Fibroids in Afro Caribbean Women.
Uterine Artery Embolisation Uterine fibroid embolisation (embolization) for fibroids is no longer a new procedure. It was first carried out in France in a small number of cases in the early 1990s. Since then there have been numerous publications on the technique(2,5,9,10,11,12,15,18,20,21,22,23,24,25,26,42,43,44). The procedure which is non surgical involves the occlusion of blood vessels supplying uterine fibroids and certainly over 100,000 and probably several hundreds of thousands of fibroid embolisations have been carried out worldwide.
Fibroid embolisation is carried out by an Interventional Radiologist and is technically demanding, requiring significant experience in the technique. Under local anaesthesia and intravenous sedation a tiny catheter is inserted under local anaesthetic into an artery in the right groin. Under X-ray control a micro catheter is introduced selectively into each of the two arteries that supply the uterus. The micro catheter is passed approximately half way down the artery and then fine particles of a solid substance called PVA (Poly Vinyl Alcohol) are injected through the catheter into the uterine artery. The particles are carried to the leash of vessels supplying the fibroids. These vessels become silted up thereby depriving the fibroid of blood which dies and shrinks. PVA is an inert harmless material which has been used to occlude vessels in other parts of the body for decades (29).
Following the procedure the patient usually experiences pain over the next 12 to 24 hours. The pain varies from mild to severe and is controlled by intravenous and oral analgesics. Occasionally over the next 1-2 weeks the patient may experience cramps and occasionally some bleeding and often run a mild intermittent temperature in the first week. Patients spend 2 days in hospital and are usually advised to take 2 weeks off work. In our series the average time to patients feeling completely 'normal' was 2.2 weeks. During the procedure intravenous sedation is administered as required.
The complete process of fibroid shrinkage or in a small percentage of cases expulsion takes about 6 to 9 months; however most patients notice a considerable improvement in their symptoms within 3 months (expulsion usually occurs early in the first 6-8 weeks).
The commonest surgical treatment for fibroids is hysterectomy. Approximately 30,000 hysterectomies are carried out for fibroids in the UK alone and 180,000 in the USA, Wallach EE(30). Over the years before other treatments became available a large number of women obtained considerable benefit from hysterectomy. It is however a major surgical operation usually requiring approximately 5-7 days in hospital and 2-3 months convalescence. Hysterectomy for fibroids carries a serious complication rate of 4-6% and a mortality of 1:1,000–1,500(27,34). Serious complications of hysterectomy include bladder, bowel and ureteric damage, infection, haemorrhage, wound dehiscence and chronic problems such as bowel dysfunction and bowel obstruction and vaginal prolapse(27,35). Most serious complications of hysterectomy require further major surgery. Treatments other than hysterectomy or UFE
The medical alternative to hysterectomy is drug treatment with GNRH analogues such as Zoladex and Synarel but such drugs can only be used temporarily, are only effective on 50% of women and may have unpleasant side effects. On stopping treatment the fibroids grow back quickly. The usual surgical alternative to hysterectomy is abdominal myomectomy. In the latter procedure the surgeon attempts to cut out the fibroids leaving the normal part of the womb intact. Myomectomy has been used widely for decades but it is a difficult operation with a significant complication rate. In addition, importantly, there is a high recurrence rate of>70% (6) that occurs in patients with multiple fibroids. A high percentage of patients having myomectomies will require re-operation for recurrence usually hysterectomy. In fact figures show 20% of women will have had hysterectomies within 5 years of myomectomy (Reed et al, 2006). Complications include bowel perforation, damage to the urinary tract, adhesion formation, infection and haemorrhage. You should ask your gynaecologist whether he or she feels that abdominal myomectomy would be of benefitin your particular case and likely to succeed.
Laparoscopic (keyhole surgery) myomectomy is an effective, much less invasive, procedure but there are major limitations on the size and number of fibroids that can be treated. Again this surgery has a higher complication rate than UAE including damage to adjacent organs which may involve a further major operation. Other recent techniques are MRI guided laser ablation and MRI guided focussed ultrasound. Essentially both of these techniques cause a burn within the fibroid which then changes to scar tissue. Only a few fibroids can be treated at particular sites and the procedure takes around 2-3 hours. It often only destroys part of the fibroid or fibroids. Only short term results are available. These would be expected to demonstrate initial improvement but the concern is that this will not be sustained as the residual fibroid tissue re-grows. Embolisation has the advantage of completely destroying all fibroids no matter how numerous at one session lasting between 45 minutes and one hour. Post-procedure pain and discharge are probably greater than with MRI ablation but this is probably because in the latter procedure not all the fibroid tissue is killed.
An article in the American Journal of Roentgenology ‘MRI guidance of Focused Ultrasound Therapy of Uterine Fibroids: Early Results’ 2004;183:1713-1719 showed a mean reduction in fibroid volume at 6 months of only 13.5% which would normally be regarded as treatment failure. Average for UAE is 60%. But more importantly in UAE in the overwhelmimg majority all of the fibroids are killed and cannot re-grow.