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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Preoperative uterine artery embolisation for a giant subserosal fibroid
Preoperative uterine artery embolisation for a giant subserosal fibroid
.Contributed by : Dhrutika Varatha
.Contributed by : Dhrutika Varatha
Introduction:
Introduction:
Uterine leiomyomata commonly known as fibroids are benign tumors of the uterus that are a common cause of heavy menstrual bleeding, pelvic pain and pressure symptoms in women. The traditional method of treatment for these benign tumors has been surgery as long-term medical therapies have not shown to be effective. Surgical options like myomectomy and hysterectomy have long been the main treatments for symptomatic fibroids, but they carry notable risks such as heavy blood loss, postoperative complications, longer recovery and loss of fertility. Even though myomectomy aims to preserve fertility, it still involves morbidity, may require emergency hysterectomy, and can reduce future reproductive potential due to high recurrence rates and adhesion formation.
Uterine leiomyomata commonly known as fibroids are benign tumors of the uterus that are a common cause of heavy menstrual bleeding, pelvic pain and pressure symptoms in women. The traditional method of treatment for these benign tumors has been surgery as long-term medical therapies have not shown to be effective. Surgical options like myomectomy and hysterectomy have long been the main treatments for symptomatic fibroids, but they carry notable risks such as heavy blood loss, postoperative complications, longer recovery and loss of fertility. Even though myomectomy aims to preserve fertility, it still involves morbidity, may require emergency hysterectomy, and can reduce future reproductive potential due to high recurrence rates and adhesion formation.
Preoperative embolisation is a safe method to reduce intraoperative blood loss - especially in large fibroids
Preoperative embolisation is a safe method to reduce intraoperative blood loss - especially in large fibroids
Case presentation:
Case presentation:
A 38 year old woman presented with significant pelvic and back pain and menstrual irregularities as well as heavy menstrual bleeding since four months.
A 38 year old woman presented with significant pelvic and back pain and menstrual irregularities as well as heavy menstrual bleeding since four months.
She complained of abdominal bloating, distension, heaviness and abdominal pain.
She complained of abdominal bloating, distension, heaviness and abdominal pain.
On physical examination, she had a infraumbilical midline mass that moved from side to side.
On physical examination, she had a infraumbilical midline mass that moved from side to side.
MRI (not shown) revealed a diffusely enhancing subserosal fibroid that measured 10 x 19 x 16 cm arising from the uterine fundus. This was associated with mass effect on the bladder and displacement of the endometrial cavity.
MRI (not shown) revealed a diffusely enhancing subserosal fibroid that measured 10 x 19 x 16 cm arising from the uterine fundus. This was associated with mass effect on the bladder and displacement of the endometrial cavity.
Interventional technique:
Interventional technique:
After counselling of the patient and relatives an informed consent was obtained. The protocol for fitness for general anaesthesia was then completed
After counselling of the patient and relatives an informed consent was obtained. The protocol for fitness for general anaesthesia was then completed
Right CFA access was secured with a short 6F sheath.
Right CFA access was secured with a short 6F sheath.
An aortogram with a 6F pigtail catheter was then performed (video 1).
An aortogram with a 6F pigtail catheter was then performed (video 1).
video1.mp4Video 1: Initial angiogram demonstrating hypertrophied uterine arteries bilaterally.
This was followed by selective catheterisation of the left uterine artery using a 2.4F microcatheter. (video 2, video 3.)
This was followed by selective catheterisation of the left uterine artery using a 2.4F microcatheter. (video 2, video 3.)
video2.mp4video3.mp4Video 2 , 3 : Left internal iliac artery and uterine artery catheterisation
The vessels were embolized using 350-500 micron PVA particles
The vessels were embolized using 350-500 micron PVA particles
The procedure was then repeated for the right uterine artery(video 4,5).
The procedure was then repeated for the right uterine artery(video 4,5).
video4.mp4video5.mp4Video 4: Right internal iliac artery catheterisation
Video 5: Injection through the microcatheter in right uterine artery showing feeding vessels to the fibroid
Post embolisation, there was complete cessation of blood flow with no residual blush in the fibroid s (video 6,7) .
Post embolisation, there was complete cessation of blood flow with no residual blush in the fibroid s (video 6,7) .
video6.mp4video7.mp4Video 6, 7: Post embolisation angiogram reduced vascularity in both uterine arteries supplying the fibroid
Final angiogram was obtained demostrating reduced vascular flow post embolisation (video 8.)
