Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids

Purpose

To evaluate the efficacy of pre-myomectomy uterine artery embolization with gelatin sponge particles to reduce operative blood loss and facilitate removal of fibroids.

Materials and methods

This retrospective study included 33 women (mean age, 36 years; range, 24-45 years), of whom at least 18 wished to preserve fertility. They presented with at least one large myoma (mean diameter, 90 mm; range, 50-150 mm) and had undergone preoperative uterine artery embolization with resorbable gelatin sponge by unilateral femoral approach between December 2001 and November 2008. Clinical, radiological and surgical data were available for all patients. Mean haemoglobin levels before and after surgery were compared with Student's t-test.

Results

No complication or technical failure of embolization occurred. The myomectomies were performed during laparotomy (25 cases) or laparoscopy (8 cases). Dissection of fibroids was easier (mean, 3 per patient; range, 1-11), with a mean operating time of 108 ± 50 min (range, 30-260 min). Bloodless surgery was the rule with a mean estimated peroperative blood loss of 147 ± 249 mL (range, 0-800 mL). Mean pre-(12.9 ± 1.3 g/dL) and post-therapeutic (11.4 ± 1.2 g/dL) haemoglobin levels were not statistically different (p > 0.05). There was no need for blood transfusion. None of the patients required hysterectomy. The mean duration of hospital stay was 7.5 ± 1.3 days (range, 3-12 days).

Conclusion

Preoperative uterine artery embolization is effective in reducing intraoperative blood loss and improves the chances of performing conservative surgery. It should be considered a useful adjunct to myomectomy in women at high hemorrhagic risk or who refuse blood transfusion.     

Preoperative Uterine Artery Embolization (PUAE) Before Uterine Fibroid Myomectomy

Purpose To evaluate the potential of uterine artery embolization to minimize blood loss and facilitate easier removal of fibroids during subsequent myomectomy. Methods This retrospective study included 22 patients (median age 37 years), of whom at least 15 wished to preserve their fertility. They presented with at least one fibroid (mean diameter 85.6 mm) and had undergone preoperative uterine artery embolization (PUAE) with resorbable gelatin sponge. Results No complication or technical failure of embolization was identified. Myomectomies were performed during laparoscopy (12 cases) and laparotomy (9 cases). One hysterectomy was performed. The following were noted: easier dissection of fibroids (mean 5.6 per patient, range 1–30); mean intervention time 113 min (range 25–210 min); almost bloodless surgery, with a mean peroperative blood loss of 90 ml (range 0–806 ml); mean hemoglobin pretherapeutically 12.3 g/dl (range 5.9–15.2 g/dl) and post-therapeutically 10.3 g/dl (range 5.6–13.3 g/dl), with no blood transfusion needed. Patients were discharged on day 4 on average and the mean sick leave was 1 month. Conclusion Preoperative embolization is associated with minimal intraoperative blood loss. It does not increase the complication rate or impair operative dissection, and improves the chances of performing conservative surgery.     

子宫肌瘤病理血管彻底性栓塞治疗的临床研究

目的　研究用聚乙稀醇颗粒 (PVA)彻底栓塞子宫肌瘤病理血管的临床效果。方法　对30例子宫肌瘤患者通过超选择性两侧子宫动脉插管 ,用直径为 2 5 0～ 35 5 μm的PVA 10 0～ 2 5 0mg将子宫肌瘤病理血管彻底栓塞。结果　 30例栓塞成功率 96 .7% ,随访 3～ 12个月。术后第 1个月月经恢复正常 2 6 /2 7例 ;贫血好转 2 0 /2 1例 ;下腹部坠痛不适减轻 15 /17例 ;肿块消失 1/3例 ;肿瘤压迫症状全部消失。术后 3个月瘤体平均缩小 40 %以上 ;术后 6个月瘤体平均缩小 5 0 %以上 ,其中 2例完全消失 ;术后 9个月瘤体平均缩小 6 0 %以上 ,其中 3例完全消失 ;无 1例出现严重并发症。结论　超选择性两侧子宫动脉插管将肌瘤病理血管用PVA彻底栓塞是子宫肌瘤安全、有效的治疗方法     

