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.     

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。     

Uterine artery embolization as a treatment option for uterine myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options.The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.     

Uterine artery embolisation for the treatment of symptomatic uterine fibroids: short-term results of work in progress

Bilateral uterine artery embolisation (UAE) was used to treat 11 women with symptomatic uterine fibroids. Uterine volume and dominant fibroid volume were assessed quantitatively by ultrasonography both before and at two and six months post procedure. Both uterine arteries were occluded effectively in all of the women, and the procedure was well tolerated, with hospital stays limited to 24-48 hours in all cases. An improvement of symptoms occurred in 10 of the 11 women. There were no significant complications. The mean percentage reductions in uterine volume and dominant fibroid volume at six months following the procedure were 45.32% and 56.34%, respectively. Bilateral uterine artery embolisation for the treatment of uterine fibroids is a minimally invasive technique with very good clinical results. This procedure may be considered as an alternative to hysterectomy, or myomectomy in properly selected cases.     

Treatment of uterine fibroids by embolization--advantages, disadvantages, and pitfalls

Uterine fibroids are the most common benign tumors of the female genital tract. Apart from vaginal or abdominal hysterectomy, which has been in use for more than 100 years, the more recently established techniques of laparoscopy and hysteroscopy provide two additional treatment approaches. In cases of symptomatic uterine fibroids, the most widely accepted alternative to surgery is the catheter-supported embolization of uterine arteries (uterine artery embolization, UAE). All patients who wish to be treated by UAE because of symptomatic fibroids should be presented to both gynecologists and radiologists. To the best of our knowledge, there are no interdisciplinary guidelines for UAE. Therefore, it would be very helpful if gynecologists and radiologists could reach an agreement for both indications and treatment strategies. However, there is no defined "gold standard" for fibroid therapy at all. In this respect, the therapeutic approach should be influenced less by the preference of the (potential) surgeon, and more by factors like size, localization, and number of fibroids. In addition, symptoms, ethnicity, and the wish to have children should be considered. Cooperation between radiologists and gynecologists is absolutely necessary, not only for the choice of the optimal treatment and care of patients, but also for the development of useful guidelines and future studies. UAE may be a therapeutic approach for selected patients. In these special cases, embolization is a safe and practical alternative to the established treatment options.     

Clinical experience and fertility outcome after uterine artery occlusion and embolization

We evaluated the effects of uterine artery occlusion and embolization on clinical results and pregnancy outcome using information provided by the literature published in the MEDLINE biomedicine database. Uterine artery occlusion has the potential to compromise fibroid growth and its symptoms. There were only a few complications and adverse events associated with laparoscopic uterine artery occlusion (LUAO) and fibroid embolization. LUAO and uterine artery embolization (UAE) procedures are both minimally invasive operating procedures that preserve the uterus and ovarian blood supply and allow achievement of pregnancy in women with symptomatic fibroids. Women who became pregnant after uterine artery occlusion and embolization had increased risk of abortion, pre-term birth, malpresentation, and/or caesarean delivery.     

Endoscopic management of uterine fibroids

Uterine fibroids are the most common benign tumours of the uterus. Management depends on the symptoms, location and size of the fibroids, and the patient's desire to conceive. Surgical management of uterine fibroids has changed from laparotomy to minimally invasive surgery. Uterine fibroids are usually asymptomatic and do not require treatment. Laparoscopic myomectomy is the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. The authors' criteria for laparoscopic myomectomy are a fibroid of <15 cm in size, and no more than three fibroids with a size of 5 cm. Compared with laparotomy, laparoscopic myomectomy has the advantages of small incisions, short hospital stay, less postoperative pain, rapid recovery and good assessment of other abdominal organs. Due to the concern of decreased ovarian reserve, uterine artery embolization is not advisable for these women. In addition, it is associated with high risks of miscarriages, preterm delivery and postpartum bleeding. Laparoscopic myolysis causes severe adhesion formation. Women with submucous fibroids receive myomectomy by hysteroscopy. For women who have completed their family, laparoscopic hysterectomy could be performed. Most fibroids can be managed endoscopically either by laparoscopy or hysteroscopy. Surgeon expertise, especially laparoscopic suturing, is crucial. Laparoscopic myomectomy is still the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. Hysteroscopic myomectomy is an established surgical procedure for women with excessive uterine bleeding, infertility or repeated miscarriages.     

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.     

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.     

