Uterine Artery Ablation

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Dr. Larry Demco: "I’m reporting here from the World Congress of Gynecological Endoscopy in Israel, and I’d like to now interview Dr. Hutchins from Philadelphia. The topic we’d like to talk a little bit about is embolization of the uterine artery for menorrhagia and fibroids. Can you give us a little update of the history of this particular procedure and its indication?"

Dr. Hutchins: "The procedure itself has been around for well over twenty years except that it was originally and traditionally used to control acute life threatening hemorrhage only. Now what the new innovation is, is that it’s being used electively to treat the problem of fibroids rather than just emergency hemorrhage. Probably the things that are becoming more and more obvious is that it is an effective procedure, it is durable, it is safe, and the issue around cost will wash out as well because if you take the total cost of the procedure, which is hospital costs as well as physician, radiologists fees, etc. and you do the same thing with a hysterectomy or equivalent procedure, you’ll find that they are basically about even. Where the big difference will come out is in the recuperative time. If we look at the cost of healthcare as being not just the cost of a particular procedure but also the cost in lost productivity of the patient because of her recuperative time, then I think there’s no question that something like endometrial ablation, etc. will turn out to be viewed as a superior procedure. I think the other thing, which we’ll be talking about here at this meeting is that more and more technologies are being developed which will bring this back into the hands of the gynecologist. This is not a procedure that needs to be done exclusively by selective angiography so contrary to what I originally thought was going to be the case as late as say six months ago, gynecologists are not going to have to learn how to become angiographers. There are at least two methodologies, one is laparoscopic ligation of the uterine artery but more promising than that are procedures using a vaginal probe ultrasound to direct occlusion of the uterine artery to accomplish essentially the same thing. So the future is, I believe, that gynecologists will do this procedure in a more simplified fashion, it will probably become close to an office based procedure and thereafter I think even more improvements on this will occur."

Dr. Larry Demco: "For the people that are not really familiar with the technique as it stands today, could you maybe go over that for us?"

Dr. Hutchins: "Basically, the technique involves selective angiography and interventional radiologists will access the pelvic arterial system through a femoral artery. They will inject contrast dye to outline the pelvic arterial or pelvic vasculature and then work the catheter into first one uterine artery and then the other and inject some kind of material. Most often, polyvinyl alcohol particles are utilized, however, jell foam as well as believe it or not even silk threads and a variety of other kinds of material have been used to accomplish the same thing. The procedure in experienced hands takes approximately an hour. Probably the biggest issue that people have found in terms of management or the actual caring out of this procedure is that after the second artery is occluded, the patient will begin to experience severe pain not just from acute fibroid degeneration but because of ischemia of the uterus itself. Over the first 8-12 hours this pain can be rather severe so that one needs to plan ahead for pain management but after that point in time, usually non-steroidal anti-inflammatory agents are sufficient to handle it because the pain you’re left with is the pain of fibroid degeneration. What happens over the ensuing weeks and months thereafter is, first of all, there is acute reduction in menorrhagia. The effectiveness of this procedure in resolving menorrhagia exceeds 90% and also because of degeneration of the fibroids, all fibroids in the uterus at the time that this is done appear to be killed so to speak and will then reduce in size on average by 50% but we’ve seen as much as 90% reduction even in very large fibroids. We’ve embolized women who have had fibroid uteri that were as large as a term size pregnancy, they will reduce by at least 50% but as I’ve mentioned we’ve seen some that have gone back to close to normal size. The complication rate associated with uterine artery embolization is exceptionally low, the quoted complication rate associated with embolo-therapy which is how this is referred to, in general, is under 5% and with this particular procedure for fibroids we found it probably is less than 2%. So it’s an exceptionally safe procedure and the complications are minor. There have been two cases in the world’s literature in the past four or five years that were associated with mortality. One was a woman who developed a pulmonary embolus several days after the procedure, which actually was unrelated to the procedure itself. This was a 60-year-old woman who was kept in bed, and there are serious questions as to why she was embolized to begin with anyway. The other was a case in England, secondary to sepsis, the exact cause for that death is still something that people question but in general these are extremely rare situations and most of the time complications are minor, extremely minor and the patients are usually back to full normal activity within 10-14 days."

Dr. Larry Demco: "Thank you very much, Dr. Hutchins, for a very good overview of the new and up and coming technique of uterine artery embolization. I’d like to thank you very much."

Dr. Hutchins: "Thank you."