Open access peer-reviewed chapter
Abstract
Uterine artery embolization (UAE) was presented as a treatment for symptomatic uterine fibroids in the early of 1990s, after initially being used as a temporary surgical procedure before the performance of hysterectomy or myomectomy. Although the existence of intraoperative complications is associated with overall survival, plenty of these complications can be prevented. Until recently, surgical management represents the treatment of choice regarding the uterine fibroids. With the arrival of UAE, the percentage of major complications such as intraoperative bleeding, adhesions and ureteral injury is decreasing. The ultimate scope of the problem remains the proper management accompanied by knowledge and experience.
Keywords
- Uterine embolization
- fibroids
- hysterectomy
1. Introduction
1.1. Uterine fibroids
Uterine fibroids are very common, non-cancerous (benign) growths that develop in the muscular wall of the uterus. Other names for fibroids include Leiomyoma, Leiomyomata, Fibromyomas, Fibromas, Myofibromas, and Myomas. They are composed of smooth muscle and connective tissue developing and enhancing the uterus wall. They can present in a very wide range of sizes, from small to enlarged myomas. Africans, in comparison with Caucasians, are three times more prone to uterine fibroids formation. They account for one third of all hysterectomies performed in the United States —approximately 100,000 procedures every year. Due to their enlarged size, fibroids deform the abdominal cavity. In most cases, more than one are detected inside the peritoneal wall.
Due to their location, uterine fibroids can be classified into the following categories:
Submucosal fibroids. Fibroids that grow into the inner cavity of the uterus (submucosal fibroids) are more likely to cause prolonged, heavy menstrual bleeding and infertility problems for women trying to achieve a pregnancy.Subserosal fibroids. Fibroids that project to the outside of the uterus (subserosal fibroids) can sometimes press on the bladder, causing urinary symptoms. If fibroids bulge from the back of the uterus, they occasionally can press into either the rectum, causing a pressure sensation, or the spinal nerves, causing backache.Intramural fibroids. Some fibroids grow within the muscular uterine wall (intramural fibroids). If they are large enough, they can distort the shape of the uterus and cause prolonged, heavy menstrual cycles, as well as pain and pressure.
According to the size, the symptomatology can vary from pressure to abdominal pain and signs of peritoneal obstruction. Vaginal bleeding accompanied with episodes of metrorrhagia, especially in premenopausal women could disturb their daily activities and their quality of life. Other symptoms comprise heavy, prolonged menstrual periods and unusual monthly bleeding, sometimes with clots; this medical situation could lead to anaemia. Fibroids’ existence may also be detected via pain in the back and legs, pain during sexual intercourse, bladder pressure leading to a frequent urge to urinate, and pressure on the bowel, leading to constipation and bloating.
Figure 1.
Classification of uterine fibroids (2011 Essential Oils Books.)
2. Diagnostic procedures
The diagnosis of uterine fibroids could be made via the taking of a detailed medical history, an assiduous physical examination, and proper imaging techniques. The anamnesis history may also include details such as the age of the patient, possible anomalies of the menstrual cycle, episodes of abdominal pain, and urgent pressure resulting from incontinence. Information on factors such as episodes of metrorraghia and diffuse vaginal bleeding could produce a successful diagnosis. The role of transvaginal ultrasonography in diagnosis is unquestionable.
Figure 2.
Ultrasonographic depiction of uterine fibroid.(Arrow). Wilde Sue and Scott-Barrett Sarah. Radiological appearances of uterine fibroids. Indian J Radiol Imaging. Aug 2009; 19(3): 222–231.
Uterine fibroids appear as well-defined solid masses with a similar echogenicity to the myometrium. They can deform the uterus’ contour, resulting in a bulky formation. Submucous fibroids could be easily differentiated from the endometrium layer but not so easily from endometrial polyps. CT examination might not prefer to choose imaging regarding the diagnosis of pelvic masses. In many cases, uterine myomas reflect a bulky, deformed uterus or a mass in continuity with the uterus.
Figure 3.
CT scan showing multiple uterine fibroids.(Arrows). Wilde Sue and Scott-Barrett Sarah. Radiological appearances of uterine fibroids. Indian J Radiol Imaging. Aug 2009; 19(3): 222–231.
