Fibroid Infected With Escherichia Coli Requiring Surgical Removal Following Uterine Artery Embolization

BackgroundUterine fibroid necrosis and infection is a rare but potentially serious event following uterine artery embolization (UAE). We describe a case of surgical removal of an infected necrotic uterine fibroid.CaseA 31-year-old Jehovah’s Witness with severe anemia presented with sepsis following UAE. The uterus was preserved by performing transvaginal surgical removal. Final pathology demonstrated Escherichia Coli infection of the necrotic fibroid. The patient improved postoperatively.Conclusionurgical removal of an infected necrotic fibroid may be a preferred option for women wishing to avoid hysterectomy following UAE. Appropriate case selection and optimization of hemoglobin concentration before UAE is important to minimize complications.     

Successful management of cervical pregnancy by selective uterine artery embolization: a case report

BACKGROUND: Cervical pregnancy is potentially associated with life-threatening hemorrhage and often requires hysterectomy to stop the bleeding. Conservative management is becoming more common as treatment of cervical pregnancy. CASE: A case of cervical pregnancy presented with a severe vaginal hemorrhage at 6 weeks' gestation. The patient was conservatively managed with selective bilateral uterine artery embolization (UAE). The vaginal bleeding stopped completely after UAE. The clinical course was uneventful and serum human chorionic gonadotropin decreased immediately. The cervical mass gradually shrank and disappeared on the 31st day after UAE. UAE. CONCLUSION: This was the second case of cervical pregnancy successfully treated with only UAE.     

Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma

BACKGROUND: The treatment regimen indicated for most advanced stage vulvar, vaginal, and cervical cancer usually involves adjuvant chemoradiation therapy. Although the risk of complications is low, there have been reported cases of radiation necrosis and osteomyelitis following treatment for vulvar, vaginal, and cervical cancer. CASES: We present a vulvar cancer patient and a cervical cancer patient, both of whom were treated with radical surgery and postoperative chemoradiation. Following therapy, they were afflicted with pelvic radiation necrosis and osteomyelitis. The patients underwent surgery to resect the necrotic bone tissue and long-term antibiotic therapy to treat their osteomyelitis. They have since recovered and are followed closely by their gynecologic oncology and infectious disease physicians. CONCLUSION: The radiotherapy utilized to treat advanced stage gynecologic cancer can cause intestinal, vaginal, and urologic complications from micro-vascular damage to the organs. Pelvic bone osteonecrosis is a rare but disabling complication of pelvic radiation. Fortunately, with aggressive therapy, these patients may do well clinically.     

Myoma expulsion after uterine artery embolization

Uterine artery embolization (UAE) has become a standard therapy in the treatment of symptomatic uterine myomas. The procedure is associated with a few complications. One of them is myoma expulsion. A 32-year-old woman was sent to our hospital with diagnosed intramural myoma with dysmenorrhea and pressure symptoms. UAE was performed since the patient preferred conservative treatment. The procedure was without any complications. Three weeks after embolization, she was readmitted because of vaginal discharge and minor bleeding. We diagnosed expulsion of necrotic myoma and performed transvaginal resection. Four months later, the patient is symptom free. Expulsion of intramural myoma can be thus considered as definite treatment and not a complication of embolization therapy.     

The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids

OBJECTIVE: To evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids. DESIGN: Multicenter, prospective, single-arm clinical treatment trial. SETTING: Eight Ontario university and community hospitals.Five hundred thirty-eight patients undergoing bilateral UAE. INTERVENTION(S): Bilateral UAE performed with polyvinyl alcohol particles sized 355-500 microm. MAIN OUTCOME MEASURE(S): Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale). RESULT(S): Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%-7%) in women under age 40 to 41% (26%-58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment. CONCLUSION(S): UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high.     

Complete uterine necrosis following chemoradiation for advanced cervical cancer: a case report

BACKGROUND: Radiation therapy is an effective therapy for advanced cervical cancer. Although generally transient, complications of radiation therapy can become severe and require further intervention. Uterine necrosis is uncommon and the management can be complex. CASE: A 46-year-old African American female with stage IB2 squamous cell carcinoma of the cervix was treated with chemoradiation after an aborted radical hysterectomy. Five months after completion, the patient developed severe pelvic pain and persistent vaginal bleeding. Several biopsies confirmed radiation necrosis without evidence of tumor. Due to the severity of symptoms, the patient underwent a total abdominal hysterectomy. CONCLUSION: Uterine necrosis is a rare, late complication after chemoradiation for cervical cancer. Although several treatment options exist for radiation necrosis, surgical intervention may be necessary in severe cases.     

