UAE (uterine artery embolization): minimal invasive surgery for uterine fibroids
The most common treatment in the presence of symptomatic fibroids of the uterus is removal of the organ. This is motivated by traditional beliefs about the lack of importance of the uterus in the body after the implementation of its reproductive function. In most cases, such a radical approach is unwarranted because there is virtually no risk of malignancy of these tumors. At the same time, embolization of the uterine arteries in uterine fibroids (EMA) allows you to save on.
The principle of the method
Many gynecologists at the present time, I believe that the womb is only «prodovolstvie» and its removal did not entail any negative consequences. In connection with this approach for 1 year in the country is about 800 thousand operations to remove the organ.
However, this routine do not represent scientific research. After hysterectomy can develop such consequences as:
- posthysterectomy syndrome (30%); it is characterized by the same symptoms that occur in severe postmenopausal change in body weight, mood, psyche, pronounced autonomic disorders (sweating, rises in blood pressure, disturbances of cardiac rhythm, etc.), increase in the incidence of cardiovascular diseases, etc.;
- increase the risk of breast cancer and thyroid glands;
- negative impact on sex life.
Thus, removal of the organ, which, seemingly, already does not perform any functions, can lead to serious disturbances in the female organism. Of course, there are cases in which there is no other alternative.
Another surgical method of treatment is removal of only the fibroids with preservation of the uterus (conservative myomectomy). It is performed using laparoscopic, or laparotomies hysteroresectoscope myomectomy. The main goal is the temporary restoration of the uterus by complete or partial removal of fibroids, which can affect the process of conception or pregnancy. This temporarily gives women the possibility of exercising their reproductive function. To get pregnant and give birth after such an operation a woman can in six months.
Myomectomy is a conservative (provisional) method because relapse occurs in 5-7% after 1 year, 14% after 2 years, and 5 years later, as a rule, most operated patients have new fibroids.
A relatively new method is the treatment of fibroids by the method of EMA. Uterine artery embolization — the most promising and quite popular method. Technology known since the 70-ies. In order to treat these tumor-like formations already from 2000-th year, he applied everywhere.
When uterine fibroids embolization is a vascular surgeon in a specially equipped operating room which is equipped with angiographic equipment. The operation is the insertion of micro-particles of polyvinyl alcohol (emboli) with the size of 300-500 or 500-700 microns in uterine artery, branches of which supply blood fibroids.
The operation of uterine artery embolization
The operation is performed under local anesthesia with the addition of sedatives. Through a puncture in the thigh in the femoral artery a microcatheter is introduced. Further, under the control of angiography and fluoroscopy the last one is performed exactly in the required uterine blood vessels. After that it slowly introduced emboli, pre-mixed saline solution and a radiopaque substance to a state of suspension. Getting to the end of small branches of blood vessels, the particles block their light.
Also produced polymer emboli for uterine artery embolization, which contain 94% water. They cause inflammatory reaction in the area of the vessel in which are introduced, as well as help minimize the risks of effects on the healthy areas of the uterus and the restoration of blood flow in myomatous nodes.
The introduction of a solution continues until the cessation of blood flow after embolization of uterine arteries diet fibroids blood gradually stopped. In the future, they are subjected to hardening («drying»), that is replacement by connective tissue and reduced in size. Small nodes (less than 3-4 cm) are myolysis, i.e., the complete dissolution and disappearance.
Directly duration of the operation averages from 10 minutes to an hour, but with advance preparation, it takes about 1.5 hours. In order to reduce or eliminate pain after uterine artery embolization after the procedure, intravenous re-introduced non-narcotic analgesics and sedatives.
The result of this operation stops uterine bleeding and other symptoms. In the first six months after the holding of the EMA, the number of nodes is reduced by 40-60%, then the dynamics of their reduction or myolysis is somewhat slower, but not stopped. In connection with a reduction in blood flow and the uterus, it also decreases in size and have an average term of 1 year becomes normal size.
Despite the cessation of the blood supply to the myometrium of the uterine arteries, which subsequently restored the blood flow in the uterus is not fully terminated. He kompensiruet from other sources, due to the peculiarities of the vascular network of the body. Due to the development of new blood vessels within, usually 2-3 weeks, the blood supply to healthy tissue becomes the same.
With myoma nodes it doesn’t work because their vascular system is imperfect, and they sklerosiruta. In the future, the uterus itself is like a «rejects» became shrunken and alien sites, particularly the submucosa, which gradually moved closer to her cavity, «derived from» or «born». The method can be used to treat nodes of any number and of any size.