The sensitivity and specificity of the MRI reflect on the accurate preoperative diagnosis of uterine myomas. The imaging findings consist of an excellent delineation of both internal and external uterine contours, measurement accuracy of intercornual diameter, visualization improvement of the endometrial architecture, and identification of uterine horns.
Figure 4.
Sagittal T2 weighted MR image showing a large fibroid mass extending to upper endplate of lumbar spine. Madhuri TK, Kamran W,Walker W, Butler-Manuel S.Synchronous
3. Management options
Leiomyomas may develop in the myometrium cavity, occasionally in the cervix, broad ligament, and ovaries. Most frequently, they develop in the myometrial wall and could lead to uterine distortion. The treatment of choice consists of surgical or laparoscopical myomectomy avoiding all the intra- or postoperative complications. The advantages regarding laparoscopic myomectomy involve less blood loss, shorter hospital stays, and fewer intraoperative complications. The technical skill required for the excision of myoma and a lack of surgical experience are considered significant limiting factors to the wide acceptance of this technique.
Factors such as diffuse abdominal bleeding, adhesions, and multiple and enlarged myomas contraindicate the use of laparoscopic management. In cases of episodes of vaginal bleeding accompanied with abdominal pain, constipation, and ureter obstruction, the choice of a hysterectomy seems mandatory. Among all the intraoperative complications, the necessity of the treatment of the fibroid bleeding appears to be paramount. Specific research takes place continuously regarding the development of an ideal, minimally invasive method, trying to reach the goals of a treatment that is safe and tolerated well. Plenty of surgical or non-surgical methods have been performed, such as laparoscopic uterine ligation, myomectomy, and high-intensity, focused ultrasound. The arrival of uterine artery embolization (UAE) has changed all the therapeutical options. No limitations appear regarding the fibroids’ size and number that can be treated with UAE.
4. Uterine arteries embolization
4.1. Basic principles
The embolization of uterine fibroids arteries represents a minimally invasive procedure as far as the treatment of uterine fibroids is concerned. Indications of uterine artery embolization are the following:
Trauma
Malignant gynaecological tumours
Post-labour bleeding
Bleeding following gynaecological surgery
This specific technique manages to be extended during the last two years enhancing the management of arterial venosus malformations of the genital tract and gestational trophoblastic disease. The limitations of uterine fibroid embolization (UFE) are many, and subsume women with no symptomatology regarding their condition, existence of cancer, or pelvic infection. Women with a known allergy to contrast materials should undergo preoperative treatment or follow a different treatment option. The gold standard is based on fibroid reduction by obstructing its vessels with embolic elements during the catheterization of uterine arteries. Through this procedure, a successful devascularization and prolonged quality of life can be achieved. The fibroid shrinkage may cause a significant decrease of all intra- or postoperative complications.
4.2. Equipment
Before the performance of the procedure, it is mandatory to perform a preoperative depiction of the uterine cavity, certifying that uterine fibroids are the main cause of the uterine bleeding, and the number, the size, and the location of uterine myomas. The appropriate information should consist of many details, such as gestational status, known allergies, reception of medications such as NSAIDs, and known medical status. The necessary equipment is the following:
X-ray equipment
Catheter
Embolic material
The presence of fluoroscopy for the transformation of the X-rays into video depictions is obligatory. The catheter encloses a long plastic tube approximately 1/8 of the catheter in diameter. The necessary embolic agents are the following:
Calibrated microspheres of 500, 700, and 900 μm, alone or in combination
Gelfoam, a gelatine sponge material
All the mentioned substances certify the safety and effectiveness of the procedure regarding the uterine fibroid embolization. In conclusion, the necessity of an intravenous line and the monitoring of heartbeat and blood pressure should always be stressed. During the procedure, all the security instructions should be followed, achieving the prevention of all possible intraoperative complications.
Figure 5.
Procedure of uterine fibroid embolization (Medscape)
Figure 6.
Left: A large fibroid is seen in the uterus (arrows). Right: Four months following uterine fibroid embolization, the fibroid has substantially decreased. (Fibroid.png)
Figure 7.
Uterine arteries embolization. Pre- and Post-embolization angiogram.(Georgetown University Hospital-Divison of Vascular and International Radiology)
4.3. Procedure
Transcatheter arterial embolization represents an alternative type of hysterectomy regarding the treatment of symptomatic uterine myomas. By the time the embolic agents are injected inside the uterine arteries, they can reach the entire arterial central branch, including the arterial in- and outflow. The successful collateral blood supply provides arterial flow, prohibiting the ischemic establishment of the area. The impact of the embolic agents could produce conditions of shrinkage throughout the uterine fibroids. This ischemic devascularization prohibits intraoperative bleeding and the following hysterectomy. The success rate depends on the skills and the expertise of the surgeon.