Final angiogram was obtained demostrating reduced vascular flow post embolisation (video 8.)
video8 .mp4Video 8 Post embolisation aortogram showing successful embolisation
Fig 1: Pre-embolisation vasculature feeding the fibroid
Fig 2: Post embolisation vasculature showing occlusion of both uterine arteries
Myomectomy was performed via laparotomy one day after the embolisation (Fig. 3,4). There was minimal blood loss intraoperatively - less than 100 mL.
Myomectomy was performed via laparotomy one day after the embolisation (Fig. 3,4). There was minimal blood loss intraoperatively - less than 100 mL.
Fig 3 Intraoperative image: The large tuft of embolized vessels is seen. The congested black blood inside, is due to the blockage by embolization
Fig4: Post myomectomy specimen.
Discussion:
Discussion:
Uterine leiomyomas, also known as uterine fibroids, are benign tumors of myometrial origin and are the most common solid benign uterine neoplasms. Most fibroids do not cause symptoms and are detected incidentally. When symptomatic, medical therapy is the first step.
Uterine leiomyomas, also known as uterine fibroids, are benign tumors of myometrial origin and are the most common solid benign uterine neoplasms. Most fibroids do not cause symptoms and are detected incidentally. When symptomatic, medical therapy is the first step.
Symptoms include menstrual irregularities, pain in the abdomen, palpable mass per abdomen and infertility. (1)
Symptoms include menstrual irregularities, pain in the abdomen, palpable mass per abdomen and infertility. (1)
The FIGO classification system for uterine leiomyoma (fibroids) classifies uterine
The FIGO classification system for uterine leiomyoma (fibroids) classifies uterine
leiomyomas based on the basis of location and morphology. It is as follows: -
leiomyomas based on the basis of location and morphology. It is as follows: -
FIGO Classification
FIGO Classification
Submucosal group
Submucosal group
type 0: pedunculated intracavitary
type 0: pedunculated intracavitary
type 1: <50% intramural
type 1: <50% intramural
type 2: ≥50% intramural
type 2: ≥50% intramural
Other group
Other group
type 3: 100% intramural; contacts endometrium
type 3: 100% intramural; contacts endometrium
type 4: intramural
type 4: intramural
type 5: subserosal ≥50% intramural
type 5: subserosal ≥50% intramural
type 6: subserosal <50% intramural
type 6: subserosal <50% intramural
type 7: subserosal pedunculated
type 7: subserosal pedunculated
type 8: other
type 8: other
The traditional treatment of symptomatic fibroids has been surgical, namely myomectomy or hysterectomy. However, surgery may be associated with significant morbidity in terms of increased blood loss (2), postoperative complications, longer hospital stay and permanent infertility.
The traditional treatment of symptomatic fibroids has been surgical, namely myomectomy or hysterectomy. However, surgery may be associated with significant morbidity in terms of increased blood loss (2), postoperative complications, longer hospital stay and permanent infertility.
Pre-operative uterine artery embolization (3) prior to surgery whether in the form of myomectomy of hysterectomy provides excellent predictable outcomes such as providing a hypovascular plane to perform surgery in, minimising blood loss during myomectomy to remove large subserosal fibroids which can potentially lead to preserving the uterus in a larger number of cases.
Pre-operative uterine artery embolization (3) prior to surgery whether in the form of myomectomy of hysterectomy provides excellent predictable outcomes such as providing a hypovascular plane to perform surgery in, minimising blood loss during myomectomy to remove large subserosal fibroids which can potentially lead to preserving the uterus in a larger number of cases.
References
References
1. Goodwin SC, Vedantham S, McLucas B, et al. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol. 1996:8:517-526
1. Goodwin SC, Vedantham S, McLucas B, et al. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol. 1996:8:517-526
2. Unger J B, Paul R, Caldito G. Hysterectomy for the massive leiomyomatous uterus. Obstet Gynecol. 2002; 100:1271-1275. doi: 10.1016/s0029-7844(02)02453-5. |DOIE] [PubMed]
2. Unger J B, Paul R, Caldito G. Hysterectomy for the massive leiomyomatous uterus. Obstet Gynecol. 2002; 100:1271-1275. doi: 10.1016/s0029-7844(02)02453-5. |DOIE] [PubMed]
3. Ravina J H, Bouret J M, Fried D. et al. [Value of preoperative embolization of uterine fibroma: report of a multicenter series of 31 cases] Contracept Fertil Sex. 1995; 23:45-49. [PubMed]
3. Ravina J H, Bouret J M, Fried D. et al. [Value of preoperative embolization of uterine fibroma: report of a multicenter series of 31 cases] Contracept Fertil Sex. 1995; 23:45-49. [PubMed]
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