Pelage JP, Le Dref O, Soyer P, et al. Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology. 2000;215:428-431.
- Spies QOL, Spies JB, Warren EH, Mathias SD, et al. Uterine fibroid embolization: measurement of health-related quality of life before and after therapy. J Vasc Interv Radiol. 1999;10:1293-1303.
- Worthington-Kirsch R. Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology. 1998;208:625-629.
- Lanocita R, Frigerio LF, Patelli G, Di Tolla G, Spreafico C. A fatal complication of percutaneous transcatheter embolization for treatment of uterine fibroids. Presented at: Society of Minimally Invasive Therapy Annual Meeting; 1999; Boston.
- Vashisht A, Studd J, Carey A, Burn P. Fatal septicemia after fibroid embolization. Lancet. 1999;354:307-308.
- Chrisman HB, Smith S, Ruy R, et al. The impact of uterine artery embolization on resumption of menses and ovarian function. J Vasc Interv Radiol. 2000;11(Part 2):172.
- Pron G, Common A, Sniderman K. Radiological embolization of uterine arteries for symptomatic fibroids: preliminary findings of a Canadian multi-center trial [abstract]. J Vasc Interv Radiol. 1999;10(2, Part 2):247.
- Bradley EA, Reidy JF, Forman RG, Jarosz J, Brause PR. Transcatheter uterine artery embolisation to treat large uterine fibroids. J Obstet Gynecol. 1998;105:235-40.
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- Siskin GP, Stainken BF, Dowling K, et al. Outpatient uterine fibroid embolization: experience in 73 patients [abstract]. J Vasc Interv Radiol. 2000;11(Part 2):190.