Additionally, blood pressure monitoring, oxygen flow, and available sedatives in case of pain during the injection appear necessary. The next step reflects the transformation of the X-ray guidance into video depiction. At the end of the procedure, the transarterial catheter is removed and a haemostasis of the area is achieved by applying local pressure. The majority of the women on whom this procedure was performed declared that they were satisfied: an average of 50%. The ultimate goal depends on the fertility rate regarding nulliparous premenopausal women. For women who are interested in future fertility, a myomectomy seem to be a suitable choice. In general, uterine fibroid embolization seems to be a safe procedure in correlation with all intraoperative instructions, minimizing all intra- or postoperative complications.
4.4. Complications
During the procedure of uterine arteries embolization concerning the treatment of uterine fibroids, many intra- or postoperative complications could emerge. The complication rate depends, as mentioned, on the skill and expertise of the surgeon. Infection, local bleeding, or local hematoma represent the earliest postoperative complications.
Allergic reactions or spasms of the uterine arteries with the after-effect of pain, due to contrast medium and local ischemia, can be treated with vasodilator agents or micro-catheter techniques. The intraoperative abdominal pain in terms of the local ischemia responds to NSAIDs. Postoperative infection followed in many cases, as local or diffuse sepsis caused by endometritis or tubo-ovarian abscess, which can be treated preoperatively with broad spectrum antibiotic agents according to established guidelines. In many cases, episodes of pain persistence over two weeks after the procedure have been reported. In these conditions, and in the case of an absence of infection, surgical intervention seems mandatory. The possibility of hysterectomy due to chronic abdominal pain is estimated in 2% of the women who underwent uterine embolization.
The procedure of uterine arteries embolization can lead to postembolization ovarian failure in women over 45. The pathophysiologic mechanisms remain unknown. The whole procedure is significant, mostly in cases of fertility preservation. The postoperative impact of uterine arteries embolization reflects the improvement of menstrual disorders. Improvement during episodes of menorrhagia and metrorrhagia has been reported. In many cases, the generated embolization can lead to amenorrhea due to ovarian failure. Uterine wall defects, episodes of uterine fistula or uterine necrosis represent neglected cases of uterine arteries embolization. Due to treatment failure, the possibility of hysterectomy performance after uterine arteries embolization appears as a reality. The main causes reflect the existence of persistent bleeding, abdominal pain, fibroid prolapse, and episodes of uterine malignancies.
Figure 8.
Arteries of the female reproductive tract (
4.5. Other techniques
The uterine arteries embolization regarding episodes of symptomatic uterine fibroids represents the treatment of choice in cases of diffuse intraoperative abdominal bleeding. Apart from this skilled and expertised procedure, alternative techniques such as ligation of uterine arteries or providing pharmaceutical agents such GnRH agonists with the ultimate scope being the increase of apoptosis among symptomatic fibroid muscle cells may emanate.
In cases of symptomatic uterine fibroids, focusing on fertility preservation via a laparoscopic ligation of uterine arteries seems to be a logical option. It reflects an effective procedure and stands as a worthy alternative to hysterectomy or myomectomy. Necessary conditions required for this procedure may be laparoscopic skills and the precise location of the uterine vessels. The collateral blood supply could lead to shrinkage due to ischaemia and infraction. The procedure can be performed laparoscopically or abdominally, though the laparoscopic procedure is superior. Every procedure has specific indications and contraindications. The crucial condition concerning the success rate increase remains the performance in centres with appropriate expertise in laparoscopic surgery. If these conditions cannot be fulfilled, massive abdominal bleeding could occur with the final result being the performance of a hysterectomy.
The existence of vaginal spotting after uterine ligation is considered to be a prohibitive factor. The second alternative procedure represents the supply of GnRH agonists with the principle example being the use of triptorelin. The pharmaceutical impact of GnRH agonists reflects the cell death, cell necrosis, and finally apoptosis. As result, all the apoptotic cells could lead to vessel obstruction and decrease of uterine flow. This procedure deputizes as its ultimate goal the fibroid shrinkage and the management of possible intraoperative bleeding. New strategies have been conducted in order to minimize the operative complications. The hysteroscopic endometrial ablation represents an alternative option. All these non-surgical procedures increase the fertility preservation in women of reproductive age.
