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Uterine artery embolization for symptomatic fibroids: Pros and cons

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This procedure—less invasive than hysterectomy or myomectomy—is becoming increasingly popular among patients. Here, a look at the state of the art.


 

References

KEY POINTS
  • Uterine artery embolization (UAE) may be especially useful in women who are poor surgical candidates or have extensive adhesive disease, or who refuse blood products or are perimenopausal.
  • The average reported symptom improvement is 87%; the mean reduction in fibroid volume is 46%.
  • Most patients are discharged within 24 hours of the procedure and experience an average recovery period of 8 days.
  • Women undergoing UAE for fibroids are more likely than those undergoing myomectomy to need further invasive treatment within 3 to 5 years.
  • Although several series and case reports have noted successful pregnancies following UAE, desire for fertility is considered a relative contraindication by some authorities.

With the increasing demand for nonsurgical alternatives to hysterectomy or myomectomy for fibroids, uterine artery embolization (UAE) has grown in use and popularity—and most patients report a high level of satisfaction after the procedure.

UAE has been shown to be safe and effective in selected patients with symptomatic fibroids unresponsive to medical treatment. If they are not contemplating pregnancy and do not have additional pelvic pathology, these women may elect UAE as an appropriate alternative to hysterectomy or myomectomy. This article reviews the indications, contraindications, technique, complications, and outcomes of UAE.

Limits of primary surgeries increase demand for UAE

Most of the 590,000 hysterectomies performed each year in the United States are for symptomatic fibroids, the most common tumors of the female reproductive tract.1 Although hysterectomy is the definitive treatment, increasing numbers of patients express a desire for alternatives, primarily to preserve the uterus. While myomectomy spares the uterus, as many as 25% of women who undergo this procedure require another surgery for recurrent symptoms.2 These limitations of the primary surgeries for fibroids have increased the demand for UAE.

Embolization of the uterine arteries has been utilized for more than 20 years to treat pelvic hemorrhage following delivery or abortion, ectopic or cervical pregnancy, gestational trophoblastic disease, or malignancy.3,4 It was first reported as an effective intervention for fibroids in 1995, when Ravina et al5 noted that several women with symptomatic leiomyomata who underwent UAE as a pre-hysterectomy treatment had such significant clinical improvement that hysterectoMy was no longer required.

In a study involving 200 patients undergoing UAE for leiomyomata, Spies et al6 noted improvement in heavy bleeding in 90% (95% confidence interval [CI], 86%, 95%) and a reduction in bulk-related symptoms in 91% (95% CI, 86%, 95%) at 1 year.

Because data are limited on the safety of pregnancy following uterine artery embolization, some authorities consider the desire for future fertility a relative contraindication.

On a global level, more than 30,000 UAE procedures have been performed for symptomatic uterine fibroids.

A turf war

The economic considerations surrounding uterine artery embolization (UAE) have led to a turf war of sorts between gynecologists and interventional radiologists. In Philadelphia, Pa, the average reimbursement to an interventional radiologist for a UAE is approximately $1,650; for a gynecologist performing a hysterectomy or myomectomy, it is approximately $1,000.

Some Ob/Gyns are reluctant to recommend UAE for their patients for a variety of reasons. Because of this reluctance, UAE is increasingly marketed directly to the consumer over the Internet and in print media. Large proportions of women undergoing UAE are self-referrals or are referred by their gynecologist after specifically requesting the procedure.

UAE may represent a societal savings in terms of direct and indirect costs. For example, a Canadian cost analysis found that UAE was associated with significantly lower hospital costs ($1007.44 Canadian) than abdominal myomectomy ($1,781.73 Canadian).1

Reference

1. Al-Fozan H, Dufort J, Kaplow M, Valenti D, Tulandi T. Cost analysis of myomectomy, hysterectomy, and uterine artery embolization. Am J Obstet Gynecol. 2002;187:1401-1404.

Technique

UAE is a radiologic procedure performed with either local or regional anesthesia. Most commonly, an approach through the right femoral artery is used, after a preliminary arteriogram (FIGURE 1) has been made to visualize the pelvic vasculature.

Fluoroscopic guidance enables a catheter to be passed into the right femoral artery and through the right external iliac artery to the aorta, then down the left common iliac artery to the left internal iliac, down the anterior division, and finally to the left uterine artery. When the catheter is properly positioned, polyvinyl alcohol particles or acrylic copolymer beads (300 microns to 700 microns) are infused until slow flow or stasis occurs in the uterine artery and the fibroid vasculature is occluded (FIGURE 2). The catheter is then pulled back and manipulated into the right uterine artery, which is similarly embolized. Procedure time ranges from 15 to 120 minutes, depending on the patient’s anatomy and the skill of the operator.1,6,7

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