Outcomes After Unilateral Uterine Artery Embolization: A Retrospective Review

Purpose Bilateral uterine artery embolization (UAE) is considered necessary to provide effective treatment for symptomatic uterine fibroids. Occasionally, only unilateral embolization is performed, and this study evaluates these outcomes. Materials and Methods As part of a prospective observational study of more than 1600 patients treated with UAE since 1996, there have been 48 patients in whom unilateral embolization has been performed. This study retrospectively reviews clinical response as assessed by our standard questionnaire and radiological response assessed by either magnetic resonance imaging or ultrasound. Results Two principal groups emerged: the largest, where only the dominant unilateral arterial supply was electively embolized (30 patients); and the second, where there was technical failure to catheterize the second uterine artery as a result of anatomical constraints (12 patients). Favorable clinical response with a reduction in menorrhagia at 1 year was seen in 85.7% (18/21) of those patients with a dominant arterial supply to the fibroid(s). In contrast, in those patients where there was technical failure to embolize one uterine artery, there was a high rate of clinical failure requiring further intervention in 58.3% (7/12). Comparison of the technical failure group with the dominant uterine artery group demonstrated a statistically significant (Fisher’s exact test) difference in the proportion of patients with evidence of persistent fibroid vascularity (p < 0.001) and requiring repeat intervention (p < 0.01). Conclusion We conclude that unilateral UAE can achieve a positive clinical result in the group of patients where there is a dominant unilateral artery supplying the fibroid(s), in contrast to the poor results seen following technical failure.     

Patient radiation exposure in uterine artery embolization of leiomyomata: calculation of organ doses and effective dose

The goal of this study was estimation of patient effective dose from uterine artery embolization of leiomyomata. Parameters and data relevant to patient dose were recorded for 33 consecutive procedures. Using Monte Carlo simulation of radiation transport, organ and effective doses were calculated in detail for a subset of five procedures, to estimate the effective dose for all procedures. Mean dose area product was 59.9, median 23.4, and range 8.8–317.5 Gycm². Mean absorbed ovarian dose was calculated as 51 mGy in the five procedures. Using the dose conversion factor estimated from the Monte Carlo simulation for all procedures a mean estimated effective dose of 34 mSv (median 13 mSv, range 5–182 mSv) results, with a tendency to lower values regarding the succession of the procedures. Patients radiation exposure level is up to twice of that of an abdominal CT examination . Angiographic equipment related dose-reducing features and radiographic technique essentially influence organ doses and effective dose. Consistent application of dose-reducing techniques and awareness of radiation exposure justifies uterine artery embolization as a therapeutic option for the treatment of uterine fibroids.     

Midterm Clinical and First Reproductive Results of a Randomized Controlled Trial Comparing Uterine Fibroid Embolization and Myomectomy

The purpose of this study was to compare the midterm results of a radiological and surgical approach to uterine fibroids. One hundred twenty-one women with reproductive plans who presented with an intramural fibroid(s) larger than 4 cm were randomly selected for either uterine artery embolization (UAE) or myomectomy. We compared the efficacy and safety of the two procedures and their impact on patient fertility. Fifty-eight embolizations and 63 myomectomies (42 laparoscopic, 21 open) were performed. One hundred eighteen patients have finished at least a 12-month follow-up; the mean follow-up in the entire study population was 24.9 months. Embolized patients underwent a significantly shorter procedure and required a shorter hospital stay and recovery period. They also presented with a lower CRP concentration on the second day after the procedure (p < 0.0001 for all parameters). There were no significant differences between the two groups in the rate of technical success, symptomatic effectiveness, postprocedural follicle stimulating hormone levels, number of reinterventions for fibroid recurrence or regrowth, or complication rates. Forty women after myomectomy and 26 after UAE have tried to conceive, and of these we registered 50 gestations in 45 women. There were more pregnancies (33) and labors (19) and fewer abortions (6) after surgery than after embolization (17 pregnancies, 5 labors, 9 abortions) (p < 0.05). Obstetrical and perinatal results were similar in both groups, possibly due to the low number of labors after UAE to date. We conclude that UAE is less invasive and as symptomatically effective and safe as myomectomy, but myomectomy appears to have superior reproductive outcomes in the first 2 years after treatment.     

