This document summarizes a presentation on the future of percutaneous uterine fibroid embolization. It discusses who is at risk for fibroids, hysterectomy statistics, fibroid anatomy and imaging, patient selection criteria for embolization, clinical outcomes of the procedure, potential adverse effects and recommendations to increase access to embolization. Key points include that embolization significantly improves bleeding and pain for most patients, with fibroid volume reduction of 20% at two months and 60% at one year on average. Potential risks include post-embolization syndrome and rare fibroid infection.

1. The future of percutaneous Uterine
fibroid embolisation
The Mater Hospital
Multifaculty/ multidisciplinary professional development
20th
march 2015
Breakfast lecture
By Dr. Henry Wanga
Interventional Radiologist

2. Who gets fibroids?
Incidence increase with age
20% of women in their 20’s
40% of women in their 40’s
50% at autopsy
Genetic predisposition
African-American women 3 to 9 times
Risk of sarcoma is 0.04% to 0.13%

3. Introduction
Hysterectomy is one of the most common operation done in
the developed world
In USA, it is second only to caesarian section in women in
the reproductive age group
Roy Gordon in UCSF in 2OO7 stated that more than one
third of US women will have undergone hysterectomy at the
age of 60 years

4. Anatomy of fibroids
Subserosal- grow outwards, possibly pedunculated,
differential diagnosis, gives pressure rather than bleeding
Intramural – most common ; gives rise to bleeding, pressure
symptoms
Sub mucosal fibroids- are the least common, may cause
bleeding and if pedunculated they lead to extrusion

5. MRI imaging of the uterus showing
Myoma
MRI scanogram axial setting

6. MRI Female pelvis
Coronal view ,left
Sagittal view ,right

7. Are we ready?
Raise the flag of UAE now!

8. Pelvic embolisation in Obstetrics and
Gynecology
Post partum/caesarian section –birth canal laceration,
placenta, retained products atony or rupture
Ectopic
Post surgical
Cancer
Arterio-venous malformation

9. Indications
Heavy bleeding
Pain and pressure on back/abdomen
Urinary frequency and or obstruction
Constipation
Dysparaunia
Body habitus
Infertility
Recurrent pregnancy loss

10. American College of Obstetrics and
Gynecology(ACOG) Criteria for Hysterectomy
1. asymptomatic leiomyoma >12 weeks/ patient concerns
Profuse bleeding with clots. flooding> 8days , anemia
Pelvic discomfort
Distended abdomen
Back pains
Bladder symptoms

11. Patient selection
Patient preference; UFE
Uterus-sparing
Rapid recovery
Aversion to surgery

12. Patient selection
Consider alternate procedure
Patients with –
small pedunculated fibroids with narrow attachment; may
slough into endo cavity
Pedunculated serosal fibroids >10cm, particularly with narrow
attachment
Are easily removed at myomectomy
Shrink more slowly post-UFE
May detach
Prone to adhesions
Uterus greater than 24 weeks
Reproductive ambitions/ this position has since changed.

13. fibroid
Multiple mural and subserosal fibroid

14. MRI; fibroid
Posterior fibroid pressing on bladder

15. Bulky uterus
Submucosal fibroid

16. What are the absolute contraindications for a Uterine
Fibroid Embolisation?
Asymptomatic fibroid disease, leiomyosarcoma of the
uterus and pregnancy are absolute contraindications
and will be worked up as part of the consultation
process. Relative contraindications include allergies to
iodinated contrast and infection, but these can be
premedicated or treated prior to undergoing the
procedure.

17. UFE Clinical outcomes
Summary of published results:
Improvement in menorrhagia- Mean: 88%
-range 79% to 98%
Improvement in pain/pressure
-mean; 71%
-range 64-98% improved
Leiomyoma volume reduction
Mean 20% at two months
Mean 60% at 12.2 months

18. Prospective follow up 200 patients
Spies Obs/Gynae Nov 2005
Patients 200
Follow up 182(91%)
Improved 73% N.B 18were lost to follow up
Failed or recurred 36(20%)
Hysterectomy 25 (13%)
Myomectomy 8(4.4%)
Repeat embolisation 3(1.6%)
Note 4 hysterectomies were unrelated to UFE
3 deaths un related to UFE

19. UFE-Fertility+Pregnancy
Do fibroids cause infertility
Does myomectomy help?
Can one conceive after UFE
Is outcome normal for age etc?
Is fetal growth retarded?

20. What are the adverse effects of a Uterine Fibroid Embolisation?
Post embolisation syndrome is common in the immediate post
procedure period. It is usually managed within the hospital before
discharge. Patients will be discharged with a management plan
and medications. Post embolisation syndrome is a triad of pelvic
pain, low grade fever and nausea and is thought to be due to
ischemia/infarction of the fibroids.
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21. Infection of the infarcted fibroid is the complication that needs to be
watched for and the patient adequately informed about. It is uncommon
(less than 2%) and the patient will usually get antibiotics during the
procedure and for 5-10 days after the procedure. However, the exact
mechanism for infection is not clear and it is also unclear whether antibiotics
will reduce the risk. Classically it occurs 4-6 weeks post embolisation, in a
previously well patient who then develops fever, sweats and/ or pelvic pain.
It is important that the patient see the interventional radiologist as soon as
possible. Hysterectomy may be required in those patients not responding to
other forms of management.
The period is often disrupted for a number of cycles post procedure. If the
period has not returned after 3 cycles then the concern is one of permanent
amenorrhea and consultation to a gynecologist should be performed either
through yourself or usually the radiologist.

22. Recommendations
Increase public awareness as to the fact that the service is readily
available at The Mater
Ready to answer questions
Introduce once monthly a gynae/counseling/ interventional
radiology joint clinic
Provide easy access to the highest standard of uterine fibroid
embolisation, post procedure management and long term follow
up
Consumables to be readily available
Train nursing, imaging and anesthetic assistant teams to motivate,
stimulate and harness desired skills by them
Carry out regular users audits

23. Customer satisfaction
JN after years of fighting back frustration, he became fertile

24. INTRODUCTION TO IR PHILOSOPHY
From inability to let well alone, from too much zeal for the
new and contempt for what is old: from putting knowledge
before wisdom, science before art, and cleverness before
common sense, from treating patients as cases and from
making the cure of the disease more grievous and the
endurance thereof, GOOD LORD, DELIVER US!
Sir Robert Hutchinson, BMJ, March12, 1953, p671

25. END
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