Treating urogenital vascular conditions

Indications for treatment

The vast majority of uterine artery embolization (UAE) is performed to manage symptomatic fibroid disease and to a much lesser extent, other uterine pathologies associated with menorrhagia. UAE is an alternative to surgery (hysterectomy or myomectomy) for patients in whom medical treatment (e.g. with gonadotrophin-releasing hormone [GnRH] analogues) has failed.

UAE is also important in the management of postpartum haemorrhage ( Ch. 46 ).

The procedure in itself is not particularly technically demanding; however, there is a lot of work in developing and implementing appropriate protocols for assessment, procedural pain relief and post-procedural management. It is essential that the service is delivered in conjunction with a gynaecologist.

Assessment

Patients with menorrhagia and with bulk symptoms are candidates for treatment; they should have both gynaecological and imaging assessment. Ultrasound is principally used to assess the uterus and ovaries, establish the diagnosis of fibroids and assess uterine size. In the majority of centres, dedicated pelvic magnetic resonance (MR) examination is used to assess suitability for UAE and as part of follow-up to gauge the success of treatment.

Suitability for uterine artery embolization

UAE will only succeed if the fibroids are vascular, hence they must show enhancement following contrast on T1-weighted MRI; following treatment evidence of devascularization predicts shrinkage. Pedunculated fibroids may be expelled (or require hysteroscopic removal). If the predominant fibroid is intracavitary then primary removal by hysteroscopy should be considered.

Tip

Delay embolization for 3 months after treatment with GnRH analogues as the uterine arteries are small and extremely difficult to catheterize during treatment.

Consent issues

Patients should be seen in the interventional radiology (IR) clinic. It is essential that the patient receives both adequate information and an opportunity to discuss the potential complications. Patients undergoing UAE are relatively young, most are hoping to avoid the morbidity associated with hysterectomy. A few will wish to become pregnant, patients wishing to conceive should be assessed for suitability for myomectomy. The risks of UAE are less than those of surgery.

In addition to the usual angiography risks patients should be warned of important side-effects including severe pain and significant complications ( Table 40.1 ).