Laparoscopic Uterine Vessel Occlusion vs Uterine Artery Embolization for Fibroids
Abstract & Commentary
Synopsis: In a comparison with uterine artery embolization, laparoscopic occlusion of uterine vessels for the treatment of symptomatic uterine fibroids had less associated postoperative pain and comparable effects on fibroid-associated symptoms.
Source: Hald K, et al. Am J Obstet Gynecol. 2004;190: 37-43.
This Norwegian study evaluated the outcomes in 46 premenopausal women with symptomatic fibroids who underwent either uterine artery embolization (UAE) or laparoscopic closure of the uterine arteries. There were 24 patients assigned to UAE, and 22 to laparoscopy, but not randomly so. Patients were considered candidates for laparoscopy if the uterus did not reach above the umbilicus on physical examination.
The UAE technique used polyvinyl alcohol particles. The laparoscopic procedure included the following features: legs in "frogleg" position, without abducting the legs; Foley catheter during and after surgery for 24 hours; a 10 mm intraumbilical port and 2 lower quadrant ports; incisions of the peritoneum between the round and infundibulopelvic ligaments; occlusion of the uterine artery at the level of the internal iliac artery with a clip; bipolar cauterization of the collateral arteries in the utero-ovarian ligament.
Closure of the uterine vessels was accomplished in all 22 patients with 3 suspected of having obturator nerve damage. All but 1 UAE was successful, the one failure due to bilateral vessel spasm. Two patients in each group had temporary increases in FSH levels. Both groups had significant reduction in menorrhagia and also reduction in uterine volume as well as the size of the dominant fibroid. Patients undergoing UAE used significantly more analgesics than the surgical group.
Comment by Frank W. Ling, MD
Here’s the latest option that your patients will be asking about (if they haven’t already). It used to be hysterectomy or myomectomy. Then both could be done through the laparoscope. Then myolysis came along. Then the radiologists got involved because they could offer UAE. Now the gynecologists try to recapture some of their old clinical turf by occluding vessels endoscopically. Oh yeah, and don’t forget about GnRH agonist to shrink the size of the fibroids. It’s FDA approved to shrink them pre-operatively, but let’s face it: sometimes that planned surgery doesn’t occur. It all seems pretty logical to me, but to patients (and sometimes to their physicians who are trying to counsel them), the choices can be a bit daunting.
Which is best for me, doctor? Which technique is tried and true? Which is too new, too experimental? For that matter, what will the insurer pay for? Yes, that last question definitely makes a difference! When informed consent is being provided a patient with symptomatic fibroids, should this laparoscopic technique be included as a viable option? I would venture to say that as yet, the data need to be more compelling for me to suggest this procedure to a patient. For that matter, I'm not convinced that UAE is all that it's cracked up to be. I don’t mean to sound cynical, but I've not seen radiologists achieve enough success, at least in the medical community in which I practice, for UAE to be touted as the "gold standard" for fibroid treatment.
It may sound too simplistic, but we know that a hysterectomy will address the symptoms of large fibroids, whether it's pressure sensation, pain, bleeding, etc. Yes, it carries with it significant potential morbidity, but that morbidity is well known, both to the surgeon as well as the patient. Similarly, myomectomy has enough of a track record so that a patient can be well informed what might lie ahead. Particularly in cases of multiple fibroids, none of us can predict what the outcome of the myomectomy will be, especially if preservation of the uterus is the top priority and hysterectomy is to be avoided at all costs. If your experience with UAE is at all similar to that of many of your colleagues, you have seen some patients have excellent results, while others have been less than satisfactory.
In any medical community, some physicians embrace new techniques sooner than others. Similarly, some are just better than others at any given procedure. Just as not all gynecologic surgeons are created equal, not all interventional radiologists are created equal. It makes sense to speak with those with whom you share patients with symptomatic fibroids to make sure that patients are given data that truly applies to them, ie, a patient should get informed consent about UAE or laparoscopic vessel occlusion based on experience that her physicians have had, not idealized from the literature in which experts with far greater expertise are quoted.
One of the greatest services that we can provide our patients is to put what they read and hear in perspective. That includes what they are exposed to on the Internet, on television, in the lay press, as well as from other physicians. As of now, the laparoscopic occlusion of uterine vessels is an intriguing option that holds some promise, but is certainly not a panacea. For that matter, I would place UAE in that same category.
So, in summary, this article, a self-described pilot study, compared 2 options for the treatment of symptomatic fibroids, both of which still need lots of study before they become more "mainstream" for the general population.
Frank W. Ling, MD, Professor, Dept. of Obstetrics & Gynecology, University of Tennessee, Health Science Center, Memphis, TN, is Associate Editor for OB/GYN Clinical Alert.