A study of uterine fibroid embolization with its therapeutic role and complication

 

Yadav Waghaji Munde¹, Kiran Vinayak Naiknaware^2*

 

¹Assistant professor, Department of Interventional Radiology, Bharati Vidyapeeth Medical College, Satara Road, Pune, Maharashtra, INDIA.

²Consultant Interventional Radiologist, Department of Interventional Radiology, 7 Orange Hospital, Pawana Nagar Housing Society, Chinchwad, Pimpri-Chinchwad, Maharashtra 411033, INDIA.

 

Abstract               Background: Uterine fibroids are a major cause of morbidity in women of reproductive age (and sometimes even after menopause). UFE was used since 1995, because the embolization is either solely or primarily performed through the uterine artery, the procedure is often referred to as uterine artery embolization (UAE). Objectives: To see the therapeutic role of uterine fibroid embolization in fibroids with its associated complications. Material and Methods: This analytical prospective study was done on 30 cases with uterine fibroid. Embolization was performed by using 355-500 microns poly vinyl alcohol (PVA) particles. Data analyzed using SPSS version 20. Results: Out of total 30 cases, most common (46%) age group was found to be 40-45 years. Pain in abdomen was the most common symptom seen in 74%. Intramural fibroids seen in majority 60% of study cases. There was statistically significant reduction in volume of fibroid after embolization 83±174cc when compared with before embolization volume 273±567cc. Complications were seen in 11 cases in which post embolization syndrome was most common 6 (54%) complication. Conclusions: UFE is having high success rate and very good fibroid volume reduction in this study.

Key Word: Uterine fibroids, Embolization, Post embolization syndrome.

 

 

INTRODUCTION

Uterine fibroids (also known as leiomyomas or myomas) are the commonest benign uterine tumors, with an estimated incidence of 20%–40% in women during their reproductive years.^1,2 They are monoclonal tumors of the uterine smooth muscle cells and consist of large amounts of extracellular matrix that contain collagen, fibronectin, and proteoglycan.^3,4 Even though their pathogenesis is not clearly known, there is considerable evidence that estrogens and progestogens proliferate tumor growth,^5,6 as the fibroids rarely appear before menarche⁷ and regress after menopause. They are classified by their location relative to the layers of the uterus.⁸ Arterial embolisation is a long-established technique in the treatment of abdominal and pelvic haemorrhage but has only recently been used to treat uterine fibroids. Until recently, surgery has been the only effective treatment for fibroids.^9-13 Hysterectomy is major surgery and disadvantage of myomectomy is the risk of fibroid recurrence and the requirement for further surgery that arises in 5.7% to 51% of patients.¹⁴ UFE has been shown to reduce pain, bulk symptoms (pressure and ab­dominal wall distortion), and menorrhagia in most cases.¹⁵ Although hysterectomy has long been considered the definitive treatment for symp­tomatic fibroids and remains the most common intervention for fibroids, there is growing interest in less invasive therapies and treatments that avoid removal of the uterus, including medical manage­ment, abdominal or laparoscopic myomectomy, endometrial ablation and UFE.¹⁶ So this study was carried out to see the therapeutic role of uterine fibroid embolization in fibroids with associated complication out of it at our hospital.

MATERIAL AND METHODS

This interventional prospective study was conducted at the Department of Interventional Radiology, Bharati Vidyapeet Medical College and Department of Interventional Radiology at 7 Orange Hospital. Total of 34 cases were selected 2 lost to follow up and 2 had technical failure so were excluded from this study. So, 30 cases that completed study follow up formed the sample size. All those with symptomatic fibroids were included in this study. Cases who were pregnant at that time or those desiring pregnancy were excluded. All the cases were informed about procedure and written informed consent was taken. All of the patients were advised to wait 6 months after treatment for pregnancy. Uterine artery embolization was performed by using255e500-mm poly vinyl alcohol (PVA) particles. The preferred endpoint was complete occlusion of flow to the fibroid, with slow flow remaining in the main uterine artery, as described by Spies et al.⁹ All patients were admitted for overnight care, with pain management. Patients were followed-up as visit to hospital with clinical assessment at 1 week, 3 months, and 6 months, with a scheduled visit 1 year after the procedure. On an average all the 30 cases were followed for 1.5 years.

