Uterine fibroid embolization (UFE) is a minimally invasive procedure performed regularly by Albany IR to treat patients with symptomatic uterine fibroids. Embolization is a procedure that is performed in many other parts of the body for many reasons. It was first used to treat patients with fibroids in France in the early 1990s. We have been offering UFE to patients with symptomatic fibroids since 1998 and have since developed one of the busiest UFE practices in the country. Our experience has been published in several articles in medical journals and our physicians have lectured on this procedure nationally. In addition, we have had the opportunity to lead national teaching programs on UFE and to participate in all clinical trials evaluating the effectiveness of this procedure. Our experience with this procedure pertains not only to the physicians performing the procedure but also to the nurses and technological staff that are integral members of the entire team involved in the care of patients undergoing UFE. As a result, gynecologists in this region have been supportive of our role in the care of patients with uterine fibroids and support their patients as they seek information about the treatment options available to them.
Whiteboard Video On UFE Narrated by Dr. Gary Siskin (http://www.freedomfromfibroids.com).
Indications for Treatment
The UFE procedure is performed in patients with symptomatic uterine fibroids (also known as myomas, leiomyomas, or leiomyomata). Uterine fibroid tumors are extremely common, benign growths of the uterine muscle. They occur in approximately 20-25% of women of childbearing age and are more common in African-American women. Fibroids are the most common reason for women to have a hysterectomy in the United States. While the cause of fibroid development is not known, it is known that fibroid growth depends on hormones such as estrogen since they develop during adolescence and regress after menopause when the ovaries stop producing estrogen.
Most fibroids do not cause symptoms and in fact, most women with fibroids do not know that they have fibroids until they are told about their diagnosis by their gynecologist. However, 10-20% of patients with fibroids will develop significant symptoms, including heavy bleeding, pelvic pain/pressure, frequent urination, abdominal distension, and pain during intercourse. Patients with heavy bleeding can develop an iron-deficiency anemia and may even require a transfusion if the bleeding becomes severe.
Many people ask if candidacy for the UFE procedure depends on where the fibroids are located within the uterus. There are three types of fibroids based on their location within the wall of the uterus. Submucosal fibroids are located inside the lining of the uterine cavity and can grow into the uterine cavity over time. They are often associated with heavy and prolonged menstrual periods. Intramural fibroids develop within the wall of the uterus and they can result in pain/pressure symptoms as well as heavy bleeding. Subserosal fibroids develop in the outer portion of the uterus and can potentially grow into the abdomen. They are usually associated with pain/pressure symptoms. The UFE procedure can effectively treat all of these fibroids and can relieve patients of their associated symptoms
Procedural Details
We perform the UFE procedure in a hospital setting. Once patients arrive in the hospital, an IV is placed within a vein of the arm. The IV is needed so that antibiotics can be administered before the procedure, sedation can be administered during the procedure, and medications to address pain and nausea can be administered after the procedure. In addition to the IV, a Foley catheter is placed within your bladder. This is done for your comfort during and after the procedure and to eliminate the build-up of x-ray dye in the bladder during the procedure. Finally, anti-nausea medication is given to our patients in order to prevent some of the nausea experienced after the procedure. Once these steps have all been completed, you will be taken to one of the interventional radiology procedure suites within the Department of Radiology. In the procedure room, a technologist will clean and prep both the right and left groin prior to the start of the procedure.
The first part of the UFE procedure involves entering the arterial system of the body. This is done via the right common femoral artery, which is the artery responsible for the pulse that you can feel in the right groin. Local anesthesia (lidocaine) is used to numb the area surrounding this artery and once this has been administered, a very small incision is made in the groin and a small needle is placed into the common femoral artery. Once the needle is inside the artery, a wire is advanced through the needle into the artery. This allows us to remove the needle and place a catheter, which is approximately the size of a piece of spaghetti, inside the artery. An angiogram is then performed by injecting X-ray dye into the catheter. This lets us see the arteries of the pelvis so that we can determine where the right and left uterine arteries are located.
Once the uterine arteries have been identified, the catheter is repositioned under X-ray guidance and moved into the left uterine artery. X-ray dye is once again injected in order to confirm the position of the catheter. Once this is done, gelatin-based microspheres (Embosphere Microspheres, Merit Medical Inc.) are injected into the catheter in order to stop the flow of blood within the left uterine artery. This particular agent is FDA approved for use during UFE procedure. Once it is injected, the microspheres cause inflammation, slow blood flow, and clot formation within the artery. The clot that forms within the uterine artery stays within the uterine artery because the vessel beyond the clot is too small for it to pass further into the system. When flow has stopped in the left uterine artery, the catheter is moved into the right uterine artery and the procedure is repeated in order to embolize the right uterine artery. In our experience, most patients can be embolized with a single catheter entering the arterial system on the right side; a second catheter placed into the left common femoral artery is necessary in only the most difficult cases.
Once the right and left uterine arteries have been embolized, a final angiogram is performed in order to confirm the absence of flow in these vessels and to make sure that no other vessels are seen that may be supplying blood to the fibroids. If additional arteries are seen (including the ovarian arteries) then consideration may be given to embolizing these vessels as well. Once the blood supply to the fibroids has been eliminated, the catheter is removed and a seal is placed into the artery to insure that there will be no bleeding from the site. On average this procedure takes less than an hour to complete.