子宫肌瘤血管造影特点及对栓塞治疗的意义

目的 研究子宫肌瘤血管造影表现特点及对栓塞治疗的意义。资料与方法 本组75例，其中黏膜下肌瘤9例，肌壁间肌瘤50例，浆膜下肌瘤16例。单发肌瘤21例，多发肌瘤54例。局麻下采用Seldinger技术经右侧股动脉穿刺插管，应用5F Cobra导管分别插入双侧子宫动脉造影，观察子宫肌瘤供血动脉、肌瘤的血管网及其肌瘤的形态、大小、部位及数目、供血类型，然后进行栓塞治疗。结果 (1)一侧子宫动脉供血为主型，即一侧子宫动脉的供血量超过子宫肌瘤主体的1／2，表现该侧子宫动脉明显增粗，供血范围达到或超过肌瘤染色的1／2，38例，占51％。(2)双侧子宫动脉供血为主型，即双侧子宫动脉的供血量均超过子宫肌瘤主体的1／2，28例，占37％。(3)单纯一侧子宫动脉供血型，即肌瘤的血供全部来源于一侧子宫动脉，而另一侧子宫动脉不参与供血，9例，占12％。结论 无论是一侧子宫动脉供血为主型，双侧供血为主型，还是单纯一侧供血型子宫肌瘤都应行双侧子宫动脉栓塞才能彻底切断子宫肌瘤的血供。对于单纯一侧子宫动脉供血者，栓塞时供血侧应用永久性栓塞剂，另一侧应用短效栓塞剂，可避免侧支循环的形成和子宫肌层的坏死。     

真丝线段颗粒栓塞双侧子宫动脉治疗子宫肌瘤(附300例报告)

目的：探讨治疗子宫肌瘤的新方法,方法：首次以真丝线段颗粒为栓塞剂,运用介入血管插管技术超选择栓塞双侧子宫动脉治疗300例子中肌瘤。（1）两次栓塞法：分次栓塞双侧子宫动脉。（2）一次栓塞法;一次穿刺同时栓塞双侧子宫动脉。结果：（1）子宫肌瘤血管造影表现：小肌瘤无阳性征象,大肌瘤血供非常丰富,部分肌瘤血供来自肌瘤侧子宫动脉,部分肌瘤双侧子宫动脉的参与供血,另外,发现10例患者一侧子宫动脉发育缺如,此种变异尚未见报道,（2）肌瘤较术前明显缩小,临床有效率98.4%。（3）贫血明显改善。（4）月经量减少,经期恢复正常。结论：真丝线段颗粒栓塞双侧子宫动脉治疗子宫肌瘤是一种疗效好、创新小的新方法,值得应用和推广。     

超选择子宫动脉栓塞术治疗子宫肌瘤疗效及并发症分析

目的：研究超选择子宫动脉栓塞术（UAE）对子宫肌瘤的临床疗效。方法：我院于1999年8月－2001年6月对405例子宫肌瘤患者进行双侧子宫动脉栓塞并对其进行随访分析疗效。结果：插管的成功率为99．8％，随访3－12个月。B超示术后3个月肌瘤体积平均缩小40％－60％，6个月后子宫肌瘤体积平均缩小50％－70％，其中22个肌瘤消失。96％的患者症状消失或改善，并发症发生率1％。结论：子宫肌瘤的介入治疗是一种创伤小，恢复快，疗效肯定的方法。     

MR Venography of Deep Veins: Changes with Uterine Fibroid Embolization

Deep veins (DVs) can be compressed by a uterus enlarged with fibroids. The purpose of this study was to assess the degree of luminal narrowing of DVs caused by a myomatous uterus, and the change in DV narrowing in women with symptomatic fibroids after embolization using time-of-flight (TOF)-magnetic resonance venography (MRV). Twenty-nine consecutive women with symptomatic uterine fibroids underwent TOF-MRV and pelvic MRI before and 4 months after embolization. Based on the TOF-MRV, we evaluated the luminal narrowing of three DVs, including the inferior vena cava, and the bilateral common and external iliac veins, and divided the findings into three grades. The scores for each DV were added for each patient (lowest, 0; highest, 6). DV scores and symptom severity (SS) scores were compared between the baseline and 4 months after embolization using the paired t-test. The relationship between DV scores and uterine volume was investigated using Pearson’s test. DV scores decreased significantly, from 1.52 ± 1.70 at baseline to 0.93 ± 1.56 at 4 months after embolization (p = 0.004). The uterine volume decreased from 948 ± 647 mL at baseline to 617 ± 417 mL at 4 months after embolization (p < 0.001). DV score correlated with uterine volume (r = 0.856, p < 0.001). SS scores decreased from 54.5 ± 14.6 at baseline to 26.8 ± 15.4 at 4 months after embolization (p < 0.001). In conclusion, the degree of luminal narrowing of DVs caused by a uterus with fibroids is correlated with the uterine volume. Uterine artery embolization may induce an improvement of luminal narrowing of DVs due to a reduction of the myomatous uterus volume.     