Patient satisfaction and disease specific quality of life after uterine artery embolization

OBJECTIVES: This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after uterine artery embolization (UAE) and to consider the impact of these changes on satisfaction with the procedure. STUDY DESIGN: A validated, fibroid specific, symptom, and HRQOL questionnaire was mailed to 80 women who had undergone UAE from 1998 through 2002. Pre- and postprocedure symptom severity and HRQOL scores were obtained. The primary outcome measure was change in fibroid symptoms and HRQOL after UAE. Secondary outcomes included objective measures of patient satisfaction, and the decrease in uterine volume after UAE. RESULTS: Questionnaires were completed by 64 women (80.0%) at a mean of 32.1 months from UAE (range: 57.5-6 months). After UAE, mean uterine volume decreased by 26.3% (95% CI 19.6-33.0), and 17 of 79 women (21.5%) underwent an additional procedure after a mean of 18.6 months. Symptom severity scores decreased by a mean of 35.2% (95% CI 29.3-41.1) and HRQOL scores increased by a mean of 35.7% (95% CI 28.9-42.4). Satisfaction with UAE was correlated with the change in symptom severity and HRQL scores (P <.0001 and P=.0004, respectively) and the decrease in uterine volume after UAE (P=.0196). CONCLUSION: Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL, associated with high levels of satisfaction with the procedure, even when subsequent therapies are pursued.     

Fibroids Treated With Uterine Artery Embolization: Do Imaging Findings Correlate With Patient Outcomes?

ObjectiveTo evaluate whether changes on ultrasound in uterine and fibroid volume and fibroid vascularity correlate with changes in symptom severity and health-related quality of life (HRQL) perceived by patients after uterine artery embolization (UAE).Materials and MethodsSixty-four women (mean age 45.3) with symptomatic uterine fibroids underwent UAE at the Hysterectomy Alternatives (HAlt) clinic in Winnipeg, Manitoba. They completed a validated questionnaire assessing symptom severity and HRQL at baseline and at three and six months post-embolization, and ultrasound was also performed at these intervals. Changes in uterine and fibroid volume were compared with changes in symptom severity and HRQL. Data from patients with residual fibroid vascularity, extremes of baseline fibroid volume, and concomitant adenomyosis were analyzed to determine whether the outcomes were different in these patient groups.ResultsChanges in uterine and fibroid volumes did not correlate with changes in symptom severity or HRQL after UAE (P> 0.05). Residual fibroid vascularity was a negative predictor of reduction in uterine and fibroid volume (P< 0.05), but did not affect changes in symptom severity or HRQL. Extremes of baseline volume in the dominant fibroid did not affect symptom severity or HRQL. Patients with concomitant adenomyosis experienced greater improvement in symptoms than those without adenomyosis (P< 0.05).ConclusionWe found poor correlation between imaging findings and patient- perceived outcomes after UAE. Ultrasound cannot be used to predict improvement in symptoms or HRQL after UAE.     

Vaginal expulsion of submucosal fibroids after uterine artery embolization. A report of three cases.

BACKGROUND: Since October 1996, at our fibroid center, we have been using the uterine artery embolization (UAE) procedure as a nonsurgical means to treat patients with fibroids and menorrhagia. We have performed this procedure on over 180 patients, 3 of whom experienced vaginal expulsion of submucosal fibroids from two to seven months later. CASES: A 37-year-old woman underwent UAE in November 1997 and expelled five submucosal fibroids two to three months later. A 43-year-old woman underwent UAE in August 1997 and expelled a submucosal fibroid four months later. A 46-year-old woman underwent UAE in April 1997 and expelled a submucosal fibroid seven months later. CONCLUSION: The use of UAE to treat patients with fibroids and menorrhagia is relatively new. Our experience has revealed that a significant percentage of patients who have had the embolization procedure will have reduction in menorrhagia and also in the volume of their fibroids. Complications and side effects have been few. Vaginal expulsion of submucosal fibroids can be viewed as a side effect of the procedure, and, to the best of our knowledge, these are the first reported cases of this postembolization occurrence.     