Recovery
It is common for us to hear from our patients that the recovery after UFE is often the most difficult part of the entire experience surrounding this procedure. Following UFE, patients return to an observation area, where they recover with our nursing staff for at least 4-6 hours. During that time, most patients experience pain and nausea due to the effects of the procedure.
The pain and cramping after this procedure can range in severity from very mild to quite severe. This pain is most likely due to the effect that the procedure has on both the fibroids and the normal uterus. Immediately after the procedure, IV medication is given for pain relief and is effective at increasing the comfort of our patients. Depending on the degree of discomfort, these medications are given either upon request to our nursing staff or on-demand by a patient-controlled device. As a result of these medications and the medications given for sedation during the procedure, most patients are drowsy for several hours after the procedure. Nausea can cause a great deal of discomfort to our patients after this procedure and is due to both the effect of the procedure on the fibroid and to the medications given to our patients for pain relief. We have found that this side effect of the procedure can typically be controlled with medication and does not usually last more than 24 hours.
Most patients stay overnight after UFE and are discharged the following morning. Antibiotics and pain medication are supplied to patients upon discharge with a detailed schedule as to when to take each medication. Once discharged, they are taken home by a family member. It is recommended that once patients are home, they limit their activity without any heavy lifting or exercise for at least two days. The recovery period and the way patients feel during the recovery period have varied greatly among the women that we have treated. Normal activity is permitted two days after the procedure. However, an individual patient’s activity will be limited by the degree of pelvic cramping and nausea experienced during the recovery period. After two days, individual tolerance for activity is the best indicator of what a patient can and cannot do.
During the first 5 days after discharge, most patients experience additional episodes of pain. This can catch some patients by surprise as it frequently occurs after 1-2 relatively pain-free days. We therefore recommend that patients follow our pain medication schedule for at least 3-4 days so that they are not caught “off-guard” by these episodes. As the pain improves, narcotics are discontinued and patients are maintained on over-the-counter medications such as ibuprofen. Most of our patients have been able to return to work within 10 days of the procedure. We do recommend that patients abstain from sexual intercourse for at least 2 weeks after the procedure or until any post-procedure discharge they may have been experiencing has stopped.
Results
To date, there have been several hundred articles in the medical literature that have demonstrated the success of UFE in treating patients with symptomatic fibroids. The success of UFE is best measured by its ability to address the symptoms that prompted the patient to seek treatment in the first place. These results have been consistent throughout the many studies evaluating this procedure, with 85-95% of patients citing significant improvement in either abnormal uterine bleeding or bulk-related symptoms such as abdominal distension, frequent urination, or pelvic pain. Most importantly, studies have demonstrated that UFE has been associated with improvements in health-related quality of life. The success of UFE can also be measured in its ability to reduce the volume of the uterus and dominant fibroids. Most studies have shown an average decrease in uterine and fibroid volume of 40-65%.
Recent data has suggested that the ability of UFE to completely devascularize a fibroid (eliminate its blood supply and destroy the tissue) may be the most important effect of UFE as it relates to long-term control of symptoms. If a fibroid has been successfully devascularized, it will demonstrate the signs of tissue death (infarction) on a post-procedure MRI, which is what we look for on the 6-month follow-up MRI that we routinely recommend for all of our patients. This is seen in the MRI images pictured below.
Pre-procedure MRI of the uterus showing a central fibroid that enhances (gets brighter) after intravenous contrast is administered.
Post-procedure MRI of the uterus showing the central fibroid that does not enhance (stays dark) after IV contrast.
While there is robust data that demonstrates the clinical and imaging success of UFE at treating fibroids, the past several years have produced data from several prospective, randomized trials comparing UFE to other procedures. Trials known as the EMMY trial, the REST trial, the HOPEFUL trial, and the FUME trial have directly compared the outcomes after UFE and surgical procedures such as hysterectomy or myomectomy. Each of these trials have continued to demonstrate the success of UFE at treating fibroids.
When evaluating the results seen after UFE, it is important to remember that while 85-95% of patients receive significant clinical benefit, there are 5-15% of patients that do not. Possible explanations for treatment failure include incomplete embolization, extremely large uterine fibroids, the presence of a uterine cancer (leiomyosarcoma) or coexisting disorder such as adenomyosis, and the persistence of alternative sources of blood for the fibroids (such as an ovarian artery or a round ligament artery). Many of these possible causes of treatment failure are actively sought out on images obtained before and during the procedure.
Potential Risks
It is also important to remember that there are potential but rare complications that all patients need to be aware of when considering UFE. One potential risk is that of a uterine infection. This was one of the earliest reported complications of UFE. Most patients with an infection after UFE can be treated successfully with antibiotics while others may require a hysterectomy. In very rare cases, a severe infection can lead to uterine rupture or death. Given the potential severity of an infection, antibiotics are given to all of our patients in association with UFE. In addition, all patients with a prolonged fever (>7 days) are evaluated for a possible uterine infection with a pelvic examination, pelvic imaging, and blood work. Patients may also experience changes in their menstrual cycle after UFE. These changes can range from temporary to permanent loss of normal menstrual cycles and are likely due to the microspheres entering the ovarian circulation. This risk has been shown to increase after 45 years of age. It is also known that submucosal fibroids are at an increased risk for being passed out of the uterus and vagina after UFE. If this occurs, some patients may require further treatment to remove parts of the fibroid that are retained within the uterus in order to minimize the possibility of infection. Other rare complications, such as the development of blood clots in the veins of the leg or in the arteries of the lungs have been reported as has injury to the wall of the uterus due to reduced blood flow, have been reported as well.