Uterine artery embolisation

Nick Harper4th yr SSC

• Asymptomatic• Heavy uterine bleeding• Pain• Dyspareunia• Pressure symptoms

Uterine Leiomyomas - Fibroids

• Benign monoclonal tumours

• 9% of women < 44 years old

• 40% of women > 40 years old

• Myomectomy• 35,000 a year (US)

• Hysterectomy– 300,000 a year (US)

NICE: Symptomatic Fibroid(s) >3cm:

• Gonadotrophin releasing hormone (GnRH) analogue

• Uterine artery embolisation

Uterine artery embolisation• Day case• Sedation – Diazemuls (5mg/min IV infusion)• Analgesia - Paracetamol (500mg IV)• Local anaesthesia - Lidocaine

• Morphine (5mg IV)

• Metoclopramide (10mg IV)

Seldinger technique

1.

2.

3.

4.

•Polyvinyl alcohol (PVA) particles•Trisacryl gelatin microspheres•Gelatin sponge

•Preferential flow to fibroid vessels

Evidence Base

• Introduced in 1997

• 4 RCTs (n= 403)

• 1 Comparative study

• 3 Case series

• UK registry (n= 1387)

• US registry (n= 2112)

• SymptomsSymptoms improved in 85 – 95% of patients

• 30 – 48% decrease in fibroid volumefibroid volume (all studies)

• Improved quality of life quality of life 39/100 (US registry n=2112)

• 91% would recommendrecommend to a friend (HOPEFUL n=649)

• 90% < 2 nights 2 nights in hospital (Gabriel-Cox n=562)

Efficacy

Complications

Procedure •Early: 6.9% (Mara n=58)

•1st month: 20.7% (Mara n=58)

•1 year: 17.6% (HOPEFUL 649)

Non target emboli•Amenorrhea•Buttock/Bladder•1 death(Goodwin 2009)

Failure•11% required further treatment (UK registry n= 1387)

Fertility •27 women •37 pregnancies •19 live births (HOPEFUL n= 649)

References• Dutton S, Hirst A, McPherson K, et al. (2007) A UK multicentre retrospective cohort study comparing

hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. BJOG 114: 1340–51.

• Edwards RD, Moss JG, Lumsden MA, et al. (2007) Uterine-artery embolization versus surgery for symptomatic uterine fibroids. New England Journal of Medicine 356: 360–70.

• Gabriel-Cox K, Jacobson GF, Armstrong MA, et al. (2007) Predictors of hysterectomy after uterine artery embolization for leiomyoma. American Journal of Obstetrics & Gynecology 196: 588.e1–588.e6.

• Goodwin SC, Spies JB, Worthington-Kirsch R, et al. (2008) Uterine artery embolization for treatment of leiomyomata. Obstetrics & Gynecology 111; 22–33.

• Goodwin, S.C. & Spies, J.B. (2009) Uterine Fibroid Embolization. The New England Journal of Medicine. 361:690-697

• Gupta, J.K., Sinah, A., Lumsden, M.A. & Hickey, M. (2009) Cochrane Review – Uterine artery embolization for symptomatic fibroids. The cochrane collaboration.

• Hirst A, Dutton S, Wu O, et al. (2008) A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technology Assessment 12 (5).

References• Mara M, Maskova J, Fucikova Z, et al. (2008) Midterm clinical and first reproductive results of a

randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovascular & Interventional Radiology 31: 73–85.

• Marshall LM, Spiegelman D, Barbieri RL, Manson JE, Colditz GA, Willett WC, et al.Variation in the incidence of uterine leiomyoma among pre menopausal women by age and race. Obstetrics & Gynecology 1997;90:967–73.

• Moss JG, Lumsden MA, Murray GD, et al. (2010) Long term (3-5 year) follow up and MRI imaging of the REST trial cohort. Unpublished personal communication.

• O’Grady EA, Moss JG, Belli AM, et al. (2009) UK uterine artery embolisation for fibroids registry 2003–2008. The British Society of Interventional Radiology.

• Spies JB, Bruno J, Czeyda-Pommersheim F, et al. (2005) Long-term outcome of uterine artery embolization of leiomyomata. Obstetrics & Gynecology 106: 933–9.

• Volkers NA, Hehenkamp WJK, Birnie E, et al. (2007) Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years’ outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology 196: 519.e1–519.e11.

• Walker WJ, McDowell SJ. (2006) Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies. American Journal of Obstetrics & Gynecology 195: 1266–71.