Laparoscopic UAO: Minimal Risks, Considerable Benefits

Use uterine countertraction on the ipsilateral side while identifying the round ligament. Incise the posterior broad ligament laterally next to the round ligament over the psoas muscle, using endoscopic scissors.

This will free periadnexal adhesions and release uterine lateral displacement from myomas; it also avoids injury to the femoral vessels.

Grasp the cut edges of peritoneum and pull them laterally. Dissect to below the round ligament and lateral to the uterus.

Identify the lateral umbilical ligaments—vestigial obliterated umbilical arteries that reflect from the anterior peritoneum and become retroperitoneal in this avascular area. Trace the fibrous white element cephalad.

When this ligament is pulled laterally, it is easy to visualize the origin of the uterine artery by following the fibrous, bloodless, obliterant hypogastric artery to the internal iliac artery. This artery is straight for the first 2–3 cm, where it can be seen pulsating; it then becomes tortuous and surrounded by veins as it crosses medially above the ureter. It is an extensible artery that tolerates significant maneuvers.

Apply two successive preloaded 5-mm or 10-mm vascular clips at an area that is devoid of venous plexus, further from the ureter and more lateral to the uterus than during laparoscopic hysterectomy.

We do not dissect the round ligaments, vesicouterine space, or ureters.

Blanching of the uterus can be observed once both arteries are occluded.

Manageable Complications

In our study, there were no perioperative complications, and estimated blood loss was less than 25 dL in all cases. The average operating time was 35 minutes, which we have now reduced to 20 minutes in our current experience of more than 100 cases.

Postoperative pain was managed by nonsteroidal anti-inflammatory drugs in all but one case, a patient who requested parenteral narcotic analgesia in the recovery room. In our more recent experience, the majority of patients require only ibuprofen, with an occasional use of Vicodin or Tylenol #3. The study patients were discharged after 12–20 hours, a period primarily for monitoring purposes related to the protocol; today, our patients go home the same day as their surgery.

Among eight patients in the study, seven reported complete resolution of fibroid-related pain at 3 months. One patient's pain declined from moderate to mild. These results have remained consistent in our larger series.

The five patients who previously reported menorrhagia reported eumenorrhea; no patients became amenorrheic. We have seen two patients in our larger series become menopausal, but both were older than 50 years at the time of surgery. None of the patients we have followed with FSH levels has lost ovarian function.

The average decrease in uterine volume at 3 months was 39.4%.

One of our patients has become pregnant and is currently doing well at 20 weeks' gestation.

Complications have been few. Among our original study patients, one passed round tissue vaginally 3 months postoperatively, but her white blood count was normal and she showed no signs of infection.

Simple endometrial adenomatous hyperplasia was diagnosed on the day of another patient's procedure; repeat office curettage showed benign endometrium 3 months later.

We bill for this procedure using code #37617 (ligation of major artery of the abdomen), after having obtained precertification with insurance companies. We have had no trouble being reimbursed for the procedure.

This procedure carries a very low risk of anesthesia complications, and abdominal entry injuries are possible.

Any procedure involving UAO has potential complications related to uterine ischemia.

Prolapse, vaginal expulsion of necrotic tissue, and pelvic infection are possible. Selecting patients who have adequate perfusion around myomas may decrease the risk of postocclusion infection.

Patient selection is also important with regard to myoma size. Laparoscopic visualization becomes difficult in patients beyond a 20-week gestation uterine size, and we therefore refer these patients for embolization if they will not consider myomectomy or hysterectomy.

A Comparison of the Two Procedures

As opposed to radiologic embolization, which is a blind procedure, laparoscopic UAO offers an opportunity to diagnose endometrial cancer and sarcomas via fine-needle aspiration and myometrial biopsy.

Additionally, it can be offered as a global treatment for gynecologic complaints other than leiomyomas.

The majority of patients who are candidates for these procedures also have adhesions and/or endometriosis that may be a cocontributor to their pelvic pain.

In conclusion, we have found that the risks of laparoscopic UAO are minimal, and the benefits to carefully selected patients are considerable.

By contrast, radiologic UAE is a simple procedure that has been proven efficacious for reducing symptoms. It is not, however, without risks.

Misembolization has been reported to the collateral uterine-ovarian vessel and the legs. Unintended embolization can lead to ovarian failure in 1%–4% of cases.