Embolization Therapy

 

Uterine fibroid embolization (UFE) is a procedure performed by interventional radiologists on an angiography (DSA) device under local anesthesia. After the patient is given pain killers and anxiety relievers, the groin skin is anesthetised and a small incision is made. Next, the groin artery is punctured with a thin needle and a very thin tube (catheter) is advanced into the arteries supplying the uterus. After the necessary angio shots are taken, small particles that block the uterus and myoma vessels are given via this tube. After this procedure, which takes about an hour, control angio shots are taken and the catheter in the groin is removed. To prevent bleeding, the groin artery is manually pressed for 15 minutes and a bandage is applied. ​ ​

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During the embolization, most of the particles delivered from the catheter will go into the fibroid arteries, because fibroids contain much more vessels than the uterine tissue. Since fibroids feed only on the uterine vessels, they cannot withstand ischemia after embolization and die (necrosis) quickly. Only a small part of the particles will also go into the arteries that feed the healthy uterine tissue. However, since the uterus is fed by other vessels from the surrounding organs in the abdomen, it is not damaged by the embolization process. Thus, during embolization process, the normal uterine tissue is preserved and all fibroids, large and small, located inside the uterus become dead. This is easily seen on the control MR images taken after embolization (image) ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

 

After embolization, the majority of patients stay in the hospital for 1-2 days and then go home and resume their daily activities. They can return to their normal lives in an average of 5-7 days. After the procedure, pain, nausea and fever may occur for a few days, but these can be easily relieved with oral over-the-counter medications.

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After embolization, symptoms such as excessive vaginal bleeding, anemia and urinary frequency either improve or disappear in over 90% of the patients. This rate is similar to the rates of hysterectomy and myomectomy. It has been observed that fibroids do not easily recur after a successful embolization. In one study, patients were followed for 6 years and no regrowth of embolized fibroids was observed. If the embolization is insufficient, it can always be repeated, and if the repetition fails, surgical treatment options can always be applied for the patient. Because of these features, embolization is the first line treatment method to be applied in most myoma patients.

 

​ ​ Video: Fibroid embolization animation, Prof Dr Saim Yılmaz ​ ​

 

History

Occlusion of the uterine arteries with particles (embolization) is a method that has been used successfully for decades to stop postpartum or tumor-related vaginal bleeding. It was discovered by chance in the 1990s that the same method could also treat uterine fibroids. ​ ​

 

Uterine fibroid embolization was first reported by a French gynecologist named Jacques-Henri Ravina. In 1989, after reviewing the medical literature he saw that the embolization successfully stopped tumor bleeding in the uterus and thus, he decided to use this method to decrease blood loss during surgery in patients who were going to have myomectomy. Dr. Ravina aimed to first occlude the vessels of fibroids with embolization and then to perform myomectomy in a bloodless and comfortable way. Surprisingly, however, he noticed that some of the patients did not come to the operation since their complaints disappeared after embolization, and that the fibroids were dead and shrank in the majority of those who came to the operation. Based on these observations, Dr. Ravina reported that embolization method can be used as a stand-alone treatment method in the treatment of uterine fibroids.

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Since then, embolization has been widely used in the treatment of uterine fibroids all over the world, especially in Europe and the USA, after the 2000s. With the widespread use of embolization in France, where the method was first applied, there was a dramatic decrease in hysterectomy surgeries performed for myomas, and this decline began to be seen in other European countries also.

 

Today, more than 25,000 myoma embolizations are performed each year in the USA alone and more than 100,000 in other countries, and this number is increasing every year. Condelisa Rice, one of the former foreign ministers of the USA, also chose this method for the treatment of her fibroids in 2004 and was successfully treated.

 

​ ​ Video: Myoma embolization from A to Z, Prof Dr Saim Yılmaz ​ ​

 

Risks of Embolization

Fibroid embolization is a very safe treatment method, and the rate of complications (treatment-related problems) is lower than myomectomy and hysterectomy. However, like any treatment, some side effects may occur after embolization: ​ ​ Amenorrhea (cessation of menstruation) may be seen after the procedure in a small proportion of patients. This event is usually temporary, but may be permanent in approximately 1-5% of patients. Persistent amenorrhea is more common in women over 45 years old and approaching menopause. In less than 1% of patients, uterine infection may develop after embolization and additional treatments may be required. Again, less than 1% of patients may develop non-microbial inflammation and associated vaginal discharge after the procedure. In 2-3% of patients, embolized fibroids can be expelled from the vagina as if giving birth. This makes it easier for the fibroids to disappear and is usually what most patients want. However, large pieces of fibroids may sometimes cause pain when expelled through the vagina.

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Advantages of Embolization

Embolization has the following advantages over myomectomy and hysterectomy  used in the treatment of fibroids: ​ ​ 1. The procedure is performed only by numbing the groin, no general or regional anesthesia are required. 2. Since there is no blood loss, no blood transfusion is required. 3. There is no surgical incision and no scar. The whole treatment is applied through a 2mm angio hole in the groin. 4. The hospital stay and return to normal life are much shorter. 5. Complications related to the procedure may occur, but this complication rate is much lower than myomectomy and hysterectomy. 6. Unlike hysterectomy, the uterus and ovaries are not removed, so that both fertility is preserved and the problems caused by hysterectomy are not experienced. 7. Unlike myomectomy, where not only the fibroids that can be removed are treated, all the uterine fibroids can be treated without a single incision. For this reason, recurrence rate is much lower than myomectomy.

 

​ ​ Video: 5 reasons to prefer embolization in myoma, Prof Dr Saim Yılmaz '

 

The Effect of Embolization on Fertility

There are many women who become pregnant after embolization and have completely normal births. Therefore, it is generally believed that embolization therapy does not interfere with conception and healthy delivery. However, there is a small theoretical risk of damage to the ovaries and uterus during the embolization procedure. This risk is especially relevant when using very small occlusive particles and aggressive embolization. However, this risk is minimal if medium-large particles are used during embolization and the embolization is terminated when the main vessels of the uterus begin to become occluded. The risk of damaging the uterus during myoma treatment is also present in other treatment methods; The sutures used during myomectomy may cause infection, adhesions and deformation in the uterus. If the bleeding cannot be stopped, emergency hysterectomy may be required. In HIFU and percutaneous ablation, the heat applied to the fibroid may also damage the surrounding tissues and the inner surface of the uterus.

 

In conclusion, each treatment option in myoma may affect the possibility of pregnancy in a positive or negative way. Studies comparing treatment methods on this subject are few. In a recent study, the rates of getting pregnant after myomectomy and embolization were found to be the similar in patients with fibroids who wanted pregnancy (Pisco et al, Fertil Steril 2010). ​ ​

 

Video: Myoma embolization and pregnancy, Prof Dr Saim Yılmaz

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