子宫动脉栓塞治疗子宫肌瘤的疗效评价

1995年Kavin首次应用子宫动脉栓塞术治疗症状性子宫肌瘤获得成功,子宫肌瘤体积缩小20％～80％,并可减少子宫肌瘤引起的月经过多,缓解贫血症状,被认为是可以代替外科手术切除子宫治疗子宫肌瘤的新方法。近年这一疗法应用的报道较多。我院1999年5月～2004年5月应用此法治疗子宫肌瘤75例,现将有关结果报道如下。     

超选择栓塞供血动脉治疗子宫肌瘤的临床研究与应用

目的：通过DSA研究子宫肌瘤（UM）的供血和超选择栓塞其供血动脉探讨其治疗效果。方法：83例UM患者经超声、血管造影确诊后，超选择UM供血动脉注入白芨微粒混悬剂栓塞。结果：83例插管成功率100%并栓塞相应供血动脉。随访6个月16例（19.2%）患者UM消失、63例（75.9%）不同程度缩小，81例（97.6%）月经周期恢复正常。结论：超选择栓塞UM供血动脉，能使UM缺血、变性、坏死和萎缩，UM行介入治疗是一种微创、安全有效的新方法。     

中晚期肺癌动脉聚乙烯醇栓塞的疗效分析

目的探讨聚乙烯醇(PVA)颗粒动脉灌注栓塞治疗晚期支气管肺癌的近期疗效。方法对31例中晚期肺癌患者进行选择性支气管或肋间动脉造影,造影确定有富肿瘤血供动脉后行灌注栓塞术,先行将5-FU、阿霉素(THP)、顺铂灌注再用PVA颗粒经导管栓塞患侧供血动脉。结果31例患者中供血动脉以支气管动脉为主者21例,以肋间动脉为主者10例。治疗后临床症状改善率100%,且无严重并发症,有效率为80.6%(25/31)。结论PVA颗粒选择性栓塞治疗中晚期支气管肺癌具有较好的临床疗效,安全性高且并发症较少。     

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience

Objective

To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids.

Materials and methods

Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids.

Results

UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n = 6), open laparotomy (n = 3), hysteroscopy (n = 2), or laparoscopy and hysteroscopy (n = 1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14–37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman.

Conclusion

In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.     

白芨加明胶海绵栓塞治疗子宫肌瘤的临床应用

目的：探讨白芨加明胶海绵栓塞治疗子宫肌瘤的临床应用,了解此方法的疗效;不良反应及并发症。方法：采用Seldinger技术,对21例子宫肌瘤患者进行选择性子宫动脉栓塞。通过动脉导管注入白芨微粒和明胶海绵颗粒,阻断肌瘤供血。结果：血管造影发现子宫肌瘤主要由双侧子宫动脉供血,血供丰富,双侧子宫动脉栓塞后,肌瘤部位血管征象消失,治疗后3－6个月随访结果表明：肌经治疗前缩小38％－90％,临床症状改善,1例因感染而行子宫切除。结论：白芨加明胶海绵栓塞治疗子宫肌瘤近期临床效果好,远期疗效尚有待观察。     