Many studies must be further conducted, in order for precise and detailed results to emerge. The research steps must follow all the current guidelines focusing on the minimization of all intra- or postoperative complications. The ultimate goal remains the increase of survival rates and improvement of the surgical procedure. In comparison with all mentioned techniques, the B-Lynch technique represents an alternative procedure with remarkable results regarding fertility preservation and the management of operative bleeding after resection of uterine fibroids. The special advantage of this innovative technique is that it presents an alternative to major surgical procedures for controlling pelvic arterial pulse pressure, or hysterectomy. To date, this suturing technique, when applied correctly, has been successful with no problems and no apparent complications.
Figure 9.
Schematic depiction of B-Lynch technique. (B-Lynch & Shah, A Comprehensive Text Book of PPH 2nd Ed. 2012)
5. Fertility preservation
The fibroid shrinkage due to uterine artery embolization in young nulliparous women, and especially the management of extensive metrorrhagia, involves important issues regarding fertility preservation. Due to the arrival of reports describing gestation and labour after uterine artery embolization (UAE), many alternative procedures have been performed.
Many studies reported individually with respect to postoperative complications. Many cases reported episodes of miscarriage, preterm deliveries, pre-eclampsia, and intrauterine growth restriction, as well a high incidence of caesarean sections. Finally, several cases of intrauterine adhesions, endometrial atrophy, and fistula creation between the uterine cavity and the embolized intramural myoma have been reported in the current literature. Despite all the intra- or postoperative complications, uterine artery embolization prevents hysterectomies. This procedure must be properly planned depending on the haemorrhagic conditions of the disease and the surgical expertise of the surgeon.
Uterine artery embolization (UAE) has gained a great impact due to its uterus preservation, a necessary condition regarding female psychological and reproductive status. Uterus preservation is related to female psychosocial integrity and decreases anxiety and depression in correlation with women who have undergone hysterectomies. Many studies have reported the correlation between the performance of hysterectomy, and psychological and bodily disorders. In our period, in a world characterized by anxiety, economical, and physical stress, and difficulties within human relationships, fertility preservation has a high value. Nulliparous women feel mutilated after the performance of a hysterectomy, unable to achieve the ultimate aim of childbirth. All these reports try to demystify concepts such as uterine artery embolization and fertility preservation. Multidisciplinary cooperation is mandatory for ultimate procedure management.
6. Patient counselling
The most significant factor for uterine artery embolization involves patient counselling. The patient must be informed regarding the procedure, all intra- or postoperative complications, as well as conditions which are related to fertility preservation and the increase of life expectancy. Prior to any management procedure, all patients need evaluation through their medical history and physical examination. Daily habits, reception of medicament agents, and menstrual disorders must be mentioned in order to make clear the correlation with the management options.
The next step will be the evaluation of the severity of the lesion. Imaging findings and laboratory examination could confirm the results from the physical examination. A basic principle will be the constant updating regarding all the predisposing factors, which could influence the management selection. The patient must understand all the possible management options, the mechanisms procedure, and decide on the ultimate management option. The physician’s duty will be analysis and understanding the condition’s status. The final decision depends on the patient. A well-informed patient together with the medical stuff will map the proper procedure, taking into consideration not only the marital and reproductive status, but also the individual family planning of the patient.
All studies derived from the current bibliography agree that patient counselling could produce fewer intra- or postoperative complications and increase the life expectancy rate. Besides the preoperative patient counselling, an important role could be played by the well-trained psychologists and health professionals concerning the postoperative course. They should inform the patient regarding the postoperative options in order to prevent the possible stress and depression that could emerge. The postoperative mapping after uterine artery embolization as an alternative to a hysterectomy consists of future pregnancy. Many studies must be conducted in order to ensure future results.
7. Conclusion
Embolization of uterine arteries in cases of symptomatic fibroids introduces a vital and precise procedure in order to minimize all the intra- or postoperative complications, as well as to increase life expectancy and survival rates. Surgical skills, patient counselling, and properly trained medical staff should be taken into consideration as the proper indicators of the uterine arteries embolization. Multidisciplinary cooperation is mandatory with a view to proper and uneventful management.
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