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Uterine Fibroid Embolization
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In France during mid 1980's, Jacques Ravina, MD, observed
that some of his patients receiving uterine embolization as
pre-operative maneuver before myomectomy experienced resolution
of their symptoms and canceled their surgeries. Later that year
a group of physicians from UCLA, a gynecologist and an interventional
radiologist, initiated the use of UFE as primary treatment for
uterine fibroids. It is estimated that more than 100,000 women
have undergone this treatment worldwide. Yearly 15,000 to 18,000
cases are performed each year in the United States.
It is estimated that 80% of women who have fibroids with
symptoms are candidates for UFE. Patients should be symptomatic
with respect to their fibroids. Balk symptoms include pain
or urinary frequency, excessive bleeding, or both.
Approximately 90% of patients will have resolution of their
heavy bleeding or pelvic pain and pressure. Symptom relief
is the goal of the therapy. In three months after UFE patient
symptoms are better even though an imaging study will not
show the fibroids to be completely resolved. Fibroids will
continue to shrink beyond this time, and the patient will
continue to improve. Of course, the bigger the fibroid, the
longer it will take to shrink and for the patient to achieve
symptom relief.
The vast majority of patients will be back at work in a week
to 10 days. There are plenty of patients or ready to be back
to full activity or nearly full activity in about three to
four days, and then there are others we need to weeks. Heavy
lifting and deep bending are avoided for a few days after
the procedure, as is routine after any arterial puncture.
Myomectomy is the standard of care for fibroid treatment
in women who want to preserve fertility. Compared with myomectomy,
UFE is superior in terms of durability and relieving bleeding
symptoms and sometimes the pain. However it is not quite as
effective as myomectomy for relief of pressure symptoms, at
least initially: it takes a bit longer to see improvement
because volume reduction after UFE is a gradual process, rather
than immediate as it is after myomectomy. One drawback of
myomectomy is that although their larger fibroids are removed
small seed fibroids a left behind and can continue to grow.
The recurrence rate of fibroid symptoms after myomectomy is
10% per year, cumulative. Therefore, three years after the
procedure, about a third of patients will experience symptoms
again, and by 10 years, patients who have not yet entered
menopause will have at least some of their symptoms return.
There are no comparable 10-year data for recurrence of symptoms
after UFE.
UFE is performed as any other angiogram. After preparing
the skin at the strain local anesthesia, a needle is placed
into the femoral artery and then switched for a diagnostic
catheter. Fluoroscopy is used to guide the catheter into the
uterine artery where tiny round particles are injected directly
into the main uterine artery segment; individual fibroids
are not injected. There is variety of embolic materials used
for this procedure. Also different embolic material is used
for women that wish to preserve fertility.
Blood flow carries the particles into the uterus, where they
permanently lodge in the small vessels around the fibroids
to block the flow of the blood and oxygen to these fibroids.
The fibroid choke, shrink, and die, and a body converts them
into scar tissue. This process is called hyaline degeneration,
and is similar to what occurs naturally after menopause. Fibroids
need estrogen as much as oxygen to live; after menopause,
they stop receiving any estrogen and turn into scar tissue.
Since the entire uterus is embolized, every fibroid, including
seed fibroids, is infarcted. Clinical studies have shown that
UFE does not affect the rest of the uterus because there is
sufficient collateral blood flow to maintain a healthy myometrium.
There are women who have had successful pregnancies after
UFE, and most women continue to have menses on a normal schedule
after the procedure. That said advisability of UFE in women
who desire future fertility currently remains unresolved.
UFE is an outpatient procedure and our centers are designed
specially with this procedure in mind. Patients usually return
home after resting a few hours while being carefully monitored
in our specialty center. Following release, any pain or inflammation
can usually be handled with over-the-counter analgesics and
prescribed medications.
The most significant complication with UFE is infection,
which fortunately is relatively uncommon. About 5% of patients
will slough at fibroid. Complications associated with the
Artriography itself are about 1 in 1000 to 1 in 500.
Based on 30-day and one-year data, close to 90% of patients
responded to UFE during this time. Most patients, particularly
those over 30 years of age, experienced durable responses
to the treatment. Recurrence of symptoms and repeat procedures
occur in about 10% of patients by 3 years, and we predict
that about 20% of patients will have another procedure after
UFE in five years. These rates are the same as or better than
the rate seen with myomectomy.
We tell our patients to take one week off from work or from
routine activities. The average recovery time is four days.
Almost every patient who was not back to baseline in four
to five days is constipated, and this condition is a major
factor in the discomfort at that time.
Universally, patients who have had both myomectomy and UFE
report that the pain after myomectomy was much greater than
after UFE. Intuitively, it is not difficult to understand
why this is so. Studies have demonstrated lower pain control
requirement for patients recovering from UFE than for those
recovering from myomectomy or hysterectomy.
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