子宫肌瘤的非手术治疗进展

子宫肌瘤是发病率高且发病机制不明的良性疾病。目前子宫肌瘤剔除术或子宫切除术是传统治疗最常用的方式,但对于要求保守治疗或有生育要求的女性,追求最佳治疗选择显得尤其重要。目前,GnRH激动剂/拮抗剂、选择性孕激素受体调节剂、左炔诺孕酮宫内缓释系统、子宫动脉栓塞、高强度聚焦超声等非传统手术治疗从不同角度为子宫肌瘤的保守治疗提供了新的治疗选择。     

Spontaneous vaginal expulsion of an infected necrotic cervical fibroid through a cervical fistula after uterine artery embolization: a case report

BACKGROUND: Uterine artery embolization (UAE) is promising, minimally invasive therapy being offered to women for treatment of fibroids. Although it seems to be safe and effective, major complications and adverse outcomes have been reported. CASE: A patient treated with UAE for a huge cervical fibroid presented with an infected, necrotic cervical mass lesion 4 weeks after the procedure. Spontaneous vaginal expulsion of the infected cervical fibroid from the left lateral cervical fistula tract occurred 3 weeks later while the patient was receiving antibiotic therapy. After 6 months of intervention, an approximately 99% regression rate in the fibroid volume was achieved. The patient gave birth to a healthy, female infant following a spontaneous, uneventful pregnancy and vaginal delivery. CONCLUSION: UAE appears to be associated with a significant reduction in fibroid volume. Expulsion of the infected, necrotic parts of the fibroid after UAE may be accepted as a natural process. Warning the patient about this potential risk, early recognition of infective complications and lose follow up seem to be crucial to avoiding potentially fatal septic shock.     

Treatment of uterine fibroids for abnormal uterine bleeding: myomectomy and uterine artery embolization

Uterine myoma is a common benign tumour in women and most cases do not require treatment. Excessive uterine bleeding is usually due to a submucous myoma or an intramural myoma that is encroaching into the uterine cavity. After eliminating endometrial malignancy, perimenopausal women could be managed expectantly or with gonadotrophin-releasing hormone agonist until menopause. Hysteroscopic myomectomy is highly effective in controlling menorrhagia that is related to submucous myoma. Concomitant endometrial ablation improves menorrhagia; however, the subsequent hysterectomy rate remains the same. For those with an intramural myoma, abdominal myomectomy results in good bleeding control. It could also be done by laparoscopic approach; however, the surgeon should have expertise in laparoscopic suturing and the uterine incision should be properly sutured. In women who have completed their family, hysterectomy remains the most effective treatment for excessive uterine bleeding. Compared with uterine artery embolization (UAE), it is associated with better improvement in pelvic pain. Nevertheless, UAE is a good alternative to hysterectomy.     

Ischemic uterine rupture and hysterectomy 3 months after uterine artery embolization

The exact frequency and extent of complications after uterine artery embolization (UAE) have yet to be documented in the literature. Ischemic necrosis and rupture of the uterus is a theoretical concern of this procedure. Rupture of the uterus from any cause is a very serious gynecologic complication requiring immediate surgical intervention to prevent death. Ischemic necrosis and rupture of the uterus can occur months after UAE. In our patient they occurred 3 months after UAE for treatment of symptomatic uterine myomas, and required hysterectomy. To our knowledge, this is the first report of ischemic uterine rupture after UAE in the United States.     

Modern management of uterine fibroids

Uterine fibroids are the most common tumor of the reproductive tract in women of reproductive age. Although they are benign tumors that are often asymptomatic, uterine fibroids may cause debilitating symptoms in many women, such as abnormal uterine bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, pregnancy loss, dyspareunia, and in some cases infertility. Several approaches are available for the treatment of uterine fibroids. These include pharmacologic options, such as hormonal therapies and gonadotropin-releasing hormone agonists; surgical approaches, such as hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, magnetic resonance imaging-guided focused ultrasound surgery, and uterine artery embolization. The choice of approach may be dictated by factors such as the patient's desire to become pregnant in the future, the importance of uterine preservation, symptom severity, and tumor characteristics. New treatment options for uterine fibroids would be minimally invasive, have long-term data demonstrating efficacy and safety, have minimal or no incidence of fibroid recurrence, be easy to perform, preserve fertility, and be cost effective. New treatment approaches are under investigation, with the goals of being effective, safe, and less invasive.     

