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
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.
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