by Dr W J Walker MBBS FRCR
Royal Surrey County Hospital, Guildford
Consultant Diagnostic & Interventional Radiologist
The London Clinic, London
Introduction
Uterine artery embolisation (embolization) for fibroids is a relatively new procedure first carried out in France in a small number of cases in the early 90s [1,2]. The procedure which is non surgical involves the occlusion of blood vessels supplying uterine fibroids. Uterine fibroids are benign growths of the uterine muscle occurring in 30-40% of women. Most fibroids do not cause any problems and do not require treatment. Some fibroids however can cause heavy periods which can lead to anaemia and debilitation, or if the fibroids grow large they can lead to ‘compression syndrome’ in which adjacent organs may be compressed such as the bladder leading to frequency of urination, the bowel leading to constipation and bloating or they may cause backache and sciatica.
Procedure - Also see figures 1-5
A tiny catheter is inserted under local anaesthetic into an artery in the right groin. Under X-ray control a micro catheter is introduced selectively into each of the two arteries that supply the uterus. The micro catheter is passed approximately half way down the artery and then fine particles of a solid substance called PVA (Poly Vinyl Alcohol) are injected through the catheter into the uterine artery. The particles are carried to the leash of vessels supplying the fibroids. These vessels become silted up thereby depriving the fibroid of blood which dies and shrinks. PVA is an inert harmless material which has been used to occlude vessels in other parts of the body for decades [3].
Following the procedure the patient usually experiences pain over the next 12 to 24 hours. The pain varies from mild to severe but is adequately controlled by analgesics. Occasionally over the next 3-4 weeks the patient may experience cramps and occasionally some bleeding and if the fibroids are large a mild intermittent temperature. Patients spend 2 days in hospital and are usually advised to take a week off work. In our series the average time to patients feeling completely ‘normal’ is 2.2 weeks.
During the procedure intravenous sedation is administered as required.
World Experience
So far the world experience would indicate a success rate for fibroid embolisation of 85%. The main complication of the procedure is infection leading to hysterectomy. The incidence of this complication is approximately 1-3% (University of California, Los Angeles, and Royal Surrey County Hospital, Guildford, figures). A very small number of patients have stopped having periods altogether following the procedure.
Hysterectomy and Alternatives
The Hysterectomy and Alternatives are drug treatment with preparations such as Zoladex and Synarel but such drugs cause a temporary medical castration, have very unpleasant side effects and only cause transient shrinkage of the fibroids.
The usual surgical alternative to hysterectomy is abdominal myomectomy. In the latter procedure the surgeon attempts to cut out the fibroids leaving the normal part of the womb intact. Myomectomy has been used widely for decades but is a difficult operation with a significant complication rate. Approximately 15% of patients having a myomectomy will require re-operation, usually hysterectomy. Complications include bowel perforation, adhesion formation and haemorrhage. You should ask your gynaecologist whether he or she feels that abdominal myomectomy would be of benefit in your particular case and likely to succeed.
Other surgical alternatives are laparoscopic myomectomy, myolysis and hysteroscopic resection of fibroids encroaching on the uterine cavity.
Fertility
In the world experience 9 patients have become pregnant. One patient who had AIDS aborted and another underwent a termination. The rest have had successful deliveries or are ongoing.
The main surgical alternative to embolisation for those wishing to retain their reproductive potential is myomectomy. You should ask your gynaecologist about the chances of a successful myomectomy and the realistic likelihood of this improving fertility in the case of your particular fibroid problem.
Dr W J Walker, Consultant Interventional Radiologist at the Royal Surrey County Hospital, has so far carried out fibroid embolisation on over 150 patients and has received considerable national coverage; see Publicity section. and also References section [4,5] He has been carrying out embolisations for conditions other than fibroids since 1974.
Most patients have had a successful outcome with marked reduction or elimination of their symptoms and a reduction in fibroid size of between 47 and 100% - average 64%. Current articles on fibroid embolisation by Dr W J Walker are listed in the References section; Articles 6, 7, 8, and 9.
Two infective complications have occurred leading to hysterectomy. Both these patients had possible pre-disposing conditions and since that time we have changed our prophylactic antibiotic regime. One patient had a haemorrhage at 4 weeks requiring a blood transfusion but has had no further complication on follow up. A further patient had an infection treated by hysteroscopy and drainage.
In addition five patients have become amenorrhoeic (stopped having periods) due to ovarian failure. Three patients in their 40s developed transient amenorrhoea only and reverted to a normal hormone profile. The other two patients were perimenopausal, one being 54 and the other 55. It is well known that hysterectomy may also be a cause of ovarian failure and premature menopause.
Patients wishing to undergo fibroid embolisation must understand that this procedure is still in the trial stage and that long term follow-up is not available.
References