子宫动脉造影解剖分析及对栓塞治疗子宫肌瘤的指导意义

目的研究子宫肌瘤血管造影表现特点及其临床价值。方法75例患者,经临床症状,彩超和(或)CT检查确诊子宫肌瘤,其中黏膜下肌瘤9例,肌壁间肌瘤50例,浆膜下肌瘤16例;单发肌瘤21例,多发肌瘤54例。经右侧股动脉穿刺插管,导管分别插入双侧子宫动脉造影,观察内容包括：子宫动脉的起源及其分支、不同类型子宫肌瘤的血管造影表现,然后进行栓塞治疗。结果①大多数患者子宫动脉大部分发自髂内动脉的臀下动脉阴部干,其次为髂内动脉主干和臀上动脉。②子宫肌瘤供血情况分为：a、一侧子宫动脉供血为主型。b、双侧子宫动脉均衡供血型。c、单纯一侧子宫动脉供血型。③卵巢支的栓塞几乎不可避免,其临床后果仍存在争议。结论子宫动脉栓塞是治疗子宫肌瘤的一种安全有效的方法,熟悉子宫肌瘤的血管解剖对提高技术成功率、合理选用栓塞方法有重要意义。     

单纯子宫动脉栓塞术在宫颈妊娠刮宫术前预防出血的应用

目的：探讨单纯子宫动脉栓塞术联合刮宫术治疗宫颈妊娠的临床疗效。方法对31例确诊宫颈妊娠患者,行超选择性子宫动脉插管后注射明胶海绵颗粒进行栓塞治疗,术后24-48h再行刮宫术。结果31例患者双侧子宫动脉超选择性插管及栓塞成功率均为100％,血β-HCG水平术后7-15天恢复正常,术后24-48h行刮宫术胚胎组织易于剥离,出血量少在5-25ml之间。结论单纯子宫动脉栓塞术能明显降低宫颈妊娠刮宫术中大出血的风险,成功率高、安全有效。     

子宫肌瘤导管栓塞治疗后的病理改变

探讨子宫肌瘤行经导管子宫动脉栓塞(TUAE)治疗后的病理变化及临床意义。研究证实,TUAE后肌瘤组织随时间改变呈现动态病理变化,即先发生充血、水肿,随后发生坏死,最后出现纤维组织增生,这一动态病理变化是TUAE后肌瘤体积不断缩小的病理基础。绝大多数肌瘤呈不完全坏死,因此肌瘤可能复发。影响坏死范围的因素包括肌瘤大小与部位及栓塞后时间长短。TUAE后正常子宫组织可能出现炎症反应,但无坏死改变。周围附件器官末梢血管发现栓塞剂,提示TUAE对卵巢、输卵管功能有潜在的影响。     

经导管子宫动脉栓塞治疗症状性子宫肌瘤的临床观察

目的:探讨经导管子宫动脉栓塞术(UAE)治疗症状性子宫肌瘤的临床疗效及副反应。方法:选择有明显临床症状的32例子宫肌瘤患者,运用Seldinger技术超选择性子宫动脉插管,以平阳霉素碘油乳剂进行栓塞,术后3个月、6个月、8个月1、2个月观察疗效。结果:32例患者在术后随访12个月,子宫体积平均缩小60.6%,肌瘤体积平均缩小76.3%。所有病例,月经恢复正常,贫血改善,压迫症状基本消失,未出现严重并发症。结论:UAE治疗症状性子宫肌瘤是一种疗效显著、安全性高的微创治疗方法。     

Uterine artery embolization for adenomyosis without fibroids

AIM: To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for symptomatic adenomyosis in patients without uterine fibroids. MATERIALS AND METHODS: Uterine artery embolization using polyvinyl alcohol particles sized 250-710 mm was performed in 43 patients (mean; 40.3 years, range; 31-52 years) with dysmenorrhoea, menorrhagia, or bulk-related symptoms (pelvic heaviness, urinary frequency) due to adenomyosis without fibroids. All patients underwent pre-procedural and 3.5 months (range 1-8 months) follow-up magnetic resonance imaging (MRI) with contrast enhancement. Clinical symptoms were also assessed at the time of MRI before and after embolization. RESULTS: Significant improvement of dysmenorrhoea (95.2%) and menorrhagia (95.0%) was reported in most patients. Contrast-enhanced MRI revealed non-enhancing areas suggesting coagulation necrosis of adenomyosis in 31 patients (72.1%), decreased size without necrosis in 11 patients (25.6%), and no change in one patient (2.3%). The mean volume reduction of the uteri after uterine artery embolization was 32.5% (from 321.7+/-142.9 to 216.7+/-130.1 cm(3)). CONCLUSION: Transcatheter uterine artery embolization is an effective therapy for the treatment of symptomatic pure adenomyosis, and may be a valuable alternative to hysterectomy.