子宫动脉栓塞治疗子宫肌瘤的疗效和并发症分析

目的　探讨选择性子宫动脉栓塞治疗子宫肌瘤的临床疗效和并发症的发生情况。方法　 2 0 0 0年 10月～ 2 0 0 2年 5月选择 4 0例子宫肌瘤患者用PVA颗粒做栓塞剂行子宫动脉栓塞 ,栓塞后定期评价临床疗效和并发症 ,彩超监测子宫和最大肌瘤体积。根据SCVIR制订的并发症分级系统 ,评价并发症的严重性。结果　4 0例患者行子宫动脉栓塞 ,平均随访 18 9个月 ,97%临床症状改善。子宫和最大肌瘤体积平均缩小 4 3 8%和6 3 5 %。栓塞前子宫和最大肌瘤体积的中位数为 2 4 3 4cm3和 14 8cm3,栓塞后 6个月中位数为 10 7 1cm3和4 1 1cm3,(P <0 0 0 1)。 88 5 %的并发症为A、B级 ,1例 (2 5 % )D级并发症为阴道排瘤继发感染再入院治疗。7例 (17 5 % )较严重的栓塞后综合征。 1例 (2 5 % ) 2年后复发。 4例 (10 0 % )卵巢功能衰竭 ,发生在栓塞后2～ 18个月。 2 0例 (5 0 0 % )患者阴道排液。 92 5 %患者对治疗的结局表示满意。结论　子宫动脉栓塞治疗子宫肌瘤能有效的改善症状 ,缩小瘤体 ,失败率低 ,严重并发症少。术前严格选择适应症 ,术后预防感染是降低并发症的关键。     

子宫肌瘤子宫动脉栓塞术后妊娠情况及影响因素分析

目的:探讨子宫肌瘤患者行子宫动脉栓塞术(UAE)后的妊娠结局,以及肌瘤位置对妊娠率和结局的影响。方法:对行子宫动脉栓塞术的84例有生育要求和497例无生育要求的子宫肌瘤患者进行随访,了解其术后妊娠和产科并发症的发生情况。结果:(1)截止2011年4月,本研究中有50例患者60次妊娠。其中有妊娠要求组共30例39次妊娠,无妊娠要求组共20例21次妊娠。(2)有妊娠要求组妊娠结局为分娩26次(自然分娩9次,剖宫产17次),人工流产4次,自然流产5次,异位妊娠1次,宫内死胎3次(同1人);无妊娠要求组均行人工流产;(2)分娩的26例患者中,发现产科并发症7例26.92%(7/26),其中子痫前期1例3.85%(1/26)、胎盘前置状态1例3.85%(1/26)、早产4例15.38%(4/26)、中央性前置胎盘1例3.85%(1/26);(4)有妊娠要求的单发性肌瘤组(黏膜下、肌壁间、浆膜下、不明)和多发性肌瘤组的妊娠率分别为25.00%、59.09%、62.50%、14.29%和27.58%;单发浆膜下肌瘤组无产科并发症发生,黏膜下子宫肌瘤患者的产科并发症发生率高达75%。结论:子宫肌瘤患者在UAE后可正常妊娠,但自然流产率、胎盘异常等的发生率明显增高,特别是黏膜下和多发性子宫肌瘤患者。     

Outpatient Uterine Artery Embolization for Symptomatic Fibroids: Short- and Long-Term Single Institution-Based Outcomes

ObjectiveTo assess the short- and long-term efficacy and safety of uterine artery embolization (UAE) in the management of uterine fibroids, and to assess patient satisfaction with this procedure when performed on an outpatient basis.MethodsOne hundred one patients who had undergone UAE for symptomatic uterine fibroids in the past five years were interviewed over the telephone, using a standard uterine fibroid symptom and quality-of-life questionnaire. The severity of post-procedural pain, occurrence of adverse reactions, complications, need for subsequent hysterectomy or myomectomy, and overall patient satisfaction were also recorded.ResultsUAE resulted in a mean 39.1 point improvement in fibroid symptom scores and a mean rise of health-related quality of life score to 93.6, which is near normal. The mean pain score was highest (3.7/10) on the first night after the procedure. Ten patients returned to the hospital in the first 48 hours after UAE, but of these only one required admission because of sepsis. The only other major complication was spontaneous fibroid expulsion in one patient. Fourteen patients remained hypermenorrheic, 78 had regained normal or light menses, five reported spotting, and four became amenorrheic. Six patients underwent subsequent hysterectomy and one a subsequent myomectomy. Six patients found the procedure less than satisfactory.ConclusionUAE is a safe, effective, and durable alternative to hysterectomy and myomectomy in women with symptomatic fibroids who wish to avoid surgery. It can be performed safely on an outpatient basis.     

