Women's and Men's Health
Procedure Guide
Indications
Symptomatic uterine fibroids
Cellular fibroids (T2 hypointense, enhancing) respond better.
Pedunculated subserosal fibroids may have less benefit.
Postpartum hemorrhage (>1L during c-section, >0.5L vaginal birth, >10% fall in Hct, bleeding after hysterectomy)
Can be prophylactic in the setting of placenta accreta spectrum, especially percreta, which recommended by the Royal College of OB/Gyn
Uterine trauma
Contraindications
Suspected gynecologic malignancy
Renal insufficiency (Cr >1.5)
Uncorrected coagulopathy (INR >1.7, Plt <50K)
Desire for future pregnancy - debated
2012 Cochrane review found very low-level evidence that myomectomy is superior
SIR Quality Improvement Guidelines suggest discussing this with patients and suggesting that myomectomy may be superior but that patient preference should be respected and UFE may be preferred if the patient is a poor surgical candidate
Previously pedunculated subserosal fibroids. Previous concerns of stalk infarcting and falling off into the peritoneal cavity but data suggests this may be over blown.
Efficacy and alternatives
Symptomatic Fibroids
Uterine Fibroid Embolization (UFE): Average 50-60% volume reduction, uterine size 40-50% reduction
Bulk symptoms 88-92% reduction
Abnormal uterine bleeding >90% reduction
Reintervention rate 10-14% at 3-5 yrs
Medications: Can help relieve symptoms as bridge to menopause, after which, symptoms usually improve. However, ~60% of patients who trial medications require an intervention within 2 yrs.
Hysterectomy: most invasive and definitive. Can be abdominal, transvaginal, laparoscopic, or robotic
REST trial: UAE shorter recovery and hospitalization, no difference in QoL, higher re-intervention rate (26% v 0%)
EMMY trial: no difference between UAE and hysterectomy, except higher re-intervention rate with UAE (28% v 11%)
FEMME trial: debated concluded that myomectomy was superior to UAE in terms of QoL at 2 yrs; lots of limitations re how UAE was performed and stats; seems more like they were similar in terms of QoL
Meta-analysis of four RCTs: better short term benefits with UAE, similar long term QoL, but increased long-term re-intervention
Myomectomy and UFE: less invasive, 75-90% effective, higher recurrence (5-10% re-intervention in 1 year)
Magnetic resonance guided ultrasound surgery (MRgFUS): promising but less data
Adenomyosis
Uterine Artery Embolization (UAE): symptom improvement 83% overall, 94% if adenomyosis + fibroids, 74% if pure adenomyosis
Complications: amenorrhea 6.3%, hysterectomy 2.6% pure adenomyosis vs 1.4% adenomyosis + fibroids
Post-partum Hemorrhage
Generally, 80-100% hemorrhage control across small studies. Ultimately require hysterectomy in 0-9%
Complications 4-9%, often minor access site rather than major ischemic or neurologic.
Pre-procedure care
Gynecology evaluation within 1 year with pap smear and endometrial biopsy.
MRI to characterize fibroids, not absolutely necessary but generally helpful.
Utero-ovarian anastomoses: (type 1) small connection between ovarian and uterine artery usually <500 um vs (type 2) ovarian artery directly feeding fibroids
PT/INR, CBC, serum creatinine
Hold coumadin/Plavix 5d prior, Eliquis 48 hrs, harpin 24 hrs. No need to hold ASA/NSAID
Hold gonadotropin-releasing meds 3 mo prior (can constrict uterine arteries)
Premedication regimens
Example 1: Procaria XL 30 mg/d x 3 d and scopolamine patch 1.5 mg 1 day prior and removed on POD 2 or 3 -> in pre-op, gabapentin 900 mg PO, toradol 30 mg IV, Ancef 2g IV, medication log, order PCA for post-op (1-2 mg MS q10 min PRN, no basal rate), heating pad
Example 2: Scopolamine patch 1 mg for 3d, lorazepam 1 mg, acetaminophen 1000 mg, ketorolac 30 mg
If transradial, assess Barbeau and radial artery >2 mm -> mark skin and apply EMLA cream and 0.5 in nitroglycerin paste -> cover with tegaderm or Opsite
Berbeau: (type A, 15%) no dampening; (type B, 75%) dampening of pulse tracing; (type C, 5%) loss of pulse tracing followed by recover w/in 2min; (type D, 5%) no recover, radial access is contraindicated
Procedure
Uterine Fibroid/Adenomyosis Embolization:
Some give IV Solumedrol at the beginning to reduce post-embolization pain.
Others start with hypogastric ganglion/nerve block
Advance 21/22G needle to anterior aspect of L4/L5 just inferior to aortic bifurcation via anterior approach.
Inject small amount of contrast to confirm positioning.
Inject 20 mL 0.5% ropivacaine.
Systematic review showed 98.8% same day discharge with 6.9% readmission; mean pain score 3.4 vs 4.3 in controls; major adverse event 0.4%, however no RCT
Obtain access left radial or common femoral access.
