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  • Writer's pictureFrancesco Bruno Tagliaferro

Uterine fibroid embolization (UFE)

Uterine fibroid embolization (UFE) is a minimally invasive procedure, performed under local anesthesia, which aims to reduce the size of uterine fibroids by occlusion (embolization) of the uterine arteries. This determines a controlled ischemia and a consequent size reduction of the uterine fibroids (even up to their disappearance.)

Embolization of uterine fibroids is a valid alternative to removal of the uterus (hysterectomy) or surgical resection of the fibroid (myomectomy).


UTERINE FIBROIDS


Uterine fibroids, also known as leiomyomas, are benign solid tumors originating from the muscular wall of the uterus (myometrium), made up of smooth muscle cells and connective tissue.



Uterine fibroids are very common in the female population, in fact they affect 25% of women of childbearing age and up to 70% of women over 50 years of age.


They are multiple in two thirds of the cases and have extremely variable dimensions, from a few mm to several tens of cm.


Based on the location they are classified as:


  • INTRAMURAL: the most common. They develop within the uterine wall.

  • SUBMUCOSAL: the least frequent (5%) and the most problematic. Often ulcerated and bleeding, they are associated with menorrhagia and infertility. They develop close to the endometrium and can protrude into the uterine cavity.

  • SUBSEROSAL: sessile or pedunculated, they develop below the serosa of the uterus, of which they can alter the profile

Furthermore, some fibroids can be pedunculated, when they develop towards the outside or inside of the uterus and are fixed to it through a thin filament, called a peduncle.

THE SYMPTOMS

  • Pelvic pain

  • Menorrhagia/menometrorrhagia: particularly intense and/or long menstrual cycles with increased blood loss up to iron deficiency anemia

  • Urinary symptoms (urgency, incontinence) due to compressive effects on the bladder

  • Intestinal symptoms, due to the compressive effects on the intestine

  • Ureteropyelectasis, by compression of the ureters

  • Dyspareunia (painful sensation during sexual intercourse)

  • Pelvic sense of weight

  • Infertility (submucosal fibroids)


In most cases, uterine fibroids are completely asymptomatic!


THE DIAGNOSIS


ULTRASOUNDS

I level exam in the study of pelvic masses. The transvaginal approach is the most accurate.


Uncomplicated fibroids are usually hypoechoic, but may be isoechoic or even hyperechoic relative to the normal myometrium.


The calcifications appear as echogenic foci with a posterior shadow.


Anechoic cystic areas of necrosis or degeneration may be observed.


MAGNETIC RISONANCE IMAGING

Sagittal T2 image

MRI is not usually required for diagnosis, except in complex cases. It is, however, the most accurate way to detect, locate and characterize fibroids.


Signal characteristics are variable and include:


T1

  • nondegenerate fibroids and calcifications show low to intermediate signal intensity compared to the normal myometrium

  • characteristic elevated T1 signal

T2

  • nondegenerate fibroids and calcifications appear hypointense

  • fibroids that have undergone cystic degeneration/necrosis may vary in appearance, but they usually show an elevated T2 signal intensity

  • hyaline degeneration appears hypointense on T2

  • cystic degeneration, which is an advanced stage of intratumoral edema, also appears hyperintense on T2 sequences and does not take contrast

T1 + contrast medium

  • variable enhancement after contrast administration


UTERINE FIBROID EMBOLIZATION (UFE)


Uterine fibroid embolization is a minimally invasive procedure, performed under local anesthesia, that aims to occlude the uterine arteries (from within) to reduce blood flow to the uterine fibroids. This causes a controlled ischemia which determines a dimensional decrease of the fibroids, up to their complete disappearance, with consequent reduction of symptoms.


INDICATIONS


UFE is indicated in case of

  • Symptomatic uterine fibroids

Especially when the fibroids are multiple, small, and cause menorrhagia in patients not desirous of pregnancy.


CONTRAINDICATIONS


Absolute

  • Pregnancy

  • Gynecological malignant neoplastic pathologies

  • Active uterine or adnexal infections

Relative

  • Allergy to m.d.c

  • Coagulopathies

  • Kidney failure


HOW UFE IS PERFORMED


Uterine fibroid embolization is a minimally invasive procedure performed under local anesthesia. In the angiography suite, in a strictly sterile environment, the patient is placed in a supine position on the operating table and is prepared as for any other operation (hair removal, skin disinfection, preparation of the operating field, etc.).


The Interventional Radiologist, after local anesthesia, performs an ultrasound-guided arterial puncture of the common femoral artery (right or left or both), at groin level, and inserts a vascular sheath, a plastic cannula with a diameter of a few millimeters equipped with an anti-reflux valve that allows to work in the blood vessels without blood leakage.



After inserting the sheath, without further cuts, the Interventional Radiologist, guided by of X-rays images, navigates inside the patient's arteries using small catheters (tubes of various morphology) and places a microcatheter (with a millimeter diameter) in the arteries that vascularize the uterus; here the embolic agent is released in a super-selective way which allow to occlude (embolize) the vessels responsible for the vascularization of the uterus, and therefore of the fibroids.


Uterus arteriography. a) before embolization. b) after embolization

AFTER THE PROCEDURE


After the procedure, the arterial catheters are removed and the arterial access is closed to avoid bleeding, without the need to apply any stitches, as no surgical incisions have been made.


Once the procedure is finished, the patient returns to the ward, with adequate pain relief therapy.


The discharge takes place 24 hours after the procedure.


RESULTS


The interruption of bleeding and a substantial improvement of the painful symptoms are obtained in over 90% of cases.


Excellent results are also achieved on compressive symptoms on nearby organs (e.g. bladder or intestine).


In patients who are infertile due to fibroids, the success rate of a pregnancy is 50% after the procedure.


ADVANTAGES AND DISADVANTAGES COMPARED TO SURGERY


Advantages

  • Less invasiveness and lower operative risks (no surgical cuts, local anesthesia)

  • Minor post-operative complications

  • Shorter hospitalization (one night only)

  • Faster recovery

  • The uterus is preserved (like myomectomy and unlike hysterectomy)

Disadvantages

  • Higher persistence of residual symptoms post-surgery

  • Higher incidence of re-operations (such as myomectomy)

  • Lower post-treatment pregnancy rate (50% UFE vs 70% myomectomy)


COMPLICATIONS

Minor complications

  • Hematomas at the arterial access site

  • Short-lasting pain

  • Post-embolization syndrome

Major complications

  • Venous thromboembolism, averted with appropriate heparin therapy

  • Fibroid expulsion. The risk is greatest for submucosal fibroids

  • Ovarian failure with amenorrhea (premature menopause, in case of bilateral ovarian embolization)

  • Infections, treated with antibiotic therapy



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