Symptomatic fibroids: the need to include low dose OCPs as a treatment option

Symptomatic fibroids are one of the most common reasons women undergo surgical intervention (hysterectomy, myomectomy, endometrial ablation) or other invasive interventions (uterine artery embolization). Although pharmacologic therapy with GnRH analogues, Danazol, RU486 and NSAIDs are occasionally prescribed, rarely are oral contraceptives (OCPs) prescribed for either fibroid prevention or treatment of symptoms. It appears that OCPs are underutilized as a first-line treatment option because of the common belief that OCPs will stimulate fibroid growth and worsen symptoms. This paper reviews the literature on the effects of OCPs on fibroids and evaluates the prevalence of OCP use in a subset of women with fibroids presenting for uterine artery embolization (UAE). From 1/98 through 11/98, women who presented for a UAE were consecutively evaluated under an IRB protocol and data were collected on the reasons for their requesting UAE, the symptoms they were experiencing and what treatment options they had been offered before coming in for UAE. Information was also collected on the number of women who had been treated pharmacologically (ie low dose OCPs) and who had been admitted to a hospital for a surgical procedure (ie myomectomy, D&C, endometrial ablation) before presenting for a UAE. Information also was collected by a MEDLINE search on the effect of OCPs on uterine fibroids. Eighty-four women between the ages of 29 and 60 with symptomatic leiomyoma presented for uterine artery embolization. Three of the women in this cohort had prior surgery. None of the women had been given OCPs as treatment for their pelvic pathology. The literature did not support the association of the use of low dose OCPs and fibroid growth. Women in this cohort with the chief complaint of leiomyomatous uterus had not been offered low dose OCPs. It appears that practitioners are still concerned about possible fibroid growth with low dose OCPs. Education in this area is important to dispel misconceptions about OCP use in women with uterine leiomyoma. As well, there is a need for more research that evaluates the benefits of low dose OCPs in this subset of women.     

Serious complications of uterine artery embolization for conservative treatment of fibroids

OBJECTIVE: Document major complications following treatment of fibroids by uterine artery embolization (UAE). DESIGN: Two case reports. SETTING: University medical center. PATIENTS: Two women with symptomatic fibroid uteri. INTERVENTION(S): Selective bilateral uterine artery embolization. MAIN OUTCOME MEASURE(S): Complications attributable to UAE. RESULT(S): Two patients experienced significant morbidity requiring hysterectomy due to infection and/or partial bowel obstruction resulting from UAE. CONCLUSION(S): Reports of the management of symptoms related to fibroids with UAE infrequently include adverse outcomes and/or complications. The two cases we managed reinforce that UAE is not free of the risk of life-threatening complications that require emergency hysterectomy. Increasing surveillance for complications may help define the selection criteria that decrease the risks of UAE.     

Repeated pulmonary embolism with cardiac arrest after uterine artery embolization for uterine arteriovenous malformation: A case report and literature review

Objective

Uterine arteriovenous malformation (AVM) is an abnormal and nonfunctional communication between uterine arteries and veins, currently managed by uterine artery embolization (UAE). Pulmonary embolism (PE) is the most severe and life-threatening complication of this procedure.

Embolization of uterine arteries for uterine fibroids: state-of-the-art

Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.     

Current state of uterine artery embolization for treating symptomatic leiomyomas of the uterus

A number of new approaches in treating symptomatic leiomyomas of the Uterus have been introduced in recent years. Only little scientific data is available an percutaneous or laparoscopic myolysis using focussed ultrasound, laser, or coagulation guided by magnetic resonance imaging or an laparoscopic ligation of the uterine vessels by means of bipolar coagulation or clipping. Established therapeutic options are limited by a number of disadvantages, except for total laparoscopic hysterectomy with morcellation. The latter is a minimally invasive procedure that spares important pelvic structures and thereby reduces the risk of prolapse and is associated with rapid recovery of the patients. Another minimally invasive therapeutic approach with preservation of the uterus is transarterial catheter embolization of uterine leiomyomas in which the vessels supplying the leiomyomas, in particular the branches of the uterine artery, are partly occluded by injection of synthetic (polyvinyl) beads. Uterine artery embolization has since developed into a good alternative to other therapeutic options. Studies report cure rates ranging from 77-93 %.     

Uterine fibroids and their treatment

Uterine fibroids are the most common benign disease of women. They occur in women under 30 years of 20-30% for women over 30 years in 50%. The most frequent indication for hysterectomy, uterine fibroids are just. Symptoms of uterine fibroids are various forms of pelvic pain and trouble from the oppression of the surrounding organs, irregular uterine bleeding and fertility disorders resulting from the inability to conceive or recurrent pregnancy loss. Problems of surgical treatment of fibroids applies not only to symptomatic patients who wish to preserve the uterus, but also women who have uterine fibroids negatively affect their reproduction. Treatment of uterine fibroids include monitoring, administration of medications and surgical techniques that preserve either the uterus or not. In recent years the conservatives have extended performance of minimally invasive surgery, which is a common feature of the endoscopic approach, or uterine fibroid devascularization. Gynecologist surgeon must be familiar with the history of the patient and based on history and examination to consider which procedure is best for the patient.