For radial, administer “cocktail” mixed with patients blood after access (200 mcg nitroglycerine, 2.5 mg verapamil, 4000 units heparin)
For femoral, some use an access sheath whereas other “bareback” a 4 Fr catheter and then close with manual compression.
Access the contralateral internal iliac artery and perform a run in 30 degree ipsilateral oblique to lay out vascular anatomy.
Radial - angled 4 or 5 Fr (e.g. BERN 1 Performa) and a glidewire
Femoral - RUC vs C2
Select the uterine artery.
Can often select origin with the base catheter and then advance a microcatheter (e.g. Excelsior, ProGreat) + hydrophilic guidewire (e.g. Headliner, Fathom).
NOTE: if no uterine on one side, think about ovarian or round ligament artery from external iliac. Check at end. Often common end supply so really only care if still supplying at the end
Perform run of the uterine to avoid embolizing proximal to cervicovaginal branches.
(Optional) Can perform cone beam CT to confirm uterine perfusion but often unnecessary and just increases radiation.
Embolize first side, e.g., PVA or Embospheres (>500 um, often 500-700 um particles).
Some administer 200 mcg nitroglycerine prior to embolization followed by 5-10 mL 1% lidocaine preservative-free +/- 30 mg toradol after embolization.
Some upsize the particles to 700-900 um after multiple vials of 500-700 um
1-2-3 protocol very successful for adenomyosis (82.5% complete necrosis, 100% if dark SI): 150-250 um PVA -> 250-350 um PVA -> 355-500 um PVA
Post-embolization angiography to access adequacy (5 heartbeat stasis)
Access the ipsilateral internal iliac artery
Radial - can use the same catheter-wire combination
Femoral - can use the same RUC, C2 with a Waltman loop, or a Sos 1
Repeat same process as above for selecting and embolizing the other uterine artery
(Optional) Can perform aortogram to assess for ovarian artery supply but debated due to excess radiation
Some always do it, others only if evidence on MRI or during UAE, others only if the patient doesn’t respond to UAE as a second procedure
~5% will have ovarian artery contribution that can be selectively embolized used a Mikaelsson catheter
Little evidence that ovarian artery embolization impairs ovarian function
Remove access catheter/sheath and achieve hemostasis
Some give Zofran 4 mg, hydromorphone 1 mg, Ketorolac 60 mg at the end of the procedure
Post-partum Hemorrhage:
Can prophylactically get bilateral CFA access with occlusion balloons in the internal iliac or uterine arteries that can be inflated intra-operatively
Often get a flush aortogram either at the beginning or end to identify other sources of bleeding, e.g, ovarian, broad ligament (off inferior epigastric), other internal iliac branches
Embolization often performed with gelfoam rather than particles
Complications
Intrauterine Devices were initially thought to increase risk of infection but other studies suggest no increase in complications.
Effects on pregnancy - debated with low level data, generally UAE likely increases some pregnancy related complications so myomectomy is recommended.
Only this RCT showed increased miscarriage all during 1st trimester.
Likely does increases miscarriage, abnormal placentation, decreased implantation due to decreased endometrial integrin.
Permanent amenorrhea: 0-3% (<45 yo), 20-40% (>45 yo)
Hematoma, bleeding, infection
Fibroid passage (3-15%): cramping, bleeding. More common with intramural lesions, often in part rather than whole fibroid -> some admit and start abx -> full passage in 2-4 days. Incomplete passage can cause sepsis.
Fibroid prolapse: can cause significant pain but not unique to UFE -> transvaginal excision
Chronic vaginal discharge: 60% have some discharge, lasting 8 wks for a fifth of patients, persistent 3-6mo post-procedure for a fourth of those patients. Can be secondary to a focal defect in uterine wall, endometrial atrophy, but most resolve on their own.
PE/DVT (1/400)
Myometrial injury (1/500): persistent/worsening pain 4-5d post procedure
Fistula: rare, often with surgical history and scar tissue with bladder or bowel stuck to the uterus
Non-target embolization (1/1000)
Post-procedure care and follow up
Most places discharge the same day. Some admit for observation overnight.
Advance diet slowly with PRN antiemetics for nausea
Discharge with follow up in 1-2 weeks.
Example 1: Naproxen 375 mg PO BID, hydromorphone/acetaminophen 5/325 mg PO q4hrs PRN, Zofran 4 mg q8hrs PRN, docusate 50 mg PRN
Example 2: naprosyn 250 mg q6hrs x 5d (40 tabs, 20 for recovery, 20 for 1st menstrual cycle), gabapentin 300 mg TID x 5d (20 tabs), oxycodone 5 mg q3hrs (30 tabs), senna 2 tabs BID x 7d or until normal BMs return (28 tabs), zofran ODT 4 mg q6hrs (20 tabs)
Fever, pain, cramping, discharge is worth a phone call. Avoid CT as it will look terrible (gas, non-enhancement, heterogeneous).
Afebrile/mild fever -> Naprosyn 250 mg Q6 +/- Doxycycline 100 mg for 7-10d
High fever -> admit, IV abx (e.g. unasyn, ampicillin, or gentamicin + flagyl), IV toradol (30mg q6), gyn consult/speculum exam, consider MRI for troubleshooting