Procedure of UAE: Transfemoral route was used for accessing the arteries. Arteriography was performed for uterine and ovarian artery. Selective catheterization of the contra-lateral internal iliac artery using a Cobra catheter was done under fluoroscopic guidance. 355-500 microns poly vinyl alcohol (PVA) particles used for embolising fibroids arteries.

RESULTS

Figure 1: Distribution as per age

Most common (46%) age group was 40-45 years. Mean age of this study was 46.2±17.6 years.

 

Figure 2: Distribution as per presenting symptoms

Pain in abdomen was the most common symptom seen in 74%, mass in abdomen seen in 39% cases.

 

Intramural fibroids seen in majority 60% of study cases.

Table 1: Reduction in fibroid volumes before and after embolization by ultrasound

There was statistically significant reduction in volume of fibroid after surgery 83 ± 174 cc when compared with before surgery volume 273 ± 567cc.

 

Table 2: Complications of uterine fibroid embolization (JOHN)

Out of 30, complications were seen in 11 cases in which post embolization syndrome was most common (54%) complication seen in this study. Infections, Haematoma were seen in 9% cases.

 

DISCUSSION

This was a prospective interventional study conducted at our hospitals on 30 cases presented with fibroid were taken for fibroid embolization by using 355-500 microns poly vinyl alcohol (PVA) particles. The most common age group presented in this study was 40-45 years which formed 46%. While next common age group was 45-50 which formed 30%. This finding of age distribution was supported by a study done by Subramanian R et al¹⁷, which found 40-45 age group as most common 42%. Our finding was also supported by Lahori et al¹⁸, were majority of cases belonged between 41-50 years (46.84%). Mean age of study cases in this study was found to 46.2±17.6 years. In a study done by Walker et al⁹ the mean age was 43.2 years, while another study done by Dsouza J et al¹⁹ the mean was found to be 36 years. Both of these studies had more or less similar mean age for the study cases. In this study pain in abdomen was the most common symptom seen in 74%, second common symptom mass in abdomen seen in 39% cases. Infertility seen in 9% and prolapse of uterus seen in 3%. In a study done by Dsouza J et al¹⁹ the most common presenting symptom was menorrhagia, 14 (56%) with dysmenorrhoea and 8 (32%) with pressure symptoms. Subramanian R et al¹⁷ study found mass per abdomen in 50% as most common symptom in their study. Bulman JC et al²⁰ study also had similar presenting symptoms in their study. In this study intramural fibroids seen in majority 60% of study cases. In Subramanian R et al¹⁷ study also intramural fibroids were seen as most common (35%) type of fibroids. Dsouza J et al¹⁹ study also found intramural fibroids in 40% cases. Both of these studies supported our findings. In this study there was statistically significant (p<0.05) reduction in volume of fibroid after embolization (83 ± 174 cc) when compared with before embolization volume (273 ± 567cc). Other studies like Walker WJ et al²¹, Pelage JPet al²² and Brunereau L et al.²³also supported our finding of reduction in volume after embolization. Out of 30 cases, 11 showed some kind of complications. ‘Post-embolization syndrome’ which can occur commonly, although it is only severe in a minority of cases. It consists of pain, nausea, a flu-like illness, mild pyrexia and raised inflammatory markers. It was seen as most common complication post UFE in 54% cases. Similarly Dsouza J et al¹⁹ found that pelvic pain was the commonest side effect and complication during UAE with an incidence of 64%.Similarly Soyer P et al²⁴ found more than 50% cases of post-embolization syndrome in their study. Other less common complications were vaginal discharge, temporary amenorrhea similar was seen in Dsouza J et al¹⁹. No any major complications were seen at the end of follow up period. Smaller sample size would be the limitation of this study.

 

CONCLUSION

This study results shows that uterine fibroid embolization is an effective method for fibroids with a low complication and failure rate.

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