Expediency of its use is explained by the fact that pregnancy after uterine artery embolization is possible. Moreover, such an operation is an alternative to any other surgical methods when there is a need to preserve the uterus in the reproductive age women. This is especially true in cases in which surgical myomectomy is difficult or associated with serious complications in terms of the possible loss of the ability to bear children.
The possible consequences of uterine artery embolization and rehabilitation
They are to develop in the nearest postoperative period in 30-40% of women post-embolic syndrome of varying severity that manifests itself:
- «spilled» pain in the lower abdomen;
- high temperature and chills;
- General weakness or mild discomfort;
- nausea and vomiting;
- the increase in the number of leukocytes and ESR in conducting General analysis of blood.
Its maximum reach of these symptoms for 6 to 8 hours. As a rule, their duration is 1-2 days. They are connected with eating disorders individual sections of the uterus and the response to introduction into the vasculature a contrast agent. Despite the fact that the patient can be discharged home from hospital on the 2nd – 3rd day, when pain, nausea and vomiting, and restored the ability of the receiving drugs inside, some signs of post-embolic syndrome in some patients can be maintained with a progressive decrease up to 2 weeks.
The rehabilitation period
Rehabilitation after embolization in the nearest postoperative period depends on the severity of post-embolic syndrome and is aimed at its relief. For these purposes, re-introduced non-narcotic or narcotic short-acting analgesic drugs. In case of significant pain syndrome it is possible to conduct prolonged epidural analgesia. In addition, intravenously or intramuscularly are used to treat it, desensitizing, anti-emetic and sedative.
In order to more rapid elimination from the body radiopaque solution, reduce the severity of intoxication and improve the overall condition carried out many hours of fluid resuscitation with electrolyte solutions in a volume of 3 liters and more during 1 day. This is done under the control of urine (daily urine) by inserting a catheter into the bladder.
Other negative effects of uterine artery embolization is an anaphylactic reaction to radiopaque preparation and accession of infectious endometritis. These complications can be avoided with proper screening and careful selection of patients for the procedure, and for the prevention of infectious complications before and after by the courses of prophylactic antibiotics.
Occasional temporary amenorrhea is not a complication constant is also possible in women in premenopause, which is favorable in terms of cessation of bleeding.
Basic guidelines after surgery is abstinence from sexual intercourse, the rejection of heavy lifting, hot tubs and saunas, increased drinking regime during the first weeks and re-visit the surgeon after 7 days – 1 month and the control ultrasound after 1 month, six months and 1 year. Sex life after uterine artery embolization can be restored at the end of the first after the procedure of menstruation.
Indications and contraindications
Indications for uterine artery embolization is:
- The same indications exist for surgical treatment of myomas the maquis.
- Isolated form of adenomyosis of the uterus, as well as its prevalence in combination with the fibroids. In this case, the EMA is an alternative to hysterectomy.
- Adenomyosis in the late reproductive or early eligibility ages. In this case, the EMA is the initial stage of complex treatment carried out in order to preserve the body.
- Some cases of postpartum bleeding (thick placenta accreta).
- Amyloidosis of the uterine arteries, and the pathological relationship of the arterial vessels of the pelvic organs with venous blood vessels that have to be congenital (malformations).
- Preparation for surgical myomectomy (removal of fibroids) in the presence of a very large site (more than 20-22 weeks) in order to reduce its volume to reduce the morbidity of the operation, as well as for anemia, which occurred when myomatosis as a result of prolonged and/or profuse bleeding.
- Palliative treatment of uterine cancer: EMA leads to stoppage of bleeding from a cancerous tumor and increases the effectiveness of chemotherapy.
In addition, in comparison with surgery, treatment of fibroids by the method of uterine artery embolization is preferred in the presence of obesity, arterial hypertension, varicose veins and diabetes.
The main contraindications to the EMA:
- Allergic or anaphylactic reactions in the past to the introduction of radiopaque agents.
- Pregnancy and the presence of acute infection of the uterus and appendages.
- Submucous and subserous fibroids on a thin stalk, as the former can be more easily removed available hysteroscopic method is less traumatic, and in the second case, there is a risk of future branch site in the abdominal cavity.
- Coagulopathy (blood clotting disorder) that can not be or difficult to be corrected.
- Malignant tumors of the internal reproductive organs.
- Severe chronic renal failure.
- Autoimmune connective tissue diseases.
- Condition after radiotherapy treatment of the pelvic organs.
Thus, the prospects and the benefits of treatment by uterine artery embolization is associated with:
- the possibility of preservation of the body;
- the duration of the procedure and a long persistence of the effect;
- with a rare number of relapses;
- with a high percentage of regression of fibroids, symptoms and uterine volume;
- with the absence of significant side effects and complications;
with the possibility of the treatment of patients with concomitant pathology of other organs and systems.