Laparoscopic UAO: Minimal Risks, Considerable Benefits
Pain is a considerable feature of the procedure, both from hypoxia and cramping, as the uterus attempts to expel the polyvinyl pellets. Many patients remain in the hospital for 23 hours on a morphine pump.
Up to 15% of patients experience postembolization syndrome, characterized by fever, anorexia, and nausea/vomiting.
Most importantly, radiologic UAE can be performed in patients with undiagnosed cancer that can evade diagnosis for many months.
There are several reports of embolization in a patient with undiagnosed uterine sarcoma.
Endometrial biopsy and MRI can assist in the presurgical diagnosis of sarcoma; however, the laparoscopic approach is clearly more thorough in ruling out cancer.
The only real obstacle to widespread use of laparoscopic UAO is the dearth of advanced laparoscopic surgery training among U.S. gynecologic surgeons. This is a retroperitoneal vascular procedure, requiring skillful knowledge of the vascular anatomy.
Future Vaginal Approach?
Because there appears to be a need for a gynecologic alternative to the increasingly popular radiologic UAE, I have recently been working with colleagues and a private company—Vascular Control Systems of San Juan Capistrano, Calif.—to develop a technique to temporarily occlude the uterine arteries with a Doppler-guided, uterine artery clamp using a vaginal approach.
This procedure is still experimental, and we have thus far achieved fibroid shrinkage of approximately 30%. A clinical trial is under way to advance and improve this technique.
In this view of the left retroperitoneum, two 5-mm endoscopic clips occlude the proximal portion of the left uterine artery.
This uterus is blanched as a result of hypoperfusion and ischemia after laparoscopic bilateral uterine artery occlusion. Photos courtesy Dr. Moises Lichtinger
Gynecologists Strike Back With Laparoscopic Uterine Artery Occlusion
One only needs to check the Internet to see how aggressively our colleagues in radiology are marketing uterine artery embolization/uterine fibroid embolization.
Although the radiologic approach certainly has merit, the risk of inadvertent embolization to other organs is recognized. Laparoscopic uterine artery occlusion not only removes this concern but also returns to the practicing gynecologist the treatment of leiomyomas.
Moises Lichtinger, M.D., is a well-known advocate of laparoscopic uterine artery occlusion for the symptomatic uterine fibroid. Not only has he worked to develop a safe and reproducible technique for the laparoscopic approach, but he is researching a transvaginal approach to uterine artery occlusion as well, in cooperation with Vascular Control Systems of San Juan Capistrano, Calif.
Dr. Lichtinger currently chairs the department of obstetrics and gynecology at Holy Cross Hospital in Fort Lauderdale, Fla.
He received his undergraduate and M.D. degrees in Mexico and completed his internship and residency at Jackson Memorial Hospital in Miami. He remained at Jackson Memorial to complete a gynecologic oncology fellowship as well.