Retained calcified fibroid fragments after uterine artery embolization for fibroids

OBJECTIVE: To document a case of retained calcified fibroid fragments after uterine artery embolization (UAE) for fibroids. DESIGN: Case report. SETTING: Teaching district general hospital. PATIENT(S): A woman with past history of UAE for fibroids. INTERVENTION(S): Bilateral UAE. MAIN OUTCOME MEASURE(S): Retained calcified fibroid fragments. RESULT(S): Retained calcified fibroid fragments can occur after UAE. CONCLUSION(S): Retained calcified fibroid fragments can occur after UAE and may be associated with infertility and menstrual disorders. Measures to detect this complication in women with these problems who have undergone UAE are appropriate.     

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

Objectives  Comparison of medium-term safety and efficacy of hysterectomy and uterine artery embolisation (UAE) for symptomatic uterine fibroids.
Design  Multicentre retrospective cohort.
Setting  18 UK NHS hospital trusts.
Participants  Four hundred and fifty nine women who had hysterectomy within a national audit during 12 months from October 1994 (VALUE study) (average follow up of 8.6 years) and 649 women receiving UAE from 1996 to 2002 (average follow up of 4.6 years).
Methods  Clinical data from existing hospital records and patient completed postal questionnaires.
Main outcome measures  Complication rates, side effects of embolisation, satisfaction with treatment, relief from symptoms and requirement for further fibroid treatment.
Results  Fewer complications were experienced by women receiving UAE (19 versus 26% hysterectomy, P = 0.001), the adjusted odds ratio for UAE versus hysterectomy was 0.48 (95% CI 0.26–0.89). One-third of women undergoing UAE experienced anticipated general side effects associated with the procedure. More women in the hysterectomy cohort reported relief from fibroid symptoms (95 versus 85%, P < 0.0001) and feeling better (96 versus 84%, P < 0.0001), but only 85% would recommend the treatment to a friend compared with 91% in the UAE arm ( P = 0.007). There was a 23% (95% CI 19–27%) chance of requiring further treatment for fibroids after UAE. Twenty-seven women who had had UAE reported 37 pregnancies after treatment resulting in 19 live births.
Conclusions  UAE results in fewer complications than hysterectomy. Side effects after embolisation should be anticipated, and almost one-quarter of women having UAE were likely to require further treatment for fibroid symptoms. Both treatments appear to be safe and effective over the medium term, and the choice of treatment may be a matter of personal preference for each individual woman.     

Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis

OBJECTIVE: To create an endocervical canal in a patient with a complete cervical agenesis. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 12-year-old girl presented with lower abdominal pain. On examination, complete vaginal agenesis was noted, with a 2-cm vaginal dimple. A pelvic magnetic resonance imaging scan disclosed an hematometra and absence of the cervix and vagina. INTERVENTION(S): Initial surgical therapy consisted of a vaginoplasty with a sigmoid bowel segment and opening of the uterus by puncture and stenting. The cervical permeation failed, with immediate complete stenosis. A new attempt was made through a low sagittal hysterotomy by removing a central muscular cylinder and lining the channel with a free tubularized bladder mucosa graft. A stent was left in place. MAIN OUTCOME MEASURE(S): Hysteroscopy, hysterography, and clinical follow-up evaluation. RESULT(S): The cervical stent was removed after 5 months. A hysterography and hysteroscopy confirmed the permeability of the cervix, which was lined by a well-vascularized longitudinally folded mucosa. Regular menses had been noted for more than 3 years as of this report. CONCLUSION(S): Cervicoplasty with mucosal lining permits the creation of a patent cervical canal, even in the reputedly unfavorable forms of congenital cervical agenesis.     

Laparoscopically assisted vaginal hysterectomy in a patient with micro-invasive cervical cancer after two liver transplantations

BackgroundAdvances in surgical techniques and immunosuppressive therapy have improved graft survival in transplant recipients. However, intense long-term immunosuppression increases the incidence of cancer in these patients compared with the general population, not least because of viral infections. Cervical cancer is the third most common malignancy worldwide. In early invasive cervical cancer, surgery is the treatment of choice.CaseIn 2010, we performed a laparoscopically assisted vaginal hysterectomy (LAVH) in a 42-year-old patient with micro-invasive cervical adenocarcinoma (FIGO stage IA1) who had undergone two liver transplantations in 2006 and 2008. The patient was followed up for 18 months after surgery. Despite upper abdominal adhesions and minor difficulties in inserting the Veress needle, the pneumoperitoneum was created safely. The procedure was completed within 157 minutes without any intraoperative complications. Blood loss was less than 100 mL. Postoperative course was uncomplicated with minimal fluctuations in liver function markers. Immunosuppressive therapy was continued without modification. The patient was discharged on postoperative day 9. No complications or recurrence were reported during the 18-month follow-up.ConclusionsThe laparoscopic approach is a justifiable form of surgical management in the treatment of a liver transplant recipient with early-stage cervical cancer.     

