Embolization Therapy

Uterime fibroid embolization (UFE) is a procedure performed by interventional radiologists on an angiography (DSA) device under local anesthesia. For the procedure, the patient is first given IV conscious sedation, then the groin is disinfected and and anesthetized. Next, the artery is punctured and a very thin tube (catheter) is advanced into the arteries supplying the uterus. After the necessary angio shots are taken, small particles that block the uterus and myoma vessels are slowly injected through this tube. After both uterine arteries are occluded, which takes about an hour, control shots are taken and the catheter in the groin is taken out. To prevent bleeding, the inguinal artery is manually pressed for 15 minutes and a compression bandage is applied. ​ ​

 

Video: How we do fibroid embolization from A to Z, Prof Dr Saim Yılmaz ​ ​

 

During UFE, most of the particles delivered through the catheter will go into the fibroid arteries, because fibroids contain much more blood vessels than the uterine tissue. Since fibroids feed only on the uterine vessels, they cannot withstand the ischemia that occurs after embolization and die quickly (necrosis). A small part of the particles also goes into the arteries that feed the normal uterine tissue. However, since the uterus is fed by many other vessels in the abdomen, the uterine tissue is preserved and all the fibroids, large and small, located inside the uterus become dead. This can be easily seen on control MR images taken after embolization. On MRI, the dead fibroids are seen as round-dark areas whereas the healthy uterine tissue are seen as the surrounding white areas.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

After embolization, the majority of patients stay in the hospital for 1-2 days and then go home and retain most of their daily activities. They can return to their normal lives in an average of 5-7 days. After the procedure, pain, nausea and fever may occur for a few days, but these can be easily relieved with medication. After embolization, symptoms such as bleeding, pain and other complaints dcrease significantly or disappear completely in over 90% of the patients. This rate is similar to the rates of hysterectomy and myomectomy. It has also been observed that fibroids do not easily recur after a successful embolization. In one study, patients were followed for 6 years and no regrowth of embolized fibroids was observed. If the embolization is insufficient, it can always be repeated, or if it proves unsuccessful, surgical treatment options can always be applied for the patient. Because of these features, embolization is the first line treatment method to be applied in most myoma patients. ​

 

​

​

​

​

​

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

 

​History:

Occlusion of the uterine arteries with particles (embolization) is a method that has been used successfully for decades to stop postpartum or tumor-related vaginal bleeding. It was discovered by chance in the 1990s that the same method could also treat uterine fibroids. ​ ​

 

A gynecologist from Paris, France Jacques-Henri Ravina is the first to apply embolization in uterine fibroids. In 1989, he reviewd the medical literature and saw that the embolization was able to stop successfully tumor bleedings in the uterus and decided to use this method before myomectomy to decrease blood loss during the operation. Surprisingly, however, he noticed that some of the patients did not come to the operation after their complaints disappeared after embolization, and that the fibroids shrunk and died (necrosis) in the majority of those who came to the operation. Based on these observations, Dr. Ravina reported that embolization can be used as a stand-alone method method in the treatment of uterine fibroids

​

Video: Embolization or myomectomy surgery? Prof Dr Saim Yilmaz ​ ​

 

Embolization has been widely used in the treatment of uterine fibroids all over the world, especially in Europe and the USA, after the 2000s. With the widespread use of embolization in France, where the method was first applied, there was a dramatic decrease in hysterectomy surgeries performed for fibroids, and this decline began to be seen in other European countries later on. Today, more than 25,000 myoma embolizations are performed each year in the USA alone and more than 100,000 in other countries, and this number is increasing every year.

 

 

 

 

​

​

​

 

 

 

 

 

 

 

 

 

 

 

​ ​

 

​Risks of Embolization

Fibroid embolization is a very safe treatment method, and the rate of complications (treatment-related problems) is lower than myomectomy and hysterectomy. However, like any treatment, some side effects may occur after embolization: ​ ​ Amenorrhea (cessation of menstruation) may be seen after the procedure in a small proportion of patients. This event is usually temporary, but may be permanent in approximately 1-5% of patients. Persistent amenorrhea is more common in women over 45 years of age who are approaching menopause. In less than 1% of patients, uterine infection may develop after embolization and additional treatments may be required. Again, less than 1% of patients may develop non-microbial inflammation and associated vaginal discharge after the procedure. In 2-3% of patients, embolized fibroids can be expelled from the vagina as if giving birth. This makes it easier for the fibroids to disappear and is usually what most patients want. However, large pieces of fibroids may cause pain when expelled from the vagina.

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Advantages of Embolization

Embolization has the following advantages over myomectomy and hysterectomy surgeries used in the treatment of fibroids: ​ ​ The procedure is performed only by numbing the groin, without general or spinal anesthesia. Since there is no blood loss, no blood transfusion is required. There is no surgical incision or scar, the whole treatment is applied through a 2mm angio hole in the groin. The hospital stay and return to normal life are much shorter than surgery. Complications related to the procedure may occur, but this complication rate is much lower than myomectomy and hysterectomy. Unlike the hysterectomy, the uterus and ovaries are not removed, so that both fertility is preserved and the problems caused by hysterectomy are not experienced. Unlike myomectomy, not only fibroids that can be removed by surgery, but also all uterine fibroids can be treated without a single incision in the uterus. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​

 

​

​

​

​

 

 

 

 

 

 

 

 

 

 

​ ​ ​ ​ ​ ​ ​ ​ ​ ​

The Effect of Embolization on Fertility

There are many women who become pregnant after embolization and have completely normal births. Therefore, it is generally believed that embolization therapy does not interfere with conception and healthy delivery. However, there is a small theoretical risk of damage to the ovaries and uterus during the embolization procedure. This risk is especially relevant if very small diameter occlusive particles are used and aggressive embolization is performed. However, this risk is minimal if medium-large particles are used during embolization and the embolization is terminated when the main vessels of the uterus begin to become occluded.

The risk of damaging the uterus is  also present in other treatment methods; The sutures used during myomectomy may cause infection, adhesions and deformation in the uterus. If the bleeding cannot be stopped, emergency hysterectomy may be required. In HIFU and percutaneous ablation, the heat applied while burning the fibroid can also damage the surrounding tissues and the inner surface of the uterus. In short, each treatment applied in fibroids may affect the possibility of the patient to become pregnant. Studies comparing treatment methods on this subject are few. In a recent study, the rate of getting pregnant after myomectomy and embolization was found to be the same in patients with fibroids who wanted pregnancy (Pisco et al, Fertil Steril 2010). ​ ​

 

Video: 5 reasons to choose embolization therapy for fibroids ​ ​

 

Embolization + myomectomy:

Both embolization and myomectomy are methods that can treat uterine fibroids . However, in some cases, the combination of the two methods may be more beneficial for the patient. For example, in patients who have many intramural fibroids in the uterus (hence suitable for embolization), but also have thin-stemmed subserous or submucous fibroids (thus more suitable for myomectomy), all the fibroids with embolization + laparoscopic or hysteroscopic myomectomy. In addition, it has been shown that in myomectomies performed after embolization, blood loss during the operation is greatly reduced, the operation is significantly easier, and more fibroids can be removed from the uterus without any problems.