uterine artery embolisation
TRANSCRIPT
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Uterine artery embolisation
Nick Harper4th yr SSC
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• Asymptomatic• Heavy uterine bleeding• Pain• Dyspareunia• Pressure symptoms
Uterine Leiomyomas - Fibroids
• Benign monoclonal tumours
• 9% of women < 44 years old
• 40% of women > 40 years old
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• Myomectomy• 35,000 a year (US)
• Hysterectomy– 300,000 a year (US)
NICE: Symptomatic Fibroid(s) >3cm:
• Gonadotrophin releasing hormone (GnRH) analogue
• Uterine artery embolisation
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Uterine artery embolisation• Day case• Sedation – Diazemuls (5mg/min IV infusion)• Analgesia - Paracetamol (500mg IV)• Local anaesthesia - Lidocaine
• Morphine (5mg IV)
• Metoclopramide (10mg IV)
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Seldinger technique
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•Polyvinyl alcohol (PVA) particles•Trisacryl gelatin microspheres•Gelatin sponge
•Preferential flow to fibroid vessels
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Evidence Base
• Introduced in 1997
• 4 RCTs (n= 403)
• 1 Comparative study
• 3 Case series
• UK registry (n= 1387)
• US registry (n= 2112)
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• SymptomsSymptoms improved in 85 – 95% of patients
• 30 – 48% decrease in fibroid volumefibroid volume (all studies)
• Improved quality of life quality of life 39/100 (US registry n=2112)
• 91% would recommendrecommend to a friend (HOPEFUL n=649)
• 90% < 2 nights 2 nights in hospital (Gabriel-Cox n=562)
Efficacy
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Complications
Procedure •Early: 6.9% (Mara n=58)
•1st month: 20.7% (Mara n=58)
•1 year: 17.6% (HOPEFUL 649)
Non target emboli•Amenorrhea•Buttock/Bladder•1 death(Goodwin 2009)
Failure•11% required further treatment (UK registry n= 1387)
Fertility •27 women •37 pregnancies •19 live births (HOPEFUL n= 649)
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References• Dutton S, Hirst A, McPherson K, et al. (2007) A UK multicentre retrospective cohort study comparing
hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. BJOG 114: 1340–51.
• Edwards RD, Moss JG, Lumsden MA, et al. (2007) Uterine-artery embolization versus surgery for symptomatic uterine fibroids. New England Journal of Medicine 356: 360–70.
• Gabriel-Cox K, Jacobson GF, Armstrong MA, et al. (2007) Predictors of hysterectomy after uterine artery embolization for leiomyoma. American Journal of Obstetrics & Gynecology 196: 588.e1–588.e6.
• Goodwin SC, Spies JB, Worthington-Kirsch R, et al. (2008) Uterine artery embolization for treatment of leiomyomata. Obstetrics & Gynecology 111; 22–33.
• Goodwin, S.C. & Spies, J.B. (2009) Uterine Fibroid Embolization. The New England Journal of Medicine. 361:690-697
• Gupta, J.K., Sinah, A., Lumsden, M.A. & Hickey, M. (2009) Cochrane Review – Uterine artery embolization for symptomatic fibroids. The cochrane collaboration.
• Hirst A, Dutton S, Wu O, et al. (2008) A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technology Assessment 12 (5).
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References• Mara M, Maskova J, Fucikova Z, et al. (2008) Midterm clinical and first reproductive results of a
randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovascular & Interventional Radiology 31: 73–85.
• Marshall LM, Spiegelman D, Barbieri RL, Manson JE, Colditz GA, Willett WC, et al.Variation in the incidence of uterine leiomyoma among pre menopausal women by age and race. Obstetrics & Gynecology 1997;90:967–73.
• Moss JG, Lumsden MA, Murray GD, et al. (2010) Long term (3-5 year) follow up and MRI imaging of the REST trial cohort. Unpublished personal communication.
• O’Grady EA, Moss JG, Belli AM, et al. (2009) UK uterine artery embolisation for fibroids registry 2003–2008. The British Society of Interventional Radiology.
• Spies JB, Bruno J, Czeyda-Pommersheim F, et al. (2005) Long-term outcome of uterine artery embolization of leiomyomata. Obstetrics & Gynecology 106: 933–9.
• Volkers NA, Hehenkamp WJK, Birnie E, et al. (2007) Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years’ outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology 196: 519.e1–519.e11.
• Walker WJ, McDowell SJ. (2006) Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies. American Journal of Obstetrics & Gynecology 195: 1266–71.