Is myomectomy always the best choice for infertile women with symptomatic uterine fibroids?

Uterine artery embolization (UAE) is still regarded by most gynaecologists as contraindicated for women with symptomatic fibroids and otherwise unexplained infertility. For such patients, myomectomy is the usual option. We performed UAE as treatment of menorrhagia in an infertile woman with multiple subserosal and intramural fibroids who had previously failed multiple myomectomy. UAE resulted in durable symptom relief and substantial reduction of the uterine and fibroid size. The patient conceived spontaneously 20 months after UAE and progressed through pregnancy uneventfully. At 38 weeks of gestation, she underwent elective cesarean section and delivered a normal, healthy, 3180-g fetus without complications. The present case demonstrates that in symptomatic women with multiple subserosal and intramural fibroids and otherwise unexplained infertility, UAE may have symptomatic and reproductive outcomes superior to those of myomectomy.     

Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation and subsequent pregnancy in the treatment of early invasive cervical cancer

BACKGROUND: Recently, pregnancies in patients after radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy have been reported. Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation has been previously described; however, subsequent outcome and pregnancy has not. METHODS: Three patients with cervical carcinoma, 1 with stage IA1 with lymph-vascular space invasion and 2 with stage IA2, were treated with radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation. RESULTS: All patients underwent the planned procedure with no significant intraoperative or postoperative complications. All patients had return to normal menstrual function. One patient had a successful pregnancy delivered at 39 weeks by cesarean section and is now subsequently pregnant with a second pregnancy. CONCLUSION: Radical abdominal trachelectomy is a technically feasible operation that uses operative techniques familiar to the American-trained gynecologic oncologist and results in wider parametrial resection than radical vaginal trachelectomy. In young patients desiring to retain fertility, successful pregnancies after radical abdominal trachelectomy are possible. Intraoperative and postoperative complications are likely to be lower with an abdominal versus a vaginal approach. Long-term survival of patients treated with radical trachelectomy for early invasive cervical cancer are yet to be determined.     

Fibroids treated by uterine artery embolization. A review

An increasing number of reports indicate that uterine fibroids can be successfully treated with uterine artery embolization (UAE). UAE seems to be a promising treatment for women who want to retain their uterus. This review summarizes the technical considerations and the results. UAE is a radiological procedure using angiography for visualization of the blood circulation. Subsequently, the flow through the uterine arteries is blocked resulting in infarction of fibroids. Success rates of 87% have been achieved with an average 57% reduction of fibroid volume. Complications have been few compared to hysterectomy and patient satisfaction is high. However, none of the reports include controls. Further studies are needed to optimize patient selection and to evaluate long-term results.     

Recurrent invasive adenocarcinoma after hysterectomy for cervical adenocarcinoma in situ

BACKGROUND: Unlike its squamous counterpart, therapy for cervical adenocarcinoma in situ with positive endocervical cone margin remains controversial. CASE: A 52-year-old gravida 2, para 1,0,1,1, presented with vaginal bleeding. Gynecologic history was significant for cervical cold knife conization with a positive endocervical margin and endocervical curettage with atypical endocervical cells. Repeat cone biopsy was considered unsafe given the large initial cone specimen. An extrafascial hysterectomy was performed 5 weeks later and pathology confirmed a disease-free cervix. Pap smear performed 1 year later was interpreted as recurrent adenocarcinoma but later downgraded to inflammation. Inspection and random biopsies of the vaginal cuff revealed only inflammation. Two subsequent Pap smears also returned inflammation. Seventeen months after the hysterectomy physical examination revealed a 2 x 3-cm smooth mass at the vaginal cuff. Biopsy revealed invasive adenocarcinoma. The patient underwent an upper vaginectomy followed by postoperative pelvic radiation. CONCLUSION: This case suggests that despite extrafascial hysterectomy for presumed adenocarcinoma in situ of the cervix, a residual focus could remain and present later as invasive adenocarcinoma.